Philippa Garson
WHETHER doctors should get more training and give some service to society at the same time is less in dispute than whether the country — and the students — are ready for it.
The Interim National Medical and Dental Council has been criticised for implementing radical changes to the profession before the legwork has been done and without giving medical students due warning.
Clearly, where 40% of women are giving birth without medical supervision, for example, there is a crying need for more doctors in rural areas. But some health professionals are asking whether these trainee doctors will simply work without supervision as a short-term cure in a collapsing health system.
Questions are also being raised about the council’s independence from the government. The council ignored the recommendation of its own “expert team” which proposed one year of extra study, and went with the health department’s proposal of two years instead.
University of the Witwatersrand dean of Health Sciences Professor Max Price criticised the council for this but said he would keep an “open mind” until it came up with its detailed plan on available facilities and supervision in October.
Council president Professor Soromini Kallichurum said two years’ training would be more beneficial if students were given a diploma. “If the students have misgivings with serious reasons we will relook at it,” she said, denying that the council had been pressured by anyone.
Price said the logistics of implementation “need to be carefully worked out”, adding, “If the quality of training is not satisfactory I will withdraw my support of the system.”
Professor David Sanders, director of the University of the Western Cape’s public health programme, said: “Everyone agrees there ought to be some kind of payback and that graduates do some work in the public sector in peri-urban and rural areas where there is greatest need. But we are also suprised at the pace it was introduced, with no preparation in place.”
Sanders said there was more a maldistribution of doctors than a shortage, with a concentration of doctors in academic hospitals. “The challenge is to relocate some of these people so the academic complex becomes much broader at regional and district levels.”
The Junior Doctors’ Association of South Africa has objected to increasing the training period from seven to nine years and called for the curriculum to be shortened instead.
Many students believe that the council’s decision to extend doctors’ training by two years is a way of introducing “community service” through the back door, to avoid possible battles on the constitutionality of compulsory service.
But the health department’s Tim Wilson, chief director of academic complexes, says the department has declined in the past to implement compulsory service and that vocational training will achieve the same objectives, while allowing doctors to gain higher qualifications. The department is looking to fill 1 000 posts in the first year of implementation, 1998, and 300 in the second.
“There is an assumption that everyone will be sent to distant rural areas. But if there is no supervision, we won’t send people,” Wilson said.
The department hopes, with radically revised salary scales, to pull more doctors into the public service who will supervise the trainee doctors. But all this has yet to happen.
Wilson said the health department had not pushed the council into any decisions. “I have great respect for the members of council. They are not likely to be steam-rollered into a decision,” he said.
Wilson pointed out that the change will only affect the 30% of medical graduates who don’t specialise, and who will have to stay longer in the public service. Those who specialise will probably not be affected. They will have to do an extra year but the council has yet to make proposals on this.
Contrary to the stereotype of white doctors going overseas to escape compulsory service, Price says: “Those who will be affected most are black students who tend to graduate with much higher debt than white students. They tend to go into private practice much sooner than white students.”