Training is a core business of the Council. It assures the public that a doctor whose name appears on the medical register has met appropriate training standards for medical practice in Ghana. It protects both the public and the profession by ensuring that entry and continuing registration are granted only after the necessary training standards have been reached.
Hitherto, Housemanship training has been for one year. In October, 2004, the Ministry of Health (MOH) in consultation with the medical and Dental Council (MDC) undertook a policy change to make Housemanship training two years. This was not new in that years gone by one finished two rotations in the Teaching Hospital and continued with the other two in a Regional Hospital, under the supervision of a Specialist. It was after this period that one was considered safe to practice on his own. Unfortunately, with the decreasing numbers of Specialists in the regions coupled with the need for doctors in the rural areas, House officers were deployed to these areas, having had practical experiences only in the disciplines covered in the Teaching Hospitals.
Factors such as economic and manpower resources, socio-cultural and political considerations influence health planning and medical education policy in a variety of ways. The increasing awareness of the public and their human rights and the era of National Health Insurance Scheme (NHIS) both increase the demands for professional conduct on the House Officer who also is faced with an apparent overwhelming number of clients to care for. The formulation of the objectives of Housemanship training is, therefore, a subject that requires repeated consultations between institutions and Governmental agencies responsible for health, the political authority and representatives of the public to be served by the house officer.
Housemanship training is a very important aspect of medical and dental training, a period during which the trainee acquires the most basic but rather crucial clinical skills to lay the foundation on which to build his/her professional medical/dental career. The training should, therefore, adequately equip the House Officer both with the scientific background and the professional skills through which to apply this scientific medical/dental knowledge to the solution of health problems.
The Medical & Dental Council, therefore, considers the development of the document appropriate on the occasion of Ghana @ 50 where issues of effective health care delivery dominate discussions aimed at seeing Ghana attain the Millennium Development Goals and achieve a middle income status.
The major hurdle, however, is its implementation. The Medical and Dental Council with the shared value of ‘Guiding the Profession, Protecting the Public’ counts on all stakeholders to make Housemanship Training both an interesting and professionally impacting period for the trainee to enhance the overall health care delivery system in Ghana.
DR. K. O. ADADEY
CHAIRMAN OF COUNCIL
JANUARY, 2008
THE PROCESS
1.1 THE RATIONALE
The Ministry of Health in 2004 in collaboration with the Medical and Dental Council reviewed its housemanship training programme and decided to extend it from one to two years. This was to ensure a more comprehensive coverage of the basic clinical disciplines during internship. This is in line with current practice in many countries.
The Council after a due process of planning and sensitization of stakeholders commenced the programme in October, 2004. The sensitization programme included a workshop for heads of accredited institutions and other stakeholder.
Two years have elapsed since the new programme began. The Council decided to review the programme, noting the peculiar experiences and to evaluate emerging challenges with the view of making recommendations to improve the programme.
1.2 METHODOLOGY
Two review workshops were organised on the experiences, challenges and the way forward for heads of accredited institutions and other stakeholders. One for the Southern sector on 1st June, 2007 in Accra and one for the Northern Sector on 15th June, 2007 in Sunyani.
The workshops were opened and chaired by the Chairman of Medical and Dental Council.
Presentations were made by:
- Registrar, Medical and Dental Council
- Representatives from Teaching Hospitals
- Representative from CHAG
- Representative from 37 Military Hospital, Accra
- The Director, Human Resource, Ghana Health Service
- Representative of the Pioneering Group of the two-year Housemanship Training Programme.
- Representative from Ghana Health Service (GHS) – Head of an Accredited Institution under GHS.
The presentations were followed by group discussions on various aspects of the 2 year Housemanship Training Programme. These were:
- The Policy
- Accreditation
- Training Programmes
- Supervision and Coordination
- Recruitment and Deployment
- Conditions of Service
- Financial responsibilities
- Disciplinary Procedures
- Future Plans
Recommendations were made on the way forward towards improving the programme.
A Core Committee was constituted to compile a report on the experiences, challenges and recommendations on the way forward. The Committee comprised:
- Dr. K. O. Adadey, Medical & Dental Council
- Dr. E. K. Atikpui, Medical & Dental Council
- Dr. Ken Sagoe, Ghana Health Service, (HRD)
- Dr. Promise Sefogah, KBTH
POLICY AND ACCREDITATION
2.O THE POLICY
2.1 PREAMBLE
The urgent need for medical manpower has forced Agencies under the Ministry of Health to post some doctors to stations in the districts soon after completing their housemanship. The house job has usually been in Internal Medicine with Obstetrics and Gynaecology or Surgery with Paediatrics.
In an increasingly litigious society, it has become necessary to broaden the preparation of the physicians before they are fully registered as practitioners, ready for district posting.
