Pharmacists, nurses, others should stop competing with doctors –NMA president

The President, Nigerian Medical Association, Dr. Osahon Enabulele, in this interview with GBENRO
ADEOYE, insists that physicians are best suited to head teaching hospitals

Is it not biased to say only doctors should head hospitals when health care delivery is encompassing?

In any human system, even in heaven and hell, there is order. The phenomenon playing out in the public health care sector amounts to an unnecessary equality beauty contest and unholy quest for the doctor’s leadership authority. This is quite unfortunate and uncalled for.

Every profession and system has a ‘soul’ and a custodian of the core values. That should be someone that has a broad-based general knowledge of the intricate workings of that system or sector. In the health care sector, this professional is unquestionably the medical doctor.

People have been referring to some settings outside Nigeria where the so-called professional managers are heading hospitals. May I point out here that recent evidence has proved that physician-led hospitals perform better in terms of positive patient outcomes which are the primary concern of the health care sector. The argument as to who is best suited to head the hospitals/health establishments has essentially been put to rest by results of scientific studies, the latest being that by a world renowned researcher Amanda Goodall in the USA, who established that hospitals run by doctors were doing far better than those run by the administrators and any other groups of persons. She went further to posit that the main reason for this is that patient care is at the centre of doctors’ training and practice and are therefore in a better position to take certain decisions which are critical for patient’s survival.

Are you saying we can’t find a trained nurse, pharmacist etc who can manage a hospital better than a doctor or be a better administrator?

This is beyond emotional reasoning. In the management of public hospitals, physicians are better suited to manage hospitals as it is not purely a profit-oriented venture, but one in which a delicate balance has to be made between quality patient care/patient needs and profit making. It is expected that the manager of a hospital would be one with a broad and deep understanding of patient needs in addition to his/her cognate managerial experiences which could be garnered as head of several units and departments within the hospital.

Medical and Dental practitioners are not only good clinicians, but also good and excellent managers of human, material and financial resources through administrative acumen, generally garnered on the job through experience and other formal and informal training.

Health care or hospital management is not about democratic selection or election. If it was, then one day, the catechist would start celebrating masses in the Catholic Church since he now possesses PhD. Or the Nurse anaesthetist would start performing surgery on the basis of the votes garnered from members of the surgical team. For those who want to turn best practices upside down, I encourage them to establish a hospital and appoint a paramedic or allied health care worker as the head.

The health minister, Onyebuchi Chukwu, once said that a hospital is totally a doctor’s territory, do you agree with this assertion?

Many a time, public officers are misquoted or interpreted out of context. This is what I suspect could have happened here. I am sure the Hon. Minister was trying to explain what I just told you now. No medical doctor would want to become the managing director of a pharmaceutical industry if he has no specific training in Clinical Pharmacology or Therapeutics which are also clinical specialties. No medical doctor has attempted becoming Head of the Nigerian Institute of Pharmaceutical Research and Development whose management has been colonised by pharmacists or the Army, Navy or Air force. Doctors know their limits. Doctors are simply support staff in these sectors.

Many paramedics, including pharmacists,nurses, laboratory technologists/’scientists,’ physiotherapists, etc. have changed their professions by going back to school to study medicine and become what they feel should guarantee their happiness. Have you heard of a doctor who left the medical profession to read physiotherapy or medical laboratory science or nursing? People should be contented with their professional status, defined roles and positions instead of over-heating the health care environment with frivolous allegations and agitations.

Issues of performance can sometimes be subjective but we will find quite a number of people who will say that Prof. Eyitayo Lambo did well as a health minister. Yet, he was not a doctor but a health economist? Why can’t other health care professionals become health ministers?

Prof Eyitayo Lambo is a man well respected in NMA circles. It is on record that Prof. Eyitayo Lambo received tremendous tutelage from late Prof. Olikoye Ransome-Kuti (a medical doctor). I am sure that his performance could have been better if he had some medical training. Indeed, I am convinced that if you ask him today what else could have made his administration achieve more, he would tell you that it is medical training. This is so because the head of the health care sector should truly have a general knowledge of most, if not all the component areas of health and the health care delivery system. It is also for this reason that a lawyer heads the judicial sector. The lawyer is in addition the Permanent secretary in the ministry of justice despite the fact that there are other paralegal professionals in the judiciary.

