BACKGROUND:This paper investigates the perceptions of medical interns regarding the usefulness of non-mother tongue communication skills taught during the undergraduate curriculum at the University of Cape Town in South Africa. In 2003, the university decided to incorporate Afrikaans and IsiXhosa communication skills into the new MBChB curriculum in order to meet the Faculty of Health Sciences goals to promote quality and equity in healthcare, and to prepare graduating health practitioners for multilingual communities where they would be serving. Despite annual internal evaluations and reviews of the languages courses, the usefulness, if any, of the additional languages in the working clinical environment had not been determined.METHODS:Data were collected during the second year of medical internship across a five-year period through survey questionnaires, as well as focus group interviews conducted in the Western Cape, South Africa. Surveys were conducted from 2009 to 2013.RESULTS:The study shows that the usefulness of each of the probed categories was not consistent across both languages. The interns expressed a need for an overall improvement of the isiXhosa course offering, while the outcomes for the Afrikaans language were more positive across all categories except for cultural understanding.CONCLUSION:The study indicates a positive trend amongst the interns towards developing usefulness in communication skills in Afrikaans and isiXhosa to communicate with their patients.

In South Africa, the national policy on re-engineering primary health care (PHC) supports the implementation of ward-based outreach teams with community health workers. In the Western Cape, a community-orientated primary care (COPC) approach has been adopted in provincial goals for 2030 and the key strategies for the improvement of district health services. This approach is expected to improve health and also save costs. A task team was established in the Metropolitan Health Services to develop an implementation framework for COPC. The framework was developed in an iterative process with four learning sites in the metropole over a period of 18 months. The framework consists of 10 inter-related elements: geographic delineation of PHC teams, composition of PHC teams, facility-based and community-based teamwork, partnership of government and non-government organisations, scope of practice, information system, community engagement, stakeholder engagement, training and development of PHC teams, system preparation and change management. This framework was implemented at the four learning sites and is now being taken to scale and further assessed in the metropole

Background The MMed in Family Medicine is a professional Master’s qualification spanning 4 years of training. The outcomes were predetermined by national consensus. While these outcomes are measured in the form of a national exit examination, there has been no exploration of the experiences of registrars (residents) in this relatively new programme. To evaluate the experiences of registrars in one of the nine training programmes in South Africa and to identify areas for improvement. Methods This study used purposive sampling to recruit registrar (n = 9) and supervisor (n = 8) participants into respective groups. Data were collected via semi-structured interviews and analysed thematically, and consensus was built using the nominal group technique. Results Supervisors identified the strengths and weaknesses of the programme which will impact on further strategic planning. Data from registrar interviews yielded two themes: affirmation, referring to the positive social engagement and facilitation of professional identity formation; and frustrations, referring to structural aspects of the programme which hindered academic progress. Conclusion Qualitative programme evaluation is a useful tool in understanding the learning environment. The student perspective helped to identify the unintended consequences of the programme. It was also shown that the nominal group consensus building technique worked well in a resource-constrained environment.

Family physicians (FP) practising in different parts of the world may require different sets of knowledge and skills to satisfy the needs of the communities in which they work as well as the requirements of the professional bodies with which they are registered. This article gives an overview of the strengths and limitations of the FP globally and more specifically within India, South Africa, and the United States of America. The historical context and evolution of FM as a clinical and academic discipline is discussed in this article. The article recommends suggestions for a better future for Family Medicine as a specialty thereby providing quality primary healthcare to the community, based on the needs of the population of each country.

