Outcomes for family medicine postgraduate training in South Africa

Developing an electronic portfolio of learning for family medicine training in South Africa

Workplace-based assessment has become increasingly crucial in the postgraduate training of specialists in South Africa, particularly for family physicians. The development of a Portfolio of Learning (PoL) has been a central focus within the discipline of family medicine for over a decade. Initially, a paper-based portfolio was adopted to collect evidence of learning for 50 out of 85 agreed exit-level outcomes. Stellenbosch University led the conversion of this portfolio into an electronic format, known as e-PoL, utilising Scorion software. The e-PoL was successfully implemented in the Western and Eastern Cape regions and was subsequently adopted nationally under the coordination of the South African Academy of Family Physicians. In 2023, the e-PoL underwent a redesign to gather evidence of learning for 22 entrustable professional activities (EPAs). Key insights from this development process underscore the importance of the PoL in supporting assessment-for-learning rather than merely assessment-of-learning. This necessitates features for feedback and interaction, ensuring that the PoL functions beyond a mere repository of forms. Additionally, the e-PoL should facilitate triangulation, aggregation, and saturation of data points to effectively measure EPAs. Furthermore, the PoL has not only documented learning but has also played a pivotal role in guiding the development of clinical training by explicitly outlining expectations for both registrars and supervisors. While the initial design and development costs are significant, operational costs become affordable when shared across all training programmes.

In search of a fix to the primary health care chasm in India: can institutionalizing a public health cadre and inducting family physicians be the answer?

India's woes with an underprioritized and hence underfunded and understaffed public health system continue to plague public healthcare delivery. Though the need for appropriately qualified public health cadre to lead public health programmes is well established, a well-meaning conducive approach to implementing this is lacking. As the COVID-19 pandemic brought back the focus on India's fragmented health system and primary healthcare deficiencies, we discuss the primary healthcare conundrum in India in search of a quintessential fix. We argue for instituting a well-thought and inclusive public health cadre to lead preventive and promotive public health programmes and manage public health delivery. With the aim being to increase community confidence in primary health care, along with the need to augment primary healthcare infrastructure, we argue for a need to augment primary healthcare with physicians trained in family medicine. Provisioning medical officers and general practitioners trained in family medicine can salvage community's confidence in primary care, increase primary healthcare utilization, stymie over-specialization of care, channelize and prioritize referrals, and guarantee competence in healthcare quality for rural communities.

Perceptions of postgraduate family medicine supervision at decentralised training sites, South Africa

Background

Specialist training in family medicine (FM) is growing rapidly in sub-Saharan Africa. The strong emphasis on workplace-based learning for speciality training makes it vital to gain in-depth insights into registrar supervision. Previous studies have explored aspects of supervision at decentralised sites in high-income countries, however, little is known about the benefits and constraints of decentralised postgraduate supervision in low- to middle-income countries, especially in Africa.

Aim

This study aimed to explore family physicians’ and registrars’ perceptions of the strengths and challenges of clinical and educational supervision across decentralised training sites.

Setting

The study was conducted across two provinces at five decentralised training sites affiliated with the University of the Witwatersrand, Johannesburg.

Methods

This qualitative study involved semi-structured interviews with a purposive sample of 11 FPs and 11 registrars. The data were thematically analysed.

Results

Two of the four themes identified, ‘supervision is context-specific and supervisor-dependent’, and ‘the nature of engagement matters’, involved strengths and challenges. The other two, ‘supervision is not ideal’ and ‘the training environment is challenging’, focussed on challenges.

Conclusion

Supervisors and registrars described the postgraduate FM supervision as context-specific and supervisor-dependent. Supervisors displayed good clinical-teacher characteristics and supervisory relationships. However, several challenges, including registrars’ workload, resource shortages and a lack of standardisation across training sites, need to be addressed. Regular faculty development is essential for supervisors to be aware of relevant aspects of, and current trends in, postgraduate training.

