The extent of interruptions to primary care medical officers' consultations in the Western Cape.

BACKGROUND:  Administrative tasks are an increasing burden for primary care doctors globally and linked to burnout. Many tasks occur during consultations. They cause interruptions with possible effects on patients' and doctors' experiences and care. The burden and typology of interruptions of doctors in primary care consultations have not been studied in South Africa. Given the link between administrative loads and burnout, describing the extent of these interruptions would help. This study's aim was to assess the extent of interruptions on primary care doctors in the Western Cape. METHODS:  This was a descriptive cross-sectional survey. Doctors from rural and urban primary care clinics in the Western Cape answered an online self-administered survey on the types of interruptions experienced during consultations. Interruptions were categorised and their prevalence calculated. Clinical and non-clinical interruption categories were compared. RESULTS:  There were 201 consultations from 30 doctors. Most interruptions were from retrieving and recording the current patient's information (93.0%), paperwork for other patients (50.7%), and telephone calls about the current patient (41.8%). Other prevalent interruptions were for emergencies (39.8%) and acquiring consumables (37.3%). The median (interquartile range [IQR]) of four (2-4) interruption types per consultation was higher than global settings. CONCLUSION:  Doctors experienced many interruptions during consultations. Their wide range included interruptions unrelated to the current patient.Contribution: This study adds insights from the global south on clinicians' administrative burden. It elaborates on the types of activities that interrupt consultations in an upper-middle income primary care setting. Exploration of interventions to decrease this burden is suggested.

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.

Evaluating the new family medicine internship programmes in the Western Cape, South Africa.

BACKGROUND:  In 2021, South Africa introduced a new 6-month internship in family medicine and primary care. This study aimed to assess the new rotation at district health facilities in the Western Cape. METHODS:  A descriptive survey of interns and supervisors, as phase-two of an exploratory sequential mixed methods study. Questionnaires were developed from a descriptive exploratory qualitative study. Data were analysed with the Statistical Package for Social Sciences. RESULTS:  Questionnaires were completed by 72 interns (response rate 21%) and 36 supervisors (response rate 90%), across 10 training programmes. Interns felt more independent (97.2%), confident (90.3%) and resilient (91.6%). They learnt to manage undifferentiated and chronic conditions (91.6%), to refer patients (94.3%) and conduct procedures (77.8%). Most interns were not exposed to community-based services (68.0%) and continuity of care (54.1%). Supervision was mostly adequate during the day (79.1%) and afterhours (80.6%). Many interns reported no structured teaching programme (41.7% - 55.6%). Most supervision was from medical officers and registrars. Supervisors saw interns as valuable members of the clinical team (100.0%), who required extra support and administration (42.5%). The majority of interns (75.0%) and supervisors (72.7%) thought the rotation was the right length and the best preparation for community service (67.6%). CONCLUSION:  The rotation met most expectations of the Health Professions Council of South Africa. Programmes need to improve exposure to community-orientated primary care, public health medicine, palliative and ongoing care. Supervision and orientation of interns needs improvement.Contribution: This is the first evaluation of the new family medicine internship programme in South Africa.

How to approach patients and families at the end of life.

Healthcare practitioners are regularly faced with treating patients at the end of their life, and this can be very daunting. This article hopes to help the practitioner have an approach to managing end-of-life care that makes it less distressing. The symptoms at the end-of-life include delirium and/or agitation, breathing changes, skin changes, sleeping more, decrease in need for food and drink, incontinence, and increased secretions. These symptoms are discussed and practical ways of management are given. The article further discusses how to approach the difficult conversation with the family and gives guidance as to what needs to be discussed. A number of tips are discussed on how to prepare the family to handle a death at home. It is essential to look at coping mechanisms and selfcare for practitioners dealing with end-of-life care as the death of a patient not only affects the family but also the practitioner.

Evidence of learning in workplace-based assessments in a Family Medicine Training Programme.

