IN PRACTICE
ISSUES IN MEDICINE

 

The African Hospitalist Fellowship

 

 

A D Daniels^I; H Buys^II; R Dunkley^III; J M Wilmshurst^IV

^IMB ChB, FCPaed; Neonatology Fellow, Royal Children's Hospital, Melbourne, Australia
^IIMB ChB, MRCP, FCPaed, MSc; African Paediatric Fellowship Program, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
^IIIMB ChB, FCPaed; Ambulatory and Emergency Division, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
^IVMB BS, MRCP, FCPaed, MD; African Paediatric Fellowship Program, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

The African Paediatric Fellowship Programme is rolling out a training course for newly qualified paediatricians to equip them with the leadership skills to function in complex general paediatric settings. The care of children in Africa carries its own unique demands, from the layering effects of multiple conditions through to establishing and sustaining services under severe resource constraints. This novel training concept aims to strengthen confidence and knowledge in areas that are not priorities during standard general paediatric training. The skills gained are considered of great relevance in assisting general paediatricians to achieve their full potential in their careers.

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The dilemma following completion of general paediatrics training

The prospect of seeking a career after completing the 4 years of registrar training in general paediatrics is an increasing cause of anxiety for newly qualified specialists in South Africa (SA). In most regions, the prospects for employment are limited. Options include appointment to one of the few consultant positions in state hospitals, working in the private sector, or continuing to train in a subspecialty. Many may struggle to find regular employment and resort to locum work, which is not necessarily at specialist level. This could include overnight on-site calls, and other work well below a specialist level of experience. Subspecialty training positions may be undertaken as a means to maintain a further 2 - 3 years of full-time employment and/ or to increase the likelihood of successfully securing a future state-sector consultant post in an increasingly competitive environment.

It could be argued that there is a greater need for confident and experienced generalists to establish and run units, wards and services across all levels of care. This is particularly relevant in the African setting, where the layering effect of multiple burdens on health results in children with complex problems presenting to general paediatricians.

Another unfortunate scenario is that some newly qualified specialists feel that they are left with no option other than to enter the private sector, or to practise abroad, thus exacerbating the SA medical 'brain drain'. This misalignment of medical career trajectories of the African health workforce needs has been reported.^[1,2] These sentiments and concerns were strongly echoed in a recent survey conducted at Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, among newly qualified paediatricians and registrars who were nearing completion of their training. The survey was designed to gain insight into a number of potential concerns that these doctors might have related to career trajectories after general specialist training. The questions assessed their opinions about adequacy of training, employment options and the trend towards subspecialty training v. the idea of general paediatrics as a long-term career. The results confirmed fears about many of the aforementioned scenarios, and revealed an impressive consistency in the answers and opinions around these issues. A preference for remaining as generalists in state practice if the option were open to them was also noted.

 

Justification for an African hospitalist training programme

Newly qualified specialists who attain employment as general paediatric consultants often find themselves in the unenviable position of having to 'take the reins' and run a service without access to more experienced consultant advice and mentorship into the consultant role. The respondents of our survey consistently raised concerns about the lack of adequate training in leadership and management, child protection services, and palliative care.

The scope of clinical practice changes significantly from being a ground-level registrar at the 'front line' to taking up the baton of clinical governance and being the overall co-ordinator of clinical services, who needs to take a 'step back' and appreciate a bird's-eye perspective. Good communication and leadership skills are crucial to navigating these issues. Having on-site subspecialist support, readily available in most tertiary centres, can blind the physician to the reality of clinical decision-making and hospital practice. Furthermore, many so-called 'subspecialty' management decisions should actually be within the generalist's scope of practice. The generalist must have sufficient confidence and practical knowledge of a wide array of subspecialties to make management decisions when subspecialty support is unnecessary or unavailable, and yet also needs to know when it is appropriate to enlist that support if available. While the training gained in the University of Cape Town (UCT)'s general paediatrics programme is extremely comprehensive and the results are superb, there is still little capacity for advanced training and grooming in all these areas during the 4-year specialist training period.

