I feel compelled to write on this subject because of its seriousness and the dearth of objective analyses on our social media. It is an emotive subject for both NMA and JOHESU members, and I can understand why punches fly around, but both parties must rise above petty and emotional considerations if we are to find a way forward. For clarification purposes, the NMA represents medical doctors whilst JOHESU is a union of all health workers who are not doctors.
WHO SHOULD HEAD THE HOSPITAL
There is no contention – the medical doctor is the head of the clinical team. He/she leads the ward rounds, clinics, surgical operations, multidisciplinary meetings and so on because the ultimate and final responsibility for patient care rests in his/her hands.
The headship of the hospital is a different matter. This is an administrative office, which needs not be occupied by a medical doctor. This job is better in the hands of people who have administrative or business management skills. This is the case in countries like the UK, Canada and the US, which heavily influence our health system. Therefore, it is difficult to reason with the NMA why this job should be the exclusive right of medical doctors.
The doctor-patient ratio in Nigeria is dangerously low. In my view, the roles of non-medical professionals such as nurses, physiotherapists, pharmacists etc need to expand to cope with the demands on doctors. It is important that this is done in a safe way by providing the appropriate level of training for these individuals. This is the case in countries such as the UK, Canada and the US where consultant nurses, pharmacists etc have existed for a few decades now. I do not see any problem with non-medical consultants as long as these individuals are appropriately trained and can practise both competently and safely within an agreed framework. These professionals have separate (but complimentary) job descriptions and their roles are not designed to replace or dispense with the services of the doctor. If this arrangement enhances patient care, then where is the problem with it? The NMA needs to demonstrate to the public and to the government how the creation of these non-medical consultant positions will adversely affect patient care, otherwise, its demands will be perceived as obstructing the professional development of JOHESU members, and I don’t think this is helpful to anybody.
The types of hazard and the level to which healthcare workers are exposed vary considerably and depend on the type of job they do. For instance, psychiatrists are hardly exposed to body fluids and their risks for contracting diseases like HIV and hepatitis are much less than for a theatre scrub nurse. The risk of physical assault by a patient is higher for a psychiatrist than for a surgeon. And because psychiatry nurses spend more time with patients, their risks of assault are arguably higher than those of consultant psychiatrists. The people who work in radiology departments such as radiologists, radiographers, nurses, porters and so on have greater exposure to radioactive materials than everyone else in the hospital.
The current health hazard allowance of N5,000 is unconscionable – it needs to increase. However, I think it is imperative to get an independent risk assessor for impartial advice.
I have read far too many emotional arguments on these issues and very little of an objective discourse. It is important that I draw your attention to a few of these.
What has become obvious is the lack of understanding of the concept of teamwork. There is a pervasive notion among doctors that the other healthcare workers are there to serve them. JOHESU members think that doctors have become too conceited for their own good and are determined to put them in their “places”. The most important person in the hospital is the patient – it is not the doctor, nurse, pharmacist or laboratory scientist or anyone else. Every team member is important and must be respected, including the people who do the least clinical jobs like cleaning. I don’t imagine that any hospital will remain open for longer than a week if its cleaners went on strike and dirt was allowed to accumulate to the point where it constitutes a health risk.
I have heard so many anecdotal accounts of nurses not joining doctors on ward rounds or pharmacists altering prescriptions without first discussing these with the prescribing doctors or laboratory scientist slapping doctors; and these accounts are being given as reasons why doctors must continue to head hospitals. These are disciplinary matters, which should be managed according to existing procedures. These excuses are emotional and should not be used to block the professional development of others.
The other reason I have heard doctors give for not wanting our non-medical colleagues to bear the "consultant" title is the fear that patients will confuse them or anybody else in a white-coat for a doctor and give such people an excuse for autonomous practice. This reason is not good enough because this problem can be solved by wearing names badges and/or colour coded uniforms. Also health professionals should introduce themselves to patients at the start of consultations. But more significantly, this can be an issue of regulation - any one found to be (criminally) practising over and beyond their job description, competence level or professional registration becomes liable to disciplinary procedures.
Our health system suffers from poor regulation. This is why anyone can open a chemist and dole out antibiotics indiscriminately. It is the reason doctors are scared that consultant pharmacists, nurses and physiotherapists will steal their patients. But it is also the reason why doctors may recommend an operation to a patient where none is necessary just so they can charge more. This is a problem that is in urgent need of attention. I hope that this something both NMA & JOHESU will flag up in the near future.
Another recurrent theme in these debates is the abuse of junior doctors by both medical and non-medical staff, which appears to be endemic. There is a consistent narrative of junior doctors being asked to do other people’s jobs such as collecting blood from blood banks, taking samples to laboratories etc. In extreme cases, these doctors are asked to undertake non-clinical tasks by more senior doctors. This is simply unacceptable! I think it is fair to place the blame for this at the hands of consultants who are supposed to be responsible for junior doctors. But this in itself is not a good argument for blocking JOHESU members from becoming consultants in their specialties or for stopping them from heading hospitals if they have the right qualifications.
I am concerned that the NMA is losing public sympathy. Increasingly, I hear people describe doctors as selfish and heartless. This is very sad and rather unfortunate. They say doctors do not have any motivation to end the strike because patients are forced to pay exorbitant fees to them in their private hospitals. Those patients who cannot afford these fees are left to suffer or die. If the NMA has made any efforts to change this public perception, then these do not appear to have been effective.
The current strategy (i.e., recurrent strikes) is not working. Over the last decade or two, the NMA and non-medical health workers (more recently represented by JOHESU) have taken turns to go on strikes. Perhaps, it is time for both parties to sit together, talk to each other and resolve these contentious issues once and for all. It’s pointless for the government to enter into agreements with one party knowing fully well that the other party will ask for a reversal of those agreements.
I think the time has come to incorporate Ethics, Teamwork and Communications into undergraduate curricula. The various online comments I have read from medical and non-medical colleagues show that whilst many easily mouth off "team work", a practical understanding of what this means is lacking.
Disciplinary procedures are there for a reason. They must be followed when necessary.
Although I practise abroad, I should point out that this strike affects me too. My family and friends all live in Nigeria. And who says I am not planning to come home to practise?
Lastly, we must all be mindful of our own mortality. Most of us will be ill someday. And when this happens, the only thing that will matter to us is to be looked after by caring and competent health-workers regardless of their individual specialisation. We can create that environment if we forget our individual egos and work as a team.
Ijabla Raymond, a medical doctor of Nigerian heritage writes from the UK. Contact: [email protected]