ACADEMIC EMERGENCY MEDICINE 2011; 18:868–871 © 2011 by the Society for Academic Emergency Medicine
Africa’s first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the program’s first 7 years that may help advise other nascent training programs in developing countries.
Emergency medicine (EM) is a relatively new medical field. Formal graduate training programs began in developed countries in the early 1970s, and only recently have developing countries started postgraduate training in EM.1 Countries with longstanding EM programs such as the United States and Australia have historically served as a source of advice.2 The maturation of EM programs in developing countries brings with it a new source of knowledge and lessons learned.
Medical training in South Africa
Medical training in South Africa follows the U.K. model. Directly after high school, students enter a 6-year, government-supported medical school. Graduates subsequently complete 2 years of a general internship in rotating specialties (akin to the U.S. transitional year) as well as 1 year of community service (typically unsupervised practice at a rural outpost with limited resources). There is no exact equivalent of the U.S. residency program, as after these 3 years, doctors practice medicine independently through one of three career paths: as general practitioner (GP), nonspecialist medical officer (MO), or specialist consultant.
The majority of doctors are GPs working in the primary care setting. MOs staff hospitals and have the option to rotate through different services; it is not uncommon for an MO to go from anesthesia to internal medicine to obstetrics. Indeed, one of the reasons for becoming a career MO is the ability to switch among various specialties without undergoing specialization. Formal training for both GPs and MOs essentially ends after internship and community service.
Only a small minority enter the third path and specialize. Those who wish to specialize must enter a postgraduate training program, during which they are known as a registrar. Most programs are 4 years and are the closest equivalent to a U.S. residency. Once registrars complete this training, they become board-certified consultants (the closest equivalent to a U.S. board-certified specialist attending). Registrarships are highly sought after, as only as a small number of training programs exist, and the salary for consultants has the potential to be severalfold higher than for an MO or GP. This salary differential is standard under the U.K. system of medical practice.
EM in South Africa
South Africa’s health care system is divided into the private and public sectors. Private sector payments to physicians are derived from direct payment in fee-for-service model and private insurance. As academic training programs are all within public hospitals, this article refers to provision of care in the public sector. The public sector serves over 80% of the population. Public health care is supported by government funds, with patient contributions determined by ability to pay. Doctors at all levels are salaried workers and paid by the government.3
Workforce needs are centrally determined, with the government allocating a set number of slots per clinic for GPs and per hospital for MO and consultant posts. The higher pay for consultants, combined with the national government’s emphasis on primary care, have resulted in both financial and political pressure for the government to limit consultant posts.
Emergency medicine has been practiced for many years in South Africa, with trainees from all over the world traveling to South Africa to gain experience managing complex medical and surgical emergencies.4 South Africa has some of the highest rates of trauma and violence in the world, with approximately 66 trauma presentations per 1,000 population.5 Medical emergencies are prevalent too, with both diseases of the developing world such as tuberculosis and HIV and those resulting from urbanization and western lifestyle such as heart disease and cancer. The 2010 FIFA World Cup has put additional emphasis on the provision of EM care in South Africa, particularly with regard to mass casualty and disaster planning.6
Emergency centers (ECs) exist throughout South Africa, from the basic rural day-hospital to secondary-level district and regional hospitals to the tertiary-care central urban hospitals. ECs in secondary-level hospitals are typically staffed by MOs with little to no consultant oversight. ECs in tertiary-level hospitals are typically divided into separate surgical and medical units, with MOs staffing both units and consultants from the corresponding specialties overseeing emergency care.
The development of EM as a specialty in South Africa is described elsewhere.5 In brief, the first formal EM structure started in the late 1990s with the formation of the Emergency Medical Society of South Africa (EMSSA). In 2003, the certifying body for postgraduate training, the Colleges of Medicine in South Africa, added EM to its list of recognized specialties. Because of the lack of providers who had undergone training in EM, it created a “grandfather” clause for certification of senior EM practitioners. In 2004, the College of Emergency Medicine (CEM(SA)) was officially chartered as the licensing and accrediting body for EM in South Africa.
