Strengthening rural health placements for medical students: Lessons for South Africa from international experience

Background. This article derives lessons from international experience of innovative rural health placements for medical students. It provides pointers for strengthening South African undergraduate rural health programmes in support of the government’s rural health, primary healthcare and National Health Insurance strategies.Methods. The article draws on a review of the literature on 39 training programmes around the world, and the experiential knowledge of 28 local and international experts consulted through a structured workshop.Results. There is a range of models for rural health placements: some offer only limited exposure to rural settings, while others offer immersion experiences to students. Factors facilitating successful rural health placements include faculty champions who drive rural programmes and persuade faculties to embrace a rural mission, preferential selection of students with a rural background, positioning rural placements within a broader rural curriculum, creating rural training centres, the active nurturing of rural service staff, assigning students to mentors, the involvement of communities, and adapting rural programmes to the local context. Common obstacles include difficulties with student selection, negative social attitudes towards rural health, shortages of teaching staff, a sense of isolation experienced by rural students and staff, and difficulties with programme evaluation.Conclusions. Faculties seeking to expand rural placements should locate their vision within new health system developments, start off small and create voluntary rural tracks, apply preferential admission for rural students, set up a rural training centre, find practical ways of working with communities, and evaluate the educational and clinical achievements of rural health placements

A method of teaching clinical problem-solving skills to primary health care student nurses

The article provides a description of a method of teaching a clinical problem-solving process to primary health care nurses/clinical nurse practitioners (PHC nurses). The process was developed in the Soweto PHC Nurse Training Unit over the past 30 years as a result of the changing availability and role of nurse and doctor teaching staff. Students doing the diploma for nurse clinicians (Diploma in Clinical Nursing Science, Health Assessment, Treatment and Care) are guided in the use of mind maps, assisted by constant clinical practice and group discussions to develop their clinical problem-solving process. This method has assisted in clinical trainingKeywords: clinical problem solving process; nurse clinicians; PHC nurse training; mind maps; self teachin

How do doctors learn the spoken language of their patients?

Background. In South Africa, many doctors consult across both a language and cultural barrier. If patients are to receive effective care, ways need to be found to bridge this communication barrier.Methods. Qualitative individual interviews were conducted with seven doctors who had successfully learned the language of their patients, to determine their experiences and how they had succeeded.Results. All seven doctors used a combination of methods to learn the language. Listening was found to be very important, as was being prepared to take a risk or appear to be foolish. The doctors found that it was important to try out the newly learned language on patients and additionally stressed that learning the language was also learning a culture. The importance of motivation in language learning, the value of being immersed in the language one is trying to learn, and the role of prior experience in language learning, were commonly mentioned. The doctors deeply valued the improved rapport and deeper relationships with patients that resulted from their language learning efforts

ISSUES IN MEDICINE: Will clinical associates be effective for South Africa?

South Africa has developed an innovative mid-level medical worker model that can contribute substantively to the development of quality district-level health care. These clinical associates entered the South African job market in 2011 and have reportedly been received favourably. The first cohorts performed well on local and national examinations, with pass rates >95%. They have demonstrated confidence and competence in the common procedures and conditions encountered in district hospitals;reportedly fitted in well at most of the sites where they commencedworking; and made a significant contribution to the health team, resulting in a demand for more clinical associates. Universities and provinces involved in producing clinical associates are enthusiastic and committed. However, priorities are to establish sustainable funding sources for training and deployment, provide adequate supervision and support, monitor the initial impact of the new cadre on health services, and manage the sensitivities of the medical and nursing professions around scopes of practice and post levels. Longer-term concerns are national leadership and support, scaling up of training, the development of career pathways, and the improvement of working conditions at district hospitals

Outcomes for family medicine postgraduate training in South Africa

After 1994, the post-apartheid government decided that primary health care and the district health system would be the cornerstone of their new health policy. As a consequence of this, the academic departments of Family Medicine and primary care recognised the need for a nationally agreed set of training outcomes that were more aligned with these new priorities within the public sector. Thus in 2001, the Family Medicine Education Consortium (FaMEC), representing the eight academic departments of family medicine in South Africa, agreed to a set of outcomes for postgraduate family medicine training. At that time, all departments were running Family Medicine Master’s programmes as part-time training courses for doctors in primary health care. Recognition of the need to move towards full-time registrar training already existed, and because of this steps were taken to register Family Medicine as a speciality with the Health Professions Council of South Africa (HPCSA)

