Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries

Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context

Issue: A significant component of health professions education is focussed on students' exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students' sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed "transformative trauma" and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the 'brave spaces' framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

IDEAL: Maintaining PHC-focused training in a MBChB programme through a COVID-induced innovation

Responding to the need for authentic clinical training for students in the context of coronavirus disease 2019 (COVID-19), the Stellenbosch University Faculty of Medicine and Health Sciences developed an innovative 12-week longitudinal, integrated rotation for pre-final-year medical students, the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation. This saw 252 students being placed across 30 primary and secondary healthcare facilities in the Western and Northern Cape provinces. With a focus on service learning, the rotation was built on experiences and research of members of the planning team, as well as partnership relationships developed over an extended period. The focus of student learning was on clinical reasoning through being exposed to undifferentiated patient encounters and the development of practical clinical skills. Students on the distributed platform were supported by clinicians on site, alongside whom they worked, and by a set of online supports, in the form of resources placed on the learning management systems, learning facilitators to whom patient studies were submitted and wellness supporters. Important innovations of the rotation included extensive distribution of clinical training, responsiveness to health service need, co-creation of the module with students, the roles of learning facilitators and wellness supporters, the use of mobile apps and the integration of previously siloed learning outcomes. The IDEAL rotation was seen to be so beneficial as a learning experience that it has been incorporated into the medical degree on an ongoing basis.Contribution: Longitudinal exposure of students to undifferentiated patients in a primary health care context allows for integrated, self-regulated learning. This provides excellent opportunities for medical students, with support, to develop both clinical reasoning and practical skills.

Medical students and residents appreciate ebooks' convenience, but prefer the print book reading experience

BACKGROUND

Increasingly, libraries buy medical monographs as ebooks, but that may not be what medical students and residents want. Some studies have shown that they prefer print books for some types of reading. On the other hand, for participants in distributed medical programs, ebooks are more accessible.

OBJECTIVES

To determine whether medical students and residents at an institution with a distributed medical education program prefer medical ebooks or print books.

METHODS

In February 2019, 844 medical students and residents were invited to complete an online questionnaire on their format preferences.

RESULTS

Two hundred thirty-two students and residents responded. Most preferred electronic format for reading a few pages, but print for entire books. Respondents preferred ebooks because they were immediately available, searchable and could be used on the go, and print books because they strained users' eyes less, facilitated absorption of the text and could be held in users' hands. The location of respondents and year of study had little effect on responses.

DISCUSSION

Libraries should consider buying quick reference and large, heavy textbooks as ebooks and pocket-sized or shorter, single-topic titles, in print format.

CONCLUSIONS

Libraries have a responsibility to make both print and ebooks available to their users.

Perceptions of resources available for postgraduate family medicine training at a South African university

BACKGROUND

 Clinical training is one of the roles of family physicians (FPs) in decentralised postgraduate training. Effective training requires skilled trainers and sufficient resources. Little is known about the resources available for decentralised clinical training in district health systems in low- to middle-income countries, especially in sub-Saharan Africa.

AIM

 To explore FPs' and registrars' perceptions of the available resources in a decentralised postgraduate family medicine (FM) training programme.

SETTING

 Five decentralised training sites affiliated with the University of the Witwatersrand across two provinces in South Africa.

METHODS

 This qualitative study forms part of a broader project evaluating a FM registrar training programme using the logic model. Semistructured interviews were conducted with a purposive sample of 11 FPs and 11 registrars. The interviews were transcribed verbatim and analysed thematically.

RESULTS

 Three themes were identified: 'Impact of resource constraints', 'Family physicians' skills and knowledge could be further improved' and 'Family physicians need additional support to optimise their training role'. The additional resources needed include more FPs, equipment, infrastructure and funding. Knowledge and skills of FPs were reported variable and needed further improvement. Additional support was required from peers, the district management and the university.

CONCLUSION

 Well-resourced decentralised training environments with sufficient skilled trainers and adequate resources are needed to positively influence FP training and supervision, especially in middle-income countries like South Africa.Contribution: Clinical trainers need adequate resources and support from peers, district management and the university for effective decentralised clinical training.

Global health education in China's medical schools: A national cross-sectional study

INTRODUCTION

Despite China's large and growing global presence, data about global health (GH) education (GHE) in China's medical schools are limited. We aimed to describe GHE in these schools and determine whether some may teach GH concepts without labeling them as such.

METHODS

In 2019, 161 Chinese medical schools eligible for accreditation by the Ministry of Education were invited to complete a questionnaire as part of a national survey. Data were analyzed using descriptive analyses, Chi-square tests, Fisher exact tests, and logit models.

