Postgraduate Diploma in Rural Medicine

Purpose

The purpose of the Postgraduate Diploma in Rural Medicine is to strengthen the learner's confidence and capability as a rural health care practitioner and equip them with tools for lifelong learning and reflective practice in order to make a lasting contribution as a professional to the health of a rural community.

By the end of this qualification the learner should be able to

• Clinically manage the range of patients at a rural district hospital with limited specialist support.
• Work with the local health care team to strengthen and sustain effective health care delivery systems.
• Understand appropriate public health interventions and participate in community-oriented primary care.
• Use reflective practice to enable continuous development as a rural health practitioner.

Rationale

South Africa continues to experience a critical shortage of doctors in rural areas. Only 40% of the country's doctors work in the public sector and vacancy rates are highest in rural areas. In addition, doctors working in rural hospitals require unique knowledge and skills to clinically manage the range of patients they see and to provide services that are appropriate for rural communities.

There are a significant number of young international and South African doctors who are interested to work in the rural public health sector. Africa Health Placements, has been recruiting approximately 250 international doctors per year (mostly from the United Kingdom (UK)) to work in rural hospitals in South Africa. In addition, a proportion of the 1,200 Community Service doctors who are placed in rural hospitals have an interest in staying on at the end of their compulsory year.

Many of these doctors find the experience of working rurally to be extremely challenging however, as their previous training often does not prepare them for the specific challenges they face. These doctors (and the clinical managers of rural facilities) have reported a clinical skills gap (particularly amongst international doctors) when practicing independently in areas such as obstetrics, anaesthetics, Human Immunodeficiency Virus (HIV)/Tuberculosis (TB) and emergency medicine. Young rural practitioners also have more responsibility for contributing to service development and quality improvement at their facilities and supporting outreach into primary care and their local communities.

The Postgraduate Diploma in Rural Medicine intends to address this gap. Currently there is no such qualification in South Africa. There is no Masters qualification in Rural Medicine yet Doctors with a long-term vision for rural medicine, who wish to prepare themselves better for rural practice, often plan their own informal, unstructured and unrecognised programme, by completing rotations in a number of different clinical disciplines following their MBChB. The alternative for such doctors is to complete the MMed in Family Medicine, becoming specialist family physicians. However, many doctors are not yet ready to make that longer term commitment, but want to make a shorter term contribution through working in rural district hospitals, sometimes as part of the process of decision-making in terms of a longer term career trajectory.

The Postgraduate Diploma in Family has a different focus and purpose, namely caring for patients in primary care across any sector of the health service, rather than developing skills for rural district hospital work.

The Rural Doctors Association of Southern Africa (RuDASA) has long called for additional qualifications in this field. The WHO global policy recommendations on increasing access to health workers in remote and rural areas through improved recruitment and retention: This approach is also aligned with international trends towards what is known as rural generalist medicine and the establishment of various Postgraduate Diplomas and Masters qualifications, as well as vocational training programmes, particularly in Australia and Canada. The Centre for Rural Health has collaborated with Africa Health Placements (AHP), a non-governmental organisation involved in recruiting doctors for rural hospitals in Southern Africa, in the development of the qualification. AHP has identified this as an important gap in the field. Similarly, Doctors Without Borders (MSF) has had discussions with the Faculty of Medicine and Health Sciences about possible training programmes for their staff, of which this Postgraduate Diploma would be one possible option.

With the proposed introduction of a National Health Insurance system, it is vital that patients in rural communities have access to well-trained and skilled clinicians, who are able to perform the range of procedures required of them as generalists in rural district hospitals, within the context of understanding the nature of rural health care delivery, relating to the communities they serve and being able to take a lead in clinical governance.

Recognition of Prior Learning (RPL)

Processes are in line with the institution Regulation for the Recognition of Prior Learning (RPL) and Credit Accumulation and Transfer (CAT).

In terms of Access, applicants must be medical practitioners to be eligible to enter the qualification.

In terms of Advanced standing, consideration will be given to providing exemption to learners for up to 2 out of the 3 modules with fewer credits (Major Infectious Disease Challenges, Clinical Governance in District Health Services and Delivering Healthcare in Rural Communities), based on appropriate Postgraduate certification and/or portfolio assessment.

