Personal Views: Revalidation: a view from Africa
Authors: Andrew R Potter
Journal: BMJ (2005)

Sooner or later, if I want to remain licensed to practise medicine in the United Kingdom, I must undergo the revalidation process. As my practice in sub-Saharan tropical Africa is different from that of my UK colleagues, I wonder whether the criteria for revalidation will be identical.

I work in a charity hospital without mains electricity or water, 15 km outside the large northern town of Parakou in temperatures ranging from 26°C to 40°C. Our diesel generator allows us to enjoy cool air only in the operating theatre. In the outpatients area I sweat, along with everyone else. An unrelentingly hot, humid working environment is not conducive to the General Medical Council's ideal of constant politeness and in-depth discussions of treatment options with my patients.

Our target population is the rural community of farmers and cattle herders, most of whom exist in grinding poverty. They still live in houses of mud and wattle with thatched roofs. Their lives are dominated by the agricultural seasons: hoeing, sowing, weeding, and harvesting. Most do not read or write, watch television, or drive cars. Their horizons are local.


Must we increase our charges to poor patients so we can pay someone to audit my work?


My specialty of ophthalmology is wonderfully satisfying in this part of the world. Every working day I restore sight to someone blinded by longstanding dense cataract. Over a year the number is in the thousands; over a career it adds up to the population of a reasonably sized town. There aren't many specialties as professionally rewarding as that.

So why am I practising single handed? Why aren't doctors falling over themselves to work alongside or in similar parts of rural Africa? After all, we all share a vocation to bring health care to those in need, don't we? In these post-Shipman days the term “single handed” rings alarm bells. Teams—that's what we need. Anyone who is single handed is suspect.

For Africa, Benin isn't short of ophthalmologists. Much of the continent has very few—one per million people, on average. This is not so in Benin, which can boast more than 20 eye specialists for seven million people. Their distribution is the problem. Most work on the coast in the twin capitals of Porto Novo and Cotonou, 30 km apart. Outside these cities, and especially up here in the north, where most of the population lives, ophthalmologists are rare.

The scandal is that most doctors and medical students come from southern families, who have no interest in working in the north, where the climate is harsher and the languages unfamiliar. Another scandal is the paucity of training programmes for producing ophthalmologists to serve in French speaking Africa. Furthermore, relevant practical training that equips future ophthalmologists for work outside cities is lacking. Many francophone ophthalmologists, even after four years of training, are ill at ease in performing eye surgery.

Because I work in what is essentially a surgical eye service in a charity hospital with modest salaries and no opportunity for private practice, I'm not overwhelmed with offers from Beninois ophthalmologists to work with me. Worse, because their training has been oriented to practice in developed countries they have an overt disdain for ophthalmology adapted to poor communities. Who among my peers here would confirm to the GMC that I give “good clinical care”?

The GMC relicensing will also require me to audit my surgical case load. With a huge and growing clinical workload I have no time to spend on auditing myself. We will have to employ a clerical officer to do the job, meaning an extra salary. Must we increase our charges to poor patients so we can pay the salary of someone to audit my work to satisfy the GMC? That some of the poorest people on this earth trek hundreds of kilometres to my clinic and struggle to pay the small fees we charge is an eloquent audit in itself. They wouldn't come so far if they hadn't heard that this is where blind people can be made to see.

How do I keep up to date? I get journals (BMJ, Medicine, Tropical Doctor, Eye, Journal of Community Eye Health among others), but out here we have no clinical meetings, workshops, or journal clubs. To attend the Royal College of Ophthalmologists' annual meeting I would need a return air ticket and a week in an expensive hotel. I managed it once, thanks to a BMA grant. The Christian Medical Fellowship (UK) runs an excellent two week residential refresher course. But does all that constitute a “learning plan”? If the GMC cannot come up with flexible proposals for British doctors serving in Africa then, to preserve my hard won freedom to practise medicine at home, I might have to retreat to the UK.

Already fewer and fewer UK doctors are offering to work overseas, other than for short assignments, because of the straitjackets of specialty training and now revalidation. Shipman may have realised how he changed medical practice in the UK, but I doubt he ever imagined that rules to prevent further scandals would rob the poorest and sickest communities in the developing world of British doctors.