SO SAD......Nigerian doctors now beg for internship and postings

Wetin dey happen sef...? Reluctant to open the bottle of chilled drink in front of her at a restaurant where she agreed to meet our correspondent that hot afternoon, having a drink with a reporter in a restaurant was the last thing she wanted at such a critical time, but for the situation she found herself in and the need to vent her frustration by speaking out.

Dr. Oguntuase Moyosola, as she introduced herself, had many issues to worry about, thus, her disposition speaks loudly of a frustrated mind. Her situation is entirely understandable and one would not blame the 27-year-old anyway. Her present situation reeks of frustration, in contrast to how she felt about eight years ago when she secured admission into the prestigious University of Benin to study Medicine and Surgery.

Since she graduated from the institution over one year ago, Moyo, as she preferred to be called, has been at home, searching for placement for her housemanship. This is the one-year period after graduating from medical school during which newly qualified doctors practise, with probational licence, under supervision in designated hospitals across the country.

It’s been 19 months since she left school, but Moyo has yet to secure a place because of the scarcity of placements for internship. While she wallows in dejection each day, some of her classmates had completed theirs and are ready to go for the National Youth Service Corps programme. The situation is even more worrying because her juniors had also finished their exams and are now on the same level with her.

She has also lost money; obtaining forms, usually for N5,000, from one hospital to the other, hoping any of them would be kind enough to accept her, but that has remained a mere wish.

Regrets, regrets and more regrets

“If I had known it would be like this, I wouldn’t have studied medicine,” she began in a rather weak voice. “If someone had told me about these hurdles at an early stage, I probably would have studied another course. I mean, it is frustrating to spend seven years in school, undergoing very rigorous training and still end up sitting at home for almost two years. Many of my friends who studied courses with four-or five-year duration are already working.

“But here I am, stranded. Housemanship is an integral part of our training, and without it, you can’t make progress in your career. You can’t even do any postgraduate programme, not to even talk of Residency programme for specialists, and that one is even another kettle of fish. It is after housemanship that you can be mobilised for NYSC programme and then your residency. Sometimes I wonder what I got myself into by choosing this course, because my mates are out there making progress.”

Moyo’s depression is not just about what has happened in the past or what she is going through at present, even though those can be debilitating, her fresh worries are more of what the future holds.

As it is customary in the medical profession and according to the guidelines set by the Medical and Dental Council of Nigeria, which is the body that regulates medical and dental training and practice in Nigeria, once a doctor does not get placement in two years, including the year the probational licence was issued, the person has to go back to take an exam by MDCN.

“That is my worry now. Mine would be two years in January 2017, and I can’t even imagine going back to school when my juniors in school have finished their exam now, and so if any of them gets placement before me, that person has overtaken me. What can be more humiliating?” she asked.

She added, “After your final exam, you are inducted, during which you get your temporary licence. The year you get the licence is the first year and then one additional year. That is the way it is counted and if you don’t get a placement after those two years, you go back to resit the exam.”

The dearth of hope

To someone on the outside or anyone who is not very familiar with happenings in Nigeria’s health sector, Moyo’s case could be seen as one out of many, but her situation is symptomatic of the torturous experience many fresh doctors go through to get housemanship placement. It partly captures a looming crisis in the health sector, given the deficit the country currently has in terms of the number of doctors available. It is even more so that the situation seems to be getting worse by the day.

At the moment, many of them roam the streets or sit at home for about one year or two, looking for placement, while their mates who are lucky to secure placements would have moved on in their career. And given the importance of housemanship, those who are unable to secure placement are stuck.

Stuck and stranded

As Moyo would say, “I’m stuck as I’m talking to you. I can’t do any postgraduate programme and I can’t be mobilised for NYSC because the housemanship is an integral part of the training. It is quite frustrating seeing your mates leave you behind because of housemanship. Now, I can’t even advise anyone to study medicine because it is getting worse, and no one is even talking of brain drain yet.”

