Developing an educational research framework for evaluating rural training of health professionals: a case for innovation.

BACKGROUND: World-wide, rural clinical training of undergraduate medical students is looking to transform learning experiences, calling for the adoption of innovative approaches that create spaces for curriculum renewal and new ways of thinking. In order for these teaching models to gain acceptance and credibility among the relevant academic communities, it is critical that they be studied and evaluated. AIM: This article describes an innovative rural education intervention and a concomitant, intentional process that was adopted to establish a research framework within which the intervention will be evaluated. METHODS: Key role-players participated in a one-day workshop aimed at developing the framework. A collaborative, structured process that moved through three phases of deliberation and reflection was followed. RESULTS: The documentation and raw data generated during the workshop was used to generate the framework that will serve as a blueprint for ensuring the study and evaluation of the educational innovation. CONCLUSION: Establishing an educational research framework, by adopting a consultative and collaborative process, provides a vehicle for encouraging a culture of critical accountability that seeks to discern evidence of good practice in the training of health care workers in a rural context.

Acute hospitalisation needs of adults admitted to public facilities in the Cape Town Metro district.

INTRODUCTION: Public health care delivery in South Africa aims to provide equitable access at the most appropriate level of care. We studied to what extent the acute health care needs of adults admitted to public hospitals in the Cape Town Metropole were being appropriately met. METHODS: A retrospective study was conducted of the hospital records of adults admitted to medical beds in public hospitals in Cape Town between August and November 2008. Intensive care unit patients were not included. RESULTS: Of 802 beds in use, the estimated occupancy was at least 95%. The average time elapsed since admission was 7.9 days; 94.3% of medical admissions were acute; 45% were severely to critically ill on admission; and co-morbid disease was present in 78.1%. Of all admissions, 31.9% were HIV-positive, and 17% had active tuberculosis. At least 396 (51.6%) patients were deemed to have required specialist or subspecialist consultation to expedite appropriate care; 386 (50.3%) accessed the appropriate level of medical care required; 339 (44.2%) accessed a more sophisticated level of care than required; and 42 (5.5%) did not access an adequate level of care. CT scan and ultrasound accounted for 59% of all restricted tests done. CONCLUSIONS: Our findings support the plan to provide more primary care hospital facilities in the metropolitan area. Most patients needing specialised care are accessing such care, and most patients accessing a higher level of care than needed can be addressed by ensuring that they first access primary care and are referred according to protocols.

Career intentions of medical students trained in six sub-Saharan African countries.

INTRODUCTION: Sub-Saharan Africa(SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin. METHODS: Final year medical students attending nine medical schools in SSA were surveyed--students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained. RESULTS: Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top career-related factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom. DISCUSSION: The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.

Patient perception of cervical screening among women living with human immuno-deficiency virus infection attending an antiretroviral therapy clinic in urban South Africa.

This study aims to ascertain the perception of cervical screening practices among HIV-positive women attending an ART clinic in urban South Africa. It is a prospective cross-sectional study of 100 randomly selected patients using semi-structured interviews. Answers to fixed-response questions were recorded for statistical analysis and themes were identified from responses to open-ended questions. The study found that 59% of women surveyed reported ever having had a Papanicolau (Pap) smear and that 41% of these women had never been notified of the result. Many women surveyed lacked understanding of cervical screening; 78% had never heard of cervical cancer and around 40% had no correct knowledge about Pap smears. The findings suggest that cervical screening practices among HIV-positive women living in urban South Africa do not comply with the recommendations that are based on evidence of increased risk for this population. Systematic cervical screening programmes should be offered to HIV-positive women attending ART clinics in South Africa.

Modified early warning score predicts the need for hospital admission and inhospital mortality.

BACKGROUND: The modified early warning score (MEWS) is a useful tool for identifying hospitalised patients in need of a higher level of care and those at risk of inhospital death. Use of the MEWS as a triage tool to identify patients needing hospital admission and those at increased risk of inhospital death has been evaluated only to a limited extent. AIM: To evaluate the use of the MEWS as a triage tool to identify medical patients presenting to the emergency department who require admission to hospital and are at increased risk of inhospital death. METHODS: Physiological parameters were collected from 790 medical patients presenting to the emergency department of a public hospital in Cape Town, South Africa. MEW scores were calculated from the data and multivariate regression analysis was performed to identify independent predictors of hospital admission and inhospital mortality. RESULTS: The proportion of patients admitted and those who died in hospital increased significantly as the MEW score increased (p<0.001). Multivariate regression analysis identified five independent predictors of hospital admission: systolic blood pressure < or =100 mm Hg, pulse rate > or =130 beats per minute, respiratory rate > or =30 breaths per minute, temperature > or =38.5 degrees C and an impaired level of consciousness. Independent predictors of inhospital death were: abnormal systolic blood pressure (< or =100 or > or =200 mm Hg), respiratory rate > or =30 breaths per minute and an impaired level of consciousness. CONCLUSION: The MEWS, specifically five selected parameters, may be used as a rapid, simple triage method to identify medical patients in need of hospital admission and those at increased risk of inhospital death.

