What’s the most efficient way for South African universities to select medical students who will best serve the country’s patients?
Research shows that the race of a doctor in relation to their patients, the language they speak and where they grew up, can influence the quality of care they provide.
Why? Because how well a patient is able to communicate their symptoms to a physician and whether the doctor understands what they mean, is influenced by language, culture and background (such as whether someone grew up in a rural or urban area).
The country’s medical schools take some of these aspects into account when admitting medical students — but do these admission policies go far enough?
We look at what the research says.
What do medical student admission policies look like?
Opposition party members and an AfriForum-linked union say medical schools lock out academically deserving students unfairly based on their race, because admission policies favour black and coloured students. Academic merit alone, they argue, should be what gets a student into medical school.
Currently, most medical schools attempt to reserve a certain number of places for black and coloured students, in part because the country’s higher education laws say schools must address past inequalities. The government also pays universities a grant based on the proportion of these students they admit. All students have to meet academic requirements just to be considered though: at least 60% for maths, physics, and in some cases biology.
Starting university with good academic scores, such as in the final-year school exam or the National Benchmark Tests, typically helps students to handle the paper content of medical health studies well.
So do admission policies that incorporate demographic factors such as race, rather than solely using academic achievements, mean that medical students that get in aren’t up to scratch?
In short: no. Doctors-to-be have a much better pass rate than in other courses.
Graduation data shows that — more than two-thirds of the country’s medical students finish their degrees in the minimum six years, while roughly 91% graduate within 10 years.
In comparison, in the case of a three- to four-year engineering degree, only 21% of students had graduated after four years, while only 65% had graduated after a decade.
For physics and biology degrees (which also take three or four years to complete), only 35% of students had graduated after four years, while 73% had graduated after 10 years.
Plus, the drop-out rate is unusually low for medical students. Only 5% of students who started their degrees in 2008 had dropped out a decade later — compared to about one in five for engineers and scientists.
But wouldn’t admitting only students with the highest marks give South Africa better doctors?
Not necessarily. When it comes to clinical training, academic marks don’t seem to be a strong predictor of performance. Research from the United States (US) and the United Kingdom (UK) shows academic marks higher than the minimum requirement for getting into medical school don’t have a big effect on how well trainee doctors will work with patients.
Lost in translation: Too few SA doctors speak African languages
For good-quality care, doctors and patients need to understand each other; it’s a two-way conversation.
But this becomes difficult when physicians and patients don’t speak the same language. For example, a 2006 study at a paediatric hospital in Cape Town, where most patients spoke isiXhosa as a first language, but doctors mainly communicated in English or Afrikaans, found that less than one in 10 medical interviews (in which doctors asked patients questions about their symptoms) were run in the patients’ home language.
Moreover, more than six out of 10 of the child patients’ parents said they struggled to understand the doctors’ English, while more than five out of 10 found it difficult to express themselves. Some said they were afraid that this lack of communication would lead to them administering their children’s medication in the wrong way.
A 2006 study at Hottentots Holland Hospital in the Western Cape, for which researchers interviewed both health workers and patients about language difficulties, confirmed these fears. One nurse said: “Lots of people have already died because they cannot understand or say what is the matter with them.”
Health workers also pointed out that obtaining informed consent for procedures was problematic when patients spoke a different language than them, as patients often didn’t understand enough details about the operation or technique they had to give permission for.
Using interpreters is one way around language difficulties — but that becomes tricky if the interpreter doesn’t have a medical background, because translations are then often inaccurate, nurses said.
Because of a lack of medical staff at public hospitals, nurses can’t always be the translators. But even when they do translate, this solution isn’t perfect.
Research at Madwaleni Hospital in the rural Eastern Cape found that nurses sometimes misinterpreted the doctor’s question when relaying it to the patient. Another study found that nurses sometimes “summarised” a patient’s long, roundabout description of a problem by leaving out seemingly irrelevant details, when in fact these could have helped with making the diagnosis.
And when it comes to mental health services, where patients and doctors rely heavily on the communication of complex ideas and feelings, interpretation can get even messier.
A 2020 study at a psychiatric hospital in the Western Cape found that nurses often seemed to give doctors their impression of what the patient was trying to say — rather than a word-for-word translation — because they interpreted much of the patient’s explanation as “nonsense”.
Even worse: when there were no isiXhosa-speaking nurses available, non-clinical support staff such as security guards or cleaners were asked to step in as translators. Some laughed at the mentally ill patients’ answers or got angry when a question wasn’t answered directly.
