Has the middle-level anaesthesia manpower training program of the West African College of Surgeons fulfilled its objectives?
An audit of the West African College of Surgeons' middle-level Diploma in Anaesthesia program was carried out to determine the current status of the diplomates. Using the West African College of Surgeons' database, social media and personal communications, the current status of Diploma in Anaesthesia graduates spanning 20 years was determined.
A total of 303 (97%) out of 311 of graduates were traced. Eighty percent were still practising anaesthesia, while 5% were now in other disciplines. Two hundred and four (67.3%) still resided in West Africa (183 in Nigeria, 50 in Ghana, one in Sierra Leone), while 69 (22.7%) were abroad: 35 (11.5%) in the United Kingdom, 21 (6.9%) in the United States of America and four (1.3%) in Canada. More Ghanaian than Nigerian graduates had emigrated (41 vs 14%, respectively). Only 9% of diplomates remained in rural communities (as originally envisaged), while 31% were now consultants (as fellows) and 30% were registrars in fellowship training.
These findings indicate that most diplomates moved on to acquire further qualifications and a significant proportion migrated. The program did not appear to have achieved the objectives of meeting rural middle-level manpower needs in anaesthesia as envisaged. It has, however, boosted the recruitment drive for residency training in anaesthesia. Perhaps a less migrant cadre such as nurses may better serve this function if recruited into a suitably designed training program in countries desiring to use middle-level manpower in anaesthesia.
Key Words: middle-level manpower, postgraduate training in anaesthesia, West African College of Surgeons
About three decades ago, the governments of anglophone (English-speaking) West African countries bemoaned the dearth of trained manpower in most medical and surgical specialties and called for the training of middle-level surgical manpower in sundry fields to staff rural hospitals in the sub-region. In 1990, the West African College of Surgeons (WACS), then under the administration of the now defunct West African Postgraduate Medical College, established three diploma training programs: Diploma in Anaesthesia (DA), Diploma in Ophthalmology and Diploma in Otorhinolaryngology'. These were intended to train post-Bachelor of Medicine/Bachelor of Surgery or equivalent doctors in cognitive skills, each embodied in a 12-18-month curriculum to enable them to manage common minor to intermediate cases in rural hospitals (2). With the collective endorsement of the leadership of the governments of anglophone West Africa, a career path was created for these would-be diplomates and the diplomas were recognised as sub-fellowship diplomas of the WACS and by the national medical councils as additional degrees with some commensurate financial benefits (3).
The DA course has run for 20 years, but since its inception, there had been no comprehensive audit to determine how well the program had fulfilled its mission. There was little, if any, documentation on the fate of its products and this dearth of information had left a void in further planning. Where are the graduates of the DA course today? Are they engaged in rural practice using the DA certificate as envisaged by the planners of this middle-level manpower training? Should the program continue in its present format or should it be modified? These were the questions our study aimed to answer.
MATERIALS AND METHODS
This was a prospective, cross-sectional, questionnaire-based study, approved by the ethics committee of the WACS (March 19, 2012). A list of all candidates who had graduated from the DA program of the WACS from April 1991 to October 2010 was obtained from its database and current or last known addresses (including email addresses) were extracted. In addition, data on each candidate's gender, country of origin, country where training was done and year of graduation were also obtained. All the DA candidates were then cross-referenced with the College's list of past and current residents who trained or were training in anaesthesia, as well as fellows who had completed their residency program in the same faculty. The current status of each DA candidate, their present location and discipline were sought from Facebook[R], known contacts, associates, colleagues and trainers in the Faculty of Anaesthesia at the WACS and their training institutions. Emails were also sent to the candidates through known addresses, requesting an update on these fields. Unsure answers were recorded as missing variables. Informed consent was also obtained from each person contacted, with the assurance that the information obtained would be privileged and confidential (that those followed up could not be identified) and would not be used for any purpose other than this study. The data was analysed using SPSS[R] version 16 software package (SPSS Inc., Chicago IL, USA) for Windows to derive frequencies, mean and standard deviation.
Three hundred and eleven doctors had graduated from the DA program over the 20-year period of the study, giving an average of 15.5 [+ or -] 10 diplomates per year. Complete information about current location and or present status was obtained on 303 (97.4%) candidates who formed the subjects of further analysis in this study. There were 113 (37.3%) females and 190 (62.7%) males, giving a male to female ratio of 2:1. Two hundred and thirteen (70.3%) were Nigerians while 88 (29.1%) were Ghanaians. There was one candidate each (0.3%) from India and Kazakhstan.
Of the 303 for whom information was available, 234 (77.2%) still resided in West Africa at the time of this study. A total of 183 (60.4%) were based in Nigeria, while 50 (16.5%) still lived in Ghana. One candidate was practising elsewhere in West Africa. The remaining 69 (22.8%) had emigrated, with 35 in the United Kingdom, 21 in the United States of America and the others in Canada, Austria, Ireland, South Africa, Saudi Arabia or the West Indies (Table 1).