Family-witnessed resuscitation in emergency departments: Doctors’ attitudes and practices

Background. Resuscitation of patients occurs daily in emergency departments. Traditional practice entails family members remaining outside the resuscitation room. Objective. We explored the introduction of family-witnessed resuscitation (FWR) as it has been shown to allow closure for the family when resuscitation is unsuccessful and helps them to better understand the last moments of life. Results. Attending medical doctors have concerns about this practice, such as traumatisation of family members, increased pressure on the medical team, interference by the family, and potential medico-legal consequences. There was not complete acceptance of the practice of FWR among the sample group. Conclusion. Short-course training such as postgraduate advanced life support and other continued professional development activities should have a positive effect on this practice. The more experienced doctors are and the longer they work in emergency medicine, the more comfortable they appear to be with the concept of FWR and therefore the more likely they are to allow it. Further study and course attendance by doctors has a positive influence on the practice of FWR

Comparative vector competence of North American Lyme disease vectors

Background Understanding the drivers of Lyme disease incidence at broad spatial scales is critical for predicting and mitigating human disease risk. Previous studies have identified vector phenology and behavior, host community composition, and landscape features as drivers of variable Lyme disease risk. However, while the Lyme disease transmission cycles in the eastern and western USA involve different vector species (Ixodes scapularis and Ixodes pacificus, respectively), the role of vector-specific differences in transmission efficiency has not been directly examined. By comparing the performance of traits involved in vector competence between these two species, this study aims to identify how vector competence contributes to variable Lyme disease risk. Methods We used a suite of laboratory experiments to compare the performance of traits related to vector competence for the two USA Lyme disease vectors. For each species, we measured the rate of attachment to a common rodent host, the engorgement weight, and the efficiency of pathogen acquisition (host to tick) and pathogen transmission (tick to host) from laboratory mice. In measuring pathogen acquisition and transmission, we used two different pathogen strains, one sympatric with I. scapularis and one sympatric with I. pacificus, to assess the importance of vector-pathogen coevolutionary history in transmission dynamics. Results We found I. pacificus had significantly higher host attachment success and engorgement weights, but significantly lower pathogen transmission efficiency relative to I. scapularis. Molting success and pathogen acquisition did not differ between these two species. However, pathogen acquisition efficiency was significantly higher for both sympatric vector and pathogen strains than the allopatric pairings. Conclusions This study identified species-specific vector traits as a potential driver of broad scale variation in Lyme disease risk in the USA. In particular, the exceedingly low rates of pathogen transmission from tick to host observed for I. pacificus may limit Lyme disease transmission efficiency in the western USA. Further, observed variation in pathogen acquisition between sympatric and allopatric vector-pathogen strains indicate that vector-pathogen coevolutionary history may play a key role in transmission dynamics. These findings underscore the need to consider vector traits and vector-pathogen coevolution as important factors governing regional Lyme disease risk

Suicide and attempted suicide: the Rehoboth experience

St Mary's Hospital in Rehoboth, Namibia, attends to all individuals who have health problems that are considered serious by the community. The aim of this study was to describe the existing suicide management approach in Rehoboth.Clinical charts of all patients who attended St Mary's Hospital Rehoboth were manually collected and reviewed. In the process, analysis of the past records of patients of Rehoboth who exhibited the risk factors and/or were diagnosed and treated for suicide and/or attempted suicide for a predetermined period of 1 January to 31 December 2001 was undertaken.A total of 45 individuals were found to have attempted and/or committed suicide out of a total of 12 910 patient visits for the period. Of these, 51% were admitted, 7% were referred out and 42% were treated as out patients. Sixty-three per cent of the people used prescribed and over the counter drugs for attempting suicide. The words suicide or attempted suicide were not commonly used by healthcare providers in Rehoboth. Incidentally, HIV/AIDS did not seem to be associated with the patients who attempted suicide in this community.While there was no particular strategy in place in Rehoboth to deal with suicide and parasuicide, the emergency care for patients who attempted suicide in Rehoboth was apparently adequate, with no deaths in the hospital. However, the lack of a clear, coordinated multidisciplinary management approach to the survivors of a suicide attempt appeared to be a serious gap in management. It is also recommended that an appropriate name, code, recording and reporting system for suicide and attempted suicide should be adopted for use by health care personnel in Namibia in order to more accurately document the level of suicidal activity in the country