As a doctor who signed the Hippocratic Oath, don’t you think that you’ve broken the oath with unhealthy relationship between doctors and other health care professionals which does not help the health system?

I am quite sure that Hippocrates would be very uncomfortable in his grave or wherever he is, seeing what is happening in Nigeria today. Imagine a situation where one of his assistants would tell him to step aside for them to take over headship of the health team. That would be outright sacrilege. This is the more reason we are complaining loudly against the emerging phenomenon of unhealthy rivalry and unholy equality beauty contest in the health sector. Doctors are leaders who are always ready to accommodate the allied health professionals as members of the health team which he/she leads. After all, the doctor essentially created them in the first place when he/she transited from his solo hospital practice (where he rendered all the clinical and ancillary healthcare services to his/her patient) to hospital practice after he developed most of the support services and allied health professions and middle-level health workforce.

What about the incessant strike actions by doctors, which are mostly about allowances and money, how do you explain or relate this with the oath you signed?

The father of modern medicine did state that he made the declarations in good faith with the condition that the society would give him his due and the good things of life. The father of modern medicine never anticipated that a day would come when a physician would be owed salaries or other earned allowances for several months or made to work in despicable and rodent infested work places that constantly distract him/her or be victim of kidnappers. Today, the society and governments at all levels are flouting their own part of the covenant.

Other health professionals rarely go on strike; why is it that they are more committed to health care delivery than doctors who are always seen to be fighting for their pockets?

You must be joking about this. You talk as if you are not in this our country where the other health care workers have made strikes a past time and an instrument of blackmail. I am sure you followed up the last strike action embarked upon by allied health professionals in the month of August. I mean when they metamorphosed into an amalgam of strange bed fellows under JOHESU and other contraptions and embarked on strike action. I am sure you heard that some of them, especially at the Nnamdi Azikiwe Teaching Hospital (NAUTH), Nnewi, switched off power and water supply, as well as life support machines that were supporting patients being treated by doctors in the intensive care unit. Were you happy with these vicious attacks launched on innocent patients? What will you call this kind of method? I expect you as a journalist to hinge your position on facts.

Some people say that most doctors working in government hospitals have their own private clinics, is this ethical?

Let me state here that it is the inalienable fundamental right of any free citizen of Nigeria to utilise his time and space outside official government working hours (8am to 4pm) the way he/she so chooses. I am very conscious of the fact that many public servants on account of years of pauperisation through systematic economic deprivation now have private ventures which they superintend once they close from official government work at 4pm. Now, what we despise and abhor as a body of doctors is the use of government time for private business or practice.

Some people even say that such doctors in government hospitals go on strike to give attention to their own private hospitals? Do you think it’s fair?

If it is true that the sole motive of embarking on strike action is for selfish reasons, that can never be fair. But do you really think that the reason for incurring extra burden of work is for paltry profit? How profitable really do you think medical practice is? I can tell you that private medical practice in Nigeria is generally one of strenuous community service. Cases abound where the medical/dental practitioner treats a patient and also pays the hospital bills of the patient, as most patients who are treated in private hospitals are usually too indigent to pay their bills.

Why do some doctors aid fake drug dealers?

How? I respectfully beg to differ. Doctors are not the professionals involved in drug importation. Pharmacists are the professionals that are usually involved in drug importation. So, you may want to ask pharmacists this question. I am yet to see a medical doctor who wilfully patronises manufacturers or importers of fake drugs. No doctor would want to cause harm to his/her patient no matter how strong the desire for profit could be.

Does the Pharmacists Council of Nigeria inspect pharmacy units of hospitals, including private ones?

The Pharmacists Council of Nigeria (PCN) is only empowered to regulate licensed and registered pharmacists as these are the only group of professionals under their jurisdiction and regulatory ambit. They are not empowered to regulate the practices of medical doctors and dentists or hospitals owned by them.

Doctors seem to be complaining less about their salaries but on relativity, which describes your salary in comparison with those of other health professionals, why are you competing with them?

It is very demeaning for you to say that we are competing with any group. For very obvious reasons, medical doctors are in a distinct class and income group in virtually all countries of the world, including the United States of America and the United Kingdom. It is pertinent to state that there are international best practices guiding the remuneration of professionals and health workers all over the world. On account of the difference in the value and worth of the different categories of health workers, there is a globally acknowledged principle of relativity in the determination of the wages/salaries of health workers with the salary and allowances of medical doctors/dentists distinctly higher than that of allied health professionals or paramedics. It is only in Nigeria that this globally acknowledged practice is not observed. All the efforts of the NMA over the years to ensure institutionalisation of this globally held principle in Nigeria has not yielded much dividends.

