South African Medical Journal (SAMJ)
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The impact of the MMed research requirement on registrar training and specialist registration in South Africa: An internet e-survey
Get PDFBackground. Since 2011, the Health Professions Council of South Africa (HPCSA) requires completion of a Master of Medicine (MMed) research component by registrars, before specialist registration.
Objective. To determine the impact of the research requirement on training and specialist registration.
Methods. A closed, de-identified cross-sectional e-survey was distributed to College of Medicine of South Africa (CMSA) Fellows passing their specialist examination between 2018 and 2022. The primary outcome was the proportion of registrars completing their MMed and clinical training within the stipulated time. Secondary outcomes were: (i) proportion unlikely to complete the MMed during training; (ii) factors contributing to MMed completion; (iii) publication rates; and (iv) whether a structured learning programme was preferred for research methodology. A Likert scale identified factors influencing completion, including administrative aspects (supervision, statistical support, ethics approval process, time allocated for research, funding, and marking timelines), and the influence of the requirement for the performance of research on mental wellness.
Results. The survey invitation was emailed to 3 646 participants; 564 (15.5%) responded, across 26 specialist CMSA disciplines. Overall, 273/564 (51.6%) specialists completed their MMed research component and CMSA examinations within the stipulated registrar training completion time. For secondary outcomes, 230/563 (40.8%) respondents required extension of the stipulated training time. In 291/564 (48.4%), the MMed was not completed during the stipulated training time, with 61/291 (21.0%) respondents not receiving an extension for completion. For 183/563 (32.5%) respondents, MMed submission was required by the university before specialist examination. Of these, 121/183 (66.1%) wrote their examination within the training time; 44/183 (24%) within 6 months of completion; and 18/183 (9.8%) >6 months after completion.
Likert scale responses showed that >50% of respondents considered all the factors being assessed to be a barrier to the conduction of their research, with the exception of good supervision (304/563, 54%). The strongest associations with successful completion of the MMed research were good supervision (54%), access to statistical support (40%), and an uncomplicated and efficient ethics approval process (39.6%). Overall, 229/564 (40.62%) MMed research components were published. A structured research learning programme was preferred by 413/564 (73.2%) respondents. A total of 335/564 (59.4%) indicated that the MMed did not add value to training.
Conclusion. Nearly half of registrars could not register as specialists when their training was complete, due to non-completion of their MMed research component. All the factors examined were considered to be contributing to non-completion of the MMed by the majority of participants, with the exception of access to good supervision. A structured integrated learning programme, including research methodology, statistics, appraisal of the literature, and scientific writing, should be introduced as an alternative to the requirement for original research, which should no longer be compulsory. Registrars wishing to do original research should be strongly supported
Thyroid cancer pathology: Insights from a developing region
Get PDFBackground. The South African (SA) health sector and laboratories comprise a dual system that includes public and private providers. SA studies illustrate diverse thyroid cancer incidence across provinces, with papillary thyroid cancer (PTC) more prevalent in urban provinces than follicular thyroid cancer (FTC) and anaplastic thyroid carcinoma.
Objectives. To provide a deeper insight into the geographic intricacies of thyroid cancer types from public and private provider perspectives.
Methods. This study investigated thyroid cancer pathology in SA between 2015 and 2019, overall and by province and facility type (private, public). Laboratories provided data in different formats, requiring manual processing. The data extracted included date of birth, sex, province, specimen type and final histology results.
Results. A total of 14 157 reports were included, of which 3 235 were thyroid cancers. Multiple challenges were experienced in terms of data processing. The public sector contributed 53.6% of thyroid cancer cases. Preoperative cytology was performed in 19.8% of thyroid cancers, and was diagnostic in 23.6%. There was significantly more FTC in the public sector (20.8% v. 5.6%), and more PTC in the private sector (87.1% v. 55.2%). T3 tumours were most prevalent in the public sector (52.3%), and T1 tumours in the private (38.8%).
Conclusion. The dual SA health system and the geographical distribution of the population appear to influence the pathological landscape of thyroid cancer. Standardised thyroid cancer reporting across all public and private laboratories in the form of a prospective national thyroid registry would allow for a more accurate evaluation of thyroid disease, ultimately improving thyroid cancer care in SA
The final report of the Section 59 investigation panel: Will the recommendations be implemented, or will the report just gather dust on the shelf?
Get PDFAn assessment of South African policy and strategic framework for the development of a sufficient, equitably distributed and well-performing health workforce for the implementation of the National Health Insurance
Get PDFBackground. South Africa (SA), like the rest of the global village, is faced with the need to address health worker shortages, improve the performance of health workers and ensure an equitable distribution of health workers in all settings. This requires leadership, governance and stewardship acumen to put in place policies, practices and resources that are essential to recruit and retain human resources for health.
Objective. To determine whether SA possesses a strong and competent policy and strategic framework that would guide the development of a sufficient, fairly distributed and well-performing health workforce.
Methods. A cross-sectional descriptive quantitative study was undertaken using pretested anonymous questionnaires to solicit responses about the ability, strategies and policies needed to address health workforce challenges. The study was undertaken in SA with decision- makers and/or those who contribute to health sector reforms in SA in the realisation of the National Health Insurance (NHI). They were individuals and stakeholders who interact with and/or are in the employment of statutory health councils, regulatory bodies, medical aid administrators, medical schemes, voluntary bodies/organisations and healthcare workers who are registered with the SA Pharmacy Council, Health Professions Council of SA and SA Nursing Council.
