This document summarizes the challenges of residency training in Nigeria. It discusses how residency training began in Nigeria in 1974 to provide specialist training and halt brain drain. However, residency training faces many challenges, including inadequate funding, infrastructure, supervision and workload issues. Residents also struggle with personal challenges like family issues, illness and exam stress. Unless these systemic and personal challenges are addressed, patient care and resident training will be negatively impacted. Overcoming residency challenges requires efforts from residents, training institutions, and government to improve working conditions and better support resident physicians.

1. Challenges of
Residency training in
Nigeria
Presented by Dr Bertha C Ekeh at the 2013 AGM/Scientific
conference of the Association of Resident Doctors UUTH,
Uyo on 16TH OF December 2013

2. Outline
• Introduction
• Definition of Residency
• History
• History in Nigeria
• Components of Residency training
• Competencies
• Challenges
• Overcoming the challenges

3. Introduction

4. Definition
•The period during which a
physician gets specialized
clinical training

5. History
• Residency is an opportunity for advanced training in a medical
or surgical specialty
• Evolved in the late 20th century from brief and informal
programs for extra training in a special area of interest
• The first formal residency programs were established by Sir
William Osler and William Stewart Halsted at the Johns
Hopkins Hospital

6. Characteristics
• Residencies are traditionally hospital-based
• In the middle of the twentieth century, residents would often
live (or "reside") in hospital-supplied housing
• "Call" (night duty in the hospital) was sometimes as frequent
as every minute or third night for up to three years
• Pay was minimal beyond room, board, and laundry services
• It was assumed that most young men and women training as
physicians had few obligations outside of medical training at
that stage of their careers

7. contd
• Residencies elsewhere then became formalized and
institutionalized for the principal specialties in the early 20th
century
• But even mid-century, residency was not seen as necessary for
general practice and only a minority of primary care physicians
participated
• Became more popular by the end of the 20th century in
North America

8. Residency training in Nigeria
• Formally established in 1974
• Objective of providing specialist training at a high level and
appropriate to the needs of Nigerian population
• The other objective was to halt the brain drain taking place as
a result of relocation of the much-needed medical specialists
to the developed world
• The training of specialists in our country in the long run was
cheaper, with the downturn of the Nigerian economy

9. Myths
• Residency is not a career
• Residency is not just a job
• Residency is not fun

10. Who is a resident
• The resident is a learner while being responsible for patients
as a “provider of care”
• It is transition period
• Divided into junior and senior residency

11. Components
• Basic entry requirements
• Better earlier
• Duration
• Remuneration
• Sponsorship
• Examinations

12. Demands of residency
• Two pronged
• Training
• Work
• Each is full time

13. Training institutions
• The training institutions sponsor majority of the residents
• These training institutions are accredited by the National and
West African Postgraduate Medical Colleges
• The sites are usually tertiary institutions
• Few secondary institutions and private hospitals have training
in some specialties

14. End points
• Specialist
• Trainer/Teacher
• Leader/Manager
• Researcher

15. Objective of residency

16. 6 competencies
• Medical knowledge
• Patient care
• Practice-based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-based practice

17. Medical knowledge
• Personal study (textbooks and journals)
• Discussion groups
• Clinical rotations
• Ground rounds/journals/reviews etc.
• Bed side teachings
• Didactic lectures
• Update/Revision courses
• Conferences
• Workshops
• E-learning

18. Patient care
• Clinical rotations
• Clinical care
• Morning reviews
• Mortality reviews
• Achieve Compassionate, comprehensive and high quality care

19. Practice based learning
• Use of evidence-based medicine in clinical decision making
and patient care
• Application of critical/analytical thinking skills and critical
appraisal medical literature
• Application of quality improvement tools with focus on
improving care and ensuring patients’ safety
• Acquisition of skills( surgical, instrumentation)

20. Professionalism
• According to the American Board of Internal Medicine,
professionalism “comprises those attitudes and behaviours
that sustain the interests of the patient above one’s own self-
interest.
• Professionalism entails altruism, accountability, commitment
to excellence, duty, commitment to service, honour and
respect for others.”
• Humanism and professionalism are both however inextricably
woven into the art and practice of medicine
• Medical ethics

21. System based Practice
• The understanding that beyond the pharmacological
treatment of multiple factors can influence the outcome
of patient care
• Assess the social needs of the patients and their family
• Funds
• Care coordination with other healthcare professionals
• Availability of drugs
• Cultural beliefs
• System challenges( electricity, ambulance, oxygen, suction
machines, incubators etc.