Updated programmatic learning outcomes for the training of family physicians in South Africa

The training of medical specialists should constantly be re-aligned to the needs of the population and the health system. The national Education and Training Committee of the South African Academy of Family Physicians reached consensus on the updated programmatic learning outcomes for the training of specialist family physicians in South Africa. Learning outcomes were first developed to guide training programmes when the speciality was recognised in 2007. Fifteen years later, it was time to revisit and revise these learning outcomes. Learning outcomes define what family physicians are able to do at the end of 4 years of postgraduate training. This revision presents five unit standards and 83 programmatic exit-level learning outcomes.

A human resources for health analysis of registered family medicine specialists in South Africa: 2002-19

BACKGROUND

In South Africa, there is a need to clarify the human resources for health policy on family physicians (FPs) and to ensure that the educational and health systems are well aligned in terms of the production and employment of FPs.

OBJECTIVE

To analyse the human resource situation with regard to family medicine in South Africa and evaluate the requirements for the future.

METHODS

A retrospective review of the Health Professions Council of South Africa's (HPCSA) database on registered family medicine practitioners from 2002 until 2019. Additional data were obtained from the South African Academy of Family Physicians and published research.

RESULTS

A total of 1247 family medicine practitioners were registered with the HPCSA in 2019, including 969 specialist FPs and 278 medical practitioners on a discontinued register. Of the 969, 194 were new graduates and 775 from older programmes. The number of FPs increased from 0.04/10 000 population in 2009 to 0.16/10 000 in 2019, with only 29% in the public sector. On average, seven registrars entered each of nine training programmes per year and three graduated. New graduates and registrars reflect a growing diversity and more female FPs. The number of FPs differed significantly in terms of age, gender, provincial location and population groups.

CONCLUSIONS

South Africa has an inadequate supply of FPs with substantial inequalities. Training programmes need to triple their output over the next 10 years. Human resources for health policy should substantially increase opportunities for training and employment of FPs.

The attitude and perceptions of doctors at Letaba Hospital towards family medicine: A qualitative study

Background

It was noted that family medicine (FM) was not used properly by doctors at Letaba Hospital. Anecdotally, misconceptions and misunderstandings about FM were reported. An exploration was recommended to understand the perceptions and attitudes of doctors at Letaba Hospital with regard to FM. Identifying doctors’ misconceptions and the possible reasons for mistaken beliefs about FM by other specialists could offer possible solutions.

Methods

A qualitative study was conducted that attempted to identify the perceptions of doctors about FM and to explore their attitudes towards this specialty.

Results

The primary findings indicate more positive than negative perceptions of other disciplines towards FM. The participants viewed FM as the centre of the healthcare system, with prevention being its core business. This includes a holistic approach, the continuity of care, being community-based, and receiving recognition as a specialty. Family medicine was described by various medical personnel as making a positive contribution to the healthcare system. They note the role of FM discipline in district hospitals, its support of primary health- care and its ability to fill the gaps in the healthcare system, including surgical skills. The few negative perceptions that were identified mostly related to the status of FM as a specialty and doctors’ level of surgical ability. Based on individual interviews, 11 themes were extracted and a ‘wheel’ model was created, depicting the core values of the FM discipline.

Conclusion

The study concluded that most participants have a positive perception of the role of FM, similar to the views of the senior staff in the discipline itself. The concerns from most participants are in the area of preventative medicine, which has not been given enough priority in South Africa and where doctors are expected to rapidly attend to long queues and manage casualties. There was also concern of a perceived lack of surgical skills.

