The Registrar, Medical and Dental Council of Nigeria, Dr Tajudeen Sanusi, tells LARA ADEJORO his thoughts on medical practice in the country, mass emigration by doctors, why he believes doctors should stay back and issues of discipline in the profession
How easy or difficult has your job been as a regulator?
As a regulator, you owe nobody. You owe nobody favours and nobody owes you any favour either. Whatever you need to do must be in the interest of the public. I will not say it is difficult because I have been part of this system for more than 20 years, so I would have known what it takes to be the Registrar of the Medical and Dental Council of Nigeria, as against bringing someone from outside who may not know what to do and be confused about their responsibilities. Even when I am not in the office and people contact me, I know who to push the tasks to and I will get feedback immediately. If you are the lazy type, the job will be difficult but if you are not lazy, it is not difficult. People should know that every day comes with new challenges and you have to brace yourself for it.
In March, during the induction of 477 foreign-trained medical and dental graduates, you cautioned the doctors against relocating abroad to practice, a phenomenon now known as Japa, and you said it does nobody any good. Do you think your charge would deter them from migrating abroad?
It is an individual thing. It is a word of caution to them that at the end of the tunnel, there may be no light. Last year, some people came to ask me what we were doing about the Nigerian doctors being overworked in the United Kingdom. The question is, did we push them there? They went there on their own. For me, you determine what you want in your life. Generally, in this country, many people have this lazy attitude; they want to do so little and reap so much. We all know that members of the public complain that some doctors are not always at their duty posts. You cannot try that abroad. Over there, you clock in and clock out. I know a professor who used to be in the UK; he was living in Southampton and working in Reading as a consultant. He said over there, there was never a time he left his house in Southampton after 5am because he needed to clock in by 7am at Reading. When the man came back, he was working at the Lagos State University Teaching Hospital, Ikeja as the head of his department. He said he discovered that some consultants were not always on seat. Meanwhile, being a consultant gives you more responsibilities and you need to live above board. That is why we keep telling our colleagues that we are the leaders of the team but the leadership must be earned.
So, what do you make of the Japa syndrome?
Most of the people that want to japa are being misinformed. My advice to them is to go there, avail themselves of the opportunity of having postgraduate training, and when they qualify as specialists, they should come back home. There is so much for them to do here in Nigeria. If you examine it, most have been largely trained with taxpayers’ money. How much did they pay in the university? Is it the cost of the syringe they used or the intellectuals you want to talk about? So, you need to give back to the system. That is why the British nationals and the American nationals trained in those countries were trained using public funds and they need to pay back to guarantee continuous training of more doctors. Even at that, they still don’t have enough doctors. A lot of things continue to come up, they talk about task shifting, meaning, let us teach midwives how to do caesarean section because of inadequate manpower. They wanted to use third-world countries as guinea pigs and I said no. Getting doctors from third-world countries is cheap for them, but they invested nothing. The Nigerian government invested in these youths, why are they going when we need them?
What about medical graduates who attended private universities, whose education was not subsidised by the government?
Yes, some of them say they went to private universities and their parents paid, but where did their parents make the money? Is it not in Nigeria? Don’t you think Nigeria deserves to reap from where it has sown? I don’t encourage japa. I had part of my training abroad and I know what is there. That is why it is not fascinating to some of us. Initially, it may look good but in the long run, it is frustrating. Quite a lot of our colleagues who are there cannot boast of most things because all their lives are based on borrowing. For instance, if you live there and you are promoted, you would need to move to another area and you have to take another loan. Then, you sell the house you are staying to add to the money you are borrowing to be able to get another accommodation, and some don’t finish the payment till they die. Japa is an individual thing but we need to caution them that it is not worth it in the long run.
You also mentioned then that some of those who travelled abroad to practice were already regretting their action and that some had come back. Many people have argued that only a few people are complaining because doctors still leave every day and are sharing sweet experiences. How do you respond to that?
