21 Aug Presidential directive on Residency Program-Hunting the Scapegoat
Hunting the Scapegoat.
The recent events in the health sector have left a lot of Nigerians reeling from shock. First it was the striking doctors who went on a record strike of more than one month. Then it was the dreaded Ebola virus which found its way into Nigeria and has been wreaking havoc ever since. The latest development is the recent move of the government in terminating the appointment of residency programs and suspension of residency training in the country. The federal government woke up one day and decided to look for a scapegoat-someone to blame for all the health issues in the country and it chose the resident doctors. There’s just one problem with looking for and finding a scapegoat-it doesn’t fix the problem.
I shall attempt to look at the events in the health sector one by one hopefully unbiased. The public and a lot of people are confused about why the doctors went on strike. Some feel it’s because doctors are egotistical, pompous people with a superiority complex. Some feel they are asking for more money which is greed because the doctor presumably earns more than the average Nigerian, both in the public and private sectors. Others felt that they went on strike because of their pettiness-being that they do not want the other allied health workers to become consultants. To those unclear about the reasons behind the NMA strike, please click here to review the demands by the association. Before I attempt to clarify some of the misconceptions of people about the strike, let me just say this: Strikes are an anomaly and not the norm. Personally, I did not want a strike for any reason and definitely not one that was so prolonged and not in a sector that has to do with life and death. In my naiveté, I believed that since it was a principal part of the health sector going on strike, the government and the NMA would swiftly resolve matters at the negotiating table. As we have long since seen, the government is no respecter of persons-doctors or otherwise.
There have been insinuations that the doctors are a pompous lot who fleece the public and have a superiority complex. I can tell you that the same accusation of pomposity can be made among lecturers, lawyers, teachers and even groundnut sellers. Arrogance is a human trait that can be found in any setting. While fleecing of the public may be applicable to some doctors especially those in the private setting, it is not a generalization that can be applied to all doctors. Contrary to popular opinion, not all doctors working in the public sector also have private clinics most especially resident doctors. Their training is usually too vigorous or intense for them to do anything else. The public will do well to note that not all private hospitals are the same or have the same set of pricing system. Some are more expensive than others. Some offer more expensive services than others. Usually all demand payment for their services before or after treatment because private hospitals are business operations. If someone is hungry, he can decide to eat at a cafeteria instead of eating at a restaurant. It’s his choice.
The second insinuation is that doctors are too greedy. They already earn a lot so why do they demand for more? While it is true that a lot of freshly graduated doctors earn much more than their colleagues in other professions, the public would do well to note the type of job a doctor is required to do. We all know that doctors go through a lot of rigorous training, go through a lot of difficult exams to have the MBBS certificate. But that is not all. When they finally get that so called ‘coveted’ certificate, their journey just begins. The graduates discover that during their year of internship, they are expected to work round the clock. Somehow, they manage to survive hoping it gets better and they’ll have more time to themselves as they climb higher up. They later discover that it only gets worse. In the US and other developed countries, doctors are not required to work more than 80 hours a week. There is no such regulation in Nigeria partly because of the dismal doctor to patient ratio. Doctors have been known to slump while attending to patients or to faint in the theatre. If they ask for a little more compensation because of the superhuman burden of work placed on them, are they being callous? One only needs to compare the wages a doctor earns in Nigeria with other doctors in developed and developing countries such as ours to see that demands for better remuneration are not unreasonable especially in a country like ours where inflation of goods and services is the order of the day.
In addition, doctors have been accused of being petty- wanting to rob other health workers of their due. If the other allied health workers want to be consultants then let them! This sentiment seems perfectly reasonable on the surface but in a country that reeks with quackery where the chemist and ‘agbo’ (herbal concoction) sellers are lords in their own rights it is a decision that must be taken with extreme caution. The poor health indices in Nigeria is not just due to the lack of facilities or medical equipment but because a lot of untrained hands are allowed to do trained people’s jobs. During my time in a public hospital, we would receive referrals from medical directors of hospitals who actually turned out to be auxiliary nurses who set up practices because they believed they had acquired all the necessary training after having spent a lot of time in hospitals. The funny thing is that becoming a doctor does not take place by osmosis. It is as much science as art and before we give people responsibility, then we must ensure that they are adequately prepared for it. We must not put the cart before the horse. Personally I think that if other allied health workers want consultancy, then they should be allowed to have it after an adequate structured programs for their attaining consultancy have been put into place just like it is done in other countries. There will be problems if they are just made honorary consultants because of their long term experience.
