The knowledge and skills gap of medical practitioners delivering district hospital services in the Western Cape, South Africa

IntroductionDistrict (community) hospitals play an important role in the delivery of health services at community level, especially in rural areas. These hospitals provide comprehensive level-one health services to their communities, and serve as a resource for the whole health district. Most district hospitals are situated in rural areas, with medical services in these hospitals being rendered by generalist medical practitioners.The education and training of generalist practitioners for rural practice needs specific attention. Firstly, the unique nature of rural practice makes it necessary for doctors to undergo relevant and focused instruction. Rural family practice requires that doctors have the knowledge and skills to practise in settings where high technology and specialist resources are not available, while at the same time requiring that they be able to perform a wide range of advanced functions and procedures.Secondly, it is argued that appropriate education and training for rural practice can positively influence the recruitment and retention of medical practitioners in rural areas.5 The teaching of the knowledge and skills required for rural practice should take place in an appropriate setting that promotes interest in rural practice and familiarises the student with its particular challenges. There is a paucity of data in South Africa on medical practitioners staffing district hospitals, especially in terms of their knowledge and skills levels. Such information is critical if rural hospitals are to deliver equitable and quality health services, and also for guiding appropriate undergraduate, postgraduate and continuing professional education for rural practice.With this as background, health service managers in the Western Cape requested a skills audit of medical officers in district hospitals to identify a possible gap in competencies that may impact on service delivery. The aim of this study was thus to identify the knowledge and skills of medical practitioners delivering these services in the Western Cape and to compare them with service needs in order to make recommendations for education and training. This article reports on the results of the knowledge and skills gap analysis, while the results of the district hospital performance data and in-depth interviews are reported elsewhere.Method The competencies of medical practitioners working in 27 district hospitals were explored by using a self-administered questionnaire containing a competency rating of proxy markers. The data were analysed using the SAS statistical package. Variables were examined for statistically significant differences.ResultsA response rate of 75% (110/147) was achieved. Part-time (older) medical officers regarded themselves as more experienced and more competent than full-time (younger) employees in most areas, except when managing problems relating to HIV/AIDS. Termination of pregnancy was the procedure most frequently not performed despite practitioners being competent to do so. A substantial need for supervision was identified for managing less common emergency conditions, as well as for some outpatient problems, including preventative, promotive and rehabilitation activities.ConclusionsThe knowledge and skills gaps varied considerably according to the individuals' education, training and experience, as well as their circumstances and working conditions. The superior competencies of the older practitioners reinforce the importance of the recruitment and retention of more experienced practitioners. The uneven skill and knowledge base in aspects of HIV/AIDS management should be addressed urgently by initiatives such as the internet-based course on HIV/AIDS developed by the Family Medicine Education Consortium (FaMEC). Departments of Family Medicine should urgently re-orientate their curricula to meet the training needs for level-one hospital practice.Keywords:Skills gap; education; family practitioners; survey; knowledgeFor full text, click here:SA Fam Pract 2006;48(2):16-16

Doctors' views of working conditions in rural hospitals in the Western Cape

There has been a lively debate in the media about working conditions in rural South African Hospitals, with a particular focus on staffing and quality of care. From a medical perspective, it has been stated that poorly equipped and managed hospitals, inappropriate training and an excessive workload are significant contributors to the problem. This study was conducted to investigate the experiences of medical practitioners in performing their professional duties in rural district hospitals in the Western Cape. Twenty in-depth, free-attitude interviews were conducted. Three major themes became apparent from the data, namely the importance of situational factors, knowledge and skills, and support structures. Two conceptual frameworks emerged from the themes that describe the impact of working conditions on the quality of care, and captured positive and negative factors influencing performance. This study provides evidence that substantial after-hour duties, an excessive workload and a perceived lack of management support impact negatively on doctors' views of working in district hospitals. Unless these are addressed, the problem of retaining medical staff in rural hospitals will continue, and equity of access to health services for rural communities will remain an unfulfilled obligation. Recommendations are made on how these issues can be addressed. Key words: district hospitals, working conditions For full text, click here: SA Fam Prac 2004;46(3):21-2