BACKGROUND:  Learning portfolios (LPs) provide evidence of workplace-based assessments (WPBAs) in clinical settings. The educational impact of LPs has been explored in high-income countries, but the use of portfolios and the types of assessments used for and of learning have not been adequately researched in sub-Saharan Africa. This study investigated the evidence of learning in registrars' LPs and the influence of the training district and year of training on assessments. METHODS:  A cross-sectional study evaluated 18 Family Medicine registrars' portfolios from study years 1-3 across five decentralised training sites affiliated with the University of the Witwatersrand. Descriptive statistics were calculated for the portfolio and quarterly assessment (QA) scores and self-reported clinical skills competence levels. The competence levels obtained from the portfolios and university records served as proxy measures for registrars' knowledge and skills. RESULTS:  The total LP median scores ranged from 59.9 to 81.0, and QAs median scores from 61.4 to 67.3 across training years. The total LP median scores ranged from 62.1 to 83.5 and 62.0 to 67.5, respectively in QAs across training districts. Registrars' competence levels across skill sets did not meet the required standards. Higher skills competence levels were reported in the women's health, child health, emergency care, clinical administration and teaching and learning domains. CONCLUSION:  The training district and training year influence workplace-based assessment (WPBA) effectiveness. Ongoing faculty development and registrar support are essential for WPBA.Contribution: This study contributes to the ongoing discussion of how to utilise WPBA in resource-constrained sub-Saharan settings.

Development of entrustable professional activities for family medicine in South Africa.

South Africa is undergoing a significant shift towards implementing enhanced workplace-based assessment methodologies across various specialist training programmes, including family medicine. This paradigm involves the evaluation of Entrustable Professional Activities (EPAs) through comprehensive portfolios of evidence, which a local and national clinical competency committee then assesses. The initial phase of this transformative journey entails the meticulous development of EPAs rooted in discrete units of work. Each EPA delineates the registrar's level of entrustment for autonomous practice, along with the specific supervision requirements. This concise report details the collaborative effort within the discipline of family medicine in South Africa, culminating in the consensus formation of 22 meticulously crafted EPAs for postgraduate family medicine training. The article intricately outlines the systematic structuring and rationale behind the EPAs, elucidating the iterative process employed in their development. Notably, this marks a groundbreaking milestone as the first comprehensive documentation of EPAs nationally for family medicine training in Africa.

Palliative care in a rural subdistrict in South Africa: A 4-year critical review.

BACKGROUND: Palliative care (PC) is a priority in South Africa, focussing on integrating PC into primary health care. Few examples exist showing how this is done. In 2018, a rural PC project was implemented, which subsequently evolved into an integrated service between the hospital and the community. AIM: The aim was to review the PC project over 4 years. SETTING: The setting was the George subdistrict of the Garden Route district in South Africa. Community-based services were offered to all patients with PC needs by three non-governmental organisations who deliver home community-based care via community health workers. They were supplemented by primary health care clinics, an intermediate care facility and two hospitals. METHODS: This was a retrospective descriptive study. Inpatient ward round data and patient referrals between 2018 and 2022 were analysed using descriptive statistics. Variables included patient demographics, diagnosis, home visits and place of death. RESULTS: A total of 819 patients were referred. Inpatients were reviewed on weekly ward rounds by a multidisciplinary team. The most common diagnosis was cancer (57%). Home visits enabled patient follow-ups, of which 152 were recorded. CONCLUSION: The programme has become sustainable and integrated in the public healthcare system. Contributing factors included dedicated staff, using simple tools and continuous training. The findings may be useful to PC programmes in similar contexts elsewhere.Contribution: This work adds new knowledge to the field of PC in an underresourced rural healthcare environment in sub-Saharan Africa, by describing how system-wide integration of a new service was navigated to become sustainable.

Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review.

BACKGROUND: Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT. METHODS: A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting. RESULTS: After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services. CONCLUSIONS: Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

Workplace-based learning opportunities in a South African family medicine training programme.

BACKGROUND: Workplace-based learning (WBL) provides authentic learning opportunities to develop fit-for-practice healthcare workers. Different types of WBL opportunities have been described in high-income countries, but the opportunities in the district health systems of sub-Saharan Africa have not been characterised. AIM: This study explored family physicians' (FPs) and registrars' perceptions of WBL opportunities in a decentralised postgraduate family medicine registrar training programme. SETTING: The study was conducted at five decentralised training sites across two provinces affiliated with the University of the Witwatersrand in South Africa. METHODS: This instrumental case study involved semi-structured qualitative interviews with 11 FPs and 11 registrars purposively sampled across the training sites. The verbatim transcripts were thematically analysed using Braun and Clark's six-step approach. RESULTS: Workplace-based learning opportunities were grouped into four themes: Learning from interpersonal interactions, learning from district activities, self-directed learning and contextual influences on learning opportunities. Registrars learnt from patients, peers, FPs and other professionals. Feedback, self-reflection, portfolio use, involvement in various district events, such as student and staff teaching, and continuous medical education augmented learning. Contextual influences originated from health facilities, resource availability, district management and university support, excessive workload and a need for standardised district learning opportunities. CONCLUSION: Registrars are exposed to several types of WBL opportunities in district health systems. Effective engagement with available opportunities and addressing contextual challenges could enhance registrar learning.Contribution: Maximising learning opportunities to promote registrars' acquisition of required skills and competencies to efficiently address community needs in a middle-income country such as South Africa.

