By Dr Awkadigwe Fredrick Ikenna
(MBBS, LLB, MWACS, DSC)
The term “internship” is the most abused money-spinning coinage in the Nigerian Teaching Hospital setting. This term has witnessed untold employment and usage by different categories of health professionals to obfuscate the players in the use of the national treasury under the guise of legitimate and legal prosecution of statutory requirements.
The categories of health professionals who have capitalized on the ignorance of the Nigerian health services leaderships and government, about the legality or otherwise of the medical and paramedical internship programmes, to redistribute the meagre national resources on health include the medical laboratory scientists, the pharmacists, the radiographers, the physiotherapists and now the nurses. These health professionals have obtained circulars from the relevant ministries that have empowered them to undertake paid internships in the Nigerian Teaching Hospitals.
This article aims at finding the meaning of internship, discovering the meaning of medical internship, clarifying the categories of health professionals whom their enabling laws require that they undertake the internship programs, point out the categories of health professionals who can undertake such internship programs in our teaching hospitals, find out the categories of health professionals that the Teaching Hospital laws permit to do their internships in the teaching hospitals, and then conclusively determine the categories of health professionals whose internship programs are relevant in the Nigerian Teaching Hospitals.
Internship program has been described as the position of a student or trainee who works in an organization, sometimes without pay, in order to gain work experience or satisfy requirements for a qualification.
According to Cambridge Dictionary, Internship means:
1. A period of training spent in a hospital by a young doctor in order to finish their medical qualification
2. A period of time during which a student works for a company or organization in order to get experience of a particular type of work
3. A period of time spent receiving or completing training at a job as a part of becoming qualified to do it.
It is clear from the foregoing that internship is not synonymous with a compulsory preregistration health professionals requirements as is being bandied about by the preregistration paramedical in the Nigerian Teaching Hospitals. In fact, most of the paramedical professionals have no need for this program. The program is neither a preregistration requirement, nor a necessary process in their professional progression.
Internship is not a hospital based paramedical duty or activity. It could be undertaken in any establishment outside the hospital setting. It can be done in a bank by banking graduates, in an engineering establishment by engineering graduates, in the correction facilities or in any place relevant to the practical experience of the intern. It only becomes a hospital based activity if it involves the medical graduates going for their horsemanship programs during their medical internship.
It must be stressed that Internship Programs are requirements of law. In other words, professionals undertake internship programs because the laws creating their professional bodies require that they undertake the internship programs.
Thus, no professional body can just wish in internship program or wish it out. No professional body, created by law, can suddenly prescribe internship programs for their graduates if the law creating such professional bodies did not enact internship into their enabling laws.
It is trite law that once legislature has legislated on a subject matter, executive fiat is incompetent to modify or alter the provisions of the law. Even where the executive order is provided for, its exercise shall be strictly limited to the area of its relevance and application. The powers of the Minister are always circumscribed in the enabling laws. Only legislative alterations in the unaffected provisions of the relevant legislation can bring in modifications. The federal and state governments are incapable of using circulars to bring into operations what is not contemplated in a federal or state legislation enacted for the subject matter.
It does not just stop at the enabling laws prescribing internship in their laws. The enabling laws shall also define what is intended to be done as the internship as well as the modus operandi; where the internship shall be undertaken; and where the internship programs would be done outside the training institutions of the professional body, the proposed accepting internship institution shall be so created as to be able to accept such professional body for the internship program.
Thus, in the instant cases under discussion, the enabling laws of the relevant health professional bodies must prescribe internship requirements for professional progression, and the Teaching Hospitals where they intend to undertake their internship attachments, must be legally empowered to accept such interns. An institution solely built for the training of lawyers, for instance, cannot be given the function of training accountancy interns by the law creating accountancy profession. A law for an establishment cannot create functions for another establishment if that other establishment is strictly limited in scope.
We shall now look at the different health professionals and their enabling laws to see those that are statutorily qualified to perform internship programs in the Nigerian Teaching Hospitals and those that are not. We shall then discover the level of illegal activities perpetrated by some Chief Medical Directors in our teaching hospitals. Those Chief Medical Directors abandon the laws that they are appointed to apply, and implement their personal whims and caprices.
First off, we look at the medical profession and horsemanship program. The relevant provisions of the Medical and Dental Practitioners Act which is the Act that regulates the training of medical practitioners, and the issue of medical internship, are self explanatory, and are hereby laid down below.