Results. The findings indicate that the current policies and frameworks to address health worker shortage, their performance improvement and the rural-urban disparities in the distribution of health workers are not sufficient to address the current challenges. The study found that specific efforts to address policy shortcomings need to be embarked upon.
Conclusion. The current policies and strategies are not sufficient to address health workforce challenges to improve performance, maintain appropriate skills, improve working conditions and ensure an equitable distribution of health workers to address the healthcare needs of SA. Commitment to the NHI should be matched with the capacity to deliver health services, which is highly dependent on the availability of a qualified and motivated workforce. The capacity to deliver services aligned to the objectives of the NHI will require that policy-makers consider interventions aimed at addressing challenges related to recruitment and limitation of career opportunities. Performance and productivity challenges may best be addressed by meaningful engagements and collaboration with the private for-profit, voluntary and independent sectors
The clinical utility of tissue polymerase chain reaction, tissue culture and tissue histology in blood culture-negative infective endocarditis in South Africa – insights from the Groote Schuur Hospital Infective Endocarditis Registry
Get PDFBackground. Infective endocarditis (IE) poses significant diagnostic and therapeutic challenges, especially in cases of blood culture-negative infective endocarditis (BCNIE). Among patients undergoing surgery for IE, valve tissue may be evaluated for additional microbiological information by performing a broad-range 16S rDNA polymerase chain reaction (PCR) test, tissue culture and tissue histopathology. In patients with BCNIE, these diagnostic tests may identify the causative agents, guide further clinical management and improve local IE-related epidemiological data. The clinical utility of additional analysis of explanted tissue in a local South African (SA) setting has yet to be described.
Objectives. To assess the clinical utility of performing PCR, culture and histopathology on the tissue of surgically explanted valves in BCNIE patients in an SA public sector hospital. We assess their diagnostic yield and treatment impact in a cohort of BCNIE patients treated with empirical antibiotic regimens.
Methods. We analysed data from the Groote Schuur Hospital (GSH) Infective Endocarditis Registry, a prospective observational study of adult patients with infective endocarditis. Participants for this analysis were selected based on clinical and pathological criteria for IE and negative blood cultures. All participants were treated between January 2017 and March 2021.
Results. During the study period, we identified 165 IE cases, 57 (34.5%) of which were blood-culture negative. BCNIE patients had a mean (standard deviation) age of 40.2 (13.4) years, and 41 (71.9%) were male. Twenty-seven of the 57 BCNIE patients underwent cardiac surgery and had tissue analysis performed. Tissue PCR identified an aetiological agent in 17/27 (63%) cases, with Bartonella spp. (12/27, 44%) being the most common organism. Tissue culture was positive in 3/27 (11%) cases, but the organisms identified were thought to reflect sample contamination. Tissue histopathology was performed in 22/27 (81.5%) cases and provided macroscopic confirmation of IE, but did not identify any specific organisms in any of the specimens. Only a small subset of the overall BCNIE cohort (11/57 (19.3%)) had serum serology for Bartonella spp. and Coxiella spp. performed, and 5/11 (45.5%) were positive for Bartonella spp. There was a 100% concordance rate between positive serum serology and tissue PCR. Tissue PCR impacted the antimicrobial regimen in 20/27 (74%) cases. Tissue culture and tissue histopathology did not influence antibiotic regimens in any patients.
Conclusion. In this single-centre study, perioperative serum serological testing was underutilised in BCNIE. Tissue PCR was valuable in determining the aetiology of BCNIE, and influenced management. Tissue culture and histopathology had a poor yield and added little value in identifying the microbiological cause of BCNIE. Finally, the most common BCNIE causative organism identified by additional non-culture testing in our setting is Bartonella spp
Right of reply - Response to: In defence of South Africa’s National Health Research Ethics Council guidelines on heritable human genome editing
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The National Health Insurance Act: Possible private health funding reform scenarios
Get PDFThe passing of the National Health Insurance (NHI) Act was an important milestone in the reform of the South African healthcare system and will have a profound impact on the funding and provision of healthcare in the country. While the impacts will be felt across the entire system, the focus of this article is on the potential impact on the private health funding sector, which currently enables financial risk protection for those with private health insurance. This article highlights some key trends and challenges in this sector from 2007 to 2022 and then examines two possible extreme scenarios for the sector during the NHI transition phases. In the first scenario, a passive’ process is assumed. This is characterised as a continuation of the current policy environment, where the sector is allowed to continue a downward trajectory without any specific actions to maintain its viability during the transition. A key risk in this scenario is that the sector becomes unsustainable before the NHI can provide an alternative financial risk protection mechanism to those currently protected through private health insurance. In the second scenario, an active’ process is followed, where steps are taken to keep the sector sustainable during the NHI transition. While part of this would include the purposive shifting of government-related funding from the private funding sector to the NHI, other actions would include regulatory and other reforms necessary to keep the private funding sector viable, which would also provide a stronger foundation for the NHI