2.2 ROTATION
- Each house officer (Medical) shall do four (4) rotations in all the major specialties – namely Internal Medicine, Surgery, Paediatrics, and Obstetrics and Gynaecology.
- Each rotation should last for six (6) months including proportionate leave
- Each House Officer (Dental Discipline) shall do all 3 major specialties namely Oral and Maxillofacial Surgery, Restorative Dentistry and Preventive Dentistry.
The House Officer during the 2nd year shall for convenience be referred to as Senior House Officer and also to ensure there is no financial loss to him/her as he or she shall receive the remuneration of ‘medical officer’ during the second year.
2.3 LEAVE
- Each House Officer is entitled to eighteen (18) working days leave per each 6 month rotation which must be taken during the rotation.
- Each House Officer (Dental) is entitled to 12 working days leave per each 4 month rotation which must be taken during the rotation.
- Maternity leave period shall be as per the provisions in the labour law
2.4 EXTENSION OF ROTATION PERIODS
- In case of non-performing House Officers, female House Officers taking maternity leave, etc. an extension in the period of Housemanship should be at the discretion of hospital management in consultation with the institutional coordinator and the Medical & Dental Council duly notified.
- Any further extension after the initial extension period should be referred to Medical and Dental Council.
2.5 LOCATION FOR TRAINING
- Two rotations (and not more), preferably the first two MUST be done in the Teaching Hospital or 37 Military Hospital.
- The other rotations shall be done in any other accredited institution.
2.6 ACCREDITATION
2.6.1 Guidelines for Accreditation
2.6.2 Introduction
The Medical and Dental Council is the statutory governmental agency that regulates the standards of training and practice of medicine and dentistry in Ghana. It was established under the Medical and Dental Decree. 1972 (NRCD 91), specifically Section 4(2) (a) states:
‘’ensure that courses of study and training in medicine or dentistry at any Medical School or University in Ghana are such as can sufficiently guarantee possession of the knowledge and skill needed for the efficient practice of medicine or dentistry’’.
There is general acceptance that some external process of evaluation of training programmes and the quality of practitioners of training institutions is required to ensure that the professional standards of any one training institution do not fall below acceptable standards and that practitioners are suitable for the full registration as interns under supervision.
2.6.3 Accreditation Procedure
The process of accreditation shall be as follows:
- Council Identifies an institution or an institution applies for inspection and accreditation.
- Questionnaire is forwarded to the institution for filling (as attached for the various disciplines, Appendix VIII).
- Questionnaire is completed and returned to Council.
- Team of Inspectors identified, informed and commissioned.
- Date is set for the inspection and communicated to team and the institution
- Inspection conducted and report submitted to Education Committee
- Report discussed by the Education Committee
- Recommendations submitted to Council for consideration
- Council approves accreditation or otherwise
- Council’s decision is communicated to the institution.
2.6.4 Departmental Check List for Discipline to be accredited
Departmental check list for each discipline to be accredited shall be as per the attached appendix.
2.6.5 Minimum Manning Level
For each discipline, the number of trainees allowed shall be based on the number of specialists, junior specialists and medical officers available. The appropriate numbers shall be determined by Council during its consideration of the accreditation.
2.6.6 Monitoring and Evaluation
Following accreditation:
- Institutions shall submit bi-annual Reports on housemanship training activities to Medical and Dental Council covering:
- Number of trainers available per accredited discipline
- Number of House Officers admitted per each accredited specialty
- Equipment available.
- Any concerns regarding housemanship training.
- Recommendations
2. An accredited institution shall duly inform Council of any movement of specialist to/from the institution within two (2) weeks of the transfer.
3. Baring any transfer of a specialist for an accredited discipline from an accredited institution, Council shall normally review an accredited institution/discipline every two (2) years for possible renewal or otherwise.
4. House officers shall conduct a Compulsory Evaluation of their training through a designed evaluation form to be submitted together with logbooks before full registration. (Sample attached as appendix III)
TRAINING PROGRAMMES, SUPERVISION AND COORDINATION
3.1 PREAMBLE
Various observations were considered, critically analysed to arrive at workable guidelines on the way forward.
3.2 OBSERVATIONS/ANALYSIS
3.3 THE TRAINEE
3.3.1 Job Description
Observations / Analysis and Guidelines
- Indifferent performance was prevalent among the recent batches of house officers.
- It was felt that this could derive from a lack of appreciation of what is expected of them.
- Generally, the logbooks did not carry a clearly defined job description for the house officers
- The job description of the House Officer is clearly defined (Appendix V).
- The rules and regulations for induction, provisional registration and commencement of housemanship training are explicitly stated (Appendix VI).
3.3.2 Attitudes of Trainees
Observations / Analysis and Guidelines
- The trainees took the Housemanship training as a routine but not as an essential professional training period.
