The journey to being a doctor is not for the poor or faint-hearted

Training one doctor in Kenya takes at least Sh3.5 million in fees. [iStockphoto] "I want to be a doctor." "I want to be a neurosurgeon." For years, these have been the aspirations of enthused high-achieving teenagers, riding the crest of Kenya Certificate of Secondary Education (KCSE) results. The youngsters, overwhelmed by attention, songs, piggyback rides and dazed by media cameras, have always considered medicine one of the high-flying careers in Kenya. Well, it was until times changed. Unknown to many, the profession thirsted after by youngsters as the seat for the best brains, is today bedraggled by many stumbling blocks. It is today a career filled with cases of 'downing tools' and carrying placards while marching on the streets to demand fulfilment of 'some prior Collective Bargaining Agreements'. And as The Standard found out, by the time a medical trainee in Kenya walks out of university and secures a place in the now famous programme described as medical internship, they have stacked up over Sh3.5 million in loans. Loans that must be cleared by the youthful medics before they embark on planning their lives. But this is only if they are educated through funding by the Higher Education Loans Board (Helb). The self-sponsored ones would have spent Sh3.8 million on fees alone, besides other expenses incurred on accommodation, transport and food. As of today, doctors have been on strike for more than 45 days, the payment of intern doctors acting as an incendiary for the industrial action. The Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) is demanding that the interns be paid the agreed amount of Sh206,000 and not Sh70,000 as proposed by the Salaries and Remuneration Commission. They are also demanding improvement of working conditions, infrastructure and facilitation to pursue post-graduate studies. While the doctors are fighting for their juniors who are about to join the profession officially, the government claims that the interns are students and cannot be paid that amount. During an interview on KTN News, Public Service Cabinet Secretary Moses Kuria said interns are students. "This is a guy who has just done his last CAT (Continuous Assessment Test). We have budgeted for doctors we do not have a budget for students," he said. However, medical experts differ with Kuria's version. "Interns are not students. This is a graduate, if there were no processes they would go on and start working as doctors. We need to understand that an intern is not a student, because if they were, then they would go back to the university and graduate," says Dr. Diana Marion, the Secretary General of the Kenya Medical Association (KMA). Kibet Shikuku, Head of Operations at Nairobi West Hospital and a lecturer at The University of Nairobi, says the moment medical students complete their first degrees, they graduate. However, they need to be assessed during the internship for proficiency purposes. "By the time you are graduating as a doctor, you actually are someone who should be relied upon, but then you need some level of supervision for you to fine-tune your skills," says Dr Kibet KMPDU Deputy Secretary General Dennis Miskellah adds that internship postings should be in January-February or June-July. "Most universities do not align their graduation with these postings so if someone graduates in July they have to wait until February. If the government does not honour the posting like this year, that means there is someone who graduated last year and they have not been posted," he says. There are 73 internship centres where interns are distributed randomly. There's no luxury of choosing where to do internship. "You can be from Bungoma and you are posted to Lamu, so you have to plan your transportation, accommodation, and everything and that is the challenge now when we talk about the internship salary," he says. One would wonder why medicine takes at least six years to study, and why there are students who never complete the race. Kibet says the medical training is intense, hence the number of students reduces every year. The number that started in year one is not the number that will graduate. "Every year there is an exam and this is what will distinguish the boys from the men, every year we get a good number of dropouts. When you finish with year one, out of 600 students you get 200 failing, and that happens gradually, to the extent that by the time they are graduating, we have around 50-60 per cent of the original number graduating," he says On the cost of training doctors, this varies. There are self-sponsored students and those who rely on the Higher Education Loans Board. "The University of Nairobi charges between Sh600,000 and 700,000 per year, a small number is sponsored by the government, says DR Shikuku, adding, "The figures could be much higher than that." He states that the figure is just the tuition fee since there are other costs like accommodation books, and other basic needs, which can push up the expenses by more than Sh1 million per year, depending on the medical school and its annual activities. According to Dr Diana Marion, by the time the students complete their training, they owe so much, some to so many institutions. "If your parents pay for you per