Teaching Medical Students in a New Rural Longitudinal Clerkship: Opportunities and Constraints.

BACKGROUND: Medical schools in Africa are responding to the call to increase numbers of medical graduates by up-scaling decentralized clinical training. One approach to decentralized clinical training is the longitudinal integrated clerkship (LIC), where students benefit from continuity of setting and supervision. The ability of family physician supervisors to take responsibility for the clinical training of medical students over a longer period than the usual, in addition to managing their extensive role on the district health platform, is central to the success of such training. OBJECTIVE: This study investigated the teaching experiences of family physicians as clinical supervisors in a newly introduced LIC model in a rural sub-district in the Western Cape, South Africa. METHOD: Nine semi-structured interviews were conducted with six family physicians as part of the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) five-year longitudinal study. Code lists were developed inductively using Atlas.ti v7, they were compared, integrated, and categories were identified. Emerging common themes were developed. Findings: Three overarching themes emerged from the data, each containing subthemes. The rural platform was seen to be an enabling learning space for the LIC students. The family physicians' experienced their new teaching role in the LIC as empowering, but also challenging. Lack of time for teaching and the unstructured nature of the work emerged as constraints. Despite being uncertain about the new LIC model, the family physicians felt that it was easier to manage than anticipated. Conclusion: The centrality of the rural context framed the teaching experiences of the family physicians in the new LIC, forming the pivot around which constraints and opportunities for teaching arose. The African family physician is well positioned to make an important contribution to the upscaling of decentralized medical training, but would need to be supported by academic institutions and health service managers in their teaching role.

Building quality mHealth for low resource settings.

In low- and middle-income countries (LMIC), community health care workers (CHCW) are the primary point of care for millions of people. Mobile phone health applications (mHealth app) are the preferred technology platform to deliver clinical support to CHCW. In LMIC, limited regulatory oversight exists to guide quality and safety for medical devices, including mHealth. During the development of a mHealth app to assist CHCW with patient assessment and clinical diagnosis in rural South Africa, we applied human-centred design (HCD) and a bioethics consultation. The HCD approach enabled us to develop a mHealth app that responded to the needs and capacities of CHCW. The bioethics consultation prompted early consideration of safety concerns, social implications of our mHealth app and our technology's impact on the CHCW-patient relationship. In this study, we found that combining a HCD approach with bioethics consultation improved the design quality and reduced safety concerns for our mHealth app.

Towards tailored teaching: using participatory action research to enhance the learning experience of Longitudinal Integrated Clerkship students in a South African rural district hospital.

BACKGROUND: The introduction of Stellenbosch University's Longitudinal Integrated Clerkship (LIC) model as part of the undergraduate medical curriculum offers a unique and exciting training model to develop generalist doctors for the changing South African health landscape. At one of these LIC sites, the need for an improvement of the local learning experience became evident. This paper explores how to identify and implement a tailored teaching and learning intervention to improve workplace-based learning for LIC students. METHODS: A participatory action research approach was used in a co-operative inquiry group (ten participants), consisting of the students, clinician educators and researchers, who met over a period of 5 months. Through a cyclical process of action and reflection this group identified a teaching intervention. RESULTS: The results demonstrate the gaps and challenges identified when implementing a LIC model of medical education. A structured learning programme for the final 6 weeks of the students' placement at the district hospital was designed by the co-operative inquiry group as an agreed intervention. The post-intervention group reflection highlighted a need to create a structured programme in the spirit of local collaboration and learning across disciplines. The results also enhance our understanding of both students and clinician educators' perceptions of this new model of workplace-based training. CONCLUSIONS: This paper provides practical strategies to enhance teaching and learning in a new educational context. These strategies illuminate three paradigm shifts: (1) from the traditional medical education approach towards a transformative learning approach advocated for the 21(st) century health professional; (2) from the teaching hospital context to the district hospital context; and (3) from block-based teaching towards a longitudinal integrated learning model. A programme based on balancing structured and tailored learning activities is recommended in order to address the local learning needs of students in the LIC model. We recommend that action learning sets should be developed at these LIC sites, where the relevant aspects of work-place based learning are negotiated.

Impact of Introduction of a Colposcopy Service in a Rural South African Sub-District on Uptake of Colposcopy

Objective.To describe the establishment of a colposcopy service at a district hospital in a rural sub-district of the Western Cape; South Africa; and assess its impact on colposcopy uptake. Design. A retrospective double-group cohort study using a laboratory database of cervical cytology results; clinical records and colposcopy clinic registers.Setting. The Overstrand sub-district; where 80 000 people are served by seven clinics and a district hospital in Hermanus; 120 km from its referral hospitals in Cape Town and Worcester. A colposcopy service was established at Hermanus Hospital in 2008.Subjects. All women in the sub-district who required colposcopy on the basis of cervical smears done in 2007 and 2009.Outcome measures. Numbers of women booked for colposcopy at distant referral hospitals in 2007 and at the district hospital in 2009; the proportions who attended colposcopy; the time from cervical smear to colposcopy; and comparison between the two years.Results. Uptake of colposcopy booked at distant referral hospitals was 67 in 2007. Uptake improved by 18 to 79 for the district hospital colposcopy service in 2009 (p=0.06). When patients from an area with no public transport to the district hospital were excluded from analysis; the improvement was more marked at 22 (p=0.02). The delay from cervical smear to colposcopy improved significantly from 170 to 141 days (p=0.02).Conclusion. Establishment of a colposcopy service in a rural sub-district increased uptake of colposcopy and decreased the delay from cervical smear to colposcopy. The service removed 202 booked patients in one year from the colposcopy load of the referral hospitals

A Medical Audit of the Management of Cryptococcal Meningitis in HIV-Positive Patients in the Cape Winelands (East) District; Western Cape

Background: Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District.Method: Following an initial audit in 2008; the researchers and a new audit team introduced interventions; and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals; one regional hospital; and one tuberculosis hospital) were audited.Results: Spinal manometry was performed more consistently in the regional hospital; than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths; drug stock problems; and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling was better in the district hospital setting. However; both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART.Conclusion: Deficiencies in the quality of care remained. Between the prior and current audit cycles; there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed; and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future