A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa.

BACKGROUND: Until recently South Africa had no triage system for emergency department (ED) use. The Cape triage group developed a triage scale called the Cape triage score (CTS). This system consists of a basic physiology score, mobility score and a short list of important discriminators that cannot be accurately triaged on a physiological score alone. Highest priority is given to a red colour code, followed by orange, yellow and green. AIM: The purpose was to evaluate the components of the CTS and identify amendments that would improve the quality of the scale in terms of its accuracy to identify patients more likely to require admission or at high risk of death in the ED. METHODS: Data were prospectively collected over a 4-month period. Data captured included the parameters of a basic physiological score (respiratory rate, pulse rate, systolic blood pressure, temperature and a simplified score measuring level of consciousness), mobility, a list of selected clinical conditions (discriminator list), final clinical diagnosis and final outcome in the ED (admission to hospital or death). RESULTS: 798 patients were triaged and analyzed. The CTS undertriaged 24% (overtriage 25%) of cases who required admission. By altering the colour code parameters, amending the discriminator list as well as the addition of a trauma factor, undertriage was reduced to 12% (with an overtriage of 45%). CONCLUSIONS: The amended CTS has an acceptably low undertriage rate and is capable of predicting patient disposal over a wide spectrum of ED presentations.

Effect of introduction of nurse triage on waiting times in a South African emergency department.

BACKGROUND: In a resource poor setting with poverty, a high burden of disease and critically low medical staff numbers, triage could potentially improve the long waiting times experienced at South African public hospital emergency departments (ED) and render timely emergency care to those in most need. AIM: To evaluate the impact of introducing nurse triage (using the Cape Triage Score (CTS)) on waiting times for patients presenting to a South African public hospital ED. METHODS: Pre-triage waiting times were collected retrospectively through accessing hospital records of four randomly chosen months of the preceding year. This was compared with data collected prospectively over a 3 month period using nurse triage and the CTS triage tool. Captured data included CTS priority category, time of nurse triage and time of attendance by ED doctor. RESULTS: Waiting times were significantly reduced in all but the lowest priority category. The introduction of nurse triage, using the CTS, resulted in an overall reduction in waiting time from 237 min to 146 min (p<0.001). Patients triaged "red" (highest priority) demonstrated a mean reduction in waiting time from 216 min to 38 min (p<0.001). CONCLUSIONS: The results demonstrate that use of the CTS, as implemented by trained nurses, dramatically reduced the waiting time of patients attending a busy public hospital ED in South Africa.

Are specialist certification examinations a reliable measure of physician competence?

High stakes postgraduate specialist certification examinations have considerable implications for the future careers of examinees. Medical colleges and professional boards have a social and professional responsibility to ensure their fitness for purpose. To date there is a paucity of published data about the reliability of specialist certification examinations and objective methods for improvement. Such data are needed to improve current assessment practices and sustain the international credibility of specialist certification processes. To determine the component and composite reliability of the Fellowship examination of the College of Physicians of South Africa, and identify strategies for further improvement, generalizability and multivariate generalizability theory were used to estimate the reliability of examination subcomponents and the overall reliability of the composite examination. Decision studies were used to identify strategies for improving the composition of the examination. Reliability coefficients of the component subtests ranged from 0.58 to 0.64. The composite reliability of the examination was 0.72. This could be increased to 0.8 by weighting all test components equally or increasing the number of patient encounters in the clinical component of the examination. Correlations between examination components were high, suggesting that similar parameters of competence were being assessed. This composite certification examination, if equally weighted, achieved an overall reliability sufficient for high stakes examination purposes. Increasing the weighting of the clinical component decreased the reliability. This could be rectified by increasing the number of patient encounters in the examination. Practical ways of achieving this are suggested.