 

The definition of a hospitalist

While the term 'hospitalist' may be foreign to many SA health practitioners, the concept and overall philosophy behind the idea are not. It is traditionally defined as a physician who primarily dedicates his or her practice to the care of hospitalised patients and whose activities include patient care, teaching, research and leadership related to hospital care.^[3] The daily practice of state-sector hospital-based general paediatricians in SA fulfils all the criteria to be considered a hospitalist model of care. Clinicians in centres such as George Regional Hospital already practise at this specialised level of paediatric practice, but they have had to equip themselves with these skills through a slow process of exposure and assimilation. Clinicians in these centres were also interviewed and confirmed that they had taught themselves the skills to function as 'African hospitalists'.

 

How the hospitalist differs from community paediatrics and child health training

The newly established subspecialty in community paediatrics and child health addresses the issue of improving community-wide child health. This curriculum focuses on the healthcare needs of all children across a system or region, with district health services supported by integrated and mutually supportive referral systems with general specialist (regional) and tertiary hospitals.^[4] The paediatric hospitalist and the community paediatrician are different entities. The former is primarily inpatient focused, as opposed to the more primary 'preventive' or chronic care role of the latter. In an African context, a certain amount of overlap is inevitable. While optimised primary care is the goal, with a decreased need for reactive hospital-based care of preventable illnesses, for the foreseeable future high volumes of acutely ill patients, often patients with complex problems, who will require quality and skilled inpatient management, are a reality of Africa.

The required model for an 'African hospitalist' would therefore be an adaptation of the original hospitalist concept whereby the hospitalist provides hospital-level care but remains responsible for a limited amount of outpatient (and some focused outreach) care. From the patient's and family's point of view, this is an important quality assurance thread for the continuity of care, whereby patients are guaranteed transition back into primary care with no loss of quality care and with great patient satisfaction. The communication and integration with the community-based family physician is key and does much to enhance holistic care.

 

The pilot programme of the African hospitalist

A newly qualified specialist trainee (ADD) commenced a pilot project with the African Paediatric Fellowship Programme (APFP) in the Department of Paediatrics and Child Health at UCT to address the task of training paediatric hospitalists.^[5] The aim was to create a new 1-year fellowship curriculum, targeting trainees in the immediate post-accreditation period (equivalent to a 'year 5' following general paediatrics specialisation) and designed to address the issue of successful transitioning into the role of a hospital-based general paediatrics consultant, namely an 'African paediatric hospitalist'.

The strategy of the APFP is to partner with as many academic African institutions as is feasible, where there is an identified need. Since its inception in 2007, over 80 fellows have trained or are currently in training in general paediatrics or paediatric subspecialties. Returning home to immediately take charge as the lead consultant with the responsibility of setting up and running a paediatric service is a reality for many APFP fellows.

During this pilot programme ADD took on a consultant role in the two general medical wards as well as in the short-stay ward and medical emergency department, with autonomy but also consultant mentorship. Experience was gained in leading consultant ward rounds to formulate management plans, co-ordinating ward morbidity and mortality, as well as multidisciplinary meetings (including palliation and advanced care planning), teaching and mentoring of junior medical staff, child protection team meetings and focused 'up-skilling' through work in selected subspecialty clinics.

ADD regularly fed back his experiences and suggestions to the project supervisors, who included a senior member of the APFP and two general paediatricians at RCWMCH. The feedback served as a launch pad for further ideas and suggestions to try to build and optimise the core curriculum.

In addition to clinical work, the fellowship has integrated a leadership and management training module, which is deemed essential to develop this skill set. Also included is exposure to palliative care interventions. Outreach activities with key peripheral hospitals, as well as a rotation to a secondary-level neonatal unit, were also considered essential to the training experience. Neonatal services and focused outreach both fall within the hospital paediatrician's scope of work.