In construction of a personalised learning plan for acquisition of clinical competencies as part of the major module, Clinical Skills for District Hospitals, learners who can demonstrate adequate competence in particular skills domains through an appropriate assessment may be exempted from undergoing further training in those domains.

Entry Requirements

The minimum entry requirements for this qualification is

• Bachelor's Degree and be qualified as a medical practitioner, with at least two years of post-qualification practice as an intern doctor or equivalent.

Or

• Registration with the Health Professions Council of South Africa as a medical practitioner or demonstrate that they will be able to meet the requirements for such registration with the Health Professions Council of South Africa (HPCSA).

This qualification consists of the following compulsory modules at Level 8 totalling 120 Credits.

Compulsory Modules, 120 Credits

• Clinical Skills for District Hospitals, 55 Credits.
• Major Infectious Disease Challenges, 15 Credits.
• Clinical Governance in District Health Services, 25 Credits.
• Delivering Healthcare in Rural Communities, 25 Credits.

1. Demonstrate an understanding of effective clinical governance in district health services and ability to implement quality improvement projects.
2. Demonstrate relevant knowledge for generalist clinical practice in a rural district hospital and competence in procedural skills for effective clinical practice in a rural hospital.
3. Demonstrate an understanding of unique features of delivering healthcare in rural communities and how to provide them with effective services.
4. Demonstrate a comprehensive basic understanding of the major infectious disease challenges students are likely to encounter in a rural district hospital with a focus on Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) and Tuberculosis (TB).

Associated Assessment Criteria for Exit Level Outcome 1

• Describe the structure of district health services, including the economic, financial, political and social factors that influence their management.
• Contribute effectively to the good clinical governance of district health services.
• Design and implement quality improvement projects in the rural health setting, demonstrating competency in leadership, multidisciplinary team working and systems thinking.
• Reflect on the approach and capabilities as a leader, a manager and a rural health practitioner as a pathway to greater resilience, continued learning and professional development.

Associated Assessment Criteria for Exit Level Outcome 2

• Display relevant knowledge with a focus on the following domains: emergency medicine, orthopaedics and trauma, surgery, internal medicine, paediatrics, obstetrics, and anaesthetics.
• Demonstrate skills in the following high risk areas: emergency centre, labour ward, and the operating theatre, in relation to the above domains.
• Show understanding of own limits in respect of functioning independently in rural district hospital and how to obtain help when needed in the context of providing healthcare for rural patients.
• Recognise own skills and knowledge gaps in respect of these domains and describe how they will address these appropriately, through continuous learning.

Associated Assessment Criteria for Exit Level Outcome 3

• Discuss the concept of rurality and the specific health needs of rural communities.
• Describe key factors in ensuring that health services are designed appropriately for rural people.
• Participate effectively in the delivery of community-oriented primary care.
• Design a primary care intervention to improve health based on the specific needs of a local rural community.

Associated Assessment Criteria for Exit Level Outcome 4

• Describe the diagnosis and management of people infected with HIV/AIDS and/or TB and commonly associated conditions encountered in rural health care, using current evidence-based medicine.
• Demonstrate competence in the case management of conditions commonly associated with HIV and TB in district hospital settings.
• Discuss the major other infectious disease challenges in an African context and describe approaches to the diagnosis and management of patients presenting with such conditions.

Integrated Assessment

Multiple methods of assessment will be used, with more than one assessment being required per module. Each module will have assessment formats that are appropriate to the nature of the module.

Formative feedback is given throughout the modules. There is a Summative Assessment at the end of each module. Assessment formats include the following:

• Logbook review (formative).
• Self-reflection (formative).
• Supervisor reports (formative and summative).
• Workplace based assessment (summative).
• Case studies (formative).
• Online Multiple-Choice Question (MCQ) tests (formative).
• End of module exam (summative).
• Participation in online discussions (formative).
• Online reflections (formative), quality improvement project report (summative).
• Reflective report of learning (summative).
• Community oriented primary care intervention report (summative).