Original Article Residency training in Ghana: the residents’ perspective Merley A Newman-Nartey1, Nii Otu Nartey2, Kwabena G Amoah1, Victoria A Buckman3, Thomas A Ndanu4 and Alexander A Oti Achempong 5 Ghana Med J 2019; 53(1): 13-19 http://dx.doi.org/10.4314/gmj.v53i1.3 1Department of Orthodontics and Pedodontics, University of Ghana School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Ghana 2Department of Oral Pathology and Oral Medicine, University of Ghana School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Ghana 3Department of Restorative Dentistry, University of Ghana School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Ghana 4Department of Community Dentistry, University of Ghana School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Ghana 5 Department of Oral and Maxillofacial Sciences, Kwame Nkrumah University of Science and Technology Dental School, Ghana Corresponding author: Dr. Merley Newman-Nartey E-mail: merleynn@hotmail.com Conflict of interest: None declared SUMMARY Background: Prior to 1973, West African citizens completed postgraduate medical and surgical training abroad, particularly in the United Kingdom. In 2003, the Ghana College of Physicians and Surgeons were established respectively and began to offer specialized training locally. The aim of this study was to obtain and evaluate the views of Medical and Surgical Residents of the GCPS on their training in Ghana. Method: A descriptive cross-sectional study was undertaken whereby a 25 item, self-administered questionnaire, was distributed to 170 residents of Korle Bu and Komfo Anokye Teaching Hospitals in Ghana. Information regarding the residents’ sociodemographic characteristics, level of residency, and satisfaction with the programs in terms of clinical supervision, didactic teaching, program duration and research training was collected. Results: 117 residents completed the survey, yielding a response rate of 68.8%. 59.8% were males and 40.2% females. The age of the residents ranged from 25 to 40 years with a mean age of 32.7+1.4 years. Majority of residents (92.3%) were satisfied with the duration of the programs . Slightly more than half of the residents (50.4%) were satisfied with the clinical supervision, however only a third of the respondents (33.3%) were satisfied with the didactic teaching and an even smaller percentage (17.1%) with research training. Conclusion: Whilst majority of residents were satisfied with the duration of the residency program, the perspective of the respondents was that trainees would benefit from additional didactic teaching and increased research exposure. Funding: None Keywords: Medical, Surgical, Residency, Graduate, Training, Ghana INTRODUCTION In Ghana, residency training is the basic postgraduate Formerly, specialty training in the fields of medicine, medical/surgical training for fully registered medical surgery, and dentistry and other subspecialties was doctors and dental surgeons in a chosen specialty of their completed in Europe, particularly in the United profession. The duration varies from three to seven years Kingdom. depending on the specialty. During this period, trainees acquire in-depth scientific knowledge and advanced In 1974, the Royal College of Surgeons of England and skills under the direct or indirect supervision of a mentor the Royal College of Physicians (UK) established an in their chosen professions, enabling the qualified examination centre in Accra that allowed candidates to trainees to practice at a specialist or consultant level. The complete the primary examination in Ghana and development of specialist training in Ghana has successful candidates subsequently proceeded to the undergone several stages. United Kingdom to continue their specialty training.1 13 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article Postgraduate surgical training was initiated in West concluded within two years of completion of the Part I Africa by a Cameroonian Surgeon, Dr. Victor Ngu, who training, completed his surgical training in the United Kingdom During which the training candidate was expected to and arrived in Ibadan, Nigeria, in December 1959 to take acquire advanced clinical skills and knowledge of the up a surgical registrar position.2 With the support of chosen specialty and complete a research dissertation.5,6 surgeons from English-speaking regions in West Africa, Although several specialists were trained by the WACS, he inaugurated the formation of the Association of the 40% average passing rate was very low compared to Surgeons of West Africa (ASWA) in Ibadan in 1960 to that of other comparable postgraduate programs, such as promote and direct the art of surgery, coordinate surgical the American Board of Surgery, which had an average education, and promote research in the West African sub- passing rate of 70% to 80%.6 region.2,3 In 1969, the ASWA formed the West African College of Surgeons to promote postgraduate education In 2001, due to the high attrition rates of residents from and training in surgery and in 1973, at its annual meeting the West African postgraduate medical colleges and the in Benin City, Nigeria, the ASWA transferred its exodus of health professionals from Ghana, the functions, assets and liabilities to the West African Government of Ghana decided to establish the Ghana College of Surgeons and subsequently ceased to exist. A College of Physicians and Surgeons (GCPS) which similar college of physicians developed alongside that of received its charter in 2003.7,8 the surgeons in the early sixties.2,3,4 In 1963, physicians from Gambia, Sierra Leone, Ghana and Nigeria formed Professor Paul Nyame was appointed the foundation the Association of Physicians of West Africa (APWA) Rector. The aims and objectives of the GCPS were to with Sir Samuel Manuwa as the first President. The offer structured training programs to postgraduate objectives of APWA was to promote learning and medical/surgical trainees. Although there were research among physicians in the sub region in the similarities in the faculty structures and the examinations specialties of internal medicine, paediatrics, psychiatry, of the WACS and the GCPS, residents registered with the pathology and community health.4 GCPS could exit training after successfully completing Membership examinations. A successful candidate with In 1970, the West African members of the a membership diploma was eligible to join the specialist Commonwealth Medical Association proposed to grade of the Ministry of Health.9 The duration of the establish postgraduate medical training in the sub-region. GCPS fellowship training program was a minimum of This proposal led to the establishment of the West two years and was available to all candidates who had African Health Secretariat (WAHS) by the Governments successfully passed the membership examination and of Gambia, Ghana, Nigeria, and Sierra Leone in May worked for a minimum of one year in a district hospital. 1972. In 1974, Liberia, a non-Commonwealth member, During this training period, the candidate was expected joined the WAHS and the name of the organization was to acquire superior clinical skills, in-depth knowledge in changed to the West African Health Community to the chosen specialty and complete a research project.8 include this non-commonwealth member. The West African Postgraduate Medical College was inaugurated Ten years after the establishment of the GCPS, in 1973 and in 1975 the West African College of significant progress had been achieved in medical Physicians (WACP) and the West African College of postgraduate education in Ghana. There had been an Surgeons (WACS) were integrated as the constituent increase in the number of specialists in the country, a colleges. reduction in the ‘brain drain’ of health professionals and an increase in the number of doctors and dental surgeons Although the faculties and regulations were structured seeking postgraduate training locally.8 Although similarly to the British Royal Colleges of Physicians and substantial progress has been made in local postgraduate Surgeons, the examination format was distinctive.3 The medical education, trainers nevertheless require regular duration of training after successful completion of the feedback from their trainees to improve upon these primary entrance examination was a minimum of five training programs. This study aims to assess the years in many faculties. The training program was perspectives of postgraduate medical/surgical residents divided into two sections, the Part I and Part II levels. The regarding the GCPS training program. It sought to collect duration of the Part I program was three years and during the views of residents regarding the following issues: this period, the resident was required to rotate through satisfaction with didactic teaching, research-based selected disciplines related to the field of specialization training, clinical supervision, duration of the program, prior to taking the Part I examination. The Part II challenges associated with the residency program and program, on the other hand, was expected to be suggestions on its improvement at the two Teaching Hospitals of Korle-bu and Komfo-Anokye. 14 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article 76% of the respondents were at the membership level of the training, and 19% were at the fellowship level. 5% of METHODS the respondents did not state their level of training. The Study design and participants number of residents undergoing the membership training A descriptive cross-sectional study was conducted was as follows: first year (29.9%), second year (17.9%), among 170 medical and surgical residents of the Korle- third year (24.8%) and fourth year (3.4%). The bu and Komfo-Anokye Teaching Hospitals in 2015. The fellowship levels were distributed as follows: first year chief residents of the various divisions were recruited to (6.0%), second year (10.3%) and third year (2.6%). distribute the questionnaires to the residents registered with the Ghana College of Physicians and Surgeons Distribution of Respondents by Clinical Specialties (GCPS). In 2015, there were 272 residents registered with the The residents were approached during their training GCPS, with the highest numbers recorded in obstetrics sessions and were invited to participate in the study. and gynaecology (16,2%), family medicine (13.2%), general surgery (12.5%) and paediatrics (10.3%) (Table They were informed of the objectives of the study and 1a.) There was a strong significant gender disparity in the that participation was voluntary and anonymous. They first four faculties of obstetrics and gynaecology, family were asked to provide written consent to participate in the medicine general surgery and paediatrics. Chi-square of study prior to completing the questionnaire. 48.65, df=3 and p<0.001 The questionnaire Table 1a Distribution of registered GCPS residents by The first part of the 25-item questionnaire included clinical specialty (n=272) from archives of GCPS questions of sociodemographic characteristics of the FACULTY MALE FEMALE TOTAL n (%) participants. The second part consisted of questions Obstetrics &Gynaecology 39 5 44 (16.2) regarding level of residency, and the ratings of the Family Medicine 21 15 36 (13.2) program in terms of duration, clinical supervision, Surgery 27 7 34 (12.5) didactic teaching,research training and lastly their Paediatrics 4 24 28 (10.3) recommendations for its improvement. The study was Public Health 14 10 24 (8.8) approved by the Ethical and Protocol Review Committee Internal Medicine 12 7 19 (7.0) Radiology 9 8 17 (6.3) (MS-Et\M.3-P4.2/2005-2006). of the College of Health Anaesthesia 2 11 13 (4.8) Sciences, University of Ghana, Emergency Medicine 10 3 13 (4.8) Laboratory Medicine 6 6 12 (4.4) Statistical Analysis Ophthalmology 3 6 9 (3.3) The data were compiled by the authors into Microsoft Otorhinolaryngology 4 4 8 (2.9) Dental Surgery 4 3 7 (2.6) Excel sheet and then imported into Statistical Package for Radiation Oncology 5 0 5 (1.8) Social Sciences version 22.0 (SPSS Inc., Chicago IL Psychiatry 1 2 3 (1.1) United States (SPSS) version 22 for statistical analysis. TOTAL 161 111 272 (100) Descriptive statistics and a qualitative analysis were used to evaluate the residents’ perspectives of their training. The respondents’ clinical specialties are listed in Table 1b. Nine clinical specialties out of 15 were recorded. Data Collection and Analysis The 25 item self-administered questionnaires were Table 1b. Distribution of respondents by clinical distributed to 170 present and past residents who specialty (n=117) accepted to participate in this study. The questions were Clinical Specialty Males Females TOTAL answered independently by the respondents. n (%) Internal Medicine 13 7 20 (17.1) Obstetrics &Gynaecology 15 4 19 (16.2) RESULTS Paediatrics 4 11 15 (12.8) Out of the 170 questionnaires distributed, 117 were General Surgery 10 4 14 (12.0) correctly completed giving a response rate of 68.8%. Dental Surgery 8 4 12 (10.3) 59.8% were males and 40.2%, females. The age of Laboratory 6 5 11 (9.4) Medicine respondents ranged from 25 to 40 years with a mean age Ophthalmology 4 5 9 (7.7) of 32.7+1.4 years. Most respondents (78.6%) were from Family Medicine 4 3 7 (6.0) Korle Bu Teaching Hospital (KBTH). Not Stated 3 2 5 (4.3) Otolaryngology 3 2 5 (4.3) Level of Training of Respondents Total 70 47 117 (100) 15 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article Internal medicine had the highest number of respondents (17.1%), followed by obstetrics and gynaecology (16.2%). otolaryngology recorded the smallest number (4.3%) of respondents and there were no respondents from the specialties of anaesthesia, psychiatry, public health, radiology, radiation oncology and emergency medicine. Levels of satisfaction with clinical supervision, didactic teaching and research training Figure 1. shows the distribution of the level of satisfaction of the respondents. Slightly more than half of the respondents (50.4%) were satisfied with clinical supervision by their supervisors. Two thirds (66.7%) of the respondents were dissatisfied with didactic teaching. Respondents were critical of the perceived inadequate research activity during their training. Only one in five (17.1%) was satisfied with research exposure during their training. Figure 2 Distribution of respondents by hours spent studying per week (n=117) Major challenges hindering residency training Figure 3 shows the training challenges reported by the respondents. Most residents (48.7%) identified the high clinical workload as the most important issue affecting the efficiency of their training. Figure 1 Frequencies of level of satisfaction with clinical supervision, didactic teaching and research training (n=117) Distribution of respondents by hours spent studying per week. Figure 2 shows the number of hours per week that the respondents spent studying. Majority (34.2%), spent between three and five hours per week studying and 26.5% of respondents spent between zero to three hours studying per week. Only 39.3% respondents spent more Figure 3 Major challenges hindering residency training than five hours per week studying. (n=117) 16 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article The clinical workload challenge was followed by family number of males graduating from Nigerian medical issues (25.6%) and work burnout (13. 