The Membership Certification of the West African College of Surgeons and its Relevance to the Needs of the West African Sub-Region

Introduction

The West African College of Surgeons [WACS] was founded in 1960 as an association of surgeons practicing in West Africa. At inception, it had 15 members in four surgical disciplines [Anaesthesia, Obstetrics & Gynaecology, Otorhinolaryngology and General Surgery] from both Anglophone and Francophone countries in the sub-region. At the time it became a College in 1973, it had 267 Fellows, all of whom attained fellowship by election. The college’s first fellowship by examination was awarded to Dr. Oladele Olusanya of the Faculty of Obstetrics & Gynaecology in 1983. He was the 620th fellow on the Roll of the College. Since then, the College has produced at least three thousand fellows by examination from its seven faculties [Anaesthesia, Dental Surgery, Obstetrics & Gynaecology, Ophthalmology, Otorhinolaryngology, Radiology and General Surgery]. These fellows by examination qualified as surgeons after a minimum period of training ranging from five to seven years, practically all of which was spent at accredited tertiary hospitals in the sub-region.

Training Mid-Level Human Resources for Health in West Africa

Many countries in the sub-region were having difficulty getting the human resources needed to provide surgical services to their teeming populations, particularly at the secondary healthcare-facility level. These countries began to clamour for the training of a cadre of surgical service providers who would not require such a long period of training, yet would be able to render much needed services to the people, particularly in the areas outside the cities where the tertiary health facilities were located. In its quest to meet this need, the WACS introduced the ‘Diploma’ programme in the disciplines of Anaesthesia, Ophthalmology and Otorhinolaryngology in 1990. A recent audit of the effectiveness of this approach1 revealed the following: of the 311 graduates of the Diploma in Anaesthesia programme over a twenty-year span, most had served in secondary level hospitals, although only 9% were still serving in such locales. More than 60% had proceeded, or are in training, to obtain the Fellowship of the College.

Whilst the authors of that article concluded that this was a failure of the ‘Diploma’ programmes to meet the needs of West Africa for middle level human resources for health in the sub-region, another way to interpret the data is that many of these diplomates saw the diploma as a stepping stone to the fellowship. Along the way, they had rendered much needed services at district hospitals and comprehensive health centres in many countries in the sub-region. The question the WACS ought to ask is how it could reconcile the yearning of medical graduates to complete full specialist training, and obtain fellowship certification, with the pressing needs of the population for surgical services in the smaller urban settlements and rural areas of the sub-region.

Membership Certification and Provision of Essential Surgical Services

The ‘Membership’ certification recently approved by the College meets both the needs of trainees and of the population as articulated above. Surgical trainees, having completed a minimum period of training [which all the faculties in the college have agreed will be three years] and passed the required examination, will be given a membership certificate. This qualifies them to proceed on a minimum of two years of additional training that will culminate in fellowship certification, upon passing the final fellowship examination. Before proceeding for fellowship training, holders of the membership certificate could render services at the secondary health care level in smaller urban settlements and rural areas. The curricula for membership training in the faculties have been so structured that candidates for the membership examination would have acquired certain skills and competencies that would enable them provide essential surgical care at this level with minimum supervision. Having done this for a period of time, they could return to the tertiary centres to complete their specialist training for a fellowship.

Membership Certification is a Progressive Step

Having been privileged to read the opinion article titled ‘A case against the membership programme proposal of the West African College of Surgeons’,2 which appears in this issue of the journal, it is important to offer a rebuttal to some of the assertions made in the article. Membership certification is not a retrogressive step as the authors of that article suggest, offering the example of what the Royal College of Physicians and Surgeons of Canada had done in the past as evidence. It would have been a good idea if the writers had searched the records to find out why the Canadian College took the initial decision to award ‘specialist’ certificates and why they decided to stop it at the time they did. It is likely that both decisions were taken to meet identified needs in their country.

Not providing such a vital piece of information is a big omission in sustaining the argument that WACS should not award membership certification. The two situations are not analogous in any regard. In the case of WACS, there is a deliberate curriculum design and assessment method for the membership to ensure that products of the process could offer a specified range of services to the population in need. It is not a second-tier situation but an affirmative enabling step.

The solution suggested by the writers that accredited training institutions should provide ‘internal certificates’ is supported by only a single anecdotal account! The system, in the United States of America, of having separate ‘Board Eligible’ and Board Certified’ status is totally different from what obtains in West Africa. An ‘internal’ certification system is likely to create a whole new set of problems for the sub-region because of differences in the enforcement of standards and issues of favouritism and prejudice in the various institutions.

Membership certification will not create ‘a new cadre’ of surgeons who would be competing with fellows of the WACS as suggested by the writers. The curricula in the disciplines stipulate the skills-set a membership candidate is supposed to have acquired over a specified minimum period of training. The same goes for fellowship certification. It is instructive to note that the West African College of Physicians has been awarding membership certificates for more than 10 years to those who passed the Part I Examination. The Ghana College of Physicians and Surgeons has done the same. This practice has not been shown to produce any deleterious effects in the spheres of operation of these colleges.

Conclusion

Award of membership certification is likely to enhance the quality of surgical services available to people living in West Africa, particularly those living in small towns and the rural areas. It is unlikely to do any more harm to ‘unsuspecting patients’ than what currently obtains. Patients are more aware than we give them credit for. They know those who have a reputation for providing good service. Sometimes they may opt for a less than optimal source because of a lack of financial means, but they do not go looking for the paper qualifications of who is going to care for them when they are ill. The responsibility of the WACS is to ensure that those given its membership certification have the minimum skills and competencies stipulated in its training curricula so that they provide essential surgical services to the populace.

References

1. Bode CO, Olatosi J, Amposah G, Desalu I. Has the middle-level anaesthesia manpower training program of the West African College of Surgeons fulfilled its objectives? Anaesth Intensive Care 2013; 41(3): 359-362.
2. Ajao OG, Ugwu BT. A case against the membership programme proposal of the West African College of Surgeons. Journal of the West African College of Surgeons 2012; 2(3):

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