RESULTS

Approximately 57% of schools completed the survey (n = 93). 33 (35.5%) indicated that GHE was included in the curriculum. Although the majority of responding schools reported the absence of GH in the curriculum, GH topics were identified at many institutions. Schools affiliated with the central government or an aspiring world-class university were more likely to report the inclusion of GHE and offered more opportunities at international away sites.

CONCLUSIONS

Chinese medical schools are frequently teaching GH topics, but may not label the instruction as such. Policy-makers and educators should be equipped with a global perspective to facilitate GHE at China's medical schools and take measures to address differences between schools.

Training for Transformation: Opportunities and Challenges for Health Workforce Sustainability in Developing a Remote Clinical Training Platform

Background: In 2018, Stellenbosch University's Ukwanda Centre for Rural Health led a faculty initiative to expand undergraduate health professions training to a new site, 9 hours drive from the health sciences campus in the sparsely populated Northern Cape Province of South Africa in the town of Upington. This is part of a faculty strategy to extend undergraduate health sciences training into an under-resourced part of the country, where there is no medical school. During 2019, the first year of implementation, four final year medical students undertook a longitudinal integrated clerkship at this site, while final year students from other programmes undertook short 5-week rotations, with plans for extending rotations and including more disciplines in 2020. The aim of this study was to understand stakeholder perceptions regarding the development of Upington as a rural clinical training site and how this influenced existing services, workforce sustainability and health professions education.

Methods: An iterative thematic analysis of qualitative data collected from 55 participants between January and November 2019 was conducted as part of the case study. A constructivist approach to data collection was utilized to explore participants' perceptions, experiences and understanding of the new training site. Triangulation of data collection and reflexive thematic analysis contributed to the trustworthiness of the data and credibility of the findings.

Findings: The perceptions of three key groups of stakeholders are reported: (1) Dr. Harry Surtie Hospital and Academic Programme Managers; (2) Supervising and non-supervising clinical staff and (3) Students from three undergraduate programs of the Faculty. Five themes emerged regarding the development of the site. The themes include the process of development; the influence on the health service; workforce sustainability; a change in perspective and equipping a future workforce.

Discussion: This case study provides data to support the value of establishing a rural clinical training platform in a resource constrained environment. The influence of the expansion initiative on the current workforce speaks to the potential for improved capacity and competence in patient management with an impact on encouraging a rural oriented workforce. Using this case study to explore how the establishment of a new rural clinical training site is perceived to influence rural workforce sustainability and pathways, may have relevance to other institutions in similar settings. The degree of sustainability of the clinical training initiative is explored.

Family Medicine Training in Lesotho: A Strategy of Decentralized Training for Rural Physician Workforce Development

Family medicine is a relatively new but rapidly expanding medical discipline in Sub-Saharan Africa. Specialization in family medicine is an effective means for building and retaining a highly skilled rural physician workforce in low- and middle-income countries. The Lesotho Boston Health Alliance Family Medicine Specialty Training Program is the first and only postgraduate family medicine program and the only accredited postgraduate training program in the Kingdom of Lesotho. Lesotho has unique challenges as a small mountainous enclave of South Africa with one of the lowest physician-to-patient ratios in the world. Most health professionals are based in the capital city, and the kingdom faces challenging health problems such as high human immunodeficiency virus prevalence, high maternal mortality, and malnutrition, as well as increasing burdens of non-communicable diseases such as hypertension, diabetes, and obesity. In response to these health crises and the severe shortage of health professionals, Lesotho Boston Health Alliance partnered with the Lesotho Ministry of Health in 2008 to introduce family medicine as a new specialty in order to recruit home and retain Basotho doctors. Family medicine training in Lesotho uses a unique decentralized, non-university-based model with trainees posted at rural district hospitals throughout the country. While family medicine in Lesotho is still in the early stages of development, this model of decentralized training demonstrates an effective strategy to develop the rural health workforce in Lesotho, has the potential to change the physician workforce and health care system of Lesotho, and can be a model for physician training in similar environments.

A road less travelled: Undergraduate midwifery students' experiences of a decentralised clinical training platform

Background

In South Africa, the critical skill base shortage of healthcare workers, the underperforming global health indicators and the planned roll out of the National Health Insurance have burdened South African higher education authorities to rapidly expand nursing student enrolments. The expansion in student numbers has placed increased demands on overstretched educational institutions, and students are confronted with challenges of congestion in classrooms and clinical facilities, while lecturers encounter difficulties in the process of clinical allocation. A solution is to utilise decentralised clinical training platforms (DCTPs) and allocate students in rural hospitals.

Aim

To explore and describe undergraduate midwifery students' reflections of their DCTP experiences, in order to inform future practice of decentralisation in student training.

