REVIEWED BMAS: Experts Weigh-in On Impact Of Medical Training

Though, it is not every medical school that has begun to implement the new policy initiated by National Universities Commission (NUC), experts have said it would enhance medical practice in the country. In the last few years, Nigerians have turned to India, South Africa and Europe for medical tourism.

At a lecture delivered in Ondo State during the maiden matriculation and inauguration ceremony of the University of Medical Science, Ondo State, the NUC representative had said new intakes in the MBBS programme would need to obtain a degree before entering for their medical programme.

The World Health Organisation standard stipulates the ratio of one doctor to 600 patients, in other words, Nigeria needs no fewer than 237,000 medical doctors, but the country has‎ 35,000 practicing medical doctors, which are not enough to care for the growing and teaming population, as even number in itself might not be a problem, but the quality of training competence and skills needed by the profession.

Medical education in Nigeria falls under two ministries, namely: Education and Health. The Medical and Dental Council of Nigeria (MDCN) is vested with the power to determine the standards of knowledge and skill to be attained by persons seeking to become members of the medical or dental profession and vested with powers to review those standards from time to time, as expressed in section 1, subsection 2 (a) of the Medical and Dental Practitioners Act CAP M8 Laws of the Federation of Nigeria 2004. Indeed, the MDCN has the imprimatur to regulate medical education, training and practice in Nigeria.

The duty of the medical school is to produce people with competency skills after graduation. Based on the current statistics, it will take about 100 years to have the number that Nigeria needs, and that is if none of the doctors and new graduates leave the country.

There are currently 27 medical and dental schools fully accredited by the Medical and Dental Council of Nigeria. They will produce 2, 550 medical practitioners and 175 dentists per year. There are four partially accredited medical schools, with capacity to produce 200 medical students. Each school has its quota. The reason being that they have to be trained competently based on the facilities available.

The NUC Executive Secretary, Prof. Julius Okojie, told The Guardian in Abuja, that the new Benchmark Minimum Academic Standard (BMAS) for Medicine and Dentistry, which had since been made public by the Commission, provides for a seven-year training, leading to the award of MBBS/MDS.

He said: “A seven year MBBS programme that encompass a seamless four-year acquisition of the B.Sc. (Basic Medical Science) with interest in either Anatomy/Physiology/Biochemistry.

“At the end of seven years, students would have acquired the Bachelor of Medical Science, Bachelor of Medicine and Bachelor of Surgery degrees. In case of dental programmes, students would have acquired a degree in Basic Dental Sciences and Bachelor of Dental Surgery.

“In order to allow for career change for interested non-medical health professionals, the commission has also approved a four year programme leading to MBBS/BDS for interested and qualified graduates of Nursing, Pharmacology, Physiotherapy, Image Science, Paramedics, Anatomy, Physiology and Biochemistry. It must be noted that for such to be considered for admission, they must have at the WAEC/NECO levels, minimum credit scores in Mathematics, English, Physics, Chemistry and Biology at one sitting, prior to the admission for their first degrees. They must also have a good CGPA,” he said.

The NUC helmsman said admission into universities based on the current six-year programme would be allowed to continue as suitable alternative based on the discretion of the university.

He explained that the reviewed BMAS went through a long process, which included wide consultations with the academia, professional associations and regulatory bodies, following the conduct of a Market Needs Assessment.

Okojie maintained that the consensus was that medical training should be post-graduate. He said: “The main goal is to ensure that the crop of graduates emerging from the programme are psychologically matured to practice, with a high level of competency.

“The new BMAS for medical education still retains the fundamental learning objectives that the six-year programme has: the national development goals for health, while retaining the international outlook to guarantee global competitiveness.”

While noting that the extant six-year programme shall continue to subsist for a period to be determined, Prof. Okojie observed that attempts had been made over the years to run medical programme, using course credit system and that the hallmark of the new document is that it clearly apportions credit weightings to all the courses and activities.

