By M.H. Idriss, M.D.
On a bright monday morning, I was breezing through my routine lecture for a group of medical students spending a few weeks of clinical training in the hospital I work at. As I began the last part of my lecture detailing the treatment of a common disease, I popped a question asking how many of the students had observed or perhaps done a very common procedure commonly used to treat the disease. I scanned through the group looking for an answer but to my surprise, not a single student among the 40 (about one eighth of the typical total medical school class size) or so students had ever done or seen the medical procedure being performed. The students were on their last week of training in my department so decided to demonstrate the procedure. Because of the sheer number of students and small size of the procedure room, I divvied up the students in to four groups. The procedure room was jam packed with virtually no room to move but somehow I managed to demonstrate the procedure to the first three groups. I could not do so for the fourth group as there were no patient scheduled for the procedure to teach on. I could only demonstrate the instruments used and verbally describe what is usually done. At that moment, I briefly had flashback of my days as a medical student where I and my fellow students had ample chance to observe the procedure many times and even the opportunity to actually do it once or twice under the watchful eyes and mentorship of our instructors. The stark contrast was just mind boggling. Unfortunately, such incidents of a gross mismatch between available facilities, patients or instructors and the number of medical students is seriously hampering the learning process. It is infact a grim daily reality for the thousands of doctors-in-training and their instructors across Ethiopian medical schools. Perhaps more so in the 13 new medical schools that have mushroomed in the last decade.
The training of a physician is a completely different in contrast to any other college level discipline like engineering or natural science. Medicine is an interesting combination of both science and art. It is the right mix between classroom, laboratory and apprentice training that would mould the competent future doctor. The student doctor goes through years of intensive training first in the basic medical sciences mostly thought in the classroom and laboratory followed by instruction in clinical sciences where the student is taught with real patients. This clinical (patient oriented) training introduces the future doctor with the diferent disciplines of medicine by rotating through the different parts of the teaching hospital including outpatients, inpatients and operating theaters. The students work closely with senior physicians in clinics practically learning the nature of numerous diseases affecting the human body, how to identify/diagnose between different diseases and how to treat or prevent them. The students also learns how to effectively communicate with patients and other team members. With out adequate patient exposure and training, the future doctor will be severely handicapped to practice medicine. Finally, the doctor-in-training is made to work under close supervision by senior physicians usually for one year to make sure that he/she can apply the scientific knowledge and skills acquired from previous years of training to safely and effectively practice medicine (called the intern year or internship). Graduating after successfully completing internship (in Ethiopia graduation comes after completing internship which is different in other countries), the graduate doctor is entitled to practice medicine independently. Depending on the inclination of the graduate doctor and depending upon government regulation, he/she might pursue further postgraduate training in a chosen field like Surgery, Internal medicine, Pediatrics etc to become a specialist.
Specialists might further their medical expertise by pursuing a fellowship/subspecialty training.
Rigorous training and assessment at each step in the course of medical education is the bare minimum to ensure the quality of graduates who would be entrusted in making life and death decisions are well versed in the art and science of medicine. An acceptable level of quality would need adequate facilities in terms of lecture rooms, laboratories, books and medical journals, simulation/demonstration rooms, dormitories and fully equipped teaching hospitals consonant with the number of students enrolled. In addition, a fair number of well qualified instructors to achieve an acceptable minimum student to instructor ratio is critical. During training students are continually assessed by their instructors and corrective measures are taken. Each phase of training culminates with a standardized examination including practical testing (usually on live patients) where the students should demonstrate a minimum level of competence to progress to the next level.
Ethiopia has one of the lowest number of physicians per unit of population in the world. By the year 2010 there was only 1 doctor per 25,000 population, a figure far below the African average of 1 doctor per 5000. According to a study, in the 20 year period between 1987-2006 G.C. a staggering 73.2% of Ethiopian medical doctors had left the public sector mainly due to attractive remuneration in overseas countries, local non-governmental organizations or the private sector. The aggregate number of physicians who graduated from the three main medical schools in the country right from their foundation years till 2006 totaled 3728. At the same time the enrollment capacity of all the medical schools in the year 2006 was less than 350 students per year.
