OPINION

 

Supernumerary registrars: are we helping them or are they helping us?

 

 

R Naidoo^I; B Singh^II

^ISpecialist General Surgeon, Department of Surgery, King Edward Hospital, University of KwaZulu-Natal
^IIActing Head of Department, Department of General Surgery University of KwaZulu-Natal

 

 

Supernumerary registrar program: history and objectives

The Department of Surgery at the then University of Natal can lay claim to have pioneered the Supernumerary Registrar (SR) program in South Africa, the first SR being accommodated during 1996. Since then, the concept of SR has been embraced by many Universities in South Africa (SA) that provide clinical training.

The SR program was intended to be gratuitous and to empower trainees from beleaguered facilities in Africa to attain competence in aspects of surgical practice or to undertake training to sit the Fellowship in Surgery (FCS) examination. Rather than pursuing training beyond Africa, it was felt that the admired South African training programs, cosmopolitan society, spectrum of disease therein and shared history would be appropriate for the SR of African origin.

A founding caveat was that the SR candidate would be selected and funded by a recognized training facility which would receive regular progress reports on the candidate. In addition, the SR initiative was to be endorsed by the Health Ministry of the home country. Crucially, the SR would be considered to be in excess of the standard allocation of registrars and not be used as a "service body".

On completion of their training, the SR was expected to return to their home country to enhance the level of health care there as well as to transfer skills and the competency acquired in South Africa.

To a large extent, the founding principles of the SR program have subsequently been detailed in the Department of Health's Foreign Workforce Management Programmed (FWMP).¹

 

Where do we stand today?

Presently, we find that the nobility inherent in the SR initiative is marred by deviations from its founding principles. Aside from the regulations for foreign trained doctors as prescribed by the Health Professions Council of South Africa (HPCSA) and the FWMP, there is no standard policy for SRs detailed by the participating Universities in SA.^2,3,4 With the freezing of Registrar posts (and often without reflection), SRs are increasingly deployed to bolster the shrinking pool of locally employed staff to sustain service delivery. SRs attached to Department of Surgery at UKZN during 2015 constituted 21% of the entire registrar complement and 26% during 2016. Without this proportion of SRs, it would be almost impossible to effect a credible surgical delivery in the EThekwini (Durban) Functional Region.

 

Administration of Supernumerary Registrars

Presently, the universities oversee the administration of the SR appointment in line with the HPCSA requirements and the FWMP. While the FWMP requires the "support and approval from the Health Ministry of the home country re: sponsorship", does this ensure that the most deserved candidate is selected in respect of funding, the empowerment and potential of the SR as well as the expectations of the referring health care facility ?

Presently, many SRs are self-funded, paying student fees, financing their own board and lodging as well as their transport to the different hospitals they rotate through for their specialized training, making this an opportunity largely for the financially well resourced. When SRs are self-funded there is no obligation to return to their home country, an option being to migrate elsewhere. If so, are we not falling short of the founding principles of the SR program?

While the role of the Department of Health (DoH) in providing the opportunity for clinical training platforms is pivotal, recognition of the role being played by SRs in providing service delivery without remuneration is warranted. Does the SR program in its current guise not constitute an exploitation of the SR or can it be construed that it is quid pro quo for the surgical tutelage and skills acquired during their registrar training? In the absence of national guidelines, responses will most probably be varied and reflect individual viewpoint and philosophy. The pragmatic will contend that the answer lies somewhere in the middle.

During 2015-2016, SRs constituted 30% of the registrars attached to Department of Surgery, University of KwaZulu-Natal, who passed the Fellowship in General Surgery; all SRs who undertook this exit examination during this period were successful. With SRs being self-funded, there is neither the recognition for the local training nor the opportunity to foster linkages outside SA.

The qualified SR will leave our country with their acquired expertise while the number of indigenous new specialists may decrease due to funding constraints. In addition, the pool of SRs is inconsistent and cannot be relied on as essential to service delivery. As more qualified SRs return to their home as specialists, it is conceivable that they will establish local training programs with resultant diminution of the SR pool.

 

The way forward

It is suggested that for the nobility of the SR program to be sustained in SA, consideration must be given to the following:

• The identification, selection and funding of the SR must be facilitated by the referring health care facility in collaboration with the preferred local training center and Provincial Department of Health.

• Prior to commencing training in SA, the aspirant SRs must be advised to attain language proficiency [International English Language Testing System (IELTS)]. In addition, undertaking ancillary courses necessary for their training will ensure that the SR "hits the ground running" on assumption of their training; for Surgery this includes the Basic Surgical Course (BSS), Advanced Trauma Life Support (ATLS) and the College of Medicine of SA (CMSA) Primary Examination.

• Universities in SA must subscribe to a shared philosophy and standard policies in respect of the administration of the SR program.

• Universities and the DoH must cooperate in the administration of the SR program; the role of either cannot be mutually exclusive.

Apart from the nobility of the exercise, the long-term benefits in terms of academic and skills development and transfer, addressing common challenges pertaining to specialization and service delivery and goodwill on the continent are enormous. The status of South Africa as the center and powerhouse of medical education and training on the continent will be further enhanced.

 

REFERENCES

1. South Africa. The Foreign Workforce Management Programme (FWMP) of South Africa. Available from:www.gov.za/health-foreign-workforce-management-programme        [ Links ]

2. University of the Witwatersrand. Foreign Postgraduate Studies. Available from: https://www.wits.ac.za/health/academic-programmes/foreign-postgraduate/#sthash.HO4sxC7a.dpuf        [ Links ]

3. Stellenbosch University. Policy on Supernumerary Registrars. Available from: http://sumed.sun.ac.za>MMed>Supernumeraries        [ Links ]

4. University of Cape Town. Postgraduate studies. Available from: http://www.health.uct.ac.za/fhs/apply/postgrad/specialist#sthash.K6EKZjqk.dpuf        [ Links ]