"We just don't have the resources": Supervisor perspectives on introducing workplace-based assessments into medical specialist training in South Africa.

BACKGROUND: South Africa (SA) is on the brink of implementing workplace-based assessments (WBA) in all medical specialist training programmes in the country. Despite the fact that competency-based medical education (CBME) has been in place for about two decades, WBA offers new and interesting challenges. The literature indicates that WBA has resource, regulatory, educational and social complexities. Implementing WBA would therefore require a careful approach to this complex challenge. To date, insufficient exploration of WBA practices, experiences, perceptions, and aspirations in healthcare have been undertaken in South Africa or Africa. The aim of this study was to identify factors that could impact WBA implementation from the perspectives of medical specialist educators. The outcomes being reported are themes derived from reported potential barriers and enablers to WBA implementation in the SA context. METHODS: This paper reports on the qualitative data generated from a mixed methods study that employed a parallel convergent design, utilising a self-administered online questionnaire to collect data from participants. Data was analysed thematically and inductively. RESULTS: The themes that emerged were: Structural readiness for WBA; staff capacity to implement WBA; quality assurance; and the social dynamics of WBA. CONCLUSIONS: Participants demonstrated impressive levels of insight into their respective working environments, producing an extensive list of barriers and enablers. Despite significant structural and social barriers, this cohort perceives the impending implementation of WBA to be a positive development in registrar training in South Africa. We make recommendations for future research, and to the medical specialist educational leaders in SA.

Medical interns in district health services: an evaluation of the new family medicine rotation in the Western Cape of South Africa.

BACKGROUND: In 2021, South Africa introduced a 6-month internship rotation in family medicine, in the second year of a 2-year internship programme for newly qualified doctors. This was a major change from the previous 3-months training in family medicine, and expanded the training platform to smaller district hospitals and primary health care (PHC) facilities, many of which had never had interns. The medical disciplines in South Africa needed to know if this change in the internship programme was worthwhile and successful. The aim of this study was to assess the new family medicine rotation for medical interns at district health facilities in the Western Cape Province. METHODS: Descriptive exploratory qualitative research included six intern programmes across the province. Purposeful sampling identified a heterogeneous group with maximum variation in experience. Overall, eight interns, four managers, four supervisors and four intern curators were included. Individual semi-structured interviews were audio-recorded and the transcripts were thematically analysed using the framework method and Atlas-ti software. RESULTS: Four major themes emerged around the varied structure and organisational characteristics of the rotations, the orientation and arrival of interns, their learning during the rotation, and impact on health services. A programme theory was developed that defined the key inputs (i.e. infrastructure, communication, orientation, preparation, prior learning and guidelines), processes (i.e. model of the rotation, clinical training and supervision, clinical teaching), outputs (i.e. more independent decision making, approach to undifferentiated problems, approach to chronic care and continuity, development of procedural skills, approach to sequential coordination of care and referrals, working in a multidisciplinary team and inter-professional learning, integration of multiple competencies, as well as becoming more person and community orientated). CONCLUSIONS: The new rotation in family medicine was positively experienced by most interns, supervisors and managers. It should lead to improved quality of care, better preparation for obligatory community service, and an increased likelihood of considering a career in district level health services. This study will form part of an exploratory sequential mixed methods study that incorporates the key issues into a questionnaire for a descriptive survey of all interns in a subsequent study.

Nurses' and patients' experiences of family planning services in a rural district, South Africa.