Setting

The study was conducted in the nursing discipline of an urban-based university in KwaZulu-Natal, South Africa, involving undergraduate midwifery students. The university had commenced a programme of allocating students to decentralised clinical sites.

Method

Elo and Kyngäs' content analysis was used to analyse the experiences of DCTP by undergraduate midwifery students (n = 14) as expressed in a focus group (n = 11) and three individual interviews (n = 3).

Results

The following four categories emerged: Recognition as a team member, engaging support, win-win platform and juxtaposed challenges.

Conclusion

In the presence of support and teamwork, rural settings can develop undergraduate student midwives, not only in the areas of midwifery competency but also in their personal capacity, and strengthen the responsiveness, preparedness and relevance of midwifery graduates.

Mapping Evidence on Community-Based Clinical Education Models for Undergraduate Physiotherapy Students: Protocol for a Scoping Review

BACKGROUND

Community-based clinical training has been advocated as an excellent approach to transformation in clinical education. Clinical education for undergraduate physiotherapy students is a hands-on practical experience that aims to provide a student with the skills necessary to enable them to be fit to practice independently. However, in many countries, including South Africa, this training has been conducted only in large urban academic hospitals. Such hospitals are not a true reflection of the environment that these students will most likely be facing as practicing health care professionals.

OBJECTIVE

The objective of this scoping review is to map out existing evidence on community-based clinical education models for undergraduate physiotherapy students globally.

METHODS

A systematic scoping review will be based on the 2005 Arksey and O'Malley framework. Studies involving students and stakeholders in clinical education will be included. This review will not be limited by time of publication. An electronic search of relevant literature, including peer-reviewed primary studies and grey literature, will be conducted from the PubMed, Google Scholar, Medline, CINAHL, and Cochrane Library databases. The search strategy will include keywords such as "education," "physiotherapy," "undergraduate," "community-based," "training," "decentralized," and "distributed." Boolean logic will be used for each search string. Two independent reviewers will conduct screening of titles, abstracts, and full text before extracting articles. A predesigned data-charting table will supplement the extraction of data. Version 12 NVIVO software will aide in the thematic analysis of data.

RESULTS

Data collection will commence after publication of this protocol, and the results are expected to be obtained in the following 5 months.

CONCLUSIONS

The evidence obtained from the extracted data is expected to assist in the development of a model of community-based clinical education for undergraduate physiotherapy students in South Africa, and serve as a basis for future research. The discussion of this evidence will be guided by the research question utilizing a critical narrative approach to explore emerging themes. The enablers and barriers identified from the reviewed studies can guide the development of a community-based clinical education model.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/19039.

A comparative study of medical ebook and print book prices

BACKGROUND

Although most medical libraries buy ebooks, there has been little discussion of the comparative costs of medical ebooks and print books.

OBJECTIVES

To determine whether individually purchased medical ebooks cost more or less, on average, than the same titles in print format and, if so, to calculate the price differential.

METHODS

The author searched the platform of monograph vendor YBP for the 1095 titles in the 'Clinical Medicine' category of Doody's Core Titles 2018 edition. For each title, the print price and the lowest ebook price were noted; the ratio of ebook price to print book price for each title was then calculated.

RESULTS

On average, ebooks cost 2.20 times more than their print equivalents, though the size of the price differential varied greatly with the publisher. For some publishers, ebooks cost nearly the same amount as print books, while for others, ebooks cost three or even four times as much as the print.

DISCUSSION

The greater price of some ebooks may make them unaffordable for libraries or mean that those titles cannot be purchased as ebooks even when that format would be preferred.

CONCLUSIONS

Buying ebooks, at least on a title-by-title basis, can be very costly for medical libraries.

A framework for distributed health professions training: using participatory action research to build consensus

BACKGROUND

There is a global trend towards providing training for health professions students outside of tertiary academic complexes. In many countries, this shift places pressure on available sites and the resources at their disposal, specifically within the public health sector. Introducing an educational remit into a complex health system is challenging, requiring commitment from a range of stakeholders, including national authorities. To facilitate the effective implementation of distributed training, we developed a guiding framework through an extensive, national consultative process with a view to informing both practice and policy.

METHODS

We adopted a participatory action research approach over a four year period across three phases, which included seven local, provincial and national consultative workshops, reflective work sessions by the research team, and expert reviews. Approximately 240 people participated in these activities. Engagement with the national department of health and health professions council further informed the development of the Framework.

RESULTS

Each successive 'feedback loop' contributed to the development of the Framework which comprised a set of guiding principles, as well as the components essential to the effective implementation of distributed training. Analysis further pointed to the centrality of relationships, while emphasising the importance of involving all sectors relevant to the training of health professionals. A tool to facilitate the implementation of the Framework was also developed, incorporating a set of 'Simple Rules for Effective distributed health professions training'. A national consensus statement was adopted.

