Derek Hellenberg

Developing family medicine in South Africa: A new and important step for medical education

The announcement by the National Ministry of Health on the 17th August 2007 (South African Government ), officially recognizing family medicine as a speciality in its own right is an indication of just how far ‘general practice’ has developed in South Africa. From January 2008 there is to be a compulsory, full-time four- year training programme for registrars in Family Medicine which should result in a well trained cohort of Family Physicians suitable to staff Community Health Centres and Primary Care Hospitals in the future. This article seeks to explore some of the milestones reached in the development of the community of family medicine professionals and teachers, the roles taken by the major protagonists in the development and the way that medical education can promote and sustain the discipline.

Diabetes mellitus and non-traumatic lower extremity amputations in four public sector hospitals in Cape Town, South Africa, during 2009 and 2010

BACKGROUND Diabetes mellitus (DM) is the most commonly reported cause of non-trauma-related lower extremity amputations (LEAs) worldwide, but there is a dearth of such information for South Africa (SA). OBJECTIVES To examine the proportion of LEAs due to diabetes and to describe the associated characteristics of these patients. METHODS A retrospective analysis of all LEAs was performed in four public sector hospitals in Cape Town, SA, for 2009 and 2010. Operating theatre records were reviewed to identify all patients who had an LEA. Patient records were perused and information extracted using a structured questionnaire. RESULTS Records for 941 of 1,134 patients identified as having an LEA were found (recovery rate 82.9%). Of the 867 patients with 1,280 LEAs included in the study, 925 LEAs were in 593 patients with DM and 355 LEAs in 274 non-DM patients. Therefore 72.3% (95% confidence interval (CI) 69.8-74.7) of LEAs were in people with DM, while 68.4% (95% CI 65.2-71.4) of the total patients had DM. The DM group underwent more multiple LEAs (42.0% v. 23%; p<0.001) and had more multiple admissions (14.3% v. 7.7%; p<0.005) than the non-DM group. Infection (85.7% v. 63.5%,; p<0.001) and ulcer (25.3% v. 15.3%; p=0.001) were the leading causes for LEA in the DM group compared with the non-DM group. Ischaemia was the dominant cause in the non-DM patients (49.3% v. 23.3%; p<0.001), as was smoking (69.7% v. 43.5%, p<0.001), compared with the DM patients. CONCLUSIONS These data demonstrate an alarming burden of LEAs due to DM in the public sector in Cape Town. Given that the majority of LEAs are preventable with adequate education, screening, treatment and follow-up, effective interventions are needed.

Implementing a structured triage system at a community health centre using Kaizen

Abstract Background: More than 100 unbooked patients present daily to the Mitchells Plain Community Health Centre (MPCHC), and are triaged by a doctor, with the assistance of a staff nurse. The quality of the triage assessments has been found to be variable, with patients often being deferred without their vital signs being recorded. This leads to frustration, and a resultant increased workload for doctors; management is concerned with the medicolegal risk of deferring patients who have not been triaged in accordance with the guidelines; and patients are unhappy with the quality of service they receive. Aim: We set out to standardise the triage process and to manage unbooked patients presenting to the community health centre (CHC) in a manner that is medico-legally safe, cost efficient and patient friendly, using the Kaizen method. Methods: The principles of Kaizen were used to observe and identify inefficiencies in the existing triage process at the MPCHC. Findings were analysed and interventions introduced to improve outcomes. The new processes were, in turn, validated and standardised. Results: The majority of patients presenting to Triage were those needing reissuing of prescriptions for their chronic medication, and this prevented practitioners from timeously attending to other patients waiting to be seen. Reorganising of the process was needed; it was necessary to separate the patients needing triage from those requiring only prescriptions to be reissued. After the intervention, triage was performed by a staff nurse only, using the Cape Triage Score (CTS) method. Subsequent to the implementation of interventions, no patients have been deferred, and all patients are now assessed according to a standardised protocol. The reasons for patients requiring reissuing of prescriptions were numerous, and implementing countermeasures to the main causes thereof decreased the number of reissues by 50%. Conclusion: The Kaizen method can be used to improve the triage process for unbooked patients at the MPCHC, thereby improving the quality of services delivered to these patients. As the needs of the various CHCs differ quite widely across the service platform, the model needs to be adapted to suit local conditions.