As Dr. Ibrahim Ahmed, another doctor who secured placement after spending one year at home, would put it, the process of getting placement has degenerated into some racketeering. He said he purchased forms from different hospitals, wrote many tests and attended many interviews, but all to no avail, noting that it has even become a means of revenue generation for the hospitals.

Ahmed also said it was later he found out that the surest way of getting placement, for those who have the privilege, is to get a letter of recommendation or referrals from top government officials.

“It is no longer about merit, but about who you know,” he quipped. He also recalled that out of the 50 of them that graduated in his class in 2015, some had finished their housemanship, many others were still on it, like himself, while some had yet to secure placement and would soon run out of time.

He said, “When I was home for a year, I felt so frustrated, when my mates that we graduated together were lucky to get a place earlier and were already working, while I was just at home, doing nothing serious. Although I found a private hospital where I was managing just to get busy and gain some experience, I knew I wasn’t really moving forward.

“Now, I’m still doing my housemanship whereas my mates are ready for service. If those former mates come to where I’m doing my housemanship now, they are my boss and there is nothing I can do about it. The consolation could be that some are even still at home as I speak to you.”

Placement becoming a miracle

Interactions with many of those who are yet to find placement, show that getting a placement has become more of a miracle and subject of testimonies in religious houses.

Before Dr. Makuor Emeka could secure placement, after spending four months at home while most of his friends had got placements, he said he had to travel to Niger State in Northern part of Nigeria towards the end of last year. “It is not a palatable experience. I was frustrated, seeing my colleagues that we finished together working while I was still at home. And time was going,” he said.

He added, “South West is the toughest place to get placement because there are more literate persons there, but even now, it is no longer easy to get placement in the North because they now take their own people and they employ Indians and Lebanese now. The insecurity in that region has also limited the opportunities there. When you stay at home and you don’t get anything, frustration would set in. I have friends doing theirs (one-year programme) without pay.”

Findings equally show that some do the internship without pay to avoid taking the exam again.

Torturous road to a bleak destination

Interestingly, in spite of all the challenges confronting the medical profession, it remains one of the most sought-after across the world, and it is for this reason that doctors are treated as kings in some countries.

It is about the course that has the longest duration; six years, after which the person would go for the one-year internship (which has almost become a bottleneck for those in Nigeria) and then the one year compulsory NYSC programme, for those below 30 years of age. And in spite of these, getting admitted to medical schools in Nigeria is not for the average applicant.

In fact, the battle begins from the admission process, as it remains very competitive and it has the highest cut-off mark both in the Unified Matriculation Examination and the (now scrapped) post-UTME organised by the various institutions. It is equally more expensive, compared to others. According to reports, hardly more than 35 per cent of those who apply to read medicine each year make it to the medical school, thus, those who make it to the medical school feel triumphant and are the envy of their colleagues.

According to a medical doctor, who preferred to be identified simply as Ife, most medical students, like 60 to 70 per cent, get tired of the course when they get to the fourth year, because it is highly demanding and mentally taxing.

But according to him, “the problem is that they can’t go back, so they struggle to finish it, and for such people who struggle to finish, when they are now confronted with hardship in getting housemanship or residency placement, it becomes a very frustrating experience for them.

But as things stand in the world of medical education in Nigeria now, unless a parent knows someone who can influence their child’s posting for housemanship, the probability is that the new doctor may remain a physician only on paper for sometime.

Other medical practitioners who spoke to our correspondent maintained that given how tough the course is, the critical role they play in the lives of fellow humans and the inadequate doctors in the system, doctors should not be left to roam the streets or sit at home doing nothing.

A truly bleak future

According to the information available on the website of the Medical and Dental Council of Nigeria as of Thursday, October 27, 2016, there are 31 fully accredited medical schools in Nigeria while there are additional six that are partially accredited, totalling 37. Also, the total quota (maximum number of intakes) for the 37 institutions is 3,155. In other words, the maximum number of medical graduates that Nigeria can produce per annum, as of 2016 October, is 3,155.

