Coming of Age!

Inaugural Address of Professor Akinyinka O. Omigbodun,
28th President of the West African College of Surgeons
Omigbodun AO
E-mail: omigbodun@yahoo.com

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Words are not adequate to describe the depth of my feelings as I stand before you today as the 28th President of the West African College of Surgeons. Suffice it to say that I consider the choice that you made as Fellows to confer on me the privilege of being the President of our great College the greatest honour I have received in my professional life.

My Professional Odyssey

When I enrolled in the medical school at the University of Ibadan in 1974, it was not out of a conscious decision to be a doctor. Up till the time of my matriculation, I was torn between pursuing a career in medicine or in engineering. As I began classes in Anatomy and Physiology, I became gradually convinced that I had made the right choice, or should I say I found myself in the right place! The intricacy of what the greatest engineer of all had put together in the human body made for fascinating study, a fascination that has not ceased for me up till today. I had the best of learning experiences at Ibadan as I was exposed, by choice, to scientific research from the earliest stages of my medical training. By the end of my second year in the university, there was no doubt in my mind that I was going to be a medical researcher and teacher.

The decision to specialise in Obstetrics & Gynaecology was not made until my second year of practice after graduation. Once my mind was made up about the choice, I enrolled for the primary examination in the West African College of Surgeons. The College had examined the first set of candidates in the primaries a couple of years before then, in 1979. I commenced residency training with enthusiasm in 1982. Even in that era, the College had commenced update and revision courses. I attended one in 1985 and I recall the richness of the programme and how much I learnt in the ten-day span of the course. It was immeasurably helpful to me as I took my examinations a few months later. I attended another one in 1987, a few months before my exit examination from the College. The experiences left a permanent imprint on my mind about the importance of having several such short courses organized for trainees by the College.

Why did I have to go into such detail about my experiences during training? It is because my professional life and practice has been shaped largely by this College and its sister college, the National Postgraduate Medical College of Nigeria. Without the WACS, it is hard to imagine how my career would have played out. I owe a huge debt to this College for the wonderful foundation laid for my practice as a specialist by being the institution that first certified me as an Obstetrician and Gynaecologist. At every opportunity I have had, I have tried my utmost best to make the experiences of the trainees coming after me and my contemporaries even better than ours.

The Shoulders I have Stood Upon Today, I stand tall as the President of this great College, but that is because I have so many shoulders that I stand upon. My journey of learning commenced at the public primary school next door to our family residence in Osogbo, Nigeria under the tutelage of Miss Grace Oyeleye (later Mrs Okoji). She taught me in my first two years of school. She was my first teacher after my beloved parents. She was strict but she made learning pleasurable and that foundation has served me well in all my scholarly pursuits since then.

I had remarkable teachers through secondary and medical schools. Time will not permit me to mention them all by name but I will always be grateful to them for their tutelage and guidance during those formative years of my life. I must however mention two who had a remarkable impact on my training as an obstetrician and gynaecologist.

Dr. Tony Marinho was a junior resident when I was in medical school but he spent a lot of his time teaching medical students and I was a beneficiary of his attention to detail in his teaching sessions. During my postgraduate training, he was already a consultant in a different hospital, yet he sacrificed a lot of time preparing my cohort of residents, as well as those in his own hospital, for the Fellowship examinations. I will forever be grateful to him for going the extra mile to teach us even when he had no obligation to.

The impact of the second teacher was less direct, yet very profound. His bedside manners were impeccable and I picked up a lot about how to relate to patients from the way he did. When the time came to suggest an obstetrician to my wife for her care in pregnancy and childbirth, he was the one I chose, an eloquent testimony to my assessment of his professionalism. Sadly, he passed away this past week but I will always be grateful for his impact on my practice. Prof. Pat Ibeziako, may your legacy live on.

My academic career would not have taken the trajectory it did without the opportunity I had for research training at the University of Pennsylvania, USA. My mentor there provided a very favourable environment for me to flourish in my research. He sponsored my attendance at several conferences with his research funds and through his guidance I won several awards at those conferences. Christos Coutifaris remains a professor of obstetrics and gynaecology in the same institution to date. To Christos, I say thank you for the fruitful years I spent in your unit.

When I returned from the United States in 1997, I was determined to give back to the WACS in any way I could and I have attended every annual conference of the College since then. I served as Faculty Secretary, Faculty Chairman and Chief Coordinator of Courses before taking an executive position as Second Vice President in 2011. In each of these positions I received tremendous help and encouragement from Fellows, trainees and staff of the College. I believe it is however very important to mention the encouragement I have received from those who sit in what a Fellow and friend of mine described as the ‘Elders’ Row’. I am referring to our revered past presidents.