Mentoring in medical practice.

Summary Previous articles in this series have defined words and concepts that guide our thinking in the areas of teaching and learning, set in the greater world of education; but what happens in the quiet and often lonely world of individual practice? As we reflect upon our pasts, many of us recognise that we have at some point in time engaged with a significant figure who has had a long term and positive influence on our personal development; someone who has the unusual and valuable qualities that mean that whatever else is happening to them personally, they maintain a genuine interest in at least one other persons development. All too frequently, this becomes an isolated event; a lost activity from which there is limited gain. This article explores how, as busy practitioners, we may think of using the principles implied in this experience and build upon them to facilitate a powerful and cost effective method that encourages personal development. “To know someone with whom you feel there is understanding in spite of distances or thoughts expressed… that can make this life a garden”—Johann Wolfgang von Goethe (1749–1832)

Western Cape Primary Care Assessment Tool (PCAT) study: Measuring primary care organisation and performance in the Western Cape Province, South Africa (2013)

Background Major health sector reform and the need for baseline measures of performance to determine impact. Aim Baseline audit of primary healthcare (PHC) performance. Setting Cape Town and Cape Winelands (rural) PHC facilities (PCFs) in Western Cape Province, South Africa. Method The South African cross-culturally validated ZA PCAT to audit PHC performance on 11 subdomains associated with improved health and reduced costs. Adult PCF users systematically sampled. All full-time doctors and nurse practitioners in PCFs sampled and all PCF managers in sub-districts sampled invited into the study. Results Data from 1432 users, 100 clinicians and 64 managers from 13 PCFs in 10 sub-districts analysed (figures show stakeholder percentages scoring subdomain performance ‘acceptable to good’). 11.5% users scored access ‘acceptable to good’; community orientation and comprehensive services provided 20.8% and 39.9%, respectively. Total PHC score for users 50.2%; for managers and practitioners 82.8% and 88.0%, respectively. Among practitioners access was lowest (33.3%); PHC team (98.0%) and comprehensive services available (100.0%) highest. Among managers, access (13.5%) and family centredness (45.6%) are lowest; PHC team (85.9%) and comprehensive services available (90.6%) highest. Managers scored access, family centredness and cultural competence significantly lower than practitioners. Users scored comprehensive services available, comprehensive services provided and community orientation significantly lower than practitioners and managers. Conclusion Gaps between users’ experience and providers’ assessments of PHC performance are identified. Features that need strengthening and alignment with best practice, provincial and national, and health policies are highlighted with implications for practitioner and manager training, health policy, and research.

The Education versus Training and the Skills versus Competency debate

Summary The essence of modern medical education lies in the ability of defining and developing its terminology, which all too often is used in a less than thoughtful and inappropriate manner. Educationalists place emphasis upon the concept of learning rather than teaching; learning which is specifically student centred and student directed learning rather than teacher centred didactic teaching. However within this change environment we still prefer to use the word training, as in vocational training, to describe a specific programme and aspire to levels of competency that hopefully match the learning outcomes of the programme. This article opens the debate on whether the satisfactory completion of a learning programme is sufficient (cf completion of vocational training) or whether we should be assessing the learner through levels of defined competency relevant to their professional career. “Personally I am always ready to learn, although I do not always like to be taught” Sir Winston Churchill.

Profile and anticoagulation outcomes of patients on warfarin therapy in an urban hospital in Cape Town, South Africa.

Background Warfarin is the most frequently used oral anticoagulant worldwide and it is the oral anticoagulant of choice in South Africa for reducing thrombosis-related morbidity and mortality. However, the safety and efficacy of warfarin therapy depends mainly on careful monitoring and maintenance of the international normalised ratio (INR) within an optimal therapeutic range. Aim The aim of this study was to describe the profile and the anticoagulation outcomes of patients on warfarin therapy in a major warfarin clinic in the Western Cape Province of South Africa. Setting Victoria Hospital - a district hospital in Cape Town. Methods A cross sectional review of clinical records of patients on warfarin therapy who attended the INR clinic from 01 January 2014 to 30 June 2014 was done. Data analysis was done with STATA to generate appropriate descriptive data. Results Our study showed that atrial fibrillation (AF) was the commonest indication for warfarin use in this study and hypertension was the commonest comorbidity among these patients. Only 48.5% achieved target therapeutic range; 51.5% were out-of-range. There was a significant association between alcohol consumption and poor anticoagulation outcomes (p-value < 0.022). Anticoagulation outcomes were better among the older age groups, male patients and in those with AF. The prevalence of thrombotic events while on warfarin treatment was 2.2%, while prevalence of haemorrhagic events was 14%. Most of the patients with bleeding events were on concurrent use of warfarin and other medications with potential drug interactions. Conclusion In our study, patients who achieved target therapeutic control were less than the acceptable 60%.