22. Interpersonal and communication
skills
• Day –to –day interactions with colleagues
• Interaction with other healthcare professionals
• Health education
• Communication skills with patients (e.g. breaking bad news,
providing informed consent)

23. Challenges of Residency
• System challenges
• Personal challenges

24. System challenges
• Funding
• Man power shortage/ workload
• Teething problems in new centers
• Call rooms/offices
• Library facilities

25. Other system challenges
• Facilities
• Outdated
• Below average( ICU, Theater )
• Investigations
• Procedures

26. Work load
• Residents work for between 80 and 168 hours per week
(median, 92 hours), excluding call duty
• Forgone leaves
• Sleep deprivation alone, has been shown to predispose
residents towards more medical errors, injuries, increased
alcohol and drug use, and increased conflict with other
healthcare staff

27. Personal Challenges
• Family issues
• Other extra curricular activities
• Ill health
• Accidents
• Death
• Favouritism etc.

28. Curriculum
• It is estimated that the doubling time of medical knowledge in
1950 was 50 years
• In 1980, 7 years
• In 2010, 3.5 years
• In 2020 it is projected to be 0.2 years—just 73 days
• Knowledge is expanding faster than our ability to assimilate
and apply it effectively; and this is as true in education and
patient care as it is in research.

29. Postings
• Intra department
• Intra hospital
• Outside postings
• Oversea clinical attachment

30. Exam stress
• Workload
• Ineffective studying
• Changing patterns of exams
• Bad luck

31. Women issues
• Gender bias
• Sexual harassment
• Scarcity of female mentors
• Work/family conflicts

32. Individualized
• Challenges differ
• Personality/Temperament
• Available funds
• Family issues
• Spousal understanding
• Number and ages of children

33. Problem residents
• “A trainee who demonstrates a significant enough problem
that requires intervention by someone of authority
• Problem residents are challenging to the residency program
directors, attending physicians, and often their fellow trainees
• They can threaten the integrity of a training program
• Can negatively influence the residency training experience for
other trainees

34. Categories of problem
residents
• 1)Behavioral issues
• 2)Medical conditions including psychiatric illness
• 3)Difficulty coping with stress
• 4)Substance abuse
• 5)Cognitive issues such as inadequate knowledge base or
learning disabilities (about which there is no evidence)

35. Experience of residents
• Fifty percent of residents reported their life was stressful
• There were gender differences in conditions like work
situation, residency programme, employment status, personal
and family safety, caring for children and discrimination in
favour of men
• Some residents resorted to the use of alcohol (5.2%), cigarette
(1.7%), drugs and medications (8.6%) to handle stress
• A greater majority of the residents (61.4%) would pursue
another career if they had to do it all over, while 34.5%
would consider changing to another teaching hospital for their
residency

36. Contd
• Many residents reported experiencing intimidation and
harassment
• Eighteen (31%) of the residents admitted to have had
emotional or mental health problems during the residency
program.
• About 29% will require further screening for depression,
21.6% for panic disorder, 15.8% for generalized anxiety, 9.3%
for social phobia and 8.8% for agoraphobia

37. Identified problems
• Inadequate teaching and supervision by trainers
• Absence of foreign training exposures
• No period of time dedicated strictly for research training
• Unclear structuring of training program
• Lack of adequate practical exposure with paucity of surgical
skills
• Lack of surgical equipment and paucity of facilities

38. Suggested interventions
• Incorporation of didactic lectures and enhanced teaching by
Consultants during ward rounds – 50 (89.2%).
• Compulsory overseas training program – 48 (85.7%).
• Training should be more inclined to surgical skill acquisition –
44 (78.6%)
• Commence research trainings programs – 44 (78.6%)
• Support research by Residents through grants and
sponsorships – 43 (76.7%)
• Procurement of modern diagnostic and surgical equipment–
40 (71.4%)
• Improved remuneration – 34 (60.7%)
• A closer and cordial trainer and trainee relationship – 34
(60.7%)

39. Further suggestions

40. Role of teachers and mentors
• Supervision by an experienced medical practitioner has long
been considered the sine qua non of residency training and
professional development.
• This careful professional guidance enables students and
residents to step gradually into the role of professional
decision maker under the tutelage of a more seasoned,
experienced mentor.
• In this system, highly technical learning occurs, and the habits
of day-to-day medical practice can be rehearsed.