A quick analysis of the figures above root the problem of physician shortage at two main causes: attrition and a low number of trainees. It is absolutely empirical that the number of physicians be increased for any tangable improvement to be made in public healthcare. To achieve a realistic and long lasting solution to the problem, a wise combination of policy instruments to stem the root causes; attrition with innovative strategies, coupled with a carefully planned scaling up of training quality doctors needs to be implemented. The government reasons that the problem at hand is a mere imbalance in the market dynamics of supply and demand of doctors with out due consideration of other factors at play. This misperception has led to the ill fated solution to train a large number of doctors with in a short period of time as the major policy approach to the problem. As a result, the annual enrollment of medical schools in Ethiopia has been ramped up nearly 10 times from the low 336 per year in 2005 to around 3100 per year by the end of 2012 with in a short span of 6 years. The trend is reported to continue with the number projected to reach 8000 by the year 2015. Sadly, the sharp increase in the number of trainees has not been supported with a concomitant upgrading or increase in the capacity of teaching facilities and in the number and balanced composition of qualified instructors.
A few years down the line after the implementation of the “ramp up” policy, alarming stories of badly deteriorating quality of medical education are surfacing everywhere because many medical schools are handling six to seven times the number of trainees they are built to accomodate. In a recent news piece by the world.org website, a medical student from St. paul’s millennium medical schools (one of the new medical schools) reports that “there are just not enough patients, books and computers to aid our learning” The student also reports “every time there is an increase in students the problem is further aggravated”. I can corroborate the report as it my personal experience as well as that of my colleagues. For instance it is common for patients admitted to teaching hospital wards to be interviewed and examined on average between 12-15 times by different students (it is absolutely empirical that medical students interact, examine and learn from patients as much as possible acquiring the essential skills of history taking and physical examination). The patients after a few encounters with the students are fed up that they would not like to see another student. Consequently, the students do not learn much from admitted patients. In some of the medical school teaching hospitals, the shortage of patients in relation to the sheer number of patients is so severe that many of my colleagues are hard pressed to even find patients to exam students on. They are forced to find less desirable but alternative ways. Further aggravating the problem of learning is the short supply of medical textbook and facilities like laboratories in relation to the number of students.
One of the more concerning problems besides the facilities and available patients is the shortage of well qualified senior physician with postgraduate qualification (specialist doctors). The deteriorating work conditions, lack of incentive and meagre pay is continually driving a large number of specialist physicians leaving the public sector for greener pastures elsewhere eventually draining the medical schools. The practical training of medical students is heavily dependent on the instruction, guidance and mentorship by senior physicians. Medical students cannot simply learn from attending lectures, reading books or doing laboratory experiments. They have to closely work with and learn from senior physicians in small groups where they will get a chance to correctly examine patients, perform operations or interact with patients. A surgeon colleague of mine was telling me how between his busy operating and patient clinic schedules, he had been overwhelmed by the sheer number of interns (doctors-in-training who have completed the prescribed training in medical school but have to work one year under the supervision before graduating) that he is finding difficult even to remember their names let alone carefully assess each intern’s performance to make sure they can practice medicine independently. Even with the limited the number of instructors, the daily routine of caring for so many patients trying to live up to the ever increasing demand by hospital management to see more patients (another push by the government to improve healthcare by increasing the number of patients served by a health facility) in addition to administrative tasks of supervising the paramedical staff, the teaching of medical students frequently takes the back seat. The meagre income from medical schools is driving many experienced and highly qualified physicians to work in the private settings to supplement their income which further encroaches upon their academic responsibilities. The medical schools are trying to overcome this serious problem by recruiting recent graduates to be instructors, a futile exercise where the new graduates have little or no experience and offer the medical students little in terms of practical guidance and mentorship.
The end result is nothing short of shocking. These days it is not uncommon to find medical graduates who have never inserted a urinary catheter in a patient, done venipuncture, seen the blood specimen of a patient under the microscope or delivered a baby by instruments; all essential skills for a physician practicing general medicine in Ethiopia specially in a rural setting. What is worrying even more is the awareness of the quality problems by the top brass of the government but the conviction to continue increasing the number of students enrolled year after year and seconding the quality issues to be solved in due time.