Professor Babatunde Salako, Provost, College of Medicine, University of Ibadan (UI), while tracing the genesis of the new policy, said, sometime last year, heads of colleges of medicine were invited to Abuja to consider the basic minimum standard curriculum for medical students and at that time they suggested three programmes. “The first one is a six-year programme that most college of medicine run for MBBS. The second one is a new one, which is creating access for other allied health professionals and any other person, who wishes to do medicine to come in through 300 level and spend four years and then graduate with MBBS. The third one is what had been practiced in a few colleges of medicine in the past, the one that readily come to mind is Obafemi Awolowo University (OAU), where people first do first degree in health sciences and proceed to do MBBS, thereafter, I believe at that time it was seven years that they spend, barring house jobs and the National Youth Service Corps (NYSC), we discussed this.”

Salako added, “I think the generality of the colleges then did not favour the seven years nor the four years, they preferred to run the current programme, which is six years. There were issues, the first one was; what is the benefit of spending seven years not to talk of 11 years, and will they be adding another degree?

“Already, some people in the university system feel that faculties or lecturers in clinical medicine should have a doctorate degree (Ph.D), but the MBBS programmes are designed in such a way that the Ph.D is not attractive to teachers of medicine at the beginning of their programme, because what you need to be able to teach that is acceptable in Nigerian universities is a professional degree, which is generally referred to as diploma and people have taken this diploma to mean ordinary diploma, and so, they couldn’t understand why you have a diploma and teach in medical school and become professor.

“Indeed, what they call diploma takes minimum of six years then, to get a diploma in medicine now, you will need minimum of seven years, but for certain surgical specialities you will need nine years. In medical schools, it is not easy to learn, train and to pass examinations; people take extra two years for that. After you have gone through this, then you are in the position to be employed to teach and mentor and produce doctors.

“If you don’t have that, if you have 10 Ph.Ds you cannot do that. The post graduate diploma is both a professional degree and some level of academic degrees, which has been introduced by the two colleges that run them. That does not say that those who have medical post graduate degrees cannot also have Ph.D; they can, for Ph.D is a research degree and it will enhance their research ability. There is, no doubt, that the post graduate diploma prepares a specialist to be both a professional and an academic.”

He said, “what they (NUC) are trying to copy is the American system, where people probably require a first degree before they take medical education. These days, people get to the university at the age of 16, if he does not fail the examination he becomes a doctor at 22, he is still a child who does not know much of his left from right. Though, the person has acquired hard skills, he may not have sufficient soft skills, which is the ability to make use of the degree he has acquired. This is something I believe the NUC is trying to ensure we do.”

He said, “the cost of training would be high, it may reduce people’s interest in medicine and already we don’t have enough, and so, it may mean that we may not be able to produce the nation’s required numbers of doctors.”

In line with global practice and to ensure that knowledge and skills are effectively imparted,” Okojie said, “modern course delivery systems have been prescribed. Among core teaching facilities and modes of learning recommended are:

• Clinical Skills Laboratory.

The use of the facility would represent a shift in the current mode of medical training to problem-based solving approach and the application of modern techniques, which involves use of Mannikins and simulation materials. Clinical Skills Laboratory provides a learning platform in clinical, and information technology skills to certain level of competence before direct exposure to patient, which afford the learner and teacher an advance knowledge in a seemingly practical environment. The facility can also serve as a multi professional/inter professional interactive forum for communication skills development. The simulated patients also provide the learner a safe art of clerkship before direct contact with the real patient, thus providing a learning method that efficiently fills the gap between theoretical knowledge and clinical practice.

• Classroom Equipment

Adoption of modern delivery method using ICT has become inevitable. Classrooms should be equipped with smart boards, document scanners and bio-metric scanners for lecture attendance.

• E-learning materials and Research Information Platforms

E-learning materials accelerate understanding of courses taught and have become a veritable tool for learning. Research, generally, are meant to address social issues as well as deepening the knowledge and advancement in the field of studies. Information on the developments and applications in the field of study should be readily available.”

On the above, Prof. Okojie said, “The availability of Nigerian Research and Education Network (NgREN) has made access to teaching and research information readily accessible and all Nigerian universities should key into it.”

The former Chief Medical Director, University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu, Dr Anthony Mba, while x-raying the new NUC policy, concluded that it would ultimately impact in knowledge and medical practice.

He said: “It has also restructured and streamlined the courses and examinations in line with best practices elsewhere in the world. Why, then, is there so much vituperation about the new BMAS for Medical/Dental schools?”