The role of the mature general hospital paediatrician goes well beyond the ability to manage inpatient wards. Resource management, developing and implementing guidelines, auditing throughputs and handling critical events, as well as control consultations to help mature the hospitalist, are all important components of the hospitalist training.

The feedback from the pilot project has been overwhelmingly positive and ADD has gained valuable transitioning experience, boosting his self-confidence to fulfil a senior clinician and leadership role. Furthermore, he reported feeling appreciated as a generalist clinician and that his input and service have added much-needed staff capacity and value at RCWMCH. The survey also revealed a keen interest in and overwhelming support for the hospitalist-training concept from the registrars nearing training completion, and also from other newly qualified paediatricians.

To assess senior medical staff opinion of the fellowship, a second survey was conducted among those consultants at RCWMCH who were responsible for mentoring and supervising ADD during the project. These included both generalist and subspecialist consultants. Opinions on the impact and benefit of a hospitalist fellow on the ward as well as the potential benefits to the trainee were unanimously positive. Furthermore, their recommendations for important content to be included in the fellowship curriculum were very much in line with our own.

 

Conclusion

While this programme has the training needs of the APFP trainees from outside SA in mind, ultimately any newly qualified paediatrician, including SA candidates, could benefit. This is especially true for those aspiring to be primarily hospital based and for the participants in the RCWMCH survey who unanimously supported the concept. With enough buy-in from key stakeholders, we can work towards making this an option for SA candidates as well and address the ongoing need for effective paediatric hospitalists throughout Africa, inclusive of SA.

 

Key points

• A new clinical fellowship for an adapted model of the 'hospitalist' concept for an African setting has been proposed and piloted at RCWMCH in Cape Town.

• The fellowship aims to transition and better equip the newly qualified paediatrician with the required skills to become a competent and versatile hospital-based consultant paediatrician in an African setting - an African hospitalist.
• The pilot programme has been successful in boosting the confidence and skills of the pilot fellow, and has gained the overwhelming support of the RCWMCH consultant staff.

 

Acknowledgements. The authors thank the clinicians who contributed to the insights of the programme, namely Prof. Tony Westwood, the paediatrians at George and New Somerset hospitals, and the colleagues who completed the surveys.

Author contributions. ADD contributed to the article content, administered the surveys and completed the hospitalist training programme; HB and RD devised the content of the hospitalist training programme, oversaw the first pilot roll-out of the programme, and both proofread the manuscript; and JMW devised the concept of the programme and the pilot project, and assisted with the development and final format of the manuscript.

Funding. None.

Conflicts of interest. None.

 

References

1. Burch VC, McKinley D, van Wyk J, et al. Career intentions of medical students trained in six sub-Saharan African countries. Educ Health 2011;24(3):614. http://www.educationforhealth.net/text.asp?2011/24/3/614/101416 (accessed 5 October 2017).         [ Links ]

2. Price M, Weiner R. Where have all the doctors gone? Career choices of Wits medical graduates. S Afr Med J 2005;95(6):414-419.         [ Links ]

3. Wachter RM, Goldman L. The emerging role of 'hospitalists' in the American health care system. N Engl J Med 1996;335(7):514-517. https://doi.org/10.1056/NEJM199608153350713        [ Links ]

4. Swingler G, Hendricks M, Hall D, et al. Can a new paediatric sub-specialty improve child health in South Africa? S Afr Med J 2012;102(9):738-739. https://doi.org/10.7196/SAMJ.5714        [ Links ]

5. Wilmshurst JM, Morrow B, du Preez A, Githanga D, Kennedy N, Zar HJ. The African Pediatric Fellowship Program: Training in Africa for Africans. Pediatrics 2016;137(1):e20152741. https://doi.org/10.1542/peds.2015-2741        [ Links ]

 

 

Correspondence:
J M Wilmshurst
jo.wilmshurst@uct.ac.za

Accepted 2 August 2017