Quality of care and cost of prescriptions for diabetes and hypertension at primary healthcare facilities in the Cape Town Metropole

Background: Quality of care for diabetes mellitus and hypertension has been found to be suboptimal at primary health care level. There is an expectation that improving quality will require the increased utilisation of resources. This research was intended to determine the quality of care and cost of prescriptions at 10 facilities in the Cape Town Metropole. Method: An analytical, cross-sectional study was conducted in order to relate the cost of medication to quality-of-care indicators for patients with diabetes mellitus and hypertension. Data were collected at the 10 facilities in the Cape Town Metropole over a three-month period. Results: Quality-of-care processes were performed more often in diabetic than in hypertensive patients, i.e. determination of body mass index (BMI) 52.4% vs. 46.4%, creatinine 45.2% vs. 35.7% and cholesterol 44.5% vs. 35.4%, respectively. Nevertheless, outcome measures were better in the hypertensive patients. Targets were achieved in hypertensive vs. diabetic patients, respectively, as follows: BMI (22.2% vs.18.1%), blood pressure (39.8% vs. 28.7%), creatinine (93.2% vs. 91.4%) and cholesterol (46.8% vs. 44%). The median cost per script was R44.66 and R30.06 for diabetic and hypertensive patients with good quality-of-care scores, respectively, and R51.18 and R31.00, for those with poor quality-of-care scores. Conclusion: The quality of care provided was poor when compared with the guideline recommendations, but was comparable to care provided in many other populations. There was no correlation between quality of care and the cost of the prescriptions.

Family medicine in South Africa: where are we now and where do we want to be?

Objectives: This paper outlines the development of family medicine in South Africa with special reference to the process leading to the recognition of this discipline as a medical specialty. It also examines the constraints under which the discipline has had to function, considers where the discipline should be, seeks to identify the barriers to its further development and suggests ways in which to overcome these. Methods: A short review was carried out of the available South African literature to record the advancement of the discipline and the international literature was searched for articles supporting this direction. Results: The situation in South Africa is complicated by the existence of many doctor groupings claiming to represent the generalist and the perception that family medicine only addresses the needs of middle-class citizens. A flawed consultative process leading up to the present stage has contributed to this perception. Conclusions: The available literature supports the establishment of family medicine as a speciality. Developments in South Africa, such as raising the status of Family Medicine and creating a compulsory rotation through family medicine as an extended internship and the creation of registrar posts in family medicine will advance the discipline in a positive manner, whilst possibly attempting to resolve the medical migration issues that are presently destroying Sub-Saharan Africas health services. Eur J Gen Pract 2005;11(3):127–30.

Cefetamet Pivoxil vs Cefaclor in the Treatment of Acute Otitis Media in Children

Summary74 children with acute otitis media (AOM) were entered into an observer-blind randomised multicentre general practice study to compare the efficacy and safety of the new third generation oral cephalosporin, cefetamet pivoxil, at a dose of 10 mg/kg twice daily with the efficacy and safety of cefaclor 10 mg/kg twice daily administered for 10 days.Of 36 evaluable patients in the cefaclor treatment group, 28 (78%) were cured, and a further 4 were improved, giving an overall efficacy rate (cure/improvement) of 89%. Of 36 evaluable patients in the cefetamet pivoxil treatment group, 31 (86%) were cured, and a further 4 were improved, giving an overall efficacy rate of 97%. Adverse events were reported in 4 patients: 1 cefaclor recipient and 3 patients in the cefetamet pivoxil treatment group. Diarrhoea, the most frequently observed adverse event, occurred in both treatment groups.The study results indicate that cefetamet pivoxil and cefaclor appear to have similar efficacy and safety in the treatment of AOM in children.