CONCLUSIONS

In this project, we drew on the thinking and practices of key stakeholders to enable a synthesis between their embodied and inscribed knowledge, and the prevailing literature, this with a view to further enaction as the knowledge generators become knowledge users. The Framework and its subsequent implementation has not only assisted us to apply the evidence to our educational practice, but also to begin to influence policy at a national level.

Twelve tips for distributed health professions training

Increasing numbers of health professions students are being trained in healthcare facilities that are geographically removed from central academic hospitals. Consequently, studies have evaluated this distributed training, assessed the impact that it has on student learning as well as on the facilities where the training occurs, and explored factors that enable and constrain successful clinical training at such sites. The 12 tips presented in this article have been developed from a longitudinal project that has focused on developing a framework for effective distributed health professions training through an extensive review of the literature and a national consultative process. These 12 tips should, therefore, have applicability across multiple contexts. The purpose of this article is to assist people in implementing, adapting, upscaling, maintaining, and evaluating the distributed training of students in the health professions.

Community-based primary healthcare training for physiotherapy: Students' perceptions of a learning platform

Background

South Africa is faced with an overburdened public healthcare system and physiotherapists need to be equipped to address these challenges. Community-based primary healthcare clinical training (CBPHCT) offers physiotherapy students with learning opportunities to develop core competencies in order to address the needs of a disparate healthcare system.

Objectives

To explore the experiences of physiotherapy students participating in a CBPHCT platform.

Method

An explorative qualitative approach was adopted, using focus group discussions with final year physiotherapy students exposed to a year of CBPHCT. Data from the focus groups were transcribed and analysed using content analysis.

Results

Four overarching themes were identified: prerequisite community-based primary healthcare competencies, positive factors associated with CBPHCT, negative factors associated with CBPHCT and recommendations.

Conclusion

The CBPHCT experience was seen to present challenges to, and have benefits for, physiotherapy students. The students felt that communication between stakeholders, such as academic staff and hospital personnel, could be developed, while the lack of resources, such as Internet access, posed a barrier to learning. Students felt core competencies, such as professionalism of caring, were influenced by their exposure to the clinical personnel. Furthermore, they saw themselves as health advocates and felt there was mutual benefit from engagement with communities during their clinical placements. Recommendations included a review of physiotherapy curricula to prepare students for CBPHCT.

Clinical implications

Community-based primary healthcare clinical training provides learning opportunities for undergraduate physiotherapy students to develop core competencies, such as health advocacy, necessary to address the unique needs of a disparate South African healthcare system.

Consequences, conditions and caveats: a qualitative exploration of the influence of undergraduate health professions students at distributed clinical training sites

BACKGROUND

Traditionally, the clinical training of health professionals has been located in central academic hospitals. This is changing. As academic institutions explore ways to produce a health workforce that meets the needs of both the health system and the communities it serves, the placement of students in these communities is becoming increasingly common. While there is a growing literature on the student experience at such distributed sites, we know less about how the presence of students influences the site itself. We therefore set out to elicit insights from key role-players at a number of distributed health service-based training sites about the contribution that students make and the influence their presence has on that site.

METHODS

This interpretivist study analysed qualitative data generated during twenty-four semi-structured interviews with facility managers, clinical supervisors and other clinicians working at eight distributed sites. A sampling grid was used to select sites that proportionally represented location, level of care and mix of health professions students. Transcribed data were subjected to thematic analysis. Following an iterative process, initial analyses and code lists were discussed and compared between team members after which the data were coded systematically across the entire data set.

RESULTS

The clustering and categorising of codes led to the generation of three over-arching themes: influence on the facility (culturally and materially); on patient care and community (contribution to service; improved patient outcomes); and on supervisors (enriched work experience, attitude towards teaching role). A subsequent stratified analysis of emergent events identified some consequences of taking clinical training to distributed sites. These consequences occurred when certain conditions were present. Further critical reflection pointed to a set of caveats that modulated the nature of these conditions, emphasising the complexity inherent in this context.

CONCLUSIONS

The move towards training health professions students at distributed sites potentially offers many affordances for the facilities where the training takes places, for those responsible for student supervision, and for the patients and communities that these facilities serve. In establishing and maintaining relationships with the facilities, academic institutions will need to be mindful of the conditions and caveats that can influence these affordances.

Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia

BACKGROUND

In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty.

METHODS

This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary's District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC.

RESULTS

The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future.

CONCLUSIONS

The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students' clinical experience.

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.