BACKGROUND: Family planning (FP) is a key component of primary health care (PHC). Nurses are the first source of FP information to women outside their social context. There is a paucity of research regarding clients' lived experiences of FP, particularly understanding both the client's and the healthcare worker's experiences in the same clinical context and community. AIM: This study aims to explore the lived experiences of nurses and female clients regarding FP services at PHC clinics. SETTING: Two PHC clinics in a rural sub-district in South Africa. METHODS: A descriptive qualitative study using semi-structured interviews was conducted. Clients and nurses were selected using criterion-based purposive sampling and interviewed by female research assistants in a home language in a private setting. Transcription and translation of audio recordings were done. Data were analysed inductively using the framework method. RESULTS: Ten clients and eight nurses were interviewed, with an equal number from each clinic. The median age of clients was 28.5 years and of nurses was 47.5 years. Four themes emerged: (1) Stigma, culture and the teenage girl; (2) Bad effects - the Big Five, clustered around weight changes, blood blockages and abnormal bleeding, pain, fertility and cancer; (3) FP social dynamics; and (4) FP and the health system. CONCLUSION: Family planning is highly moralised and stigmatised. Negative effects of FP were not adequately recognised by the health system. Family planning outreach into the community and dedicated FP resources at clinics were suggestions to improve the service.Contribution: This work helps to better understand patients' experiences of family planning services.

Developing entrustable professional activities for family medicine training in South Africa.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges.Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Perceptions of private specialist outreach services at a rural district hospital, South Africa.

BACKGROUND: A major disparity exists in access to specialised healthcare between rural and urban areas. Specialist outreach programmes are one of the ways in which rural specialist healthcare inequality is being addressed. A number of rural district hospitals (RDH) employ local, private specialists (LPS) to supplement public specialist outreach. Limited research exists on private specialist outreach and support (PSOS) in sub-Saharan Africa or South Africa. METHODS: This was a descriptive, exploratory, qualitative study using thematic analysis of semi-structured interviews. Non-probability, purposive sampling was used to obtain a sample size of 16 participants. The audio recordings were transcribed verbatim and analysed with the framework method and ATLAS.ti version 8© software. RESULTS: Four major themes emerged, namely roles of LPS, effects, sustainability and feasibility of PSOS. Overall PSOS was considered sustainable, feasible and had positive effects in and beyond the sub-districts. The value of PSOS was supported by improved access and timeliness of services, improved competency of RDH medical practitioners, improved coordination, comprehensiveness and continuity of care. Private specialist outreach and support was, however, associated with increased burden on the RDH resources and required a basic level of RDH infrastructure to function effectively. CONCLUSION: The perceived contribution of private specialist outreach services was positive overall. Implementation in RDHs is feasible, but should involve consideration of factors in the hospital, town, sub-district and district prior to implementation.Contribution: This paper provides evidence that private specialist outreach and support services are feasible in the state health sector, provided that certain considerations are taken into account.

Evaluating postgraduate family medicine supervisor feedback in registrars' learning portfolios.

BACKGROUND:  Postgraduate supervision forms a vital component of decentralised family medicine training. While the components of effective supervisory feedback have been explored in high-income countries, how this construct is delivered in resource-constrained low- to middle-income countries has not been investigated adequately. AIM:  This article evaluated supervisory feedback in family medicine registrars' learning portfolios (LPs) as captured in their learning plans and mini-Clinical Evaluation Exercise (mini-CEX) forms and whether the training district or the year of training affected the nature of the feedback. SETTING:  Registrars' LPs from 2020 across five decentralised sites affiliated with the University of the Witwatersrand in South Africa were analysed. METHODS:  Two modified tools were used to evaluate the quantity of the written feedback in 38 learning plans and 57 mini-CEX forms. Descriptive statistics, Fisher's exact and Wilcoxon rank-sum tests were used for analysis. Content analysis was used to derive counts of areas of feedback. RESULTS:  Most learning plans (61.2%) did not refer to registrars' clinical knowledge or offer an improvement strategy (86.1%). The 'extent of supervisors' feedback' was rated as 'poor' (63.2%), with only 14.0% rated as 'good.' The 'some' and 'no' feedback categories in the mini-CEX competencies (p  0.001 to p = 0.014) and the 'extent of supervisors' feedback' (p  0.001) were significantly associated with training district. Feedback focused less on clinical reasoning and negotiation skills. CONCLUSION:  Supervisors should provide specific and constructive narrative feedback and an action plan to improve registrars' future performance.Contribution: Supervisory feedback in postgraduate family medicine training needs overall improvement to develop skilled family physicians.

