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Getting creative with what you've got
It may be hard to imagine what life would be like working as a doctor in rural Africa, especially when one has trained in the comparatively well-staffed and well-equipped NHS. By contrast, the South African healthcare situation is characterised by uninsured patients served by dedicated staff in understaffed and often underequipped hospitals – all within the context of poverty, HIV/Aids, TB and other tropical diseases. Is this a recipe for disaster, or an opportunity to learn and grow as a doctor and person?
To gain a better understanding, we interviewed three British doctors who have worked in rural South Africa about their experiences. All three doctors were placed by Africa Health Placements (AHP, www.ahp.org.za ), a not-for-profit donor-funded organisation with a mission to support and enhance healthcare systems in Africa, by placing and supporting doctors in areas with the highest need – public and rural healthcare facilities.
Fantastic clinical exposure
Dr Roberta Hewitt has recently started a one-year tenure working as a medical officer (which approximates a UK speciality doctor) at the Moses Kotane Hospital. This is a new 200-bed referrals facility situated in a rural district of the North West province, close to Rustenburg and Sun City. The hospital was built as part of the infrastructure requirement for hosting the 2010 FIFA World Cup and boasts a well-equipped casualty (accident and emergency unit), adult, maternity and neonatal wards, a psychiatric unit, six operating theatres and a private ward for insured patients. The hospital is, “very new, very clean, and with brand new equipment.” However, not all areas are fully functional and there are only 16 doctors covering all the departments. Despite these teething issues, Dr Hewitt has been, “impressed with the range of things we can cope with”, but observes that most functions are less specialised than would be expected in the UK.
Before coming to South Africa, Dr Hewitt worked as a staff grade in emergency medicine, and also as a senior house officer in medicine and anaesthetics. She completed a diploma in tropical medicine and hygiene at Liverpool University, and says that her South African experience has, to date, been “mostly good”. She has already worked in paediatrics, HIV/Aids, anaesthetics and casualty (accident and emergency). Her first encounters with the HIV/Aids epidemic were “a shock, but also very good experience”. She goes on to attest that “the clinical exposure has been absolutely fantastic”.
In terms of work-life balance, one concern had been the frequency and intensity of work given the huge population healthcare needs and medical understaffing. In reality she has been pleasantly surprised to find herself typically working from 08:00 to 16:30, plus on-calls (approximately four per month). She lives in a “lovely” two-bedroom house on the hospital grounds, which enjoys full-time security, and is also situated a mere seven kilometres from the Pilanesburg National Park.
Difficulties include a lack of public transport, and unreliable communication with the UK – international mobile calls are expensive and phone signal is poor. The variable availability of medications at the hospital is another challenge. In short, while it is still “early days” in her African adventure, Dr Hewitt says that she has already learned a lot about patience and adapting to a new healthcare culture, and she hopes to continue delivering the best possible medicine that circumstances will allow.
Post-foundation learning curve
Dr Jenny Ievins came to South Africa straight after completing her foundation training in the UK, and was immediately “thrown into the deep end”. Through AHP she was employed as a senior medical officer (equivalent to an ST1-3) in primary care in the rural district of Lichtenburg, also in South Africa’s North West province.
Because of the sparsely populated area, her practice became a travelling one, comprising daily trips to clinics scattered throughout the district, some over 70 miles away. The remote locations and pattern of late presentation ensured that she often saw acutely unwell patients (who in the NHS would have been admitted to hospital), a high prevalence of HIV/Aids and TB, along with common primary care problems such as hypertension and diabetes. For six months, she also worked on calls in the nearest district hospital, covering the maternity and emergency units.
Having returned to the UK in June 2010, Dr Ievins attests that her work in South Africa has made her “a thousand times better as a doctor” – particularly in the domains of clinical skills, independent working, decision-making, and clinical leadership.
Upon returning home Dr Ievins tells us she is trying to re-adapt to life in the UK, having settled into the rural African way of life. This immersion in a different country and culture was one of the many factors that enriched her stay beyond the clinical experience. “I have gained so much more than just medicine”, she said reflecting that she is, “more adaptable to new situations and more easy-going. One gains new confidence when you go it alone.” Dr Ievins plans to move to Cape Town in late 2010: “I love South Africa – there is something about it that got to me”.