 Is it not embarrassing that most doctors prefer to practise abroad?

Who is to blame? Certainly, not doctors. From my earlier analysis, is it really surprising to you that several Nigerian trained medical professionals are practising outside the shores of Nigeria?

In life, man has always adopted self-preservation and survivalist tendencies as the ground norm. The doctor is not an exception. However, what embarrasses us is why people like you journalists are not trying to find out why doctors born, bred and trained in Nigeria are migrating in droves to foreign lands despite the huge burden of disease back home. In those foreign lands, they find job satisfaction, greater reward for work done, greater prospects of actualising their life ambitions; they are not encumbered in the work place by suffocating and very irritating equality beauty contest for position, status and relevance with the doctor. They are protected from kidnappers; the society they serve accords them appropriate recognition and respect which Hippocrates promised his followers. Have you now seen why things are the way they are?

Why do so many doctors engage in carrying out abortion?

I don’t know what you mean by many? I also don’t know where you got your facts from? Is it from your experience or what? What proportion of Nigerian doctors do you consider as many? Abortion is still illegal in Nigeria. I concede that some doctors may be involved in this act of abortion procurement but I must hasten to inform you that some do it as a therapeutic measure to save the life of the pregnant mother. This is allowed. What I think should worry you more is the fact that there are several unscrupulous individuals, both health and non-health professionals who are involved in this illegal practice with the patients who patronise them left to suffer unmitigated disaster and sometimes death.

I encourage members of the public to report such cases and also report themselves that approached the unscrupulous individuals for such illegal abortion services. It takes two to tangle.

These days, there are many cases where patients have been misdiagnosed by Nigerian doctors. For example, former president, Umaru Yar’Adua and late Gani Fawehinmi. Is it that doctors are not well-trained?

Medical diagnosis is a process that is influenced by several factors. There are some occasions where the doctor/clinician has to rely on other support services or technologies, including ultrasound scans, ECG, laboratory test, CT-scan, MRI and x-rays to assist him/her in making a diagnosis. This, the doctor does in about 20% – 30% of the patients that consult him. Unfortunately in our country, the state of our health facilities, particularly the medical laboratories and the individuals who operate these laboratories are unsatisfactory. This is not helped by the unhealthy and unnecessary conflict between the laboratory technologists and the clinical pathologists who are supposed to review the results produced by the laboratory technologists/scientists. This accounts for most cases of mis-diagnosis in Nigeria. Again, most clients expect a one stop miracle each time they visit a doctor. Even in developed countries, it could take certain time consuming processes to finally arrive at a diagnosis. This is the reason why we have such terminologies as preliminary diagnosis, working diagnosis and final diagnosis. Sometimes, the final diagnosis may even be made after autopsy. Yes, this is medicine.

Unfortunately, in Nigeria, doctors are judged unfairly in the court of public opinion aided with the on-going propaganda engineered by certain groups of health workers against the doctor, all in an attempt to pull the doctor down at all cost. I wish to responsibly and respectfully state here that the two distinguished Nigerian leaders you mentioned were not misdiagnosed in Nigeria but the processes at arriving at the proper diagnosis were not exhausted for several reasons.

Another factor worth considering is the evident lack of equipment in our health facilities, particularly at the primary and secondary levels of care, such that the Nigerian doctor doesn’t have most of what he requires to deliver quality services.

Majority of Nigerians believe that doctors are half-baked and killing Nigerians, is it that you doctors should be paid to kill?

It would amount to over flogging the matter to start answering that question. If our doctors are really bad, would you still find people going to hospitals? Go and check the scores of Nigerian doctors who write foreign qualifying exams, then you would be convinced that the Nigerian doctor is a genius. However, one must concede that a lot can still be done to restructure both the undergraduate and post graduate medical training curriculum, fund the medical training institutions in order to attract and retain quality medical trainers and guarantee global best standards.

People say that consultants earn millions of naira for doing nothing.