Meanwhile, the 3,155 persons are independent of the doctors trained abroad who, decidedly, come back to Nigeria to practise. In the examination usually conducted for the foreign-trained students, which holds twice a year, before they can undertake housemanship in Nigeria, reliable information showed that there are usually about 600 of them per exam, which means that there are about 1,200 of them per annum.

In total, the 3,155 plus 1,200 gives 4,355 graduates per annum.

According to the guidelines of the MDCN, fresh medical graduates are only allowed to do their housemanship in the health institutions it approved, including teaching hospitals, Federal Medical Centres, some specialist hospitals, general hospitals, military hospitals and a few private hospitals.

In the information made available on the council’s website, there are 24 approved teaching hospitals, 22 approved Federal Medical Centres, 36 approved general/specialist/military hospitals and 15 private hospitals, all with a total intake (quota) of 2,926.

Even if all the institutions take their maximum capacity, a whopping 1,429 medical graduates would be left stranded. And coupled with the fact that the number of students seeking admission into medical schools keep increasing, more medical graduates would be left to roam the streets or sit at home, which explains why the inadequacy has been blamed on inadequate health institutions or training  centres.

Even though the quota as specified on the website is 2,926, investigations by our correspondent revealed otherwise.

It was gathered that the average some health institutions take is between 25 and 30, below the quota allotted to them, due mainly to funding.

We reliably gathered that most of the health institutions do not take up to their allotted capacity because of infrastructure deficit and the attendant cost, like the salary to be paid to the doctors (interns), coupled with the economic crisis which has deprived many of the hospitals of adequate funding.

Some of the prospective interns who spoke to us also alleged that some health institutions choose not to take up to the quota allotted to them.

It is interesting to note that doctors are not alone in this as other affiliated professionals also go through similar experience, including the denticians, optometrists, dieticians and physiotherapists.

Suffering amidst plenty

Given the country’s growing population (put at 180 million) and the number of persons being admitted into the various medical schools in the country, one would naturally expect that the country would have more than enough medical practitioners, but it seems paradoxical that Nigeria still has far below the number it requires, and far below the standard set by the World Health Organisation, which is the specialised agency of the United Nations that is concerned with international public health.

The WHO had recommended one doctor to 600 patients, (1:600) but available record shows that in Nigeria, it is one doctor to 3,500 patients (1:3,500), which shows that the country has a huge shortfall of its required number of doctors.

Given the poor doctor to patient ratio in Nigeria, yet, the struggle to get admitted to medical schools sometimes pales into insignificance compared to the difficulty in securing posting for housemanship.

By the WHO standard, Nigeria with a population of 180 million, needs at least 300,000 medical doctors.

With a ratio of 1:3,500, it means Nigeria currently has about 51,428 doctors. This implies that the nation currently has a deficit of about 248,572. The Chairman, Association of Colleges of Medicine of Nigeria, Prof. Folashade Ogunsola, had said in November 2015 that Nigeria had a deficit of 237,000 doctors to meet the WHO standard, but given the increase in population without a corresponding increase in the number of doctors, the deficit keeps rising.

Meanwhile, given that the nation currently has 248,572 deficit at the moment, and with the fact that only about 4,355 fresh doctors are produced yearly, it might take the country well over 50 years to meet up with the standard, given the current situation.

Meanwhile, available information shows that it might even take longer and the situation could get worse, given the rate at which doctors relocate abroad to seek greener pastures. And that would be in addition to the bottleneck that housemanship has created, in which case many graduate doctors are unable to practise as professionals because an integral part of their training (intership) had not been completed, not to talk of those who have specialities and are having tough time to find placement for residency.

In fact, the 12th President of the Association of Nigerian Physicians in the Americas, Dr. Johnson Adeyanju, had in his post-convention remarks commended and congratulated the association for its “rapidly growing members”, which gives the indication that more Nigerian doctors are relocating to the Americas and other countries like Canada, United Kingdom, among others, for greener pastures.