Reflections and proposals for the establishment of Family and Community Medicine Master's Programs in Brazil

While Primary Health Care (PHC) and Family and Community Medicine (FCM) have expanded their space and relevance in health care and undergraduate medical courses, Brazil has no stricto sensu FCM postgraduate programs. In this paper, we analyze some aspects of the Brazilian public health field and the national stricto sensu postgraduate system that can help to explain this scenario. As a contribution to the debate on this topic, we also gathered information from international postgraduate and research experiences in FCM and devised a curriculum proposal for future national FCM master's courses. In the end, we discussed some key strategies for the emergence of stricto sensu postgraduate courses in this discipline in Brazil, highlighting the potential of these programs for evaluation and qualification of primary care services, especially the Family Health Strategy, and the training of PHC specialists required for the consolidation of the Unified Health System (SUS) as an accessible, comprehensive and equitable health system for the Brazilian population.

Implementing and evaluating an e-portfolio for postgraduate family medicine training in the Western Cape, South Africa

BACKGROUND

In South Africa it is compulsory to submit a satisfactory portfolio of learning to gain entrance to the national exit examination of the College of Family Physicians and to qualify as a family physician. A paper-based portfolio has been implemented thus far and the need for an electronic portfolio (e-portfolio) was identified. The aim of the study was to describe and evaluate the implementation of an e-portfolio for the training of family medicine registrars in the Western Cape province of South Africa.

METHODS

Mixed methods were used. A quasi-experimental study evaluated paper- and e-portfolios from the same 28 registrars in 2015 compared to 2016. Semi-structured interviews were conducted with 11 registrars or supervisors to explore their experiences of using the e-portfolio. Quantitative data was analysed in the Statistical Package for Social Sciences and qualitative data in Atlas.ti.

RESULTS

Most respondents found the e-portfolio easier to use and more accessible. It made progress easier to monitor and provided sufficient evidence of learning. Feedback was made easier and more explicit. There were concerns regarding face-to-face feedback being negatively affected. It was suggested to have a feedback template to further improve feedback. Several aspects were significantly better in the e-portfolio such as feedback on the registrar's general behaviour, alignment with learning outcomes, less feedback based on hearsay and acknowledgement of the feedback by the registrar. Although not statistically significant, there was an increase in the usage of the e-portfolio, compared to the paper portfolio.

CONCLUSION

In general, the e-portfolio is an improvement on the paper-based portfolio. It is easier to access, more user-friendly and less cumbersome. It makes feedback and monitoring of progress and development of registrars easier and more visible and provides sufficient evidence of learning. Its implementation throughout South Africa is recommended.

Development of Family Medicine training in Botswana: Views of key stakeholders in Ngamiland

BACKGROUND

Family Medicine training commenced in Botswana in 2011, and Maun was one of the two sites chosen as a training complex. If it is to be successful there has to be investment in the training programme by all stakeholders in healthcare delivery in the district.

AIM

The aim of the study was to explore the attitudes of stakeholders to initiation of Family Medicine training and their perspectives on the future roles of family physicians in Ngami district, Botswana.

SETTING

Maun and the surrounding Ngami subdistrict of Botswana.

METHODS

Thirteen in-depth interviews were conducted with purposively selected key stakeholders in the district health services. Data were recorded, transcribed and analysed using the framework method.

RESULTS

Participants welcomed the development of Family Medicine training in Maun and expect that this will result in improved quality of primary care. Participants expect the registrars and family physicians to provide holistic health care that is of higher quality and expertise than currently experienced, relevant research into the health needs of the community, and reduced need for referrals. Inadequate personal welfare facilities, erratic ancillary support services and an inadequate complement of mentors and supervisors for the programme were some of the gaps and challenges highlighted by participants.

CONCLUSION

Family Medicine training is welcomed by stakeholders in Ngamiland. With proper planning introduction of the family physician in the district is expected to result in improvement of primary care.

Perceived competency deficits and challenges of family medicine trainees in sub-Saharan Africa

BACKGROUND

A competency-based approach to family medicine (FM) post graduate (PG) training falls short of a holistic process if it focuses only on patients' needs without eliciting those of trainees.

AIM

To identify perceived competency deficits of trainees and challenges hindering achievement of learning outcomes.