7%). Other factors schools and subsequently enrolling in residency training. identified as distractions included the financial status of Furthermore, fewer females registered for residency the residents (5.1%), involvement in locum work (2.6%) training because of the reported perceived stress and the and excessive recreational activities (1.7%). additional responsibilities of raising a family. Opinion on duration of residency training The membership examination of the GCPS is an exit It was the opinion of the overwhelming majority of qualification. The trainees must subsequently work respondents (92.3%) that the duration of the residency outside of the training institutions and are only re- training program was satisfactory, while a small admitted after they satisfy the admission requirements for percentage (5.1%) thought the program was too long, and fellowship training, which may account for the larger an even smaller percentage (2.6%) thought that the number of residents observed at the membership level duration was too short. compared to that at the fellowship level. Another reason for the fewer number of fellowship residents may be due DISCUSSION to the extensive nature of the membership course and the The mean age of the residents included in this study associated highly demanding examinations at the end of (32.1+1.4 years) was lower than the mean ages reported the program, which serve as a limiting factor to the in similar studies in Nigeria.10,11 Anyaehie et al.10 progression to the fellowship level. suggested that the mean ages of the Nigerian residents were higher compared to residents in the United States The respondents did not represent all the clinical faculties because of limited access to residency training. Ojo et of the GCPS. The greatest numbers of respondents were al.11 reported similar findings to those in the current study from the faculties of internal medicine and obstetrics and and cautioned that doctors of lower mean age groups gynaecology, while otolaryngology had the lowest tended to be unmarried and more likely to seek ‘greener number of respondents, which contrasted with a similar pastures’ in developed countries if the necessary study in Pakistan in which most residents were from the 11 attractive incentives were not available to keep them in department of surgery. In this study, the surgical their respective countries. Lassey et al.9 supported this disciplines were divided into the subspecialties of general assertion by observing a remarkable decrease in the surgery, otolaryngology, and ophthalmology, therefore, number of Ghanaian doctors leaving for ‘greener surgery did not register as the largest faculty as was found pastures’ and the extraordinary stemming of the tide of in the Pakistani study, which presented a single surgical 12 the ‘brain drain’ after the pioneering incentive of the unit. establishment of the GCPS. The specialties of anaesthesia, psychiatry, public health, In this study, there was a strong gender disparity in radiology, radiation oncology and emergency medicine relation to the chosen specialty in the four most common were not represented in this study. This was due to the chosen specialties i.e. general surgery, internal medicine, overall difficulty of recruiting participants to complete obstetrics and gynaecology (O&G), and paediatrics. The the questionnaire. It is expected that stressing the male predominance in the surgical disciplines of general importance of participating in these studies and the use surgery and O&G may be due to the extreme physical of the more convenient method of online completion of demand of long operating hours which is unattractive to questionnaires may improve upon the situation. females. The aim of medical and surgical residency training is to The male predominance in the surgical disciplines of produce competent specialists with superior skills and in general surgery corresponds to findings in Nigeria 10, 11 depth knowledge necessary to manage disease conditions and Pakistan.12 In the two Nigerian studies10,11, a male at an advanced level Therefore, the observations in this 9, 10 predominance of more than 90% was reported among study and those in previous studies conducted in this surgical residents while a study from Pakistan 12, also sub-region indicating that most residents were not reported a higher male predominance of 96% among satisfied with the didactic teaching and research activities surgical residents. Ojo et al.10 attributed the insignificant in their training necessitates special attention and a number of females in the surgical disciplines to perceived possible re-orientation to meet these important gender bias, the discrimination experienced by women components of postgraduate medical/surgical training. during surgical clerkships and the lack of role models, particularly same sex role models in surgical training. In contrast, studies conducted in North 13,14,15,16,17 Anyaehie at al.10 however, attributed the high percentage America, revealed that the residents were of males in surgical residency to the proportionately large generally satisfied with didactic teaching, research 17 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article activities and mentor-resident relationships because these activities were well delineated across the various residency programs according to the guidelines of the CONCLUSION Accreditation Council for Graduate Medical Education.18 The establishment of the GCPS has been immensely beneficial in stemming the tide of the ‘brain drain’ of Specialty training involves the acquisition of ample medical doctors and dental surgeons in Ghana and an knowledge and skills. Thus, the residents need adequate overwhelming majority of residents were satisfied with study periods for personal reading and library