The maintenance of competence of rural district hospital medical practitioners

BackgroundThe maintenance of competence by rural district hospital medical practitioners is a challenge faced by all countries and, most acutely, by resource-poor nations. It is a vital element in addressing the disparity between rural and urban health care in South Africa. The wide scope of rural-district hospital practice demands updating in a variety of content areas. District hospital doctors are likely to have educational needs covering surgery, emergency and trauma, in-patient as well as out-patient care at primary service level, an understanding of the rural context and role of other health workers, public-health skills, and teamwork. Given such a broad curriculum, some prioritisation needs to be made for the content of their CPD. Rural practitioners generally use CPD activities that are most readily available to them, namely reading journals, meeting with pharmaceutical representatives and attending lectures sponsored by the pharmaceutical industry. These are not, however, the most appropriate or effective methods of acquiring the knowledge and skills that doctors define as being useful to them. Educational strategies that have been most effective in changing clinical behaviour are: an assessment of learning needs, interactive tuition sessions with the opportunity to practice the skills learned and sequenced multifaceted activities. It is equally important to have rural practitioners engage in educational activities that can be performed within their work environment. The aim of this study was to define expert consensus on the content and methods most suitable for the maintenance of competence by rural district hospital practitioners in the Western Cape province of South Africa. The study was carried out as a follow-up to an analysis of knowledge and skills of doctors in Western Cape district hospitals.MethodA study was therefore designed to investigate the content and methods used for the maintenance of competence of rural district hospital practitioners in the Western Cape province of South Africa. Expert opinion was sought to evaluate the topics requiring updating and the validity of the learning methods to maintain competence in practice. This was achieved by employing the Delphi technique to reach consensus on content and methodology. Categorical data analysis and a principal factor analysis were also performed. The qualitative data were then developed into themes and presented as a conceptual framework.Results Consensus was reached on the principal content areas requiring updating. Methods that were found most useful were inservice learning under supervision, structured courses, small group discussions and practical workshops. Rotations in tertiary hospitals, specialist lectures, journal reading and internet learning were less supported.ConclusionsThe study provides a practical model for continuing instruction plus self-directed learning in context. Three content domains were established, namely commonly encountered areas of practice, identified gaps, and needs specific to the practitioner and setting. It was concluded that the implementation of external updating programmes should be tailored to suit practitioners, while self-directed aspects should include reflective practice. Priority areas were identified and classified, as were educational methods that could contribute towards the maintenance of competence of rural practitioners.For full text, click here:SA Fam Pract 2006;48(3):18-18

Morbidity profile of admissions to GF Jooste Hospital, Manenberg, Cape Town

Background Secondary hospitals play an important, yet overlooked, role in reflecting public health status, both locally and nationally. Relatively few reports analysing the causes of secondary hospital admissions exist, which is especially unfortunate in the case of developing countries, considering the huge numbers of admissions and people at risk. In developing countries like South Africa, the quality of records varies among institutions. Some hospitals have computerised data, while others may keep no records whatsoever. A major problem facing the quality of hospital records is the constant shortage of staff in rural and urban hospitals. Thorough documentation is essential in providing an invaluable database for researchers, but morbidity statistics are unfortunately scarce.GF Jooste Hospital in Manenberg is the busiest hospital in Cape Town – serving 1.1 million people, with 224 beds and over 12 000 admissions annually. Budgetary constraints in the South African public health sector means that providing healthcare services at higher levels than necessary is too costly. Because hospitals consume the largest share of the public healthcare budget, they have been the focus in cost cutting. In particular, the budgets of referral (tertiary or teaching) hospitals have been trimmed in order to promote primary and secondary care. It is imperative to identify those services that are required most at secondary hospitals in order to improve budgeting and, more appropriately, train doctors and medical students for the job at hand. Identifying the morbidity profile of the population for which the hospital caters can aid the optimal utilisation of the available resources, as well as focusing the continuing medical education of hospital physicians. We determined disease patterns of admissions over a three-year period (2001-2003), primarily as insight towards optimal hospital resource management.Methods A retrospective study examined ward records, totalling 36 657 admissions, from which a random sample (N=608) was selected. A stratified sample (N=462) was constructed, considering the relative proportions admitted to the wards. The International Statistical Classification of Diseases (ICD) directed diagnosis sorting. Disease prevalence was expressed as the percentage of patients allocated to each ICD category among those admitted to the hospital and respective wards and, additionally, the percentage of diagnoses for each ICD subcategory among patients assigned to each major category.Results Trauma (represented by ICD categories S/T 23% and V/X/Y 16%), specifically assault-related, was most prevalent. This was followed by circulatory diseases (22%) and infectious diseases (19%), dominated by HIV (61%) and associated diseases like TB (57%). The age of the patients ranged from 13 to 87 (mean: 40 years), with the 20 to 30-year-olds predominating. Surgical patients were younger (mean: 35 years) than medical (mean: 45 years). In the medical wards, infectious (39% in men; 38% in women) and circulatory aetiologies (39% and 41% in men and women respectively) dominated. In the surgical wards, the trend varied according to sex: assault (43%) and other injuries (61%) for males; pregnancy-related (42%) for females.Conclusion The morbidity distribution reflects the ills affecting South African urban society, with young trauma admissions predominating. The hospital's budget is insufficient, considering its population's demands.For full text click here: SA Fam Pract 2006;48(6):15-15