That is preposterous, scurrilous and sacrilegious. Ordinarily, I would not have bothered to respond to this question because I am quite conscious of the fact that it was the president of the Pharmaceutical Society of Nigeria (PSN), Pharm. Olumide Akintayo, who arrogantly and mischievously told this lie. However, I am compelled to respond because I think he took his obsessive bitterness, hatred and inferiority complex too far, and certainly without the mandate of his members who are traditionally respected allies of doctors. I must say that Pharmacist Olumide Akintayo instantly lost my respect when he arrogantly told this and other blatant lies against the medical profession. We know he has a penchant to blindly deride and oppose the medical profession. I will urge his elders to pull him back from his self-destructive mission. Leaders don’t behave this way.

Fortunately, I was one of the key players that negotiated, on behalf of the NMA, the current Consolidated Medical Salary Structure for medical and dental practitioners in Nigeria (CONMESS) between 2003 and 2009, and I can authoritatively declare to you that there is no hospital consultant in Nigeria that earns that amount of money that he claimed. Not even the highest paid hospital consultant at the terminal of the public service scale takes home anything near that, especially after the heavy tax imposed on him by his/her employers.

I must posit that there is also no truth in his false and incredulous statement that the medical consultant does nothing in the hospital. By that unfortunate statement, he clearly exposed his crass ignorance of the nature, position, role and responsibilities of the medical consultant.  The medical or dental consultant is the seen and unseen guardian angel of the health team. He/she is the hand that directs; the faculty that thinks; the seal that binds the clinical decision making process and implementation of those clinical decisions taken in the hospital.  Surely, the medical consultant is the officer that takes the ultimate clinical decisions on patient care. These are weighty responsibilities which the peddlers of this falsehood have failed to appreciate. I urge them to quickly come to terms with the philosophy behind the position of the medical consultant as the ultimate clinical decision maker as it concerns patient management; and one who takes ultimate responsibility for the actions and inactions of the health team and its members.

I strongly advise the PSN President to stop misleading his members and the general public. He should stop pettifogging over very serious matters of national and international importance.

I urge the PSN President and all those who are ignorant of the role of the Medical Consultant to please study and discover for themselves the practice world over.

Consultants have abandoned their work to resident doctors, who are more or less trainees, is this not very dangerous?

Resident doctors are not medical students. They are not trainee doctors. Rather, they are trainee consultants/specialists. Please, let this sink into the faculties of those who deride house officers and resident doctors in Nigeria. Moreover, they are acting on behalf of their medical consultants who have found them worthy of discharging any responsibility assigned to them. This is the world-wide practice and training requirements for would-be medical consultants.

Nigeria currently has a huge gap in the number of medical consultants available in the country and one sure way for the needed specialists to be produced is this kind of exposure and training. So, there is nothing abnormal about this.

The clamour for the reduction of the period of medical training had recently grown, are you in support of it?

It has been proved that the  Minister of Health, Prof. Onyebuchi Chukwu, to whom this statement was credited, was actually misrepresented in that news report. He was actually condemning the practices by some professional groups who are unscrupulously elongating their years of undergraduate training as a means to equate themselves with the doctors.

We realise the gross deficiency in health manpower needs of the country but reduction of standard in any manner would be inimical to patient care. It would certainly not help to mitigate the challenge of health human resource. As an association, we are convinced the way to go is to expand the available facilities in the existing medical schools with recruitment of the appropriate and adequate number of medical trainers; We also advise that greater efforts should be made to encourage the establishment of medical schools but without compromising standards in any way.

Again, the government and the training institutions should introduce schemes to guarantee the recruitment and retention of quality medical trainers and medical consultants/specialists to deliver the right knowledge and quality training.

Assess the state of Nigeria’s teaching hospitals

Though Nigeria’s teaching hospitals may not be operating at their optimal levels as a result of evident systemic challenges and poor funding, one must appreciate the ingenuity of most of the managers of the teaching hospitals which has ensured their survival unlike the frequent collapse of other government parastatals and private companies, including banks which are managed by supposed business managers and CEOs.

Undoubtedly, the needs and challenges of the teaching hospitals are legion, but the resources to satisfy those needs are getting increasingly tenuous.

Doctors are not allowed to treat gunshot wounds, I don’t know if this has changed. But if it has not, what are you doing to change it?

There is no law banning doctors from treating patients with gunshot wounds. What happened was that the Nigerian Police started insisting that doctors should only treat those who have security clearance and police report. Many innocent doctors who treated gunshot wound patients were frequently harassed and traumatised by the law enforcement agents. Similarly many innocent citizens suffered on account of this and lives were lost.