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.

The role of community health workers in palliative care in a rural subdistrict in South Africa.

BACKGROUND: Effective palliative care is an urgent humanitarian need, particularly in less developed countries, including South Africa (SA). People can be palliated within their communities, motivating the integration of palliative care into primary healthcare systems. While community health workers (CHWs) play a vital role in health coverage at the primary care level, literature on their roles in palliation is limited. AIM: To explore the roles of CHWs in palliative care delivery in a rural subdistrict in SA. SETTING: This study was conducted in the George subdistrict of the Western Cape province, SA. METHODS: A descriptive qualitative study explored the perceptions of a wide range of stakeholders (n = 39) of CHWs' roles in palliative care. Data were collected via semistructured interviews and focus group discussions and analysed thematically. RESULTS: Patients experienced severe biopsychosocial symptoms and needed home-based palliation. While CHWs identified and referred patients, their main responsibilities were health promotion and disease prevention. Palliation was primarily a registered nurse's function. Community health workers were conflicted by their limited ability to deliver basic palliative care to patients. CONCLUSION: While there is a definite need for community-based palliative care, the optimal structure of such a service and the roles of CHWs therein are uncertain. Future research should explore the home-based palliation needs of patients in similar contexts and the service design best suited to address these needs within the primary healthcare domain.Contribution: This study illustrates the influence of individual and system-related factors on CHWs' roles in palliative care. It can inform service design to optimise CHWs' contribution to palliation within primary health care.

Patients requiring palliative care attending a regional hospital emergency centre in South Africa: A descriptive study.

Background: : Globally, emergency centers (ECs) face increasing patients with palliative care (PC) needs. This is also true for South Africa. Factors include an increasingly older population, rising rates of non-communicable and infectious diseases. A paucity of data exists on local rates and reasons for patients with life limiting conditions presenting to ECs. PC and emergency medicine are established specialties, but little is known how they interface in clinical practice. This study describes the contribution of patients with life limiting conditions to the case load of an EC in a regional hospital in the Western Cape. Methods: : This was a prospective, descriptive study. All patients entering the EC over 3 months were assessed using a validated PC identification tool, developed for low-and-middle-income countries. All patients entering the EC were captured in an electronic database. Those identified to have life limiting illnesses and potential PC needs received a secondary ICD-10 code. These files were extracted and statistically analysed. Variables included diagnosis, demographics, reason for visit, and disposition. Results: : A total of 426 patient visits (4.24%) were identified. Cancer (25.8%), neurological (19.7%) and HIV (17.4%) were the most frequent diagnoses. Patients with HIV and TB were significantly younger. Physical symptoms were the most common reasons for attendance (87%), followed by social (11%) and system issues (10%). Most patients were discharged home (55%), 26% were admitted, and 13% died in the EC. Discussion: : ECs in Africa are under-resourced and uncomfortable places for patients with life limiting illnesses. System-related visits could be avoidable, as most were due to patients running out of medication or requiring procedures such as urinary catheter changes, which could be done at the local clinic. Some attended EC due to social reasons, usually due to caregivers feeling overwhelmed. Patients requiring PC make up a significant percentage of EC visits. Optimizing health systems and community home-based care could alleviate EC pressures and improve the illness experience of patients with life limiting conditions.

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.

A values-driven approach to vaccine hesitancy conversations.

South Africa recently experienced the third wave of the coronavirus disease 2019 (COVID-19)pandemic. Social media is flooded with polarised conversations, with opinions for and against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. Many people are hesitant, and some are strongly opposed to vaccination. Vaccine hesitancy must be understood in historical, political and socio-cultural contexts. The aim of this study was to offer a values-driven approach to vaccine hesitancy conversations. It focusses on ethical dilemmas forthcoming from values violations, interrogating the personal and institutional scripts and rationalisations that prevent resolution, and offering ways of re-scripting these. Values-driven conversations provide safe spaces for vaccine-hesitant individuals to voice their reservations. The manner in which conversations are conducted is as important as the contents being discussed. Healthcare professionals are trusted by the public and should use ways of conversing that do not erode this trust. Creating respectful, compassionate platforms of engagement and incentivising vaccination are important measures for change in vaccine perspectives.