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Background: In South Africa, most palliative care takes place in health districts as part of home-based care provided by nongovernment organisations (NGOs). The National Policy Framework and Strategy on Palliative Care (NPFSPC) aims to ensure adequate numbers of palliative care trained healthcare workers. Guidelines and tools such as the Supportive and Palliative Care Indicators Tool (SPICT) assist in identifying and caring for patients needing palliative care. Aim: To evaluate the knowledge, attitudes and practices of public sector doctors to provide palliative care in the Garden Route and Central Karoo Districts. Setting: The study was conducted at public sector district-level hospitals. Methods: A descriptive observational cross-sectional survey was conducted. The study population included all public sector district-level doctors. Participation was voluntary, and 73 responses (60%) were obtained. Data were collected with an online questionnaire using the adapted ‘Knowledge Attitudes Practice’ model. Quantitative data were imported into the Statistical Package for Social Sciences for analysis. Results: Participants had poor knowledge, attitudes and practices regarding palliative care. There was a statistically significant difference between the knowledge of junior doctors and senior doctors, with 78% of junior doctors having inadequate palliative care knowledge. Only 25% of respondents had received formal postgraduate palliative care training. Seventy (96%) participants reported that home was the best care setting for terminally ill patients. Conclusion: Doctors in the Garden Route and Central Karoo need further training to meet the NPFSPC standards. Contribution: This study adds to the palliative care field, highlighting the need for ongoing training of doctors.

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.

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.

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.

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.

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

Objectives To describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals.Design A descriptive observational cross-sectional study.Setting District hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (

Background: Access to health care often depends on where one lives. Rural populations have significantly poorer health outcomes than their urban counterparts. Specialist outreach to rural communities is one way of improving access to care. A multifaceted style of outreach improves access and health outcomes, whilst a shifted outpatients style only improves access. In principle, stakeholders agree that specialist outreach and support (O&S) to rural populations is necessary. In practice, however, factors influence whether or not O&S reaches its goals, affecting sustainability. Aim and setting: Our aim was to better understand factors associated with the success or failure of specialist O&S to rural populations in the Eden and Central Karoo districts in the Western Cape. Methods: An anonymous parallel three-stage Delphi process was followed to obtain consensus in a specialist and district hospital panel. Results: Twenty eight specialist and 31 district hospital experts were invited, with response rates of 60.7% – 71.4% and 58.1% – 74.2% respectively across the three rounds. Relationships, communication and planning were found to be factors feeding into a service delivery versus capacity building tension, which affects the efficiency of O&S. The success of the O&S programme is dependent on a site-specific model that is acceptable to both the outreaching specialists and the hosting district hospital. Conclusion: Good communication, constructive feedback and improved planning may improve relationships and efficiency, which might lead to a more sustainable and mutually beneficial O&S system.

Background: Competency-based education and the validity and reliability of workplace-based assessment of postgraduate trainees have received increasing attention worldwide.Family medicine was recognised as a speciality in South Africa six years ago and a satisfactory portfolio of learning is a prerequisite to sit the national exit exam. A massive scaling up of the number of family physicians is needed in order to meet the health needs of the country. Aim: The aim of this study was to develop a reliable, robust and feasible portfolio assessment tool (PAT) for South Africa. Methods: Six raters each rated nine portfolios from the Stellenbosch University programme, using the PAT, to test for inter-rater reliability. This rating was repeated three months later to determine test–retest reliability. Following initial analysis and feedback the PAT was modified and the inter-rater reliability again assessed on nine new portfolios. An acceptable intra-classcorrelation was considered to be > 0.80. Results: The total score was found to be reliable, with a coefficient of 0.92. For test–retest reliability, the difference in mean total score was 1.7%, which was not statistically significant. Amongst the subsections, only assessment of the educational meetings and the logbook showed reliability coefficients > 0.80. Conclusion: This was the first attempt to develop a reliable, robust and feasible national portfolio assessment tool to assess postgraduate family medicine training in the South African context. The tool was reliable for the total score, but the low reliability of several sections in the PAT helped us to develop 12 recommendations regarding the use of the portfolio, the design of the PAT and the training of raters.