Background There is a global increase in the prevalence of non-communicable diseases and a growing understanding that patients need to be involved in their care. Patient experience should be assessed and the information used to improve on the planning and delivery of health services. Aim This study described the development and validation of a patient-reported experience measure (PREM) tool which is appropriate for the South African context, to assess self-reported patient experience of chronic care. Setting The study was conducted at four primary health care facilities in the Cape Town Metropole. Methods This was a validity and reliability study with multiple phases to develop and determine the psychometric properties of a novel tool. It consisted of three phases, namely: Phase 1 – Consensus Validity; Phase 2 – Face Validity; Phase 3 – Reliability. Phase 1 consisted of an expert panel reaching consensus on a draft tool. Phase 2a consisted of qualitative semi-structured interviews and cognitive interviews. Phase 3 tested the internal consistency of the tool, the time necessary to complete, as well as floor and ceiling effects with 200 questionnaires. Results The process described resulted in a final questionnaire with n = 10 items in three languages that was easily understood by patients. Internal consistency was determined with the overall Cronbach’s alpha 0.86. This PREM has been named Chronic Care Assessment of Patient Experience. Conclusion Using best practice guidance in tool construction and validation, we delivered a PREM with the potential to improve the quality of care from the perspective of patients. Implementation studies are now required to determine how best to use this tool in routine practice.

CITATION: Burger, H. et al. 2018. Medical students' perceptions on euthanasia and physician-assisted suicide : are they fully informed? South African Medical Journal, 108(9):705, doi:10.7196/SAMJ.2018.v108i9.13528.

Background: This study reflects on the development and teaching of communication skills courses in additional national languages to health care staff within two primary health care facilities in Cape Town, South Africa. These courses were aimed at addressing the language disparities that recent research has identified globally between patients and health care staff. Communication skills courses were offered to staff at two Metropolitan District Health Services clinics to strengthen patient access to health care services. This study reflects on the communicative proficiency in the additional languages that were offered to health care staff.Methods: A mixed-method approach was utilised during this case study with quantitative data-gathering through surveys and qualitative analysis of assessment results. The language profiles of the respective communities were assessed through data obtained from the South African National census, while staff language profiles were obtained at the health care centres. Quantitative measuring, by means of a patient survey at the centres, occurred on a randomly chosen day to ascertain the language profile of the patient population. Participating staff performed assessments at different phases of the training courses to determine their skill levels by the end of the course.Results: The performances of the participating staff during the Xhosa and Afrikaans language courses were assessed, and the development of the staff communicative competencies was measured. Health care staff learning the additional languages could develop Basic or Intermediate Xhosa and Afrikaans that enables communication with patients.Conclusions: In multilingual countries such as South Africa, language has been recognised as a health care barrier preventing patients from receiving quality care. Equipping health care staff with communication skills in the additional languages, represents an attempt to bridge a vital barrier in the South African health care system. The study proves that offering communication skills courses in additional languages, begins to equip health care staff to be multilingual, that allows patients to communicate about their illnesses within their mother tongues.

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.

Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and tension pneumothorax. On history, the mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) helps differentiate cardiac from non-cardiac pain. On examination, evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces and chest infections are important. A 12-lead ECG should be interpreted within 10 minutes of first medical contact, specifically to identify ST elevation myocardial infarction (STEMI). High-sensitivity troponins improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI). ACS (STEMI and NSTEMI/unstable anginapectoris (UAP)) result from acute destabilisation of coronary atheroma with resultant complete (STEMI) or subtotal (NSTEMI/UAP) thrombotic coronary occlusion. The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention(PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available. Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin) and cardiac monitoring.

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%.Keywords: Oral anticoagulant, anticoagulation outcomes, therapeutic control, percentage INR within target therapeutic range (%ITTR),Time in therapeutic range (TIR)

This position paper on Family Medicine in South Africa was written for the National Department of Health in 2014 for the purposes of delivering a comprehensive assessment of the contribution that family physicians could make to the health system, and the issues that need to be addressed in order to realise this contribution. The paper mainly addresses issues in the public sector. It outlines the policy environment, health and health services context, the contribution of family physicians, their role in relationship to other healthcare workers, the initial evidence of their impact, the implications for posts and career pathways and the current state of training programmes, as well as providing key recommendations. The paper represents the viewpoint of the South African Academy of Family Physicians and the College of Family Physicians of South Africa, and attempts to speak with one voice on the current situation and need for future action.