Section 8 of Medical and Dental Practitioners Act (MDPA): Full registration of medical practitioners and of dental surgeons
1. Subject to section 16 and to Rules made under section 6(4) of this Act, a person shall be entitled to be fully registered as a medical practitioner or as a dental surgeon if –
(a) he has attended a course of training approved by the Council under section 9 of this Act as respects the medical or dental profession, as the case may be;
(b) the course was conducted at an institution so approved, or partly at one such institution and partly at another or others;
(c) he holds a qualification so approved; and
(d) he holds a certificate of experience issued in pursuance of section 11 of this Act.
(2) Subject as aforesaid, a person shall be entitled to register any postgraduate qualification if the qualification is approved by the Council in a specialized branch of medicine or dental surgery.
Section 9 MDPA: Approval of courses, qualifications and institutions
(1) Subject to subsection (2) of this section, the Council may approve for the purposes of the Act.
(a) any course of training which is intended for person who are seeking to become, or are already members of the medical or dental profession and which the Council considers is designed to confer on person completing it sufficient knowledge and skill for the practice of that profession or for practice as members of a specialized branch of that profession;
(b) any institution in Nigeria which the Council considers is properly organized and equipped for conducting the whole or any part of a course of training approved by the Council under this section;
(c) any qualification which, as a result of an examination taken in conjunction with a course of training approved by the Council under this section is granted to candidates reaching a standard at the examination indicating, in the opinion of the Council that they have sufficient knowledge and skill to practice the profession in question or to practice as members of a specialized branch of that profession.
(2) The Council shall not, in pursuance of subsection (1) of this section, approve a qualification granted by an institution in Nigeria unless the qualification bears one of the following designations (with or without the addition of words indicating specialization in a particular field), that is to say –
(a) Bachelor of medicine and surgery; or
(b) Bachelor of dental surgery.
(3) The Council may institute an assessment, examination for holders of foreign medical or dental qualifications recognized by the government of the Countries from where such qualifications were obtained.
(4) The Council may, if it thinks fit, withdraw any approval given under this section in respect of any course, qualification or institution, but before withdrawing such an approval, the Council shall –
(a) give notice that it proposes to do so to each person by whom the course is conducted or the qualification is granted or the institution is controlled, as the case may be;
(b) afford each such person an opportunity of making to the Council representations with regard to the proposal; and(c) take into consideration any representations made as respects the proposal in pursuance of paragraph (b) of this subsection.
5. As respects any period during which the approval of the Council under this section for a course, qualification or institution is withdrawn, the course, qualification or institution shall not be treated as approved under this section; but the withdrawal of such an approval shall not prejudice the registration or eligibility for registration of any person who by virtue of the approval was registered or eligible for registration (either unconditionally or subject to his obtaining a certificate of experience) immediately before the approval was withdrawn.
6. The giving or withdrawal of any approval under this section shall have effect t such date, either before or after the execution of the instrument signifying the withdrawal of approval, as the Council may specify in the instrument and the Council shall;-
i. as soon as may be, publish a copy of every such instrument in the Federal Gazette; and
ii. not later than seven days before its publication as aforesaid, send a copy of the instrument to the Minister.
Section 11 of MDPA: Certificate of experience
(1) A person who, after obtaining an approved medical or dental qualification, satisfies the conditions specified in subsection (2) of this section shall be entitled to receive free of charge a certificate of experience in the prescribed form.
(2) The conditions which a person must satisfy under subsection (1) of this section are —
(a) he must have been employed for the prescribed period at a recognized institution in Nigeria with a view to obtaining a certificate of experience and have resided throughout that period either in the institution or near to it in accordance with requirements in that behalf specified in the terms of his employment;
(b) he must have acquired during his employment practical experience under the personal supervision and guidance of one or more fully registered medical practitioners in the practice of surgery, midwifery, medicine or dental surgery, as the case may be, for such periods as may be prescribed in relation to each of those subjects respectively; and
(c) the manner in which he carried out the duties of his employment and his conduct during the period of his employment must have been satisfactory.
(3) Any period spent under subsection (2) of this section by a person during his employment in acquiring experience of the techniques for safeguarding and improving the health of children or public health or of the activities carried on in a recognized health centre shall be calculated for the purposes of that subsection as periods in the practice of medicine.
(4) It shall be the duty of the person in charger of a recognized institution at which a person is employed with a view to obtaining a certificate of experience to ensure that the last-mentioned person is afforded proper opportunities of acquiring the practical experience required for the purposes of subsection (2) of this section.