We were in the UK last October; I mean with my chairman, Prof Abba Hassan, and the Head of Registration in the council and we met Nigerian doctors. We had a lot of complaints about the General Medical Council, so we met the GMC and someone from there followed us. The doctors complained that they were being discriminated against, but by the time the GMC person started talking, it was the same Nigerian attitude they talked about. And you know they won’t allow their citizens to die through negligence. When we investigate some incidents here, some of the deaths are avoidable and unfortunately, the victims are usually women and children. If mortality and morbidity continue to increase, we are doomed, because women are the ones who procreate.
Do you have an idea of the number of doctors who have returned, maybe in the last one year?
We don’t take note of those, because by the time some of them come back, they are tired of the practice.
Why are they tired of the practice?
When I was in the Lagos office, there were some Obstetricians & Gynaecologists that went to Saudi Arabia and when they came back, they regularised their registration. Some of them confided in me that it wasn’t worth it. The money you think you make there, when they charge you to their tribunal and you are fined, if you don’t have the money to pay, you need to work to pay the money into the system. Things are not as rosy as people portray them and that is why I am afraid for the youths of this country. But then, it is our fault because we are not offering good mentoring. Good mentoring starts from homes, not necessarily from schools. How many of us check on our children in their schools? We owe them that responsibility. Sometimes, pay your children a surprise visit and if you cannot, you can ask a trusted friend to do it when you are not around. Without informing the children, find out from the school authority how they are doing.
The motivation for relocation is largely the search for greener pastures, do you think the doctors are to blame for relocating when their counterparts abroad have a better life?
The doctors do mental arithmetic by saying their colleagues in the UK, for example, earn more, and when you change the money to naira, it is over N2m, but they fail to realise that their colleagues over there spend pounds not naira. The prices of things there are not the same here. As you earn the money, you are also spending it. In London, if your salary is about £3,000, you pay about £1,000 or £1,500 for good accommodation if you are alone. I had part of my training abroad so I know what is happening there. There is no place like home. Initially, it might be rough but when you weather the storm, you will bring something out. It’s most unfortunate that they want things to happen overnight but it cannot happen that way. The universities abroad don’t depend on the appropriation from the government, they depend on research grants. If you work hard as an institution, you will get grants and from there you can pay salaries and get some incentives. That is why you hardly see them in politics.
Health workers have for years narrowed down their concerns to improved welfare, good remuneration and a better working environment. Why has it been difficult for the government to meet this need?
Are doctors the least paid in this country among other workers? In our medical colleges, we have doctors who are lecturers, and because of the pay, the physicians are not encouraged to go to academia; to teach. We encourage universities to pay them approved allowances like call duty but the people who are not physicians will meet the vice-chancellors to say they are doing the same job and the doctors should not get those allowances. But no, they are not doing the same job. When a doctor teaches anatomy, it is different from when a non-doctor handles it. Doctors teach them applied anatomy because by the time they qualify as doctors, they are in charge of people’s lives. So, such doctors who teach are supposed to be paid some allowances, but they are not being paid, that is where we have some of the problems.
Doctors say they are overworked because many doctors are leaving the country, and because of the overwhelming schedule they say they deserve to be well paid. What is your position on this?
There is no doubt about that but there is something we have not come to terms with in this country. Go to South Korea, China and Japan, you will know that work means life. I want you to experiment with something, stay at home for two months and see how your body will be. You should appreciate that nature. I’m not saying our colleagues should be overworked but some of our colleagues are underworked. There is a need for the government to do job redistribution. In the UK, medical students are never trained in one hospital. Like you have the University of Abuja Teaching Hospital in Gwagwalada, they will adopt some district hospitals in Abaji, Kwali, or Wuse because they have their strengths. The consultants will consult there, treat patients there and they carry medical students there for training, rather than putting everything under one umbrella. That is what is causing more problems. You have more patients in those places and they have fewer doctors.
The much-publicised recommendation of the United Nations says one doctor should attend to 600 patients annually, which means Nigeria needs about 356,000 doctors for its 214 million population. But there is a gross shortage. Why has this shortage persisted, despite the number of Nigerians showing interest in studying medicine yearly?