Mortality in Patients Treated for Tuberculous Pericarditis in Sub-Saharan Africa

Objective: To determine the mortality rate and its predictors in patients with a presumptive diagnosis of tuberculous pericarditis in sub-Saharan Africa. Design: Between 1 March 2004 and 31 October 2004; we enrolled 185 consecutive patients with presumed tuberculous pericarditis from 15 referral hospitals in Cameroon; Nigeria; and South Africa; and observed them during the 6-month course of antituberculosis treatment for the major outcome of mortality. This was an observational study; with the diagnosis and management of each patient left at the discretion of the attending physician. Using Cox regression; we have assessed the effect of clinical and therapeutic characteristics (recorded at baseline) on mortality during follow-up. Results: We obtained the vital status of 174 (94) patients (median age 33; range 14-87 years). The overall mortality rate was 26. Mortality was higher in patients who had clinical features of HIV infection than in those who did not (40versus 17; P=0.001). Independent predictors of death during follow-up were: (1) a proven non-tuberculosis final diagnosis (hazard ratio [HR] 5.35; 95confidence interval 1.76 to 16.25); (2) the presence of clinical signs of HIV infection (HR 2.28; 1.14-4.56); (3) co-existent pulmonary tuberculosis (HR 2.33; 1.20-4.54); and (4) older age (HR 1.02; 1.01-1.05). There was also a trend towards an increase in death rate in patients with haemodynamic instability (HR 1.80; 0.90-3.58) and a decrease in those who underwent pericardiocentesis (HR 0.34; 0.10-1.19). Conclusion : A presumptive diagnosis of tuberculous pericarditis is associated with a high mortality in sub-Saharan Africans. Attention to rapid aetiological diagnosis of pericardial effusion and treatment of concomitant HIV infection may reduce the high mortality associated with the disease

Hyperglycaemic emergency admissions to a secondary-level hospital - an unnecessary financial burden.

BACKGROUND AND OBJECTIVES: Diabetes affects approximately 1 million South Africans. Hospital admissions, the largest single item of diabetes expenditure, are often precipitated by hyperglycaemic emergencies. A recent survey of a 200- bed hospital, serving approximately 1.3 million Cape Town residents, showed that hyperglycaemic emergencies comprised 25.6% of high-care unit admissions. A study was undertaken to determine the reasons for, and financial cost of, these admissions. METHODS: All hyperglycaemic admissions during a 2-month period (1 September - 31 October 2005) were surveyed prospectively. Admissions were classified using the American Diabetes Association classification of hyperglycaemic emergencies. Demographic data, and the reason for, duration of and primary outcome of admission, were recorded. The following costs per admission were calculated using publicsector pricing: (i) total costs; (ii) patient-specific costs; (iii) nonpatient- specific costs; and (iv) capital costs. RESULTS: Sepsis (36%), non-compliance with therapy (32%) and a new diagnosis of diabetes (11%) were the predominant reasons for admission of 53 hyperglycaemic emergency cases. Mean duration of hospital stay was 4 days, with an in-hospital mortality of 7.5%. Mean cost per admission was R5 309. Clinical staff (25.8%), capital (25.6%) and overhead (34%) costs comprised 85.4% of expenditure. DISCUSSION AND RECOMMENDATIONS: Hyperglycaemic admissions, costing more than R5 300 per patient, represent a health burden that has remained unchanged over the past 20 years. Urgently required primary care preventive strategies include early diagnosis of diabetes, timely identification and treatment of precipitating causes, specifically sepsis, and education to improve compliance.

Performance of academically at-risk medical students in a problem-based learning programme: a preliminary report.

INTRODUCTION: Racially segregated schooling, a legacy of Apartheid policies, continues to hamper education in South Africa. Students entering university from suboptimal circumstances are at significant risk of demonstrating poor academic performance and dropping out of their programmes. Attempts to address the educational needs of these students have included the introduction of extended medical programmes at several universities. Such a programme, the Academic Development Programme (ADP), was implemented at the University of Cape Town in 1991. Over the past decade the programme has graduated more than 100 students. Upon implementation of a new problem-based learning (PBL) programme in 2002, the ADP was discontinued and all students were entered directly into the new PBL programme. Students who demonstrate a need for additional academic support by the end of the first semester enter the Intervention Programme for 1 year before proceeding to the second semester of the PBL programme. An interim analysis was performed to compare the retention rates and academic performance of academically at-risk students in the new PBL programme and the ADP. METHODS: The records of all academically at-risk students entering the ADP (1991-2000) and the new PBL programme (2002) were reviewed. Retention rates for all years of study, and academic performance in the fourth year clerkship courses of the respective programmes were compared. RESULTS: A total of 239 academically at-risk students in the ADP and 43 at-risk students in the new PBL programme were studied. The median retention rates, per year of study, for at-risk students in the PBL programme was significantly better than for at-risk students in the ADP (p<0.02). Academic performance of the at-risk students in all the fourth year clinical clerkship courses of the PBL programme was significantly better than the mean performance over 10 years for at-risk students in the same fourth year courses in the ADP. CONCLUSION: The introduction of PBL at the University of Cape Town has not had a deleterious effect on the performance of academically at-risk medical students. Interim analysis suggests that retention rates and academic performance in the PBL programme are better than those achieved in the extended traditional programme.