Many of those that were always seated on that row at College events in times past are no longer with us but these great surgeons have, in their individual ways, made an imprint on my mind. I remember Professor Akin Adesola who would intervene at critical moments to douse tension at meetings. I could never forget Professor JKM Quartey who called me aside at the conference in Cotonou in 2005 to commend the work I was doing as Chief Coordinator of Courses and encouraged me to continue working hard because he was certain I would be called to higher responsibilities in the College. I remember Prof. DJO Ffoulkes-Crabbe, the first female president of our College, for her wit and ability to put a finger on the key issues in any matter being debated. I remember Prof. Festus Nwako and the vast experience in administration that he deployed to the advantage of the College at critical junctures.

Fortunately for the College, the elders’ row is still filled with wise surgeons who continue to be assets to this great institution. They make themselves available for service, often at substantial personal cost and inconvenience. I have learnt so much from each of them and that has elevated me. We will continue to tap into the wisdom of these past presidents for the benefit of our College. They serve as a veritable institutional memory and source of strength for our College.

Coming of Age

Our College started as an association of surgeons in the West African sub-region in 1960. In 1973, the Association transformed into a College with foundation Fellows being those who had been certified by other Colleges in the United Kingdom, mainland Europe, United States, Canada and elsewhere. More Fellows were added by election as the years rolled by, following criteria laid down from the earliest days of the College. These Fellows brought their varied experiences of surgical training into the lengthy discussions that led to the design of the initial curricula for the training of surgeons in the sub-region. The structure eventually agreed upon drew on the strengths of the various approaches to training in these disparate countries whilst trying to avoid the weaknesses therein. For instance, the residency approach that was developed in the United States at the tail end of the 19th Century was adopted, but the assessment of candidates at various stages of training, as exemplified by the primary, membership and fellowship examinations, derived largely from the British tradition.

After a long incubation period, training eventually commenced in 1979. The first Fellow to be admitted to the College by examination was Dr Oladele Olusanya, an alumnus of the University of Ibadan (1976) who completed residency training in Obstetrics & Gynaecology at the University of Benin Teaching Hospital and passed the FWACS Examination in 1983. Since then more than 3000 Fellowships have been awarded by examination, with more than 2000 being awarded in the last ten years alone [1]. I am one of those Fellows, passing my examination in 1987 and being admitted to the Fellowship in Monrovia, Liberia in January 1988. The Faculty of Obstetrics & Gynaecology and the Faculty of Surgery have contributed the bulk of these Fellows as shown in Figure 1.

Although the College still awards Fellowships by election to those who deserve the award, the overwhelming majority of our new Fellows have been those trained and examined by the College. The ratio rose from about 3:1 in 2005 to more than 10:1 in 2013 as seen in Figure 2.

Since 1960, all the Presidents elected by Fellows of the College had been graduates of other colleges who were admitted to our Fellowship by election. For the very first time today, a product of the West African College of Surgeons assumes office as President of our great College. The WACS has indeed come of age! The College has passed the test of sustainability. The College has thrived. The College now has 216 accredited training programmes in the seven faculties, spread out among healthcare institutions in the sub-region (Figure 3). There are now more than 3700 accredited training positions in those institutions, which means we are in a position to take in more than 600 trainees each year (Figure 4). The College is poised to march into the future with confidence. And that is why I have titled my address ‘Coming of Age’.

New Organizational Model for the WACS

With coming of age comes an increase in responsibilities. A new organizational model is evolving for medicine globally and our College cannot afford to be left behind. The steady march of medical research and the exponential increase in scientific publications reporting progress in the understanding of the complex pathology of diseases, improvement in diagnostics and the deployment of modern technology to enhance surgical care has led to an era of increasing sub-specialization. Nowadays, the training of the general surgeon is completely different from that of a gynaecologist. Yet, less than eighty years ago, gynaecologists trained along with general surgeons and obtained the same certification from the same bodies before choosing the area of focus of their surgical practice. Up till about 25 years ago in the United Kingdom, anaesthesiologists and ophthalmologists were certified by faculties in the Royal College of Surgeons; today there is are Royal Colleges for anaesthetists just as there is one for eye specialists. Knowledge is getting more specialized by the day.