year, they will pay Sh638,000. For the Mama Mboga child to become a doctor, they will have to take Sh571,000 per year from Helb and be expected to pay at the end of it all. So by the time that child of Mama Mboga graduates s/he owes so much. It is a cycle of poverty," she says. When Dr Marion and her peers trained in the early 2000s, the annual fee was Sh38,000. The parallel programmes were not available then. Currently, medical students receive a loan of Sh571,000 for six years. The Helb loan has a compounded interest of 4%. "The interest continues to accumulate until the day you get a job so that you can start paying back. By the time you graduate and become a doctor, you already owe the government a lot of money. Sadly, you will come out here to the field and somebody says during internship you will be paid a stipend. This stipend is subjected to tax, you cannot pay your loans or sustain yourself," says Marion According to the Kenyan medical training programme, the first three years are set for basic sciences: Anatomy, Physiology and Biochemistry. These number of years are for understanding how the human body functions by operating cadavers. A cadaver is a human body used by medical students, physicians, and other scientists to identify disease sites, determine causes of death and provide tissue to repair a defect in a living human being. "For an individual to train as a doctor other than going through theory, you also must accompany that with some practicals. If you want to understand the anatomy of a body you must dissect a cadaver, then gradually learn to treat those who are alive," says Kibet. Physiology will help in knowing how the body works. If one has a fever, the doctor has gone through a series of training for them to process what the fever is. And come up with a diagnosis. Biochemistry helps in understanding the system. What are the chemicals changing, and how much does the pain change how the patient is thinking? In the third year, students are taught about forensic medicine. "Forensic medicine means that if I get somebody who has died from a road traffic accident, I need to understand which impact caused what. Even later when you decide to be a pathologist that general doctor can do a postmortem, they are trained in the basics of forensic medicine and pathology," says Marion The fourth, fifth and sixth years are a whole series of clinical periods for medical students. Fourth will be an introduction but by the sixth year, they are supposed to be ready to serve the population. "When you enter into the clinical spaces as a medical student, you will work with your teachers. For example, Moi University, the training hospital is Moi Teaching and Referral Hospital, on the fourth year you are now allowed to go to the wards," says Marion Kibet adds that once those formative years are done, they graduate and start performing clinical work. The formative years happen in Chiromo for the University of Nairobi and the clinical years at Kenyatta National Hospital. During the formative years, students are allowed to take the history of the patient, examine them, and present to the teachers. They are rotated in several departments so that they now understand what they learned in the basic sciences. They are then mentored and examined during their journey. They can observe operations in theatres but as students. They also assist but do not perform the actual procedures because they are not licensed doctors. During the clinical year, the tests change. They are given living patients to talk to as a test, if they satisfy the requirements they then move to the next level. "During the training from year one to the final year you will be attached to a community based on your level. You will go to the villages and health centres to collect some data. You are being nurtured into the profession so that by the time you are posted, it is nothing new to you," says Marion Once they graduate, The Ministry of Health and the Kenya Medical Practitioners and Dentists Council (KMPDC) have put in place a process to be fully registered and to practise independently as doctors. The internship period is defined within that structure. After graduation, the interns have a temporary license from KMPDC that runs for 12 months. They only attend to patients under supervision. They are not students but doctors hence the temporary license to work. "The same way when you go to a hotel and get a receptionist, the first point of contact if you come to my labour ward, you will get midwives and the medical officer intern. The first doctor who will see you is the intern, why I say they are not students is because they are allowed to write in your file. We do not allow students to write in a patient's file because a file is a medical-legal document," says Marion KMPDC Chief Executive David Kariuki says interns require those who have been there before them to guide them on how to translate their academic knowledge, that is the apprenticeship period. "The new graduate is a qualified doctor only that they are not registered to operate independently. So for one year, they are supervised. We always say first do no harm," says Dr Kariuki. Years before, the internship was always guaranteed immediately after completing school. However, now it may take a while due to various