The migration of doctors will worsen the situation. In the last three to five years, we have tried to increase the capacity of our medical schools so that we will discourage Nigerian students from going to substandard schools, especially in Ukraine and China because they teach them nothing there. That is why they cannot even practice there. That is why some of them sit exams six times before they pass. They don’t see patients in medical schools there. If truly you give them good training, why can’t you offer them jobs in your country? They are not registered there, we see all these things but in Nigeria, we have our concept.
One part of medical training that has become a problem is the scarcity of placement for doctors seeking to do their housemanship. What do you think is the permanent solution to that problem?
It will be because there is no proper mapping. There are a lot of doctors there that have had their primaries for years, struggling to go for their residency programme and are unable to get placements and so their primaries expired. That is why we said when you do the mapping for internal medicine for the National Hospital, Abuja, it is supposed to be eight, and the eight is meant to be a maximum of eight years but some of them are spending 10 to 13 years, and you are not exiting them, and people cannot come in. So, people get frustrated and they lose interest. There is no problem that does not have solutions. I have spoken with the Registrar of the National Postgraduate Medical College of Nigeria before, they need more staff. If a particular staff member is in charge of internal medicine, they know the quota for each of the hospitals under that one, by the time somebody is spending more than seven years there, it is flagged. You develop software with which you pay their salaries and by the time somebody is spending seven years, the name drops. Recall that there was a time these younger champs were roaming around hopelessly for three to four years without getting placements until everything was centralised. Do you hear of anybody complaining about placements again? If anybody complains, he will not say it out loud because that person wants fresher posting. There is no problem that does not have solutions.
How many applications from institutions and colleges are before the MDCN for approval as a medical college?
We presently have between 45 to 50 medical colleges. What we do is that when a university gets the approval from the National Universities Commission to run a medical programme – Bachelor of Medicine, Bachelor of Surgery, and Bachelor of Dental Surgery, they come here because the degree is above academic and professional, that is why the NUC handles the academic aspect and we handle the professional aspect because we want to be sure that the people so trained are people in whose hands the public is safe and that is why our accreditation process is so detailed.
There are four stages of accreditation and the first one is called advisory visit. When the NUC has given you the go-ahead, you apply to us and we visit you, we will ask you where the hospital you intend to use to train medical students is. When you tell us, we will go there and if the place is not adequate, we will tell you. If you pass, you employ your lecturers and clinicians. When you employ them, they become honorary consultants to the hospital, providing services and drawing the awareness within the community that there is a specialist programme going on. That will draw patients to that place, not necessarily waiting for when the students move to the clinics, then you start looking for patients, and those clinicians can anchor some topics. A cardiologist can teach cardiovascular physiology, a nephrologist can teach renal physiology, an obstetrician and gynaecologist can teach reproductive physiology, a paediatric surgeon can teach embryology, an orthopaedic surgeon can teach osteology in anatomy, and a chemical pathologist can teach medical biochemistry. They are going to teach them applied medicine so that they start having the feeling from day one that they want to become doctors, rather than being taught abstract things. That is why we say all our teachers in the medical school must be medically qualified. We were supposed to start an advisory visit to the Federal University, Wukari in Taraba State some days ago, but they wrote to us that they were not ready for us. What can you say? Likewise, at the Federal University of Health Sciences, Ila-Orangun, Osun State, we wanted to visit them but they said they were not ready. When we were ready to visit Adeleke University at Ede, they were not ready. We have our cultural problems in this country.
What is the position of the MDCN on the legislative bill before the House of Representatives, which prescribes that doctors trained in Nigeria must work for five years before they travel abroad to practice?