This evolution is bound to continue and increasing sub-specialization will be the norm. Indeed, with the advances in genetic diagnostic techniques, we are entering an era of personalized medicine, including surgical care. Our College must embrace this change and develop the necessary organizational model to enable us adapt to the new reality. Each faculty ought to develop appropriate sub-speciality training programmes tailored to the needs of the sub-region. The Faculty of Surgery is already leading the way in this by establishing a programme for post-Fellowship advanced training in trauma care. Some of the other faculties are doing the same. This trend must continue and I hope that we will soon have many programmes issuing advanced certification for various sub-specialty programmes into which our Fellows can enrol.

On the other hand, a large proportion of our population have little or no access to surgical care at all and the availability of super-specialists in the big cities is totally irrelevant to their everyday needs for safe motherhood, salpingectomies for ruptured tubal pregnancies, hernia repairs, appendectomies, trauma care, cataract removal and dental care. We do not need sub-specialists for such tasks, yet we need practitioners who have been trained to proficiency in these techniques, serving the population where they live. We need the middle level surgical personnel that will take these services to our small towns and rural areas. Fortunately, the College has adopted the membership certification for all her specialities as a means of providing surgical personnel with specific competences, enabled to serve in such settings while retaining the option of future opportunities for them to continue their surgical training and obtain higher certification.

Evidence has been adduced that specialists, in choosing where to set up their practice, tend to choose settings similar to their places of training [2,3]. The onus is now on our college to find ways of identifying suitable health institutions in our rural areas and small towns that can be accredited for training up to the membership level. As this is going on, our faculties must develop sub-specialist training programmes for the surgeons who will man our apex health care centres. We must proceed with the right sense of balance.

Attracting the Right Young People into the Surgical Disciplines In the digital age, one of the commonest aphorisms is ‘garbage in, garbage out’! If we are to have the right calibre of surgical trainees and specialists, we need to devise mechanisms to attract the right young medical graduates into careers in surgery. We need to attract doctors whose FIRST CHOICE of specialty are the surgical disciplines and thereafter groom them into becoming excellent professionals. To quote Dr Eduardo Barroso, President of the European Surgical Association [4], ‘Someone who only chooses a specialty as a second or third option to get a job in a big city will never be as enthusiastic and willing to grow as those who have chosen their true calling.’

The solution suggested by Barroso and other eminent surgeons such as Debas, Neuhaus and Clavien [5, 6, 7] for dealing with this challenge is to create an atmosphere in the training institution where the trainee will look at his or her training in Anaesthesia or Ophthalmology or Radiology with pleasure, rather than as a chore or simply a means to a meal ticket. The training years are difficult enough. Trainers have an obligation not to make it more onerous for residents. Our residents should be granted progressive autonomy as they progress in training so that they will be ready to assume the mantle of surgical leadership by the time they are certified [8].We should model professionalism and also conduct ourselves in a way that bright enthusiastic medical students will observe us and make a decision to follow us into our disciplines.

Quality and Versatility of Training by WACS

As I alluded to earlier, my experience in training as a specialist was significantly enhanced by the short courses organized by the WACS in my time. After that era, I have had the opportunity to serve as the first Chief Coordinator of Courses for the College. From that vantage point, I have been able to see the strengths and the weaknesses of the educational programmes of the College.

It is important to draw the fine distinction between surgical training and surgical education. While the former focuses on clinical skills, the latter is concerned with the total professional; not focussing on surgical skills alone, but how ‘rounded’ the person is in representing the profession in different spheres of life. The College has to attract and devote more resources to both surgical skills acquisition as well as surgical education as a whole. Admittedly, most of the surgical skills a trainee will acquire can only be in the context of patient care. Modern technology has however created such advances in simulation that surgical skill laboratories are becoming the norm.

The WACS must take advantage of these developments in simulation and this will be a major focus going forward. Fortunately, the College has already taken the first steps along this route. In collaboration with colleagues from the American College of Surgeons and other partners [9], the College established the Medical and Surgical Skills Institute (MSSI) in Accra, Ghana in 2005 to provide a simulation centre where trainees can learn basic surgical skills as well as some advanced techniques in a setting that does not put patients at risk. Those trained in such a way acquire the necessary skills and confidence before they have to confront such clinical scenarios in actual practice. We need to establish more of such centres throughout the sub-region.

In the past twelve years, the College has expanded its repertoire of courses, introducing several new ones both for trainees and trainers. The College held its first training course for examiners in 2003. Since then a few college-wide and some faculty based workshops to enhance the capabilities of examiners at WACS Fellowship examinations have been held. These courses have to take place on a regular and consistent basis for quality assurance in our trainee assessment processes. We must move beyond this into holding regular courses for trainers such that we get to a point where, apart from accrediting training institutions, the WACS will accredit individual trainers who have satisfactorily completed such courses. That process has already commenced with our basic surgical skills courses. They must extend to our main training programmes.

