Why The Ambulance Driver wants (Should) to be called "Doctor" in Nigeria

For a longtime now I have come across so many articles and reports in the national dailies and in online social media on the rife in the health sector which centers mainly on the row between doctors and non-doctors working in the healthcare system. Most of these reports and articles, mostly lopsided, have one common denominator, presenting the Doctor as an enemy of the people and the manner of their submissions is such as to draw undue sympathy from the unsuspecting public. But for the neutral members of the society who have had cause to have sufficient contact with the hospital environment, I’m not talking of some quasi journalists, they need not be told, if there are, who the 

Angels and Demons are.
This article is not aimed at indicting or exonerating any of the two
combatant parties as both have had a fair share of the blame, and honestly, the deplorable state of our healthcare system is not as a result of the performance of the health workers, but it is a component of an overall failed system called Nigeria which the current government is still trying to salvage amongst other difficult challenges. Considering the lines along which the divide has been made, I shall delve into an inquest of some of the key issues at stake, mostly those that affect the general public, and this I will do by placing the Nigerian Doctor on one side to be reviewed alongside a few of the numerous “health professionals” working in the healthcare system with due consideration to the most important person in the system, the Patient. I shall concentrate mostly on the tertiary healthcare institutions where the bulk of the rivalry is most felt.

The Patient and the Hospital:

Let us begin from the beginning. A healthy person falls sick and needs to regain his health and function properly. He says to himself, “I don’t feel well enough, I need to see a Doctor. May be I should go to the hospital tomorrow”. He sets out of his house with this principal aim. On getting to the hospital, he first gets to the reception, obtains a card at the Out Patient Department and then proceeds to see a Doctor (usually a Medical Officer) who attends to him and treats him. However,if his condition is one that necessitates a Specialists attention, he is then Referred to another Doctor, the Specialist (Consultant) for further treatment. On getting to the point of referral, the Record staffs assist him in opening a folder containing case notes, and in the process of this, a Doctor (Consultant) is assigned to him. The entire processes of obtaining a card and folder have no direct effect on the patient’s condition but helps ensure proper documentation and recording within the hospital. He is then directed to the designated Specialist or Consultant Clinic where he is received by a Nurse who does further documentation and records his vital signs which may or may not be repeated by the Doctor. Then the patient enters the clinic to see the Doctor, his primary aim for coming to the hospital ab initio.

The Patient, the Doctor and Other Health Workers:

The Doctor begins by taking a complete history of the patient which includes his current complaints, previous health challenges, living condition, social habits, family history, drug history, financial capacity, religious and cultural beliefs, and then proceeds to do a complete physical examination of his entire body system, at the end of which the Doctor would have verified the patients complaints and identify any other problems unknown to the patient, before arriving at a Provisional Diagnosis. He then counsels the patient, draws up a treatment plan, which is to be strictly adhered to provided the patient is within the hospital environment, and automatically takes full responsibility for any problems encountered along the line. He finally schedules him for a follow-up visit to ascertain his response to treatment. This process of history taking creates a personal relationship between the Patient and the Doctor and this is where the confidence of a patient on the Healthcare system of a Nation is built; the Doctor-Patient Relationship.

The treatment plan of the Patient, drawn by the Doctor, may or may not include; the investigations (or tests) both laboratory or radiological to be carried out, the drugs to be dispensed and the appropriate prescription, the additional care to be rendered outside the basic nursing care and the treatment orders to be followed, some of which he does himself (or via his subordinate Doctors) and others by the Nurses. There is no stereotyped outline of what must be done for every patient; investigations to be carried out, treatment to be administered or drugs to be prescribed lies solely at the discretion of the Patient and his Doctor.

Apart from the Nurses, all other “Health Professionals” come into patient care when the Doctor’s plan involves them. Clearly, a patient has no business with the Radiographer if the Doctor’s plan does not involve radiography, neither does he have any business with the Pharmacist if the patient does not require any drugs, of course, not every patients require drugs. Therefore, it is safe to assert that if Patient Care is the sole interest of everybody in the Health sector, then the Doctor takes the Central stage in this service to Patients and must carry the Nurses along at every point in time, and together they look out for any other “Health Professional” that should be roped into patient care. Why then should the Doctor take the Central stage? Very simple. He has been trained thoroughly to do so. Invariably, the Doctor is naturally the undisputed leader of the Health team and only two classes of people can challenge this standing; the criminal minded ones pursing their selfish interests and the dim-wits incapable of any logical reasoning.