Formative assessment promotes learning in undergraduate clinical clerkships.

INTRODUCTION: Clinical clerkships, typically situated in environments lacking educational structure, form the backbone of undergraduate medical training. The imperative to develop strategies that enhance learning in this context is apparent. This study explored the impact of longitudinal bedside formative assessment on student learning in a medical clerkship. METHODS: We studied a class of 4th-year students completing a 14-week medical clerkship at the University of Cape Town in South Africa. Clinician educators assessed student performance during weekly bedside teaching sessions using blinded patient encounters (in which students had no prior knowledge of the patient's diagnosis or access to the clinical records). Student feedback was standardised using performance rating scales. The impact of formative assessment on student learning was determined from questionnaire responses. RESULTS: A total of 575 formative assessments took place during the study period. Students perceived blinded patient encounters to be a valuable learning activity that improved their clinical reasoning skills and assessed progress fairly. They reported that feedback helped inform them of their level of competence and learning needs, motivated them to read more, and significantly improved their participation in patient-centred learning activities. Participating clinicians agreed that this formative assessment strategy enhanced the learning potential of bedside teaching sessions. CONCLUSIONS: Longitudinal formative assessment, using blinded patient encounters, was successfully integrated into undergraduate clerkship bedside teaching. According to both students and staff this assessment strategy enhanced bedside learning and improved student participation in patient-centred learning activities during the clerkship.

The cost of treating serious abdominal firearm-related injuries in South Africa.

INTRODUCTION: Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15,000 lives annually. Up to 127,000 firearm-injured victims seek state health care assistance per annum. The fiscal burden of treating these injuries is not known. METHODS: All serious abdominal firearm-related injuries (requiring admission to hospital and emergency surgery) presenting to a state hospital over a 6-month period were reviewed. A cost analysis using five variables was performed: operating theatre time, duration of hospital and high-care unit stay, pharmaceutical and blood products used, laboratory services used and diagnostic imaging studies performed. RESULTS: Twenty-three patients with serious abdominal gunshot injuries were admitted, of whom 21 (91%) were treated at the hospital from admission until discharge. Each admission cost approximately US dollars 1,467. Hospital stay (47%) and operating theatre (30%) costs accounted for most of the total cost. Pharmaceuticals and blood products (20%), laboratory services (2%) and imaging studies (1%) contributed less than 25% to the total cost. CONCLUSION: Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South African government expenditure on health. This fiscal burden of approximately US dollars 2.9 million, almost 4% of the annual health budget, does not include the cost of treating other serious gunshot injuries. These findings highlight the need for successful violence prevention strategies in South African.

A structured assessment of newly qualified medical graduates.

INTRODUCTION: While there is extensive published experience with the assessment of procedural skills in undergraduate students, this is limited in newly qualified medical graduates at the time of entry to the pre-registration (internship) year. The few studies that have been published suggest that these skills are frequently deficient when objectively tested. We therefore chose to assess the competence of a group of South African medical graduates on entry to their pre-registration year. METHODS: A total of 58 graduates of South African medical schools were assessed. Each subject participated in a 7-station objective structured clinical examination (OSCE); 6 of these assessed individual competence in phlebotomy, intramuscular injection, female pelvic examination, bladder catheterisation, tracheal intubation and prescription writing, while competence in cardiopulmonary resuscitation was assessed in a seventh station in randomly allocated teams of 3 candidates. Candidates' opinions of their own competence was sought by questionnaire. RESULTS: There was a wide variation in competence between subjects and across the range of tasks studied. Mean scores ranged from 85.4% for phlebotomy to 55.3% for prescription writing. The average score across all stations was 67.5%, and no student obtained an overall cut-off score of 85% or more, which was established using a modified Angoff method. Subjects' assessment of their own performance was unduly optimistic; most believed that they had demonstrated competence despite clear shortcomings in technique. Objective scores for subjects who had been exposed to a structured skills laboratory programme were not significantly higher than for those who had not, although their self-assessed performance was indeed higher. DISCUSSION: Most of the South African medical graduates who participated in this study were unable to satisfactorily perform technical procedures appropriate to the house officer on entry to the pre-registration year. This is in line with the conclusions of the few studies published in other countries. We suggest that the learning outcomes of undergraduate medical programmes should include an explicit statement of the competencies required for practice in the pre-registration year, and that these should be adequately taught and rigorously assessed before graduation.