A case in point is a scenario that took place in one of the nation’s Federal Medical Centers that I personally witnessed. A doctor was working in the emergency and had a lot of emergency cases to attend to, when a senior nursing officer brought in a patient. The doctor was just a lowly resident and so the senior nursing officer mandated the doctor to treat the patient she just brought in. The doctor made a quick assessment of the patient and decided that he had more serious cases to attend to and would get back to the patient when he was done. He made his decision known to the senior nursing officer. He was following a principle called triage-which meant deal with the most serious and life-threatening cases first. The nursing officer was incensed at the apparent impertinence of the young doctor and the doctor was verbally insulted by other nursing officers and almost physically assaulted by another allied health worker. Whilst still on duty, he was threatened with having his license revoked and being punished. The situation finally degenerated into an all-out war where the nurses went on strike claiming that the doctor must be given a query for abusing one of their own and the doctors also went on strike because they had reason to fear both physical and verbal assault from the allied health workers. It took a long time to defuse the fire. Let us imagine what would happen if the said nursing officer was a honorary consultant. That would just mean that the resident doctor would be toast literally since he had defied the opinions of a consultant and the other patients who needed more immediate care would have been sacrificed. After all, a consultant nurse of five years is expected to know much more than a resident in training. In medicine, a consultant’s word is law, which is why I believe it should not be given lightly. However if those nurses had been made to go through a system of training they would have been able to see the doctor’s action for what it was-doing what was best for all the patients and not a personal vendetta against them. I can assure the public that a lot of scenarios like this are bound to happen if the other allied health workers are given consultancy before they are ready. And this will lead to a lot of internal strikes in the nation’s hospitals thereby grounding the health sector. I will not attempt to bore the public with numerous examples given by our doctors where nurses have been known not to attend ward rounds or provide things needed on the ward for examination even though it was in their keep or when the pharmacists or physiotherapists over-ruled a doctor’s decision on a patient whether it was in the patient’s best interest or not. I believe all these can be corrected if the other health workers are exposed to a system of training that shows them their jurisdiction over patients and their job description and attempts to remove any grey or blurred areas in how they practice in their area of specialization. In medicine, consultants consult each other and even seek second opinions. A consultant doctor might need an expert pharmacist to consult and vice-versa.
I have said a lot about the strike and explained some of the reasons behind it but I feel the need to reiterate that I personally believe the strike should not have lasted as long as it did. The NMA wanted the government to start making good on some of the promises, because they are aware of the fact that like other trade unions who have attempted to negotiate with the government, once you turn your back, the government withdraws. And all its promises enter into a ‘pending’ or ‘never to be acted on’ drawer. While this is true, another tactic might have been to call off the strike in good faith, make the appropriate information to the public and the media, then give the government some time to make good on their promises. This is not because the government can be trusted to put policies into place, but because the Nigerian public would find it extremely difficult to survive without good and affordable medical care for such a long period of time. If they failed or reneged on their promises, then another industrial action could be looked into. This I believe was the NMA’s mistake. We should have called off this strike long ago even before Ebola came on the scene. Prolonging it only made us the victims of name-calling and loss of credibility in the public’s eye.
While the government was still trying to see if it could goad the NMA into ending the strike, the dreaded Ebola virus found its way into the country. As some people have already stated on social media, it was an act of Providence that the teaching hospitals were on strike because the most likely place Patrick Sawyer would have gone to in order to receive specialist treatment would have been a teaching hospital. That would have been deadlier because of the longer chain of command it would take for him to get to a consultant. From the record officers, to the medical officer or house officer who first sees the patient with the attendant nurses with him/her, then to the unit the patient is referred to with the residents and their attendant nurses before getting to the consultant. Knowing that Ebola is not a common disease in the country, it would have taken a while before a high enough level of suspicion was reached and the number of contacts that Patrick Sawyer encountered would have been triple fold. Anyway, the government was faced with a deadly disease it knew not what to do with and it looked to the doctors for solution thinking that they would end the strike on humanitarian grounds. Unfortunately, that only extended the strike as the doctors had no cure for Ebola and no means of adequately protecting themselves from the virus because protective measures and equipment had not been put into place. They had no incentive for returning to work and wisely noted that their resumption of duty might even escalate the spread of the virus.
The Federal Government looked at the situation and could not understand the stubbornness of the Nigerian doctors or their refusal to help in the time of need and so decided to terminate the appointment of those it felt were no longer useful. The advisers of the President picked on the resident doctors-who form the core of the nation’s public hospitals and decided to fire them thinking that that would put NMA in their place. What they failed to realize was that they were effectively shutting off the nation’s health future. Because Nigerian residents are literally the future of the nation’s health. They are the bridge in the gap between medical and house officers and consultants. They are the most hardworking and overworked of all the doctors in the nation. They provide a high level of care which the few consultants in the country cannot adequately furnish and the medical officers are not equipped to provide. Terminating their appointments means that there would be no specialists in the near future. To the layman, that means if you have a complaint and the general practitioner refers you to a Cardiologist of which they are a little more than a handful in the nation with giant caseloads, you would have very little option except to wait for years to be seen by a consultant who is always booked or surrender yourself to the whims and caprices of the chemists and agbo sellers or you save up money and go abroad. The health indices of the nation will plummet even further. A more foolhardy move could not have been envisioned. The government needs to stop looking for scapegoats and start looking for answers.
The NMA and the government would do well to sit down together and see what can be done to surmount this impasse. ‘This is not the time for any party to ignore the actions of the other because even though some of our countrymen are dying from Ebola, a lot more are dying from highly treatable and preventable diseases like hypertension, diabetes and a myriad of infectious diseases. It is time now to drop the weapons and end the war and for a settlement to be reached.
P.S: I would also like to note that the demands given by the NMA at this time in our nation’s history are strategic. This year marks the end of the first term of our President and the Nigerian doctors wanted to find out just how interested our leader was in matters of health that have since plagued the nation especially since he intends running for second term. There was no better time than the year before his re-election. The Federal Government I am sure has managed to give a wrong conception to both the public and principal members of the nation’s health team. It would do well to try to correct this opinion.