On the Headship of the Hospital:

Over time, the functional head of the tertiary hospital setting has been the office of the Chief Medical Director, CMD, and part of the Act establishing the hospitals specified that this position be held by a Medical Doctor. However, there has recently been a loud cry from other “Health Professionals” under the auspices of the Joint Health Workers Union (JOHESU) for the chance to also partake in the “enjoyment” of this office, as if to say it is a political office, a “National Cake” which should be shared equally to everyone in the scene, whereas, it is the most sensitive of all positions in the hospital setting, one with huge implications on the health of patients. The Medical Doctors on the other hand, insist that the office of the Chief Medical Director and the headship in general, of the Hospitals is their exclusive reserve.

How true is this claim by the Doctors? Again, it is very simple. Healthcare is all about patient care, and in rendering care to the patient who is the main focus of everyone, the Doctor is the arrow head. He brings together the activities of all in the health care delivery system to bear fruit in the health of the patient. He has a broad-based and yet in-depth medical knowledge that enables him to function as a leader in patient management and take responsibility for the outcome. It is then indeed a funny ideology to expect the Doctor to maintain leadership of Patient Management and then cede the leadership of the Hospital Management to a Non-Doctor. Right thinking people would agree that whoever takes the blame should take the lead.

Leadership is about responsibility, and Doctors embrace such responsibility mainly as it involves lives which they have sworn an oath to protect.

Furthermore, JOHESU, a body comprising of other “health professionals”, support staffs and in fact all in the Hospital setting except Doctors, claim to be equal and allied to Medicine. But my question is, how is the clerical staff allied to Medicine? How can a support staff head the core members of the organization? Also, why should a “profession” that is “allied” to Medicine surmount Medicine?

Can a Non-Lawyer become the Attorney General of the Federation? Why isn’t the office of the Vice-Chancellor made open to every staff in the University system since ASUU and NASUU both consist of “professionals”? How would ceding hospital leadership to JOHESU improve the health indices of our country? These are people that do not deal directly with patients, people that do not really understand the agony of patients which Doctors do. The saddest part is the extent they can go to press home their irrational demands. We have a documented occurrence of how they turned off power supply to the Intensive Care Unit during a JOHESU orchestrated strike action in a southeastern Teaching Hospital leading to death of patients on life support. This was an attempt to frustrate the Doctors’ effort to keep hospital services running while they were “striking”. How can people who have displayed this level of irresponsibility be allowed to head the Health sector? Again, God forbid!

It is a common saying that Doctors are “proud”, and I insist, they have very just reasons to be, and when it comes to arrogance, the patients can tell who amongst Doctors and Nurses are more approachable. Doctors are a selected class of elites and comprise the best brains of the society. Yes, the entry requirements into the profession and the medical training ensure that only the bests emerge as Doctors. As such, the government has to understand that any arrangement that sees a Non-Doctor in a sensitive position to head Doctors in any Health related issue would be met with fierce resistance and the never ending tussle it will ensue will have detrimental effects on our nation’s healthcare delivery. In the interest of peace and decorum, the Federal Government have to dig in and ensure that the status quo is been maintained. The ear that will hear needs not be the size of a raffia palm.

On conferment of Consultancy on other “Health Professionals”:

A Consultant (Medical) is the title for a senior hospital-based physician or surgeon who has completed all of his/her specialist (Residency) training and has been placed on the specialist register (Fellow) in their chosen specialty. This level of Doctor joins the Civil service as a Consultant and automatically leads a team of Doctors comprising Residents, Medical Officers and House Officers who train under him.
Currently, there has been an outcry by JOHESU to also be awarded Honorary Consultancy based on the fact that Doctors are been appointed as Consultants, why not they too. The concession of the government to this particular demand has led to the entire hospital going berserk in some centers. This was done against the warning of the Nigerian Medical Association that the introduction of such “alien” practices would be detrimental to the lives of patients and the results are showing.

At the Nnamdi Azikiwe University Teaching Hospitals, it is been said that a “Consultant Pharmacist” invaded the wards with his team, cancelling patients prescriptions and also demanded that a Consultant Cardiologist remove a key drug in an inpatient prescription, on grounds that the drug has some known adverse effects. Another report have it that in Abuja University Teaching Hospital, the Ante-Natal Clinic was invaded by Nurses who decided to consult patients and make prescriptions, of which the Doctors left the clinic and the Patients were confused. Patients who sought to see their Doctors were told that there was a “Consultant Nurse” who does whatever a Consultant does. Also, in University College Hospital, Ibadan, stories had it that a Consultant Plastic Surgeon was barred from reviewing the surgical wound he created post-operatively because a “Consultant Nurse” had reviewed the wound earlier and was satisfied with her findings.

