hpcsa_buildingJohannesburg Health District Intern Rotation in Family Medicine/PHC

Current State of Family Medicine in Johannesburg

There are eight family physicians appointed in formal posts in Johannesburg and coordinating ±120 doctors (including 33 interns) for the 4.5m people of Johannesburg. Dr Jimmy Akii leads the team as acting District Family Physician and is involved heavily in clinically supporting health district management. Dr Michelle Torlutter is supporting Clinical Governance in Region B and managing the complete postgraduate programme of Wits Family Medicine and Johannesburg. Prof Shabir Moosa is supporting Clinical Governance in Region D (Soweto) and coordinating Chiawelo Community Practice in Soweto. Dr Humayun Kabir, as lead family physician in Chiawelo Community Practice, supervises the COPC site with weekly rotating interns and various groups of students. Dr Yava Kalula, as lead family physician in Chiawelo CHC, supervises the CHC Complex. Dr Kazombia Manda as lead family physician in Alex CHC, supervises the CHC Complex with various groups of students and manages the CPD programme with Dr Petkova. Dr Maggie Petkova is supporting Clinical Governance in Region C and supporting Dr Akii in administration. Dr Colins Mbah is clinically supporting the Clinical Associate programme almost completely in South Rand Hospital.

 

Current Internship in Johannesburg Family Medicine

Approximately 45 interns rotate every four months through Family Medicine/Psychiatry. This includes ±30 interns from Chris Hani Baragwanath Academic Hospital (CHBAH) and ±15 from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The Helen Joseph-Rahima Moosa Hospitals (HJRMH) removed their interns from Johannesburg Health District after 1 year and placed them in their OPD, citing their hospital needs. A quarter of the ±45 interns rotate through Psychiatry in their hospitals for one of these four months effectively leaving ±33 interns present per month across Johannesburg Health District at mostly Community Health Centres (CHCs). A list of current sites, named family physician supervisors and numbers per site is below. Those in brackets are recently graduated family physicians who are still in medical officer (MO) posts and in Johannesburg as of now. However, they may leave unless appointed into family physician posts.

Facilities FP Supervisors No.s After Hrs
Alex Manda 5 Edenvale
Hillbrow (Nkera) 6 Yes
Lillian Ngoyi MO 3 Yes
Mofolo MO 3 Yes
Chiawelo Kalula 4 Yes
Zola MO 0 Other CHCs
Itereleng (Ubabukoh) 3 Other CHCs
Discoverers MO 1 Yes
Lenasia South (H) (Llale) 4 Yes
Stretford MO 3 Other CHCs
South Rand (OPD) MO 0 Other CHCs

There are only 1-2 full time equivalent in registrar available in Johannesburg and working in Chiawelo / Hilbrow as registrars only spend their 1st year in primary care setting and do their 2nd and 3rd year in hospitals rotations. Some registrars may return in 4th year but this is an elective year where they may be in other settings e.g. anaesthetics, HIV or palliative care. Interns provide after-hours service mostly in emergency departments of CHCs, under supervision of medical officers. Interns have been withdrawn where after-hours supervision has been poor e.g. Alex.

Interns are oriented on their first day as a full group but are managed separately thereafter in ‘hospital clusters’, creating a fragmented approach within Johannesburg Health District. The current training includes attending weekly one hour CPD meetings in Hillbrow, Alex and Lillian Ngoyi CHCs. Interns daily clinical support can vary from very good with family physicians where they are available to very poor where career medical officers (MOs) tend to leave them unsupervised. This has resulted in poor experiences and interns being removed from certain sites e.g. Zola CHC and South Rand Hospital. There have been courses on HIV and BLS but these have been intermittent.

Interns from CHBAH also specifically rotate through Chiawelo Community Practice (CCP) in Soweto for one week during their three months. They join CCP, a practice with an enrolled population of ±30 000 people around Chiawelo CHC. CCP is a structured academic environment where interns develop an understanding of community-oriented primary care (COPC) and National Health Insurance  (NHI) readiness. They are oriented to high-quality family medicine record-keeping on the Monday and see patients most of the rest of the week. They join academic meetings 8-9am on Tuesdays and Thursdays, visit a health club on Wednesday 7.30-9am, do a home visit on identified needy patients with the Team Leader and CHW on Thursday afternoons and engage/teach CHWs on Friday 8.30-10am. They also join a monthly CCP community stakeholder / health promotion planning meeting on the second Friday of every month or a monthly CCP multidisciplinary team meeting on the third Thursday of the month or the monthly Soweto Clinical Governance meeting with Soweto managers and programme coordinators, if they happen to be around that week. They have a very positive experience in this week citing the good organisation and quality but complain of the short duration. CMJAH interns currently spend one week with CHWs  walking around Alex in unsupervised home visits.

Plans for Expanded Internship in Johannesburg Family Medicine

The number of two years interns in the expanded internship planned for the hospitals of Johannesburg are CHBAH (240), HJRM (108), CMJAH (84) and Edenvale Hospital (EH) (24). Given the option of 18mths hospital and 6mths of PHC rotation the numbers expected in Johannesburg Health District will be:

Complexes 2019 2020 2021
  Hosp DHS Hosp DHS Hosp DHS
CMJAH ±79 ±11 90 ±11 90 30
CHBAH ±218 ±22 240 ±22 240 80
HJRMH 72 0 72 ±7 72 36
EH 24 0 24 ±3 24 8

The approach will remain focused on CHCs (expanding the number of CHC sites from 9 to 16 but also including weekly supervised/supported visits to surrounding clinics). The development of such CHC complexes will assist in an integrated approach that improves clinical governance and prepares such CHC complexes for National Health Insurance.