Thirty-three (15.5%) of 213 Nigerian diplomates had emigrated from West Africa, while 36 (41.0%) of the 88 Ghanaian diplomates had emigrated.
At the time of this study, only 27 (8.9%) of all diplomates were still practising as diplomates. Ninety-five (31.4%) had proceeded to obtain specialist qualifications (fellowship certificates) to become consultants, while another 91 (30%) were registrars training in fellowship programs in West Africa or overseas. The current status of the remaining 90 (29.7%) could not be ascertained.
Records were available on the current disciplines for 258 (85.1%) DA graduates, while this field was missing in the remaining 45 (14.9%). A total of 242 (79.9%) of the DA graduates were still engaged in the practice of anaesthesia, while the remaining 16 (5.3%) had changed to other medical fields: family practice (5), cardiothoracic surgery (2), paediatrics (2), the other seven having pursued other specialties, management or health administration.
The DA program of the WACS has added over 300 middle-level trained anaesthetists to the overstretched anaesthetic manpower base in anglophone West Africa in the past two decades. This is a commendable step in the right direction. However, this study showed an unenthusiastically low rate of applications from candidates in countries most in need of this middle-level manpower cadre. Over ninety-nine percent of all the DA graduates were from Ghana and Nigeria, and only two candidates were from outside the sub-region. No candidates applied from Sierra Leone, Liberia or the Gambia. This possibly arose as a result of the long, devastating wars in Liberia and Sierra Leone, which shut down their medical schools for much of this period. Until 1999, the Gambia had no university and thus, no medical school (4). War-ravaged countries and the Gambia therefore could not produce the medical graduates required for postgraduate training (5).
Our study, however, showed that only 27 (8.9%) of the subjects continued to practise with the DA, while over 90% of them had abandoned the middle-level manpower career line in preference of specialist training in fellowship programs. This was a sad departure from the dreams of the founders of this laudable program. While sixty-nine (22.8%) of all DA graduates had emigrated overseas, over 75% of them stayed back in the sub-region. Soyannwo and Elegbe (6) bemoaned a dearth of anaesthetist trainees in the WACS programs, with less than 2% of all graduates of the College being anaesthetists. Thirty of 56 DA candidates who graduated over a five-year period from the WACS training program were pursuing fellowship programs in other tertiary institutions in that study. In a recent paper, Amponsah (7) reported that most anaesthetics in Ghana are still given by non-physicians, sometimes under the direct supervision of the surgeon, a common pattern in areas of sub-Saharan Africa (8). It is therefore clear from this study that most of the graduates of the DA program had migrated away from the designed career path into residency to become consultants. The study however showed that 79.9% of these DAs remained in anaesthesia.
A number of factors could explain the mass abandonment of the DA project by its graduates. Chief among these is the lure of better pay or conditions and associated added status when obtaining the fellowship to become consultants (7). Civil societies in Africa place great emphasis on diploma certification and mere proficiency is often difficult to reward. When recognised, an uncertified but proficient person is not as mobile in the job market, but tied to limited employment opportunities, while his or her colleagues may move more rapidly up the career ladder and also have a wider job market. In our opinion it would seem as though the career line established in government service for the DA certificate holders was not attractive enough to encourage them to stay. It is hoped this will form the subject of future studies.
The socioeconomic dynamics of West Africa have been unfavourable to the middle class in the past two and a half decades. Countries spared from internecine wars have had to contend with precipitous currency devaluations and, at times, disastrous policy formulation and implementation with inconsistent welfare packages. Basic infrastructure is lacking in large swathes of our sub-region and many villages and rural areas lack the basic amenities such as potable water, electricity and usable roads. It is not surprising to us therefore, that the DA graduates have remained within cities and metropolitan areas.
It is however, heartening to note that quite a number of DA graduates are employed to render services at federal medical centres across Nigeria. These are secondary-tier hospitals built in several less-served areas by the Federal Government of Nigeria to redress the current limitations of state hospitals in the country.
While our findings in this study would suggest that many DA graduates moved into residency training programs, the reality is somewhat different. Many candidates already in the residency program also applied and concurrently trained for the DA examination because the first year syllabus, training institution and trainers are the same for the two programs. Candidates do this not only to acquire additional certification, but more importantly to practise for the Part I examination which comes about six months later. The Faculty of Anaesthesia at the WACS also unwittingly encourages the egress by allowing any DA candidate wanting to make the leap into residency to train only for an extra year for eligibility to take the Part I examination and thus become a senior registrar.