Let us address one of these occurrences. It is grave ignorance for a Pharmacist to tamper with a drug prescription simply because he has looked through his drug formulary and have identified a known adverse effect of the drug when he/she has no knowledge of the processes involved in the making of diagnosis and prescriptions. Patient management is highly individualized. To make a prescription, the Doctors put many things into consideration viz; patient’s history and examination, financial cost of the drug, benefits against the risk of using the drug, other drugs to be administered etc. Sometimes the side effect of a drug is the desired effect needed in one patient but would remain a serious adverse effect in another patient. But no, the Pharmacist didn’t think in that line before cancelling prescriptions. I am not saying every doctor’s prescription is infallible. No. But if a pharmacist wishes to express concern over a patient’s prescription, he should discuss with the Doctor to sort out their concerns.
This whole consultancy for non-doctors arose as a result of their quest to have better remuneration. I am not opposed to better remuneration for other health workers, but looking for cheap means to it at the expense of the lives of patients is grossly unacceptable. Why would you want to be a Specialist (Consultant) when you have no specialty, or you have a specialty in an area whose service is not needed?

Even if a non-doctor must be a consultant that does not automatically make him/her a Doctor. We all know how to become a Doctor and age is no barrier.
If non-doctors must immutably be made consultants, their duties and jurisdictions must be clearly spelt out and understood by all involved. A Consultant Nurse should be confined to Nursing Practice and she will be expected to enhance it, not to invade Medical Practice. She must ensure that the management plan of a Doctor is properly carried out, even if he is a House Officer. Unfortunately, the idea of non-doctor consultant emanates from the desire of these other “health Professionals” for position and better pay than the desire to meet any specific needs. For instance, a ward Nurse that does her duties properly becomes a Consultant, what extra services and improvement does that bring to nursing care? The fact that there exist non-doctor consultants in a few foreign countries does not explain why the government should channel huge sums of money into the payment of honorarium to consultants that add nothing to the existing system but chaos.

The NMA have identified these unhealthy health policies and should do all it can to prevent it from killing Nigerians.

On relativity of Wages:

Another very important object of discord is the demand by JOHESU for a unified salary scheme for everyone in the health sector and that will see a close approximation of the eventual earnings of all in the sector. What else can be sillier? Need I remind us that in every organization there is usually an established strata.

Even in heaven, there are Angels and Arch angels, and the angels are content with their positions and would not want to usurp the duties of the Arch angels either. People cannot obtain different qualifications, different expertise, subserve different needs and end up earning similar pay. No. That cannot happen. Why would a non-specialist insist on being paid specialists allowance? Why would a Non-doctor terrorize the government because he wants to be paid like Doctors? Where in the world is that obtainable? Relativity is sacrosanct and must be reflected both on the basic salaries and all allowances.
Granted. Doctors are few. Very very few. The World Health Organisiation recommends that a Doctor should consult not more than seven patients in a clinic session and should pay maximum attention to their needs, but our environment see us in a situation where a Doctor consults over 40 patients in one clinic session, yet, he is underpaid compared to his colleagues even in nearby Ghana. There are less than 30,000 Doctors currently practicing in Nigeria subserving over 170 million Nigerians, and there is a dire need for more, but that will not push the Medical schools to take in everybody and churn out unqualified people as Doctors, neither will the Nigerian Doctor allow a Non-Doctor to tamper with the lives of patients.

Doctors swore an oath to preserve lives and the NMA must see to it that the lives of Nigerians are safeguarded. If the Hippocratic Oath is to be taken serious, then the NMA must win this battle.

More often than not, we are clear on the knowledge that it is injustice to treat equal people unequally, but it fails to come to our minds that, it is graver injustice to treat unequal people equally. This is not pride, it is a statement of fact.

Doctors and Non-doctors in the Health sector are not equal and they cannot be treated as equal. There is a reason why some students work harder than others to become Doctors. Some sat for JAMB several times to achieve that, although many fail to do so and even some do fail out of medical school and end up as “other Health Professionals”. To eventually anticipate to be rewarded equally with those who triumphed where you failed is simply madness. The government must see to it that relativity is maintained. For if a Nurse or Pharmacist consults patient, not regarding quality of the consult, earns equally with a Doctor and even get a chance to head the Doctor, why then would one need to work harder to become a Doctor when he can easily become a Pharmacist? Tampering with relativity is a conscious attempt at breeding mediocrity, again at the expense of lives. If the Nurses and Pharmacists accept to be paid equally with the Lab “Scientist” and Janitors, it’s their own cup of tea, but paying Doctors and Non-doctors equally? God forbid!