For a rounded education, the College introduced the Manuscript Writing Course in 2007 and the Health Management and Ethics Course in 2014. The Manuscript Writing Course has been delivered both in English and in French in Nigeria, Togo, Ghana, Cote d’Ivoire and Senegal. The College has, in collaboration with the Association for Academic Surgery (AAS), also mounted a ‘Fundamentals of Research & Career Development Course’ in Sierra Leone, Liberia, Ghana and Nigeria. A research methodology course will be held for the first time in June 2015. Other courses that will enhance the ability of our Fellows to respond to contemporary needs in health care and health care administration ought to be developed, particularly in the areas of adapting technology to improve surgical care. The WACS has developed a brand for quality. We must expand our versatility through appropriate use of technology.

Securing the Future

Yes, we have come of age, but we need to take steps to secure the future of our beloved College. The current facilities hosting the College secretariat are grossly inadequate. In order to archive essential documents from the past we have had to convert one of the apartments in the property owned by the College on Morris Street, Yaba, Lagos into a repository at substantial opportunity cost. The activities of the College will continue to expand and we will require more staff, yet we have run out of office space. If we are to meet the challenges that have already been identified in our current strategic plan, we need more ‘brick and mortar’. In this regard, the College acquired landed property at 4 Harvey Road, Yaba, Lagos during the tenure of our 26th President, Prof. Bomi Ogedengbe. After due processes, the construction was contracted to a firm of building contractors. The foundation for the new building was laid by our 27th President, Prof Koffi Yangni-Angate in July 2014. The challenge before all of us who owe allegiance to the WACS is to rise up to the occasion and contribute generously toward the completion of the building on schedule by the first month of 2017.

In the new millennium, it takes more than buildings to achieve institutional goals. We are in the digital age and the WACS must take advantage of emerging technology to optimize her operations. It is now possible by means of information and communication technology (ICT) to conduct training and examination without being confined to a particular location. ‘Virtual education’ is becoming the norm. The WACS must expand its fledgling ICT platform to improve efficiency in accreditation, training, examination and certification. In collaboration with a long-term supporter of WACS training activities, Ethicon, Johnson & Johnson, the West African Surgical Skills Academy has been established as a virtual academy linking ‘brick and mortar’ centres of excellence. Our fervent hope is that the ‘crown jewel’ of that network will be the surgical skills centre that will be part of the WACS permanent secretariat in Lagos. We will pursue similar initiatives in our other areas of operation. The future depends on technological enhancement of surgical training and the WACS will not be left behind in this pursuit. This will be a major thrust of WACS activities in the coming years and will be a crucial plank in the next strategic plan of the College

The WACS has integrated research training into the Fellowship training curricula in all faculties. We must continue to encourage our trainees and Fellows to conduct meaningful research that will inform our practice and drive health care policy in the sub-region. The Journal of the West African College of Surgeons has made great strides since its establishment, including being fully indexed by PUBMED. I must commend Prof. Ben Ugwu for the zeal and zest he demonstrated in establishing the journal as its founding Editor-in-Chief. More resources will be devoted toward making the journal stronger whilst also sustaining our interest in the West African Journal of Medicine that we co-publish with the West African College of Physicians.

As the WACS faces the future. Our driving principles should be responsive training, empathetic service and advocacy for the best interests of our patients. We must also continue to work at Anglophone-Francophone integration in the College. We must not relent in the effort at harmonization of the training curricula of the postgraduate medical colleges in West Africa.

The Graduating Fellows

To our new Fellows I say, today you are, in a sense, also coming of age. You are being admitted as Fellows of this great body of dedicated professionals. You have acquired new knowledge and developed new skills over the past several years. Now you are being certified and given full autonomy to make decisions that could determine whether your patients survive or succumb to illness. Such privilege must be tempered with a sober realization of the enormity of the responsibility being thrust upon you. Your decision making must always be driven by what is in the overall best interest of the patient. As young surgeons, there is the temptation to want to operate on every patient with a clinical problem that may seem amenable to surgery. I wish to commend to you the words of one of my teachers in medical school who was also a President of this College - ‘Every surgeon knows how to cut; a good surgeon knows when to cut, a great surgeon knows when NOT to cut.’ Surgeons are not butchers; our practice requires knowledge, precision, delicacy, finesse and, above all, wisdom!