The deliberate government strategy might be deemed by some pundits to be successful in increasing the number of doctors working in the public sector but the actual effectiveness of the measure in producing physicians who are are not only well qualified but also have the passion and morale to practice medicine is seriously questionable. It used to be that medicine attracted some of the academically outstanding high school graduates. The social prestige, financial reward, academic achievement and professional gratification in helping fellow human beings that comes with being a doctor lured the brightest and best the country has to offer. But the perception of the majority students in their future career as a doctor in Ethiopia once they join medical school seems to be disillusioned. In a recent study conducted to assess the attitude of medical students at Addis Ababa University School of Medicine towards medical practice and migration has yielded some “interesting” results. Of the 632 medical students interviewed, only 20% deemed their current feeling about studying medicine as excellent while 33% felt fair or bad. 35% of the students felt that the standard or quality of medical eduction was below their expectation. Only 30 % of the students want to practice medicine in a rural setting and 21% of students wanted to immediately leave the country right after graduation while 52% wanted to migrate outside Ethiopia at some point to practice medicine. The desire to migrate was interestingly highest (79% of respondents) amongst students in their final year of training who tend to be the most experienced among the medical trainees. It is worthy to mention that Addis Ababa University School of Medicine is the oldest, largest and by far one of the better equipped and staffed medical schools. I would leave to the judgement of the reader what the possible attitude and perception of medical students in the newer medical schools might be which fare far worse than Addis Ababa University in every respect.
One would ask the primary reason behind such a quick fix approach which is bound to have negative long lasting effects in the delivery of quality health care and possibly a ripple effect on the entire health of the population. After the countless hours of munching over the subject the only answer I could logically think of lies in the unquenchable desire of the Ethiopian government for a false perception of improving health care by reaching certain “magical” numbers. These numbers are put as yardsticks of achievement by referees of the third world, the UN organizations. For instance, the World Health Organization (WHO) recommends the minimum ratio of 2.3 doctors per 1000 population to achieve the minimum levels of key health interventions. According to higher officials of the ministry of health, Ethiopia is slated to inch towards its “magical” milestone by 2020. On the domestic front, the increasing statistics is a centerpiece of the state propaganda machinery that Ethiopia is rising, glorifying the achievements of the incumbent and its policies. But behind the facade, the reality is a 180 degrees opposite.
We are seeing the early cracks of the “flooding” policy. The damage has already been done to hundreds of recent medical graduates. It is high time that the top brass with in the government realize the problem, go back to the drawing board and think hard for a logical and viable solution. Traditional wisdom teaches that if one has a limited resource at hand, one should first try to minimize waste and maximize efficiency before trying to increase the supply of that specific resource. The very first step should be minimizing attrition in every way possible way. The country cannot keep on losing its precious physicians. The government should reserve no effort in improving the working condition and remuneration to make working and teaching in public hospitals more attractive to physicians.
The second measure should be the revision of the current policy with a sound and well thought out plan to scale up the number of trainee doctors in a graded manner keeping abreast with the expanding facilities and number of qualified instructors. A core component of the plan would be the establishment of an independent accreditation council fashioned similar to the North American Liaison Committee on Medical Education. The council led by prominent physicians but having members from the government and medical schools and preferably under the auspices of the Ethiopian Medical Association would have the sole authority to assess and accredit medial schools. The facilities and available human resource would be evaluated periodically by the council which would ultimately accredit the medical school for the maximum number of medical students it could train. Any medical school increasing enrollment capacity should seek the approval of the council. The council would also establish core competencies of graduates across the board and institute a board exam to assess the readiness of graduating candidates for independent practice. The current Higher Education Review and Quality Assurance Agency (HERQA) under the federal ministry of education is responsible for quality in higher education. It seems HERQA has too much on its plate dealing with all forms and shapes of higher education and expecting a single organization to handle the colossal task of ensuring quality in higher education is virtually impossible. In the Ethiopian setting, it would be unthinkable for HERQA to fairly judge quality or perhaps forward some constructive criticisms in medical education because it is part and parcel of the ministry that is spearheading the ramp up policy.To maintain impartiality, the new council shall replace HERQA for all matters related to medical education. Most importantly the council should be free of any government or political interference.
I would finally like to quote the farsighted comments of an expatriate doctor who had worked in Ethiopia for more than two decades and featured in a news flash on the current state of affairs saying “the new (medical) schools are producing a generation of doctors who don’t know what they’re doing, and the new generation of doctors could do more harm than good”. On the contrary, I am hopeful that the new generation of doctors would somehow maintain the major dictum of the Hippocrates oath: “first do no harm” to the patient.
The author is a consultant specialist physician who trained in Ethiopia and the US currently working in Ethiopia.
By M.H. Idriss, M.D.