On the Physiotherapists’ demand to make first contact with Patients:

According to Prof. K. E. Obidike, there are three reasons why patients go to see Doctors.

Firstly, is to ascertain the causes of their complaints and resolve them.
Secondly, is to identify any other health problems unknown to the patient, and again, resolve them timely,
And finally, to have a baseline documentation of the patient as a reference for subsequent health issues.

The second reason especially, answers the question as to why a Physiotherapist cannot make first contact with patients. Medicine is holistic, and the initial assessment of a patient takes the entire body system into account not just the presenting complaints. Therefore, Physiotherapists should remain Physiotherapists and should come into action when consulted. Simple.

On adoption of Foreign Healthcare Structure:

The fundamental idea behind the establishment of Tertiary Healthcare centers (Teaching Hospitals) in Nigeria was primarily for training of Medical Practitioners, Research, and provision of specialized healthcare at very affordable rate. It is not a business venture, and if this aims and objectives are to be met, then the hospital must be made to operate under the very Act that established it. Comparing our Healthcare practices with that of foreign nations without a review of the aim and objectives viz-a-viz that of our country is practically insane. Granted, a few hospitals in Canada are headed by Non-Doctors, and there are few Non-Doctor Consultants with well-defined jurisdictions in a few foreign countries, but that does not in any way directly improve their health indices. After all, high quality health care is still not affordable for a large proportion of Americans despite their very potent health insurance system.

Our very first interest should be to assist the government, which some members of the health sector have chosen to distract, to ensure there is affordable healthcare services to all its citizenry, seek ways of improving the training of the medical personnel and carry out Research programs that will elevate the quality of healthcare delivery in our own nation. Yes. We can go abroad and observe what obtains from there, but instead of disrupting order in the already existing system, by trying to blindly implement it over here, we can see how best to fit a few of them into our system and get the best out of it. The Government should concentrate on policies that will better the lives of the larger population of Nigerians, not those that pacify some disgruntled group of individuals fighting for position and their own other personal interests.

There are many other issues that do not only need Government attention, but also its speedy response.

Some of these areas include:

The appointment of Directors in the hospitals which distorts the chain of command in the hospitals, induces anarchy and expose patients to conflicting treatment and management directives;
The passage of the National Health Bill, and extension of Universal Health Coverage to cover 100% Nigerians and not 30% as currently prescribed by the National Health Insurance Scheme;
The appointment of the office of the Surgeon General of the Federation alongside many other pressing needs.
These are health issues of paramount importance and the Government cannot afford to be lackadaisical about them. No. Not this time.

My Recommendations:

First of all, JOHESU is an amorphous body comprising of different entities with varying agitations, concerns, qualifications, expertise, and eligibility status and should not be confronted in that front by the government. Our government has to recognize the various constituents independently and verify their individual complaints as some parts of it have no moral standee to withdraw its services because of the unmet demands of another.
For instance, The Medical and Health Workers Union (MHWU) comprising of Clerks, Messengers, Record Officers, Admin staffs, Janitors, Engineers, Security etc., an association of different people with absolutely no training in any Health related courses should not dare to aspire for headship positions in the hospital let alone been prevented from doing so. We do not have to give reasons why they should not.
Therefore, the five different associations and unions under JOHESU should be made to make their specific submissions independent of one another for clarity.

Secondly, the Nigerian Labour Congress and Trade Union Congress should look beyond Unionism and focus on the ultimate goal of everybody in the health sector which is adequate Health care for the Nation. They should relinquish their parochial stand in the dispute between JOHESU and NMA, and as well desist from all forms of hooliganism and attempt to bully the Government and NMA on this matter.

Finally, the Government should resist all attempts to coerce it into yielding to the demands of one party in the dispute when the matter is still in court. There should be absolute regard for the Rule of Law. And all previous “concessions” should be stalled, and pending till a decisive ruling by the court.

We can go on and on to address so many other issues in the health sector that require attention but I have decided to throw light at just some parts of it before the Doctors under the auspices of the Nigerian Medical Association, an association of all certified Medical Doctors practicing in Nigeria down their tools as proposed come July 1st, 2014. Before the health of the nation would be thrown into the hands of Non-Doctors in the Health sector that usually prefer the exclusive services of Doctors when they and their loved ones take ill. Before the general public begin to lash out on Doctors and blame them for lives lost as a result of the forthcoming massive industrial action. The onus lie on the general public to call out on the Government to resolve these life threatening issues before the Doctors take to this hurtful last resort of theirs.

God bless Nigeria.

By,
Basil, C. B. – M.B.B.S (Nigeria),
Department of Clinical Chemistry and Metabolic Medicine,
Benue State University Teaching Hospital