I strongly urge you to continue learning because that is the only way you can be true professionals. Certification is a one day event, learning is a life-long pursuit. Learn from more experienced surgeons, listen to your trainees. From the Biblical book of Proverbs, we learn that ‘in the multitude of counsellors, there is safety’.

I urge you to give something back to your College. Twenty seven years ago, I was in the position you are today. I was determined to serve and the College gave me the opportunity to. Today I have been given the highest honour this College has to offer. Seek every opportunity to serve. Share your surgical knowledge and try to impart skills to others. Doing so will not diminish what you know or can do. On the contrary, it enhances it. We must build disciples who will carry on the race as we fade away. As the saying goes, there is no success without successors!

Acknowledgments

Unto the LORD be the glory! I am but His creation and a tool in His hand.

I am grateful to God for the people He inserted into my life at critical points to assist and to guide me. In the WACS, I have had the privilege of working with several past Presidents and other officers. I have learnt so much from them all. I am particularly grateful to the current members of the executive for their support, counsel and encouragement over the period that we have worked together. I look forward to greater cooperation as we all work to make the College better.

Ten years ago, on the day I returned from the 45th WACS Conference in Cotonou, I was involved in a road crash that threatened to take me away from this planet prematurely. I am very grateful for the surgeons and other health care workers that God used to put me back on my feet. I want to specially thank Professors Temitayo Shokunbi, Segun Ogunlade and Juwon Arotiba, and Dr. O. Afuwape, who led different teams of surgeons and nurses to deal with my injuries then. They are all Fellows of WACS and their professionalism testifies to the quality of the surgeons that are Fellows of this College.

I want to thank all my colleagues from the College of Medicine, University of Ibadan and the University College Hospital, Ibadan. I have received tremendous support from you over the years. That support led to my having the opportunity to serve as the Provost of the College of Medicine from 2006 to 2010. You have also supported me in my work for the WACS. Thus, I have had the singular honour and unique privilege of holding the top leadership positions in the medical school that provided my undergraduate training and the college where I had my postgraduate specialist training. I am deeply humbled at having been so blessed!

If I look and sound confident outside, it is because of the support I have received from home. I am grateful to my parents, Papa Julius Ladunjoye Omigbodun and Mama Regina Olatide Omigbodun, both of blessed memory, for the values they instilled in us. They were always there to support me. I thank all my siblings for their support and encouragement over the years. I am also grateful to members of the extended families and my in-laws.

Today may be memorable but I still believe the most memorable day of my life was when I got Olayinka Olusola Banjo Omigbodun to sign the dotted lines as my partner for life. She is an accomplished professional and a global leader in the world of child and adolescent psychiatry, but that has not interfered with her ability to support me and care for me. Together with our children, Akinyinka and Iyeyinka, she has provided a haven from which I could go forth with confidence and return assured that I would find succour and comfort. I can never thank them enough.

Finally, I am most grateful to my creator, the Almighty, immortal, invisible, the only wise God. In Him I live and move and have my being. All that I am and will ever be are determined by Him. All glory and honour be unto Him forever.

Distinguished Fellows, Ladies and Gentlemen
Long live the Republic of Cote d’Ivoire
Long live the West African College of Surgeons!
Thank you all.

REFERENCES

1. Omigbodun A. West African College of Surgeons International Visitor; Postgraduate Surgical Education in West Africa: Evolution and Trends. Journal of Surgical Research, 2014; 186 (2): 554
2. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ. Retention of rural family physicians after 20-25 years: outcomes of a comprehensive medical school rural program. Journal of the American Board of Family Medicine, 2013; 26(1): 24-27
3. Rourke JT. Postgraduate medical education for rural family practice in Canada. Journal of Rural Health, 2000; 16(3): 280-287
4. Barroso E. The pleasure of surgery: my pleasure in being a surgeon Annals of Surgery. 2014; 260(5): 717-720.
5. Debas HT. Surgery: a noble profession in a changing world. Annals of Surgery, 2002; 236: 263–269.
6. Neuhaus P. Why should young doctors choose to become surgeons? Annals of Surgery, 2007; 246: 911–915.
7. Clavien P-A. Targeting quality in surgery. Annals of Surgery. 2013; 258: 659–668.
8. Rothmund M. Surgical leadership. British Journal of Surgery, 2013; 100: 577–579
9. Jacobs LM, Burns KJ, Darko R. Development of the medical and surgical simulation institute, Accra, Ghana, West Africa. Bulletin of the American College of Surgeons, 2010; 95 (6): 23–30

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