The consequences upon patient care of moving Brits Hospital: A case study

Background. In 2001, North West Province took the decision to increase bed capacity at Brits Hospital from 66 beds to 267 beds. After careful consideration of costs and an assessment of available land, it was decided to demolish the existing hospital and rebuild the new hospital on the same site. It was planned that during this time that clinical services would be moved to a temporary makeshift hospital and to primary health care clinics. This case study documents the consequences of this decision to move services to the makeshift hospital and how these challenges were dealt with. Methods. A cross-sectional descriptive study was undertaken. Ten key members of staff at management and service delivery level, in the hospital and the district, were interviewed. Key documents, reports, correspondence, hospital statistics and minutes of meetings related to the move were analysed. Results. The plan had several unforeseen consequences with serious effects on patient care. Maternity services were particularly affected. Maternity beds decreased from 30 beds in the former hospital to 4 beds in the makeshift hospital. As numbers of deliveries did not greatly decrease, this resulted in severe overcrowding, making monitoring and care difficult. Perinatal mortality rates doubled after the move. An increase in maternal deaths was noted. The lack of inpatient ward space resulted in severe overcrowding in Casualty. The lack of X-ray facilities necessitated patients being referred to a facility 72 km away, which often caused a delay of 3 days before management was completed. After-hours X-rays were done in a private facility, adding to unforeseen costs. Although the initial plan was for the makeshift hospital to stabilise and refer most patients, referral routes were not agreed upon or put in writing, and no extra transportation resources were allocated. The pharmacy had insufficient space for storage of medication. In spite of all these issues, relationships and capacity at clinics were strengthened, but not sufficiently to meet the need. Discussion. Hospital revitalisation requires detailed planning so that services are not disrupted. Several case studies have highlighted the planning necessary when services are to be moved temporarily. Makeshift hospitals have been used when renovating or building hospitals. During war or disasters, plans have been made to decant patients from one facility to another. From the Brits case study, it would appear that not enough detailed planning for the move was done initially. This observation includes failure to appreciate the interrelatedness of systems and the practicality of the proposal, and to budget for the move and not just the new structure. Conclusion. The current service offered at the makeshift hospital at Brits is not adequate and has resulted in poor patient care. It is the result of a planning process that did not examine the consequences of the move, both logistic and financial, in adequate detail. Committed hospital staff have tried their best to offer good care in difficult circumstances

A peer evaluation of the community-based education programme for medical students at the University of Zimbabwe College of Health Sciences: A southern African Medical Education Partnership Initiative (MEPI) collaboration

Background. The University of Zimbabwe College of Health Sciences (UZCHS), Harare, which has a long tradition of community-based education (CBE), has not been evaluated since 1991. An innovative approach was used to evaluate the programme during 2015. Objectives. To evaluate the CBE programme, using a peer-review model of evaluation and simultaneously introducing and orientating participating colleagues from other medical schools in southern Africa to this review process. Methods. An international team of medical educators, convened through the Medical Education Partnership Initiative, worked collaboratively to modify an existing peer-review assessment method. Data collection took the form of pre-visit surveys, on-site and field-visit interviews with key informants, a review of supporting documentation and a post-review visit. Results. All 5 years of the medical education curriculum at UZCHS included some form of CBE that ranged from community exposure in the 1st year to district hospital-based clinical rotations during the clinical years. Several strengths, including the diversity of community-based activities and the availability of a large teaching platform, were identified. However, despite the expression of satisfaction with the programme, the majority of students indicated that they do not plan to work in rural areas in Zimbabwe. Several key recommendations were offered, central to which was strengthening the academic co-ordination of the programme and curriculum renewal in the context of the overall MB ChB curriculum. Conclusion. This evaluation demonstrated the value of peer review to bring a multidimensional, objective assessment to a CBE programme