The plan is to distribute interns across the following sites:

Facilities CoJ Region Supervisor No.s 2019 No.s 2021 (Gross) No.s 2021 (Net)* Net Change Intern Coordinator
OR Tambo A (NONE) 0 6 3 +3 Dr Torlutter
Randburg B (NONE) 0 2 1 +1 Dr Torlutter
HJ (OPD) B (NONE) (7) 12 6 +1 Dr Torlutter
Discoverers C (NONE) 1 6 3 +2 Dr Petkova
Lillian Ngoyi D (NONE) 3 12 6 +3 Dr Ruiz
Mofolo D (Witt) 3 6 3 +0 Dr Ruiz
Meadowlands D (NONE) 0 6 3 +3 Dr Ruiz
Diepkloof D (NONE) 0 6 3 +3 Dr Ruiz
Chiawelo D Kalula 4 8 4 +0 Dr Petkova
Zola D (NONE) 0 6 3 +3 Dr Petkova
Itereleng D (Ubabukoh) 3 12 6 +3 Dr Petkova
Bheki Mlangeni (OPD / Zola Gate) D (NONE) 2 12 6 +4 Dr Petkova
Alex E Manda 5 12 6 +1 Dr Manda
Edenvale (OPD) E (NONE) (3) 6 3 +0 Dr Manda
Hillbrow F (Nkera) 6 12 6 +0 Dr Ubabukoh
South Rand (OPD) F (NONE) 0 12 6 +6 Dr Ubabukoh
Lens Ext G (NONE) 0 6 3 +3 Dr Moti
Lenasia South (H) G (Llale) 4 12 6 +2 Dr Moti
Stretford G (NONE) 3 12 6 +3 Dr Moti
TOTAL     33 154 77    

*Excluding 3 x monthly rotations in their 6mths.

The Department of Health will have to address the need for extra consulting space in CHCs/Clinics (without displacing nurses) and the need for an additional 16 junior family physicians (1 per CHC complex above and 2 for CCP) to support clinical governance and supervision. Those family physicians in brackets are available but are occupying medical officer posts.. We want to ensure high quality of supervision as medical officers and nurses abuse the extra medical capacity to leaving interns to push queues unsupervised.. An additional 68 registrar posts (4:1) will support this as well. Consideration also needs to be given to redeploying PHC Nurses from provincial CHCs to clinics with such increased medical support. A business plan is attached.

In general interns will continue overtime in 24 hour emergency centres as currently arranged but we will also seek to strengthen extended hours services e.g. Saturday mornings etc in certain primary care sites, only where there is appropriate nurse teamwork and medical supervision available.

The plan is to expand the COPC rotation through Chiawelo Community Practice to one month in their six months in PHC. The additional interns will allow CCP to cover ±150000 people in a very structured NHI group practice, allowing best practice family medicine to be fully appreciated. The COPC experience will be enhanced with active participation in health promotion activities and quality improvement projects related to key priorities from clinical governance challenges. The aim is to ensure that interns are ready as young doctors to understand the dynamics of NHI and to implement community-oriented primary care in the NHI setting.

There are other rotations that will be explored as well: ENT, Opthalmology, Dermatology, Urology (that may combine into a monthly rotation) as well as a monthly district hospital rotations based on gaps identified by interns from their 1st year internship.

A major change, that is already being planned for the current interns, is a considerable focus on training for interns (combined with Community Service Doctors) led by Prof S. Moosa. This must be transformational and ensure that interns want to return to PHC as MO’s.

  • Interns will be under supervision of family physicians (hopefully if appointed) in each CHC complex and able to get support in these sites from them and MO’s in the CHC complex.
  • Each CHC complex family physician will be expected to have a weekly hour meeting with intern to review their records and clinical function at the site.
  • Each CHC complex family physician will also be expected to do a weekly observed consultation per intern at the site.
  • Interns will be expected to continue attending the local weekly CPD programmes (including HIV sessions monthly).
  • In addition there will be Johannesburg -wide weekly hour Zoom meeting in the afternoons that will specifically look at topics from the HPCSA Logbook and facilitate discussions using a case-based approach.
  • This Zoom meeting will be facilitated by senior family physicians in Johannesburg and may include external resources. This may also include an enhanced approach to HIV and other conditions that may not be covered adequately in CPD meetings.
  • Interns may also be expected to do monthly observed consultations in weekly batches in tandem with weekly CPD meetings run by senior family physicians.
  • Interns will also be expected to register on and use Vula as a referral tool, including all family physicians in Johannesburg as well as specialists from the various base hospitals, ensuring that interns have access to consultancy at anytime and anywhere in Johannesburg.
  • Interns will be expected to participate in monthly clinical governance meetings (incl. M&Ms) at each CHC complex and tasked to work in groups on various quality improvement projects based on local clinical governance challenges.
  • There are plans to ensure interns have access to guidelines on EM Guidance and the website of the Department.
  • There will be a monthly afternoon academic meeting led by the academic coordinator (Prof Moosa) with all interns to explore gaps and record concerns
  • Prof Moosa will lead six mthly site review visits with hospital intern managers.

The plan is not only training of interns but supervised training by interns.

  • Interns will participate in expanded training of nurses and doctors (not just as beneficiaries but also as active supporters of delivery e.g. BLS, Belstac, ESMOE, ETAT, IMCI, Helping Babies Breath & MSSM.
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