Sunday, January 31, 2010

Medical education in Nigeria

Gentle readers, forgive me for not writing more about Haiti. Though I volunteered, I have not yet been asked to deploy. Those of my colleagues who have done so, and who are in a position to comment on low-resource medicine in Haiti after the earthquake, are understandably busy and not yet able to do so.

Let's turn instead to Nigeria. Dr. U.V. Okafor teaches at the University of Nigeria Teaching Hospital in Enugu. (Famed author Chinua Achebe taught at the same university.) He has written about critical care in sub-Saharan Africa and commented on the dire shortage of nurses there. He kindly agreed to answer my questions about medical education in Nigeria; what follows is a lightly edited version of what he had to say. His words reveal a great deal about the issues that face practitioners in low-resource countries, including the emphasis on teaching the physical exam; the lack of a strong emergency medicine paradigm; brain drain; payment problems for physicians; the need to attract and retain only medical personnel, but also allied professionals like engineers; and the use and misuse of federal and international funds.

Italics and hyperlinks are mine.

A little background? Basically, medical education in the country is patterned after the British system. Nigeria is of course a former British colony, attaining independence in 1960. Physical examinations are greatly emphasised in our medical education because of a large rural population without access to tertiary care centres with modern equipment. Nigeria’s Human Development Index (HDI) progressed from low to medium in 2009. And that is good news for us, and credit must go to the rural-based doctors (they will get rural posting allowances in the new salary scale).

How do you teach students? I am a senior lecturer in anaesthesia and intensive care. Medicine is a 5-6 year programme in Nigeria, and the medical students undertake a four-week posting in clinical anaesthesia, in addition to classroom lectures. Usually I use PowerPoint presentations for my lectures to medical students. As a member of the curriculum committee of the medical school, I tried to include more credits in emergency medicine, but it is still a novel concept in the country.

A word on residents' training? I also train residents in anaesthesia. The residency programme usually takes 4-7 years, depending on one’s progress. The final examination of the programme involves a dissertation or a case series, and that usually prolongs the training. Successful candidates become Fellows of the Medical College of Nigeria, or Fellows of the regional West African Postgraduate Medical College....[The WHO surgical safety checklist is] not currently in use [at UNTH]. I got it from the WHO website and hope it will be standard practice soon.

Where do residents go to train? Though [UNTH is] one of Nigeria’s premier teaching hospitals and its centre of excellence for cardiothoracic surgery, her best graduates usually pursue postgraduate training overseas, in the US or Britain, and mainly for economic reasons. Most of the first-generation consultants were UK-trained with a sprinkling of US and Canadian fellows. I think the North American-trained specialists rarely return to the country. To reverse this sad trend, the Nigerian government recently increased the salaries of medical workers, buoyed by the increased oil and gas revenue. The country is the world’s sixth largest producer of crude oil. The new emolument will take effect this year.

What kinds of resources are at your disposal? In early 2007, the hospital moved to its permanent site where the theatre was well equipped by VAMED, an Austrian health care service provider. They installed multi-channel monitors (pulse oximetry, non-invasive blood pressure monitor, temperature, electrocardiography and capnography), and modern anaesthetic machines with low-flow systems. MRIs are avaliable in some federal government-funded hospitals, but maintenance is a problem due to a paucity of biomedical engineers. To the best of my knowledge, PET scanners are not available, being quite expensive for a developing country like Nigeria, which has no health insurance for most of her citizens. Besides, the problems of infectious diseases means funds are diverted towards these areas, and their treatments are greatly subsidized (about seven dollars a month for HAART).

A word on your position as an academic physician? The major problem for those of us in academia is a lack of grants for research work, and we still depend on Western organisations like Wellcome Trust for assistance. When a nation has made billions of dollars from oil revenue, it certainly got into some hands, but funding education doesn’t seem to be on their minds. With a former university lecturer as President, we hope that will change soon. 

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