(5) Where after having been employed as mentioned in paragraph (a) of subsection (2) of this section at any institution, a person is refused a certificate of experience he shall be entitled to–
i. receive from the person in charge of the institution particulars in writing of the grounds of the refusal; and
ii. appeal against the refusal to a committee of the Council in accordance with Rules made by the Council in that behalf (including Rules as to the time within which appeals are to be brought); and after duly considering any such appeal the committee shall either dismiss the appeal or issue the certificate of experience in question or give such other directive in the matter as it considers just;
(6) The Council may make regulations to provide for the issuance of certificate of experience in respect of employment at institutions outside of Nigeria .
(7) In this section and in section 12 of this Act. “recognized” means recognized for the time being for the purposes of those sections by order of the Council.
Section 12 MDPA: Provisional registration of medical practitioners and dental surgeons
(1) A person who has obtained an approved medical or dental qualification and satisfies the Registrar that he is of good character and he is about to be employed as mentioned in paragraph (a) of subsection (2) of section 11 of this Act, shall, subject to the provisions of section 15 and of Rules make under section 6 of this Act, be entitled to be provisionally registered as a medical practitioner or dental surgeon.
(2) A person who is provisionally registered shall, for the purposes of his employment at any recognized institution with a view to obtaining a certificate of experience, but not for any other purposes, be deemed to be fully registered.
Section 21 MDPA: Interpretation.
(1) In this Act, unless the context otherwise requires—
“Certificate of experience” means a certificate granted in pursuance of section 11 of this Act”.
From the foregoing provisions of the Medical and Dental Practitioners Act, it is very clear that a graduate medical student must undertake internship program and obtain a Certificate of Experience before he can be fully registered as a medical practitioner. It is clearly intended by Legislature that a medical graduate cannot practice medicine until after the prescribed housemanship program. There is therefore a statutory requirement and prescription for internship by a medical graduate in Nigeria.
The next question is whether this experience must be in a hospital. The provisions of section 11 of the Medical and Dental Practitioners Act is clear that this period of internship must be in a hospital under a trainer.
The ball has not stopped and rested here. The next question is whether the hospitals chosen and selected by the Medical and Dental Council of Nigeria are legally empowered to accept and train medical interns. The answer to this query can easily be found in all the relevant enabling laws of the various Teaching Hospitals in Nigeria. A look at the provisions of the Lagos State University Teaching Hospital Act is instructive:
LAGOS UNIVERSITY TEACHING HOSPITAL ACT
An Act to provide for the establishment of a teaching hospital for the University of Lagos and of a management board for the hospital.
[28th December, 1961] [Commencement.]
1. Short title
This Act may be cited as the Lagos University Teaching Hospital Act.
2. Establishment of the Hospital and the Management Board
(1) There shall be established in Lagos a teaching hospital, to be known as the Lagos University Teaching Hospital, for the purpose of providing such facilities for the training of medical students as are usually provided by teaching hospitals of internationally high repute.
(2) There shall be established a board of management for the hospital, which shall be a body corporate by the name of the Lagos University Teaching Hospital Management Board.
3. Composition, functions, etc., of Board
The composition, functions and powers of the Board established under subsection (2) of section 2 shall be as provided for in the University Teaching Hospitals (Reconstruction of Boards, etc.) Act.
From the foregoing provisions, it is abundantly clear that Teaching Hospitals are the places for the training of medical students. Medical students are defined by the relevant laws as undergraduate medical students and postgraduate medical practitioners. Housemanship belongs to the postgraduate part of the medical studentship.
The selection of Teaching Hospitals for the medical internship in Nigeria is thus an apt, legal and valid selection, and the Teaching Hospital medical internship program is therefore a valid, statutory and legal program.
Going further to the paramedical internship, it may baffle the reader that none of all the paramedical professional bodies is empowered by their enabling laws to undertake internship programs. The only enabling law that furtively mentioned Internship and Certificate of Experience had no meaning attached to the brisk mention, neither did it provide for the exact venue for such a program. Worse still, the singular professional body of medical laboratory science is not among those professional bodies listed in the laws that can be trained in a Nigerian Teaching Hospital.
In conclusion, the current internship programs undertaken in the fields of pharmacy, medical laboratory science, physiotherapy, radiography, optometry, and now nursing, are all illegal acts perpetrated by the Chief Medical Directors in cahoots with the Ministry of Health in total usurpation of the legislative functions of the Legislature, and in total violation of extant laws regulating professional bodies. They are a pugnacious violation of the Teaching Hospital laws.