Background. The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has not translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinical impact, limiting generalisability to resource-constrained settings.Objectives. To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa.Methods. A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a 5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation with the referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as well as usefulness without a change in management.Results. The results show that 83.8% of the patients' management was impacted on by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment after myocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor's diagnosis, yet were still associated with a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients to determine referral to a tertiary facility.Conclusion. ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. This should alert policy makers against restriction of access to ECHO and promote training of personnel in its use.

Background: All medical students at the University of Cape Town (UCT) rotate through a Family Medicine clerkship during their final year. Students are based at community health centres (CHCs) in the Western Cape Metropole, and at a rural site in Vredenburg. At the end of the four week clerkship, students do an Objective Structured Clinical Examination (OSCE). Aim: The purpose of this study is to evaluate the students’ feedback of the OSCE at the end of the 6th year Family Medicine rotation, and to make recommendations which can be used to improve the OSCE. Methods: This is a structured qualitative study. The study population included final year medical students rotating through the Family Medicine clerkship, over a period of seven months. Each student completed a structured questionnaire im­ mediately after the OSCE. These evaluations were analysed using a “content analy­ sis” method. Results: The majority of students were happy with the structure and content of the OSCE, as well as the fact that it was aligned to what was taught during the clin­ ical rotation. However, the majority of students complained that the time allocated per station was inadequate. Conclusion: Objective ways should be utilized by the Division of Family Medicine to improve the time allocation and the current format of the OSCE.

This book is intended for those interested in the historical development of general practice in the United Kingdom (UK). It gives a comprehensive account, from the establishment of the first department of general practice in Edinburgh to the development of other departments of general practice throughout the UK. It takes us on an interesting journey through the academic and political battles fought to attain the current status of academic general practice and also describes the many colleagues and characters who contributed significantly to this struggle. In addition, it has a chapter on each university that has a department of general practice and describes how their teaching, service and research roles have evolved over the years. The book would certainly appeal to those who enjoy history written in an easily readable style.

This book is intended for those interested in the historical development of general practice in the United Kingdom (UK). It gives a comprehensive account, from the establishment of the first department of general practice in Edinburgh to the development of other departments of general practice throughout the UK. It takes us on an interesting journey through the academic and political battles fought to attain the current status of academic general practice and also describes the many colleagues and characters who contributed significantly to this struggle. In addition, it has a chapter on each university that has a department of general practice and describes how their teaching, service and research roles have evolved over the years. The book would certainly appeal to those who enjoy history written in an easily readable style.

The story of education since the first democratic elections in 1994 is significant in the context of the changes in the country as a whole. The Faculty of Health Sciences (FHS) has made significant progress in achieving equity of access for students. Remaining challenges include recruiting students from rural areas and achieving gender equality in the allied and rehabilitation professions. The FHS has developed innovative approaches to addressing the diversity of educational preparedness to maintain exit-level clinical competency standards. The comprehensive concept of curriculum has become the Faculty vehicle for placing patients’/clients’ health issues and students’ learning needs at the centre of restructuring. A diverse student body and evolving clinical training platform has created opportunities for new and different dialogues between teachers, students and patients/clients through reflective practice and assessment. The curriculum design principles of inclusiveness, participation and social responsiveness mirror the primary healthcare (PHC) approach. Furthermore, a client/patient-centred approach that strengthens inclusivity and participation has been given impetus with the integration of two of the indigenous languages, most frequently spoken in the Western Cape, and cultural competences into all curricula. Increasing numbers of staff recognise the need to enhance their professional development in educational practice and to acknowledge the implications of the PHC philosophy in their teaching. Developments in undergraduate curricula have significantly realised the intentions of the 1994 FHS’s Assembly to promote a continuous process of reflection and action to align curricula with social responsiveness and changes in the national health and higher education policies.