History of the em training program at the university of cape town (UCT)/stellenbosch university (SUN)
The formation of the CEM(SA) paved the way for the founding of South Africa’s first EM registrar program. UCT had established a Division of EM in 2001 that offered a 2-year MPhil degree for medical doctors who wanted to conduct EM research. Under the direction of Dr. Clive Balfour, then head of the division, the MPhil also organized night lectures that were open to doctors in the Cape Town area who were interested in gaining additional instruction in emergency care.7
With the CEM(SA) formation on the horizon, Dr. Balfour began to develop the EM registrar program as a 4-year MMed degree at UCT; the partnership with SUN was formalized in 2006, so that the half of registrars received degrees from each institution on an alternating annual basis. The curriculum followed the requirements set out by CEM(SA) and was comprised of the following: 3 months of intensive care, 3 months of pediatrics, 3 months of obstetrics, 3 months of anesthesia, 1 month of ENT, 1 month of ophthalmology, 1 month of psychiatry, and 3 months of prehospital/EMS care. There was a total of 30 months of EC time, with 18 months in the first and second years as junior registrars, and 12 months in the third and fourth years as senior registrars.
Training occurred at the two tertiary-level central teaching hospitals with annual EC censuses over 100,000 each and at three secondary-level regional urban hospitals with annual censuses over 40,000. Two sets of examinations were required: the first to be taken in the first 2 years of training and the second to be taken before completion of the MMed. Following completion of the MMed, registrars became eligible to be licensed by CEM(SA) as EM consultants.
The initial class of 10 registrars was primarily recruited from the doctors who had been attending the MPhil night lectures. Almost all of these candidates had multiple years of experience working as MOs in ECs (unpublished data). The goal was to have approximately eight registrars per class; however, because the initial class was recruited throughout the academic year, they completed their training at different times of the year as well. In the first 3 years, there was also a high attrition rate, with nearly half of matriculants not completing their registrarship.
Around the same time that the registrar program was being established, a Scotland-trained emergency physician, Lee Wallis, was recruited to UCT. Professor Wallis took over the MMed program in 2006 and made significant changes to the training. He also took an active leadership role in developing EM in South Africa and Africa, serving as President of the EMSSA, founding and serving as President of the African Federation of Emergency Medicine, and spearheading the Emergency Medicine in the Developing World conference, a biannual event held in Cape Town with representatives of over 50 countries. All of these efforts helped to publicize the EM training program at UCT/SUN, with internationally recognized EM leaders coming to the program to lecture and share their perspectives on EM development and training.5
Three other academic centers in South Africa have since developed EM training programs, in Johannesburg, Pretoria, and Limpopo. There are currently 43 registrars enrolled in the UCT/SUN program. As of 2011, 29 graduates have completed the program, with 21 resignations. The first several groups of registrars came exclusively from South Africa; since 2008, there have been 11 registrar candidates from throughout Africa, including Kenya, Tanzania, and Cameroon.
Changes and progress: 2004–2011
In the 7 years since the inception of the EM training program, many changes have been instituted, primarily in response to registrars’ feedback.
Given that EM was a new field in South Africa, there were few consultants available to provide clinical teaching. In the beginning, bedside teaching and “shop floor” supervision in the EC were particularly lacking, with less than 10% of shifts supervised by an EM consultant. There are now daily formal rounds conducted by board-certified EM consultants at all registrar training sites, as well as a full 8-hour day of formal didactics every third week. Registrars get protected time from their rotations to attend this session, which includes lectures by consultants as well as hands-on practice in the simulation laboratory.
The initial classes received little to no formal mentorship, again due to the lack of EM-trained senior leadership. With the increase in consultants from the graduate pool, there is now a process whereby each registrar is assigned an EM consultant mentor who meets with him or her and monitors clinical progress every 3 months. This mentor also helps to provide career counseling and advice.
No formal structure existed at the start of the program to evaluate the competency and progress of the registrar. Registrars must now undergo formal performance assessment at the end of each 3-month block. There are plans in place to implement a formal procedural log as well as competency-based teaching and evaluation.
Recruitment and Retention
The initial classes were recruited informally from the pool of experienced MOs already working in ECs. In the first 4 years, the attrition rate was nearly 50%. Resignees have cited lack of clear expectation and lack of mentorship as their main reasons for leaving (unpublished data). As the program defined expectations and improved mentorship, the attrition rate has decreased; in the past 2 years, there have been no resignations. The selection has also become increasingly competitive, with long wait lists and candidate inquiries from all over sub-Saharan Africa. Since 2008, other African nationals have been accepted into the program, with the hope that they will take back the skills learned to further develop emergency care in their home countries.