reasons. All medical schools have to maintain certain standards for them to produce quality graduates. Currently, Kenya has 11 medical schools and two dental schools. Without challenges, the medical programme takes at least six years. Challenges mean not repeating a year or exams. The dental programme takes five years. Currently, approximately 1,000 doctors graduate each year. For those who have trained locally, it is the mandate of KMPDC to set the standards through licensing and regulation of training, registration, inspections and professional practice. "As a medical council, our mandate is to set the minimum standards for the training of medicine and dentistry. We set what we will expect for a doctor trained in Kenya to provide accurate services in Kenya. We also inspect the medical schools to ensure they have the necessary facilities, this is what we do in conjunction with the Commission of University Education," adds Kariuki. For medics who train locally, KMPDC ascertains the quality provided by universities. Hence, once they graduate, they do not take them through another exam before securing internship. However, the case is different for those who train outside the country. "Those who train outside of our borders undertake an examination because we have not been able to ascertain the level of facilities and training that they undertake in the countries they go to. They undertake what we call an internship qualifying examination. There's a set pass mark, then they are allowed to start the internship," says Kariuki There's another category of those who train outside the borders and take internships in those countries. For them, once they provide proof, they are only subjected to a pre-registration examination. The internship programme helps medical trainees in determining where their strengths are, hence their choice of specialisation. There people who make decisions during the internships. That is what informs the masters programmes which again take different durations for different courses. Each department takes 10 weeks, before they are signed off and moved to the next level. Dr Miskellah says that the internship is a 12-month fixed contract. There's no leave, if you fall sick you will continue without a salary. "If you are a lady and you get pregnant, there's no maternity leave. if you take maternity leave you will have to come back and finish the months you were away without pay," says Miskella So, what happens after internship? The supervisor who, is a registered practitioner in Kenya, appends their signature on a document that certifies that the doctor is well trained and can work independently. The document is then presented before the Medical Council for full registration. Each doctor has a registration number that cannot be shared. Those who want to practice independently are required to request for licences that allow them to do so within the Kenyan borders. But those who would like to push beyond the borders, all they need is registration to seek opportunities elsewhere. No job after internship For years now, automatic absorption of doctors by the ministry has not been a guarantee. When interns get their licences some hit the road in search of jobs just like in any other sector. "Some counties persuade the doctors to continue volunteering saying they will absorb them once there's an opening. Six months down the line, no pay, you run out of funds. There's a doctor who killed himself in Kangundo last year after volunteering for six months," says Miskellah. KMPDC also punishes practitioners found culpable of malpractice. Some of the drastic punitive measures include revocation of the offending doctor's licence or deregistration and possible prosecution in the courts for criminal offenses. With the ongoing crisis in the public health sector that continues to degenerate each passing, Marion says it is unfair to pay interns stipends and say that a doctor who is doing calls is not eligible for an allowance. "The nature of humans is if you are put in a tough spot you are forced to adopt. The worst thing that can happen is to force these young people to get some meagre pay and if they have to survive they will force patients to pay for procedures they shouldn't be paying for. You start losing the integrity of a profession because they have to find a way to survive," she adds As talks between KMPDU and the government dragged on, President William Ruto urged doctors to live within their means. "We mind about them (doctors), we value the service they give to our nation but we must live within our means. The resources we have are only sufficient to pay Sh70,000, to interns, it is not a salary it is a stipend for only one year and they will be employed," said the president "Living within your means is a very bad statement from the head of state. What is living within your means? Maybe that is the definition we need to understand. So, whose means are we describing?" Marion poses. Marion says the country should focus on giving its people fundamental rights: Education, good health and security. "What we are seeing is killing the profession of medicine in a way that no young child will dream of becoming a doctor."

The journey to being a doctor is not for the poor or faint-hearted

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