Breast cancer – early detection and screening in South African women from the Bonteheuwel township in the Western Cape: Knowledge, attitudes and practices

Background Breast cancer is one of the most common cancers, rating among the most frequent causes of mortality in women worldwide, including in South Africa. Although curative treatment is increasingly successful, early detection and intervention are critical in reducing mortality rates. Early diagnosis is facilitated via breast self-examination (BSE), clinical breast examination (CBE), and mammography. Breast cancer presentation shows an apparent racial variation, with black, coloured and Indian patients presenting at a younger age than whites. In addition, whites tend to present at earlier stages of disease severity, coloureds and Indians at more intermediate stages and blacks at later stages. Socio-economic variables impact on screening practices. One American/Canadian study showed women with higher education and incomes were more likely to receive screening. In South Africa, there is scant research on breast cancer screening. In 2001, Prof. Karl Peltzer of the University of the North did a small telephonic comparative study between black and white women that identified low frequencies of BSE in both groups. Further research is necessary. While several international studies exist, little research is available on the screening behaviour of South African women. The aim of this study, therefore, was to evaluate the knowledge, attitudes, and actual screening practices regarding breast cancer among women in the Bonteheuwel township in the Western Cape.MethodsA random sample of 100 women completed a questionnaire administered by a research assistant. A separate, selected group of nine women participated in a focus group discussion.ResultsThe results indicate that the majority of the participants were aware of the dangers of breast cancer, perceived as a common (87%; 95% CI: 80%-94%) and serious (88%; 95% CI: 82%-94%) disease, which, if treated early, could be cured in most cases (82%; 95% CI: 74%-90%). Most had previously examined their breasts (65%; 95% CI: 56%-74%) and/or had been examined by their doctors (62%; 95% CI: 52%-72%). Only a minority, however, practised regular BSE (24%; 95% CI: 16%-32%) or had received a CBE in the last year (29%; 95% CI: 20%-38%). Fear of diagnosis was identified as the main barrier to screening (87%; 95% CI: 80%-94%). Despite their fears, the participants were keen to improve their knowledge and participate in the further education of their community. However, only 40% (95% CI: 30%-50%) had ever been taught BSE by a healthcare professional. Moreover, only 34% (95% CI: 25%-43%) of women who had consulted a GP in the preceding year had received a CBE during this period. A total of 38% (95% CI: 28%-48%) had never had a CBE in their lives.ConclusionThe participants were better informed and more engaged in screening than had been anticipated. Still, healthcare professionals need to play a more proactive role in breast cancer screening and education.For full text, click here:SA Fam Pract 2006;48(5):14-14

Prevalence and characteristics of erectile dysfunction in black and mixed race primary care populations of the Cape Flats and Helderberg Basin area of the Western Cape, South Africa

Objective: To estimate the prevalence of erectile dysfunction (ED) among users of primary care in a Black and Mixed Race urban population in the Western Cape, and to describe any associated health and psychosocial factors. Design: Cross-sectional survey by interviewer administered questionnaire. Setting: Two primary care medical centres, 40km apart, in Cape Town metropolitan area. Serve different ethnic groups, with no cross-contamination between them. Study period: March-June 1999 Patients: 833 Males (35-70 years old) attending these health centres for primary care. Systematic selection of all attendees. Main outcome measures: Prevalence of ED and presence of associated health and psychosocial factors. Describe patient demographics, physical attributes, sexual relationships. Results: Results of 730 males with current sexual partners: Mean ages 48 years (SD:7 years) all; 46 years (SD:9 years) Black group; 51 years (SD: 9 years) Mixed Race group. All degrees of ED prevalence: All 77.1% (95% CI: 74.0-80.2), Black 76.4% (95% CI: 71.8-80.4) and Mixed Race 77.7% (95% CI: 72.8-82.0). Significantly associated diseases: hypertension, diabetes, gastrointestinal and heart disease. Alcohol consumption (younger patients), smoking (older patients) significantly related to ED. Males with ED: more sexual partners than males without ED. More than 90% choose primary care physician/ generalist as primary ED care-giver. Conclusions: ED is very common in both study groups. Primary care workers must be prepared to manage associated risk factors and health implications. ED sufferers in this population may also be at higher risk for sexually transmitted diseases due to multiple sexual partners. (SA Fam Pract 2003;45(1):14-20) Keywords: erectile dysfunction, impotence, prevalence, black

Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study

The original publication is available at http://www.biomedcentral.comAbstract Background: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. Methods A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. Results The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real. Conclusions The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.Publishers' Versio

Focusing on Rural Health. (Editorial)

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2nd Essential National Health Research (ENHR) Conference, 22-23 August 2003, East London, Health Resource Centre. (News)

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Theatre and emergency services rendered by generalist medical practitioners in district hospitals in the Western Cape

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