A research endeavor was not part of the initial MMed course. Given the importance of research to the burgeoning field of EM, a thesis has been implemented as a required component of the course such that it must be completed prior to the second set of exams. Registrars also receive specific training on critical appraisal of articles and participate in a journal club.
With the recognition that graduates will take on leadership roles in academic medicine, the program has started to provide additional experiences to registrars in teaching and management. Registrars must provide structured teaching to undergraduate medical students, as well as supervise interns and MOs in the EC. There are now also optional management classes for senior registrars.
Starting any new training program is difficult and fraught with growing pains. The beginning of an EM training program in a resource-limited setting at academic hospitals with very strong specialist departments presents additional challenges. The problems encountered and the lessons learned from the inception of the UCT/SUN EM program will hopefully serve to instruct those from developing countries who may be considering starting their own EM programs.
Lesson 1: A Critical Mass of Board-certified EM Specialists Is Needed for Adequate Training of Registrars
The major weakness cited by the first two graduating classes was the need for more bedside teaching and supervision (unpublished data). This is likely to be a problem for all new EM programs in developing countries until they obtain a critical mass of consultants. Even Australia, a dozen years after EM training was first started there, still does not provide around-the-clock supervision of its registrars.8 One way to partially ameliorate this problem is to ensure that those who are grandfathered into the specialty play an active role in training registrars. In addition, every effort should be made to institute new graduates in academic teaching posts. Finally, formal didactics, group simulation sessions, and one-on-one mentorship should supplement the training program from the outset.
Lesson 2: The Curriculum Should Be Designed to Prioritize Academic Learning
Achieving the right balance of service versus learning is a challenge inherent in postgraduate medical training. EM training needs to be learned through experience, but especially when there is little direct supervision in the EC, sufficient time needs to be allocated to academic learning, including formal didactics, simulated laboratory learning, and self-guided reading. Competency-based teaching and evaluation should be instituted. Especially since the first groups of graduates will need to assume immediate leadership roles, preparation for faculty development should be emphasized with research exposure, teaching experiences, and graduated responsibility, as well as preparation to run ECs and liaise with other specialties through management training.9
Lesson 3: Integrating EM Into the Established Roles of Non-EM Specialties Represents a Potent Barrier
As a new field in South Africa, EM is still gaining legitimacy from other specialties. In tertiary-level academic hospitals, it remains a challenge to integrate medical and surgical ECs. In secondary-level district and regional hospitals, the role of the EM consultant still needs to be formally established. The first classes of graduates have an added responsibility for setting out to prove their field indispensable through demonstrated clinical excellence, robust research, and continued advocacy within governments and other specialties.
Lesson 4: A Clear Career Path Should Exist for Graduates
The need for EM consultants far outstrips funding available for these posts. At time of writing, virtually every EC is still staffed exclusively by MOs, and there are only one or two EM consultant posts for the 2011 class of graduates. As a result, many graduates return to working as MOs; others are recruited to the more lucrative private sector or overseas. This problem has created disillusionment by the registrars and contributed to the initial high rate of attrition. While the onus is with the national government to provide funding for consultant posts and provide much-needed capacity, it is also a lesson to those developing training programs to establish a clear career path for their graduates or to set expectations accordingly.
Lesson 5: Training of Specialists Is Not the Only Answer to Resolving Workforce Needs; in Fact, It Is Only the Start to Improving Emergency Care
The few posts that exist for EM consultants are based at major academic centers in urban areas. On the other hand, the majority of emergency care is provided in small hospitals and clinics throughout the country. To improve emergency care in South Africa, training needs to occur at rural and semirural areas. A full 4-year program may not be feasible for practitioners in these areas; rather, efforts could focus on short, targeted courses to MOs and mid-level providers on key topics such as trauma care and resuscitation algorithms.
Africa’s first EM training program has undergone significant improvements since its inception in 2004. There is much to be learned through the changes made, the problems encountered, and the ongoing challenges. The difficulties faced by the UCT/SUN program in its first 7 years will likely be similar for other developing countries looking to start their EM training program. We hope that the lessons learned in the first 7 years in South Africa can help to aid other nations in Africa and the developing world to develop EM as a specialty.
We acknowledge the dedicated individuals who continue to work tirelessly to improve emergency care and promote emergency medicine as a specialty in South Africa.