Interpreters, especially when untrained, can also be prone to errors such as incorrect word choices or language use because the step-in translator might not be equally proficient in both the patient’s and the health worker’s language. Many hospitals and clinics rely on “haphazard interpreting arrangements, in which anyone who speaks the patient’s language, is called on to interpret”, the study found.
But interpretation errors aren’t just a problem in South Africa. In a study at a US hospital, researchers found serious translation errors when listening to recordings of nurses translating conversations between English-speaking doctors and Spanish patients.
This “affected either the physician’s understanding of the symptoms or the credibility of the patient’s concerns”.
In the US, fewer black babies die – if they’re treated by a black doctor
Yet even when doctors and patients speak the same language, race can have an impact on their relationship, studies from the US have found.
For instance, in a 2020 study across nearly two million hospital births in the state of Florida, black newborns had a much lower chance of dying when the attending doctor was African American than when the physician was white.
In another study, reported in the American Economic Review in 2019, working-class African-American men were given coupons for free preventative medical care such as screenings for diabetes and heart health. Results showed that patients with black doctors were more likely to return for further medical care after their first appointment than those with non-black doctors, which could lead to a considerable drop in cardiovascular disease among African-American men — a worrying health problem among this demographic in the US.
Although the reasons for these findings aren’t clear cut, it didn’t seem to come down to the racism of the doctor or patient in this case. In fact, the study participants got to see a picture of their doctor before their consultation and were just as likely to attend the first session if their doctor wasn’t black than if they were — it was only for the follow-up visit that patients with black doctors were more likely to return.
Instead, researchers think the issue was communication. From the doctors’ notes, it seems patients may have been more comfortable discussing personal and medical issues with a doctor of the same race and to trust them. This argument is supported by the conclusion of an in-depth analysis of many other studies in the US investigating how race affects the relationship between doctors and their patients.
How much these findings apply to South Africa is hard to know, but local researchers have seen cases where race seemed to have a negative impact on the relationship between doctors and patients — even when there weren’t language barriers.
“Not just black Africans, but it should be about rural black Africans”
But even being the same race is no guarantee that doctors and patients will communicate well.
Lekan Ayo-Yusuf, the deputy vice-chancellor for research, postgraduate studies and innovation at Sefako Makgatho Health Science University, says simply admitting more black African students to medical schools won’t go far enough to fix the communication issues between doctors and patients.
“If you post a [black] person who came from a private school in Pretoria to a rural area, they have a different culture even if they’re both Africans and they may not connect. So I really argue that it should not just be about black Africans; it should be about rural black Africans.”
An example that highlights Ayo-Yusuf’s point comes from a study that concluded that isiXhosa-speaking clinical staff in Cape Town would struggle to communicate with patients who practise Ukuhlonipha, a custom more common to rural areas. In this custom, married women avoid using certain words or sounds that are similar to the names of their husband’s kin and choose alternatives or euphemisms instead — a practice alien to many urban isiXhosa nurses.
And as elsewhere in the world, rural dialects can complicate communication. As one isiXhosa nurse at a Cape Town hospital explains: “Some of these patients are speaking that deep, deep isiXhosa which we don’t know because we are grown up here and we are running away from that proper deep isiXhosa.”
Why our adjusted admission policies are still not enough
Although admissions policies for medical students have changed over the years, so that we select doctors-to-be who suit the country’s needs best, such policies can improve more.
The racial make-up of South Africa’s doctors is changing for the better — in 2019, about a third of our doctors were black (black African, coloured), double what it was 20 years before — but South Africa still needs more physicians with a rural background and who can also speak African languages.
Why? We have a shortage of rural doctors and medical graduates who grew up in rural towns are much more likely to return to work in those areas than their urban counterparts.
But there’s a problem: only a few of South Africa’s medical schools have policies to boost their intake of students from remote areas.
Then there’s the language issue.
Simply introducing language modules as part of students’ coursework doesn’t seem to work well enough to overcome communication barriers.
Six out of 10 medical students from the University of Cape Town (UCT) said in a survey that taking isiXhosa language classes didn’t help them when treating patients — especially when they had to break bad news.
In addition, two English-speaking medical graduates told Bhekisisa the structure of their medical degrees didn’t leave much room to learn a new language from scratch.
At the University of the Witwatersrand, where students took isiZulu language classes once a week, one student said the course counted so little towards their final marks that people didn’t make much of an effort. “Why would you spend your time studying for something that counted 1%, when you had a whole medical syllabus to learn?” asked one.
A student from UCT, where taking isiXhosa classes is compulsory, admitted she only focused on the language course when there was a test coming up: “I would learn it by heart like a script. Can’t speak a word of it.”
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.