Ethnicity and patterns of spondyloarthritis in South Africa--analysis of 100 patients.

OBJECTIVE: To determine the spectrum and ethnic differences of spondyloarthritis disease patterns in patients attending the Rheumatic Diseases Unit, University of Cape Town, South Africa. METHODS: A retrospective survey of case records of 100 patients with spondyloarthritis seen between January 1988 and January 1995. RESULTS: Of these 100 patients, 71 were male, 53 were Colored [mixed race descendants of Khoisan (Hottentot and Bushmen), Whites, Malays and Black Africans], 40 White, 5 Black and 2 Indian (descendants of immigrants from the Indian subcontinent). Our results show that the prevalence and disease patterns of spondyloarthritis in this South African cohort are comparable to those seen in Europe and North America with respect to clinical and radiological features, as well as therapeutic and orthopedic surgical requirements. No major ethnic differences in disease patterns were observed in White and Colored patients studied. CONCLUSION: The spectrum of spondyloarthritis in South Africa is similar to that seen elsewhere in the world. Our study confirmed the rarity of these conditions in Black South Africans.

Surgical treatment of severe autistic regression in childhood epilepsy.

We report 2 children with partial epilepsy who manifested social and language regression and partial recovery after surgical treatment. One child had seizures since the first 2 weeks of life, caused by a right temporal dysembryoplastic neuroepithelial tumor and regression in the latter part of the first year; seizures were relieved and some functions were recovered after temporal lobe resection at 12 months of age. The second child developed epilepsy at 3 years 3 months, and between 5 years 9 months and 6 years 1 month he became aphasic (Landau-Kleffner syndrome) and lost social functioning, manifesting a very severe behavior disorder. He exhibited a significant improvement in communication, social functioning, and behavior after left multiple subpial transections. Both children manifested evidence of subclinical seizure activity in both temporal lobes. Their clinical picture was one of combined language and autistic regression, and the autistic features demonstrated a clear response to surgical treatment. We suggest that in pediatric epilepsy surgical programs, autistic regression should prompt urgent investigation if drug treatment is not effective.

Conn's syndrome due to adrenocortical adenoma--a rare but rewarding cause of curable hypertension.

OBJECTIVE: To determine the characteristics of an aldosterone-producing adenoma (APA) as a cause of hypertension, its mode of presentation and investigation, as well as the outcome of surgical removal. DESIGN: Retrospective survey with follow-up. SETTING: Groote Schuur Hospital, Cape Town. PATIENTS: 18 patients who had an APA removed between 1975 and 1993. OUTCOME MEASURES: Clinical and biochemical features, morbidity and mortality rates associated with adrenalectomy, and the degree of amelioration of hypertension. RESULTS: Eighteen of 41 patients with primary hyperaldosteronism had an APA. Features of symptomatic hypokalaemia (muscular weakness 9, fatigue 7) were present for a mean of 60 (9 - 240) months. The mean systolic arterial pressure was 153 (117 - 200) mmHg. The mean potassium level was 2,2 mmol/l and the mean aldosterone level 1 639 (147 - 5 153) pmol/l, which, paradoxically, fell on ambulation in 12 patients. All renin levels were suppressed in the supine (mean 0,1 +/- 0,1 (0 - 0,6) ng/ml/h) and ambulatory positions (mean 0,4 +/- 0,5 (0 -1,8) ng/ml/h). Each of 17 tomographic and 6 iodocholesterol scans correctly identified the lesion. There was no surgical mortality, and all patients became normokalaemic. At 1 month or at the time of discharge, 12 (66%) patients were normotensive, 7 without medication. Age, length of history, severity of hypertension and evidence of target organ damage did not predict response to surgery. CONCLUSIONS: An APA is a rare cause of hypertension and hypokalaemia, but it is important to identify as surgery may be beneficial in most cases.

Collagenous colitis--a rare cause of chronic watery diarrhoea. A case report.

Collagenous colitis is a clinicopathological syndrome occurring predominantly in middle-aged females presenting with chronic watery diarrhoea. Histologically the disorder is characterised by a mononuclear cell mucosal inflammatory infiltrate and subepithelial collagen thickening. The condition was first described in 1976 and since then approximately 100 cases have been reported in the literature. We present here the first reported case of this rare disorder in South Africa.