Innovative GP trainee’s OOP partnership
Dr Kim Rollinson, a GP specialty training registrar 4 (STR 4) from London, similarly attested to having gained an impressive amount of experience during her year in South Africa, experience which “lives on long after you return home”.
During her ST1 year, she applied for the London GP Deanery’s innovative Out of Programme (OOP) partnership programme with AHP (Box). This programme allows GP STRs to take one year out of programme between ST2 and the ST3 (GP registrar year), working in a post which has been inspected, quality assured, and facilitated by senior GP trainers from the Deanery. She was stationed at Zithulele, a 140-bed former mission hospital, situated on the beautiful Wild Coast of the Eastern Cape (Figure 1), about four hours from East London (www.zithulele.org). Her post in South Africa was recognised by the London Deanery and Postgraduate Medical Education and Training Board and counted six months toward her training as a General Practitioner in the UK.
Zithulele hospital is situated in one of the most deprived parts of South Africa with only 9% of households having electricity. Despite the poverty, the local people are friendly, violent crime is rare, and hospital staff are very much valued by the community.
Some of the experience was rather different to what one might expect in London. Dr Rollinson recalls an elderly man who came to the hospital complaining of chest pain. When asked to stay for observation, the man kept insisting that he was unable to stay. It then transpired that his horse was tied up at the gate, and he needed to take it home first, chest pain notwithstanding (Figure 1). Dr Rollinson learned to innovate with existing resources: when a polytrauma car crash victim required a cervical spine collar but none was available, she and the physiotherapist cut out a firm cardboard collar, wrapped it in bandage, and stabilised the neck while awaiting helicopter evacuation. Dr Rollinson was involved in developing a service when she realised that a doctor traditionally placed in the “nutrition clinic” could be better utilised in the adjacent epilepsy or infectious diseases clinics. This necessitated negotiating with management for a dietician and nurse to run the former, and substantially increased medical time in the latter.
When asked about the difficulties, Dr Rollinson admits to being challenged by the clinical demands, and the frustrations of rural medicine particularly a lack of resources and poor management. She is grateful for an experience that has helped her to appreciate the resources of the NHS more. Her husband took a sabbatical and volunteered at the Jabulani Foundation, a local charity involved in a number of outreach projects. Dr Rollinson and her husband recorded their experiences in a blog (http://www.petegrantinsouthafrica.blogspot.com/).
Dr Rollinson now feels more competent – clinically, in terms of management, and personally, due to the “make-a-plan” style that often had to be used in practice. “Make a plan” is Dr Rollinson’s favourite newly-acquired South Africanism. The phrase serves as an injunction to improvise and find a solution. Dr Rollinson’s outlook has changed a great deal since her year out of programme, having gained a newfound appreciation for the services provided by the NHS. She is also impressed by the immense gratitude shown by South African patients for the care provided. Her experience of service development has been helpful for job interviews. She hopes that all doctors could be enabled to undertake a similar experience. Through the London Deanery, Dr Rollinson is now mentoring the next generation of GP trainees headed out to South Africa.
These three intrepid doctors at differing stages in their careers have experienced true rural African medicine with its challenges and successes. Through their hard work and creativity they have made significant differences in the lives of their patients, the staff, and the surrounding deprived communities. They have grown both as clinicians and as human beings, and last but not least they all have a unique and inspiring story to tell.
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London GP Deanery – Africa Health Placements OOP partnership “The aim of such posts is to enable GP trainees to extend their training and enhance their skills and competencies in areas that are difficult to achieve within the present three-year programme. It is recognised that GP trainees can gain a great deal from the opportunities provided by working and training in a developing country. Such complicated and challenging environments assist the GP trainee’s confidence and consolidate and develop clinical, managerial, leadership, cultural and educational skills, many of which are beneficial and transferable to the NHS.” (www.londondeanery.ac.uk/general-practice/during-training/time-out-of-programme-oop) Timeline: July – August: Advertisements to all London GP trainees October: Competitive recruitment process November – March: AHP facilitate registration and orientation in London April: Confirmation of registration and hospital posts July: final London orientation meeting and problem-solving August: two-week orientation in South Africa September: start 11-month clinical placement AHP do not charge for their services but there are start-up costs (registration, flights, etc.). More details available on the website www.ahp.org.za. For thorough guidance on taking time OOP please read the BMA paper “Broadening your horizons”: http://www.bma.org.uk/international/working_abroad/broadeningyourhorizons.jsp |