- Many house officers do not put up essential professional behaviour.
- Logbooks do not meet specific requirements e.g. knowledge, skills and attitude.
- Effective evaluation of log books shall be done at least weekly basis, to ensure that planned programmes are achieved.
- Mid Rotation assessment of the House Officer during each rotation is recommended to ensure that the requisite knowledge and skills are acquired.
- Logbooks should be certified on completion of each rotation by the trainer before inception of the next rotation.
- At the Institutional level, regular periodic lectures on ethics shall be held for House officers who should attend compulsorily.
- Consultants and Specialists shall during general ward rounds discuss ethical issues peculiar to clinical cases e.g. “care for the terminally ill patient”
- The Medical and Dental Council shall hold at least one yearly seminar on professional ethics for House officers using reported cases at the Penal Cases and Disciplinary Committees as case studies. These seminars shall be compulsory and held for Southern and Northern sectors.
3.3.3 General Appearance
Observation / Analysis and Guidelines
- Current presentation of some House Officers in public sometimes compromises their dignity and status in the community.
- A House Officer shall be neatly and decently dressed at all times.
- White Coats and Name Tags are mandatory at all times in the Institution.
- Wearing of Jeans and short skirts shall not be allowed at the work place.
- Medical/Dental Schools shall emphasize and enforce acceptable decent dressing for Trainees.
3.4 THE TRAINERS
Definition
The Trainer shall be a Practitioner with any of the following Qualifications:
- Membership of a recognized College duly cleared by the Medical and Dental Council’s Credentials Committee.
- A Part One of the West African College of Surgeons
- Fellowship of any Recognized College
3.4.1 Assignment of Specialist
Observations / Analysis and Guidelines
- Deficient mechanism of transferring specialists without adequate consultation before transferring.
- Problem of poor interpersonal relationship between newly transferred specialists and Medical Superintendents of Accredited Institutions.
- Lack of decent accommodation for Specialists at the periphery.
- Following accreditation, MDC shall have a preparatory meeting with the heads of the accredited institutions to psych them up and orient them towards a mutual working relation with their specialists
- Specialists on transfer shall have an orientation session to enhance mutual, cordial and productive working relations with their respective heads of institutions.
- MDC shall undertake intense advocacy with the MOH and the GHS for mandatory provision of accommodation for Specialists at the peripheral institutions
3.4.2 Team Work
Observation / Analysis and Guidelines
- Many Specialists posted to the peripheral institutions are left alone and miss the privilege of working together as a team with other specialists. This phenomenon also occurs at all levels.
- Specialist should be posted with complimentary staff as much as possible e.g. a surgical specialist shall be posted together with an Anaesthetist as much as possible by the GHS.
- Specialists in bigger institutions at the periphery should be given oversight roles in other smaller institutions within the catchment area. i.e. one specialist could be put in charge of a group of peripheral facilities.
3.4.3 Incentives
Observations / Analysis and Guidelines
- The current level of incentives for rural posting is unrealistic.
- Postings to the rural areas deny the specialists the opportunity of making extra income compared to counterparts in the cities.
- Salaries of Trainers in rural areas need to be sufficiently augmented possibly from IGF obtained from specialist services.
3.4.4 Continuing Medial Education
Observations / Analysis and Guidelines
- There is inadequate continuing medical education for trainers
- Inadequate educational resource e.g. library space, journals, internet facilities, etc.
- Accredited institutions shall hold at least weekly or monthly academic, morbidity/mortality meetings.
- Accredited institutions shall sponsor their Specialists to CME programmes at least once a year. Programmes by the GCPS, WACPS, Ghana Medical Association, and the Colleges of Health Sciences are recommended.
- Sponsorship of Trainers to Annual Scientific Conferences of the GCPS, WACS and WACP.
- All accredited institutions shall have adequate library space, journals, internet facilities, as part of requirement for accreditation.
3.4.5 The Cost of Housemanship Training
Observations / Analysis and Guidelines
- The two year housemanship training evidently has cost areas which need to be explored. Most of these would appear to fall to the departments or the institutions accredited to engage in the programme e.g. providing educational resource materials, equipment and funds for particular teaching sessions, courses, sponsorship of Continuing Medical Education programmes etc. Some aspects of cost may fall to Council or the mother agency.
Council’s responsibilities regarding costs are:
- Cost of coordination of the programme with the Education Directorate of Council (site visits).
- Annual workshops on ethics (Northern and Southern Sectors).
- Annual meeting of Coordinators with Council.
3.5 SUPERVISION
The role of the Supervisor and Coordinator is the day to day monitoring of the trainees and trainers to ensure effective training, viz the specific job description and logbook evaluation. (Levels of Supervision and Check List for Supervision of Trainers Appendix IV &VII)