The President of the Nigerian Medical Association, Prof. Mike Ogirima, told our correspondent that there are about 87,000 doctors on the association’s register, out of which about 45,000 are practicing in Nigeria, and that the remaining, which is almost half, are either outside the country or dead. “But, we have nothing less than 20,000 doctors in America, and  maybe another 15,000 in the European countries,” he added.

Also, while many hospitals lack doctors, especially those  in rural areas, several doctors who have left school are stuck as a result of lack of placement for housemanship.

Some experts have tied this deficiency to increasing (avoidable) deaths and the increasing maternal mortality rates, more so that the larger number of Nigerians live in the rural areas. According to the World Bank, as of 2015, about 52 per cent of the Nigerian population live in the rural areas.

A visit to any general hospital would confirm that Nigeria is indeed in dire need of more professionals. And according to Dr. Ife, “There are many doctors at home looking for job. The truth is, our health sector is very poor, and we have doctors who are ready to work, yet no work for them, while many hospitals are in need of doctors. The situation is dangerous. Let us hope it doesn’t continue like this, else there might be a problem.”

While calling on the government and the MDCN to review the quota for housemanship upwards and provide more training centres for the benefit of graduate doctors, the experts who spoke to our correspondent said the relevant authorities should take decisive steps on the issue.

Findings also showed that Nigerian doctors are relocating to foreign countries to practise due to the work load, occasioned by congested hospitals, work pressure and poor remuneration, in which some earn as low as N50,000.

Experts speak

Commenting on the issues, Ogirima, said the Minister of Health, Prof. Isaac Adewole, had set up a committee to look into the scarcity and that the committee had submitted its report. He explained that efforts were on to make the posting of fresh doctors for housemanship automatic, noting that government would also need to increase the capacities of all the hospitals and accredit more private hospitals since some of them have all the necessary facilities that a teaching hospital should have.

He said, “Ideally, doctors shouldn’t be asking for placement because it is a period of training, but we have more doctors compared to the spaces we have had years ago. Apart from that, more doctors are being trained from outside the country. For example, in the first half of this year, we had about 600 of them who were licensed. So, that has brought about an upsurge in the search for space. However, the scarcity would soon be a thing of the past.”

Speaking on incentive for doctors in rural areas, he said there is rural posting allowance by the Federal Government but most of the Federal hospitals are in towns or cities, hence, he said state and local governments could embrace the idea and give incentives to doctors in such places. “We are telling local governments to be a part of it; they should be able to pay the salary of a medical doctor in the hospital in their area,” he added.

Also, the Chief Medical Director of the Lagos University Teaching Hospital, Prof. Chris Bode, said it was worrisome that doctors would leave medical schools without getting posting for their housemanship. However, he said it is a problem that could be solved.

In a telephone interview with our correspondent, the CMD said the inadequacy of placement was largely a result of location preference by the fresh doctors and the fact that many general hospitals that should have provided spaces for housemanship were not operating in full capacity.

He added that government might need to adopt the model of the Nigerian Law School whereby doctors would also be posted to training centres once they leave medical schools.

He said, “If we can make all colleges of medicine to graduate their students at the same time, and then post them to the various health institutions at the same time, they would finish at the same time and the next batch would come in at the same time. It would simplify it, just like they do in Law School.

“Even though they may not like where they are posted, they will surely get a slot once they leave medical school. Because, it’s as if everybody wants to be in Lagos, and there are only two teaching hospitals in Lagos. I have close to 200 house officers (in LUTH), but people still seek placement. How many do I need? If I have 500 patients and I have 200 house officers, how many patients will they be treating in a day?

“Also, we should make general hospitals fully operational because you would find that many other areas where doctors can do their housemanship have not been optimised for training. This is why there seems to be pressure on the few. Apart from Lagos State, how many general hospitals in Nigeria are ‘working’ or optimised?

“So, there are enough places but they are not all optimised to serve their functions.”

While giving assurance that the Federal Ministry of Health was on top of the situation, he advised that private hospitals can apply to the MDCN for accreditation and that if they meet the standard they would b approved. “The MDCN and the ministry may also need to look outside the box, encourage hospitals and let them know what they need to get to qualify,” he added.