Fresh medical graduates are a highly mobile group, poorly suited for an endpoint career in the DA cadre. Perhaps a more stable group such as nurses would have been better suited for recruitment into an appropriate training program; more so now as a Bachelor of Science is the minimum qualification for nurses. This however, will likely meet with resistance in Nigeria where there still exists a stiff opposition among physician anaesthetists to training nurse anaesthetists. If such a proposal ever eventuates, it could be selectively run for more disadvantaged countries, which specifically request that such training be done for their nurses.
On the whole, the DA program has benefited the West African sub-region by producing a sizeable number of diplomates, who nonetheless have moved to the residency program in anaesthesia. Most of them are still serving in the sub-region.
Poor record-keeping and poor tracking of graduating candidates by the College are major limitations of this study. It is hoped that training institutions will track their graduates and the WACS will devote more manpower and resources to this endeavour to keep abreast with the progress of their output. It would have been desirable to contact each candidate directly, instead of obtaining information about them from second parties and other sources. A modern day database must necessarily update electronic addresses and contact linkages. Also, this study was confined to the graduates of the WACS, while those who obtained the DA from university-based programs were excluded, as we had no ready access to those records.
Although the DA program of the WACS has produced over 300 candidates in the past 20 years, most of the graduates of this program have moved on to train further as residents in anaesthesia specialist training programs, while a few have migrated out of the sub-region. The DA program therefore, in our opinion, did not meet the objectives of its founders. It has, however, boosted the recruitment drive for residency training in anaesthesia. Possibly, a less migrant cadre of medical personnel such as nurses would be better suited for recruitment into a suitably designed program in countries that require and desire middle-level manpower in anaesthesia.
We gratefully acknowledge the invaluable assistance obtained from recent examiners in the Faculty of Anaesthesia. We also thank colleagues, trainers and residents who furnished most of the details used for this study.
CONFLICT OF INTEREST
C. O. Bode is immediate Past Secretary General at the WACS and J. O. Olatosi is the current Assistant Secretary General at the WACS.
(1.) Middle Level Manpower and Examinations. In: Knife in Hand: The history of the West African College of Surgeons (1960-2010). Ajayi OO, Quartey JMK, Adebonojo SA (eds). Ibadam Nigeria: BookBuilders 2010; p. 61-82.
(2.) Curriculum of the West African College of Surgeons. Supplementary Edition. Lagos: Quasoz Venture; 2006.
(3.) The List of Postgraduate Medical And Dental Qualifications Which Are Registrable with The Medical And Dental Council Of Nigeria. From http://mdcnigeria.org/MDCN%20AQ.htm. Accessed December 2012.
(4.) The University of The Gambia. From www.unigambia.gm. Accessed November 2011.
(5.) Bode CO, Nwawolo CC, Giwa-Osagie OE Surgical education at the West African College of Surgeons. World J Surg 2008; 32:2162-2166.
(6.) Soyannwo OA, Elegbe EO. Anaesthetic manpower development in West Africa. Afr J Med Med Sci 1999; 28:163-165.
(7.) Amponsah G. Challenges of anaesthesia in the management of the surgical neonates in Africa. Afr J Paediatr Surg 2010; 7:134-139.
(8.) Kamm G. Towards Tomorrow: The Future of Anaesthesia in Africa. World Anaesthesia 1998; 2:1.
C.O. BODE *, J. OLATOSI ([dagger]), G. AMPOSAH ([double dagger]), I. DESALU ([section])
West African College of Surgeons, Lagos, Nigeria
* MB, ChB, FMCS, FWACS, Professor of Surgery and Consultant Paediatric Surgeon, Department of Surgery, College of Medicine, University of Lagos.
([dagger]) FWACS, MB, BS, Senior Lecturer and Consultant Anaesthetist, Department of Anaesthesia, College of Medicine, University of Lagos, Lagos University Teaching Hospital.
([double dagger]) FWACS, MB, ChB, FRCA, Associate Professor, Consultant Anaesthetist and Head, Department of Anaesthesia and Pain Management, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana.
([section]) FWACS, MB, BS, FMCA, Associate Professor and Consultant Anaesthetist, Department of Anaesthesia, College of Medicine, University of Lagos, Lagos University Teaching Hospital.
Address for correspondence: Professor C. O. Bode, Department of Surgery, College of Medicine University of Lagos, Lagos, Nigeria PMB 12003. Email: firstname.lastname@example.org
Accepted for publication on March 10, 2013.
Table l Present location of DA Diplomates (n = 303) Country DA Diplomates % Nigeria 183 60.4 Ghana 50 16.5 UK 35 11.6 USA 21 6.9 Other 14 4.6 DA = Diploma in Anaesthesia, UK = United Kingdom, USA = United States of America.
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|Title Annotation:||Original Papers|
|Author:||Bode, C.O.; Olatosi, J.; Amposah, G.; Desalu, I.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||May 1, 2013|
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