According to him, the new BMAS allows for three alternative modules for getting to the award of MB.BS or BDS degree. “Duration of training is never a strong determinant when it comes to making career choices. Those who wish to study medicine or dentistry will still do so anyway, even if takes 10 years to do that.”

While not dismissing the rationale behind new policy, Dr. Osahon Enabulele, the vice president, Commonwealth Medical Association, and immediate Past President, Nigerian Medical Association, said the quality of medical practice is influenced by several variables and not only by the quality and content of the medical curriculum. “Indeed, improvement in medical practice is brought about by the holistic and effective management of various factors before, during and after medical and dental education/training.”

He noted that the quality of entrants into medical school is very important, adding, “there is need for a rigorous selection process for admission into medical schools, predicated on merit, as against the prevalent propensity for quota system.”

Enabulele also said, “there would be need for quality upgrade of the medical education/training infrastructure across Nigeria with improvement in teaching methods and strategies for medical education in Nigeria. The trainers will need to be offered better opportunities for research, continuing professional development, exposure to new teaching methods and resources, grants, workshops and conferences, rather than the current harsh and unsupportive teaching environment in Nigeria.

“Surely, there will be need for better security, incentives and globally competitive wages for the medical and dental practitioners, along with the modernization, upgrade and sustained maintenance of health facilities across Nigeria, to support ethical and quality medical/dental practice. All these, amongst others, are what determine the quality of medical practice and not just the quality of medical curriculum alone.

“One likely negative knock-on effect of an increase in the duration of training for medical/dental education is reduced interest in the medical profession by prospective students. This, in addition to the lengthening of the medical manpower production time, will lead to a worsening of the current acute-on-chronic shortage of medical/dental manpower in Nigeria, in the face of the global health workforce crisis.

“Going by the current rate of production of medical and dental graduates (with the use of the current 6yr MBBS/BDS Training programme), Nigeria needs an additional number of over 250, 000 medical doctors to attend to the population of over 170million in an ideal doctor-population ratio. Thus, any further elongation of the duration of training will further increase the demand for doctors, worsen the medical manpower crisis with great negative impact on health service delivery and the overall health of the population.

“I will, therefore, advise the policy regulators to deeply reflect on the pros and cons of whatever policy they wish to introduce or experiment. Surely, I will advise them to appropriately balance the benefits with the cost, with both the quality of medical education/practice and the health of Nigerians taken into good account.”

Dr. Louis Okoye, the Medical Director of Victory Clinic, in Chorbe area of Jos North of Plateau State, said he neither supports the new policy nor condemns it. “In American system, if you do your thing fast, nobody stops you. I support it, if there is proper curriculum, but my major thing that let us go back to the old system, because most of us who went to the university through Higher School Certificate, we were in Europe, we studied outside the country. When we were there, we would be asking them, ‘bring the exams, bring the exam.’ They would say, ‘no, we know you would pass, you would pass’ and we were beating their boys. Things are bad now, that is why all these things are coming.”

He added, “as far as I am concerned, I will suggest that if they can do it, that after secondary school, you go in for a two year post – secondary school training before you can go on to do medicine, so that you will be used to some terminologies and that is why many students fail.”

Okoye believes that the content of the current medical syllabus is adequate, adding, however, that most of the students admitted to medical school these days are not qualified. “Not because they didn’t have school certificates, but most of them dodge exams, while some, people write exams for them, there is also god-fatherism. Until that one is stopped, then we keep proper students not minding whether the father is a cleaner or whatever.”

According to Okoye, whoever wanted to go into medical school must have finished his advanced level, either HSC or Advanced Level in those days, which was something very practicable and very nice, because education was taken very seriously in those days.

“Things are so bad now that even somebody who has finished school certificate cannot speak proper English and because of god-fatherism and whatever, they all find themselves in the university.

“So, the standard, really, has fallen seriously. It is unfortunate. If we now want to go like the Americans do, which is first of all, you must have finished bachelor’s degree before you go into the medical school, it is not an unwelcomed development.

“But if you can go back to sit things like in those days, when you finished your school certificate, either you had an advanced something or an HSC or whatever, it is still competitive favourably, because that is two years post-school certificate or whatever. But the most important thing here to place emphasis on is proper education. What I mean by proper education is that it is not education by god-fatherism,” Okoye stressed.