Leave the man (Representative Ganiyu Johnson from Lagos State) that sponsored the bill alone. Are doctors the only people that went to university? Why didn’t you do the same thing for graduates who read English and tell them to work for five years before giving them their certificates? Let us be realistic, you do not need to be discriminatory. I had expected him that before presenting that bill, he should have made some findings because, from our end, we have tackled that issue. For the postgraduate programme, because of the inadequacies of the specialists in other West African states, the West African Postgraduate Medical College started issuing membership while our own NPMCN refused, so it was that membership they were using to flee. So what we did was to downgrade it to category C, and by the time you go there and you request a letter of good standing, we will write them that the certificate is not a specialist certificate, even though you have some advanced training, because the long term implication of that is that in the long run, we will not have trainers again. So, go and complete your programme even if you want to leave, so people are now terminating at that level. That is why I said you should leave the man alone.
In the past, MDCN used to publicise information about doctors who were undergoing disciplinary actions for various forms of misconduct. Could you share with us how many doctors are currently under investigation and how many have been sanctioned so far?
We still do that but I cannot give the exact number now. Before the council wound down late last year, we had over 70 cases waiting for trial and we have about 150 waiting for investigations. Since the awareness is there, people keep reporting doctors, which is okay for the system. Quite a lot of them have been sanctioned. Two years ago, the name of a professor of surgery was removed from the relevant register. That is to tell you that the tribunal is no respecter of any individual, no matter your status in society.
What is the commonest offence such doctors have been most guilty of?
It is negligence; when you are not seeing the patients as the condition warrants. You are on call as a consultant and your Resident Doctor gets across to you and you are nowhere to be found. And you know some of these conditions mean delay can be very dangerous.
In the past 10 to 20 years, how many doctors has Nigeria produced?
Since 1963, we have not produced 110,000 doctors, and out of this figure, some have died, while some have neglected the profession. We are now about 104,000. Medical training is not cheap and that is why some of us believe they should introduce realistic tuition. If they cannot afford it, the government should create a health bank where they can go and take loans so that when they qualify, they will be forced to stay back to pay the money. When you don’t ask some of us that are on the field, you cannot just go there and just start talking. There are levels to the medicine programme and by the time you pass your exams in anatomy, physiology and biochemistry, you do not have holidays again. The only holiday you have is in December and New Year, apart from public holidays. When you go to medical schools during public holidays, you will see medical students in the ward because that is where they acquire the skills. Medical training is not a tea party, but some people often look at us as if we are arrogant. We are not. By the time you come in as a medical student and you are going back, your personality has changed. As a medical student, your social life is little or nothing, and that is why you hardly have time for relationships. When you see those who are married to them, they will tell you the life of doctors is entirely different.
What are the challenges the council faces in fighting quackery?
The tragedy of our law is that we cannot try the quacks. Once we apprehend them, we hand them over to the police. I have always said that I will be one of the last people chasing quacks in this country. What we discover is most of these quacks in their localities are big-time members of the ruling parties. Usually, the Divisional Police Officers in those environments know them, so I have other responsibilities. Chasing quacks is like wasted effort unless the government decides to amend our law and give us the power to try them. Lagos State has done well and they are still trying but I can tell you I was part of it. I worked with the former Commissioner of Health in Lagos State, Dr Jide Idris, and the efforts were on record. When he was the Permanent Secretary when this thing started, I was invited and I was asked what could be done to curb quackery. I advised that he worked with his counterpart in the Ministry of Justice and let them make a draft for the bylaw to be passed by the state House of Assembly, in addition to creating a mobile court so that any quack caught within 24 to 48 hours is sentenced. He listened and implemented it. Afterwards, quacks were picked up and sentenced to 24 months to 34 months’ imprisonment, in addition to the confiscation of what is met on their premises. Then, they started moving to other states and I alerted Ogun State to it then, given its proximity to Lagos State, but they did nothing. When the thing became a problem, they started working but it was too late. There is a place called Yakoyo at Ojodu, one part is Ogun State and another part is Lagos State. The quacks moved from Lagos State to Ogun State, and one of the tragedies of our law is that you cannot cross boundaries. That is why I said when you are looking for solutions to some problems, the people on the field will give you solutions.