work. Most the duration of the residency program. respondents in this study spent between three and five hours studying per week, which was inadequate for The perspective of the respondents, nevertheless, was advanced medical knowledge acquisition. Residents that trainees would benefit from improved didactic need more time for individual study and library activity. teaching and increased research exposure. Most residents (48.5%) reported that the high clinical workload affected their acquisition of skills. In the ACKNOWLEDGEMENT United States, in 2010, due to the high workload of The authors would like to thank all the residents who trainee residents, the Accreditation Council for Graduate participated in this study. Medical Education proposed an 80-hour limit on the residents’ workweek.18 REFERENCES Studies in Nigeria and Pakistan also revealed a high 1. Archampong EQ. Priorities of Professional clinical workload of postgraduate medical residents. In Specialist Training. Postgraduate Med J Ghana most developing countries, there are no official limits or 2014; 3(2): 92-7. monitoring of the work hours spent by the residents. 2. Addae S, editor. Evolution of Modern Medicine in a There is a need to establish reasonable limits on the Developing Country: Ghana 1880-1960. 1st Ed. working hours of these residents to reduce fatigue, sleep Durham: Durham Academic Press Ltd; 1996. deprivation and, subsequent patient management errors. pp.477-9 Despite the lack of adequate study periods, over 90% of 3. Bode CO, Nwawolo CC, Giwa-Osagie OF. Surgical residents were satisfied with the duration of the program education at the West African College of Surgeons. and only 2.6% were of the opinion that the program was World J Surg 2008; 32(10): 2162-6 too short. 4. Evans Anform E To the thirsty land (Autobiography of a patriot): 1st Ed Accra: African Christian Press Ltd; 2003. pp. 363. Recommendations by the Residents The following interventions were recommended by the 5. Hewlett SA, Amoah KG, Donkor P, Nyako EA, respondents to improve upon residency training in Abdulai AE, Nartey NO, et al. Postgraduate dental Ghana: education in Ghana: past, present and the future. 1. Formal lectures and journal clubs should be Postgraduate Medical J of Ghana 2014; 3(1): 50-6. established. 6. Ajao OG, Ajao OO, Ugwu BT, Yawe KDT, Ezeome 2. The clinical work schedule and library and ER. Factors determining the results of the personal learning periods should be clearly examination of the West African college of surgeons specified. in general surgery. J West Afr Coll Surg 2014; 4(4): 3. Adequate supplies be should be made available 1-26. to avert the need for some residents of Dental 7. Republic of Ghana Act 635. Ghana College of Surgery to procure their own materials to Physicians and Surgeons, Act. Accra: Government manage patients. Printer, Assembly Press; 2003. pp. 1–14. 4. More emphasis should be placed on research 8. Clinton Y, Anderson FW, Kwawukume EY. Factors work and adequate funds should also be made related to retention of Postgraduate trainees in available to encourage research and its obstetrics-gynacology at the Korle-Bu Teaching dissemination at local and international Hospital in Ghana. Acad Med 2010; 85(10): 1564- conferences. 70. 9. Lassey AT, Lassey PD, Boamah M. Career destination of University of Ghana Medical School Limitation The convenience sampling method, the relatively small graduates of various year groups. Ghana Med J sample size and the lack of respondents from nine 2013; 47(2): 87-91. faculties might limit the generalizability of the results. 10. Anyaehie UE, Anyaehie USB, Nwadinigwe CU, Emegoakor CD, Ogbu VO. Surgical resident 18 www.ghanamedj.org Volume 53 Number 1 March 2019 Original Article doctors’ perspective of their training in the Southeast relation to the International Council of region of Nigeria. Ann Med Health Sci Res 2012; Ophthalmology guidelines. J Curr Ophthalmol 2(1): 19-23. 2016; 28(3): 146-51. 11. Ojo EO, Chirdan OO, Ajape AA, Agbo S, Oguntola 15. Flint JH, Jahangir AA, Browner BD, Mehta S. The AS, Adejumo AA, et al. Post-graduate surgical value of mentorship in orthopaedic surgery resident training in Nigeria: the trainees ‘perspective. Niger education: the residents’ perspective. J Bone Joint Med J 2014; 55(4): 342-7. Surg 2009; 91(4): 1017-22. 12. Webb JM, Rye B, Fox L, Smith SD, Cash J. State of 16. Cohn DE, Roney JD, O’Malley DM, Valmadre S. dermatology Training: the residents’ perspective. J Residents’ perspective on surgical training and 5he Am Acad Dermatol 1996; 34(6): 1067-71. Resident-Fellow Relationship: comparing 13. Freiman A, Barzilai DA, Barankin B, Natsheh A, Residency programs with and without Shear NH. National Appraisal of dermatology gynaecological oncology fellowships. Int J Gyn Can residency training: a Canadian study. Arch Dermatol 2008; 18(1): 199204. 2005; 14(9): 1100-04. 17. Drolet BC, Spallito LB, Fiscer SA. Residents’ 14. Abdelfattah NS, Radwan AE, Sadda SR. Perspective perspective on ACGME regulation of supervision of ophthalmology residents in the United States and duty hours. a national survey. N Engl J Med about residency programs and competency in 2010; 363: e34. Copyright © The Author(s). This is an Open Access article under the CC BY license. 19 www.ghanamedj.org Volume 53 Number 1 March 2019