41. contd
• Learning the mechanics of patient care under supervision
• Enhances patient safety
• Helps prevent unnecessary medical errors
• And lays the foundations for the public trust in physician
competence
• The contribution by consultants to training is between 26%
and 50% as reported by some 53 (44.5%) of the respondents
• When the student is ready, the teacher
will appear ( Chinese saying)

42. Impact on health care
• When residency programs are not working well, both patients
and residents are placed at risk.
• Patients are put at risk because residents may not be
receiving the guidance they need to provide optimum patient
care and to avoid making errors.
• Residents are at risk because they may not be learning what
they should be learning to become independent practitioners.
• The goal of residency training should not be only to develop
their competence to care for patients in the hospital today,
but to develop the capability to care for their patients of
tomorrow

43. Health financing
• Nigeria’s overall heath system performance was ranked 187th
among the 191 member states by the WHO in 2000
• Public expenditure is <$8 per capita as against the
recommended $34 internationally
• Private expenditures are estimated to be >70% of total health
expenditure with most of it coming out of the pocket despite
the endemic nature of poverty

44. Revised
• A minimum of 15% of the allocation to health shall be devoted
to human resources for health development
• Private participation in human resources for heath
development shall be encouraged through foundations,
philanthropies and endowments shall be encouraged

45. Overcoming challenges
•"Pain and death are part of life
• To reject them is to reject life
itself.”
Havelock Ellis

46. Few tips
• Be aware of, and accept that these challenges are inevitable
in life
• Build your internal resources
• Prepare yourself mentally for confronting these challenges
head-on.
• Another invaluable inner resource is faith. Faith that
everything will work out; faith that there is always light at the
end of the tunnel, and faith that "this too shall pass.“
• Motivate yourself
• Plan/organize yourself

47. Contd
• Build your external resources
• Build a support system of family, colleagues and friends
• We all need encouragement and support
• Let failure fuel and fear you in a positive way. Everyone fails
at times.
• Pick yourself up, and learn from why you've failed, and move
on in positive direction.
• Take inspiration and learn from others who have dealt
successfully with these challenges
• Help others

48. Overseas clinical attachment
• 1-year elective posting abroad
• Helps bridge the gap between our training and the training
abroad
• Offers residents the opportunity to observe and practice
medicine at the best of centers
• The benefits cannot be overemphasized
• Stopped because of lack of funds
• A Senior Registrar shall be granted study leave with pay for
one year only for clinical attachment overseas subject to
availability of funds.
• Extension beyond the one year period shall not normally be
granted

49. Sponsorship of residency
programme

50. Sources of funding
• Public funds
• Non governmental
• Individuals
• Alumnus
• Endowment funds
• Cooperative
• NGO’s
• International bodies

51. The way forward

52. Norwegian saying
•There is no such thing as bad
weather: only poor clothing

53. Requirements
• Mentors/referees
• Professional organizations
• Networking
• Papers/research

54. Pray

55. Summary
• Residency is the period of specialization
• Residency is time constrained
• Residency is tough call
• Challenges are many

56. • FLY,
• IF YOU CANT FLY, RUN
• IF YOU CAN’T RUN, WALK
• AND IF YOU CAN’T WALK THEN CRAWL
• BUT BY ALL MEANS, KEEP MOVING
FORWARDS
• Martin Luther King
Conclusion

58. References
• Zikos E. Professionalism in residency training. CPA Bulletin
2002;34:32–4.
• J Grad Med Educ. 2010 March; 2(1): 37–45.
• Baldwin DW C, Daugherty SR, Ryan PM. How Residents View
Their Clinical Supervision: A Reanalysis of Classic National
Survey Data; J Grad Med Educ. 2010 June; 2(2): 153.
Yusufu L M D, Ahmed A, Odigie VI, Delia IZ , Mohammed AA
Residency training program: Perceptions of residents. Ann Afr
Med 2010;9:91-4
• Anyaehie UE, Anyaehie USB, Nwadinigwe CU, Emegoakor CD
and Ogbu VO. Surgical Resident Doctor's Perspective of Their
Training in the Southeast Region of Nigeria. Ann Med Health
Sci Res. 2012 Jan-Jun; 2(1): 19–23.

59. References contd
• Ogunsemi OO, Alebiosu OC, Shorunmu OT. A survey of
perceived stress, intimidation, harassment and well-being of
resident doctors in a Nigerian Teaching Hospital. Niger J Clin
Pract. 2010 Jun;13(2):183-6.
• Wong TY, Chong PN, Chng SK, Tay EG. Postgraduate family
medicine training in Singapore--a new way forward. Ann Acad
Med Singapore. 2012 May ;41(5):221-6.
• Omisanjo O A: The ideal Resident doctor: A Resident’s
perspective. Ann Ib Postgrad Med 2005: 3;67-71