SETTING

PG FM programmes in sub-Saharan Africa.

METHODS

We conducted a cross-sectional survey using a web-based questionnaire with a list of competency items and challenges. Common Factor Analysis was used to ascertain which competency items and challenges accounted for the highest shared variability. A perceived competency deficit was assumed for any item with a component loading of <0.5. For challenges, higher component loadings denoted higher levels of agreement with the annotated item. Data were analysed using SPSS (version 16).

RESULTS

A total of 150 trainees took the survey. Appraising and utilising scientific knowledge was the item with a perceived competency deficit, while poor mentor-mentee relationship was considered the foremost challenge that hindered learning outcomes.

CONCLUSION

Critical appraisal and utilisation of scientific knowledge should be part of every stage of the African FM trainee's learning experience. To achieve this and other learning outcomes, improving mentor-mentee relationships are essential.

Assessment of the impact of family physicians in the district health system of the Western Cape, South Africa

BACKGROUND

In 2007, South Africa made family medicine a new speciality. Family physicians that have trained for this new speciality have been employed in the district health system since 2011. The aim of the present study was to explore the perceptions of district managers on the impact of family physicians on clinical processes, health system performance and health outcomes in the district health system (DHS) of the Western Cape.

METHODS

Nine in-depth interviews were performed: seven with district managers and two with the chief directors of the metropolitan and rural DHS. Interviews were recorded, transcribed and analysed using the ATLAS-ti and the framework method.

RESULTS

There was a positive impact on clinical processes for HIV/AIDS, TB, trauma, noncommunicable chronic diseases, mental health, maternal and child health. Health system performance was positively impacted in terms of access, coordination, comprehensiveness and efficiency. An impact on health outcomes was anticipated. The impact was not uniform throughout the province due to different numbers of family physicians and different abilities to function optimally. There was also a perception that the positive impact attributed to family physicians was in the early stages of development. Unanticipated effects included concerns with their roles in management and training of students, as well as tensions with career medical officers.

CONCLUSION

Early feedback from district managers suggests that where family physicians are employed and able to function optimally, they are making a significant impact on health system performance and the quality of clinical processes. In the longer term, this is likely to impact on health outcomes.

The national portfolio of learning for postgraduate family medicine training in South Africa: experiences of registrars and supervisors in clinical practice

BACKGROUND

In South Africa the submission of a portfolio of learning has become a national requirement for assessment of family medicine training. A national portfolio has been developed, validated and implemented. The aim of this study was to explore registrars' and supervisors' experience regarding the portfolio's educational impact, acceptability, and perceived usefulness for assessment of competence.

METHODS

Semi-structured interviews were conducted with 17 purposively selected registrars and supervisors from all eight South African training programmes.

RESULTS

The portfolio primarily had an educational impact through making explicit the expectations of registrars and supervisors in the workplace. This impact was tempered by a lack of engagement in the process by registrars and supervisors who also lacked essential skills in reflection, feedback and assessment. The acceptability of the portfolio was limited by service delivery demands, incongruence between the clinical context and educational requirements, design of the logbook and easy availability of the associated tools. The use of the portfolio for formative assessment was strongly supported and appreciated, but was not always happening and in some cases registrars had even organised peer assessment. Respondents were unclear as to how the portfolio would be used for summative assessment.

CONCLUSIONS

The learning portfolio had a significant educational impact in shaping work-place based supervision and training and providing formative assessment. Its acceptability and usefulness as a learning tool should increase over time as supervisors and registrars become more competent in its use. There is a need to clarify how it will be used in summative assessment.

The national portfolio for postgraduate family medicine training in South Africa: a descriptive study of acceptability, educational impact, and usefulness for assessment

BACKGROUND

Since 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio's acceptability, educational impact, and perceived usefulness for assessment of competence.

METHODS

Two structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software.

RESULTS

Half of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning.

CONCLUSION

This first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized.