My final six months as a Community Service Doctor in rural RSA

The service: In a Rural District Hospital

Coping or not, working with what you have is all you can do! That was my experience of the last six months at my facility as a Community Service Medical Officer (CSMO). The last few weeks “out in the bundus” were immersed with profound reflections on South Africa’s (SA) healthcare system.
In case you are wondering what Community Service (CS) is? CS is one-year remunerated service in the public health sector prescribed by South African legislation for health professional graduates, in order to register for independent practice.¹ The objective when CS was first introduced in 1998 was to improve provision of health services, mostly to rural and underserved areas.^1,2

The community: Middle of nowhere?

The Internship and Community Service Placement (ICSP) online application system managed by the National Department of Health allocated me to a health facility in the town of Amersfoort. The google search I did because I had never heard of “an Amersfoort” before revealed some interesting colonial history. Amersfoort is named after a city in the Netherlands, the hometown of the Dutch farmers who donated the land for the establishment of a Dutch Reformed Church settlement during the mid-19th century, with the town subsequently developing around the parish.³ Pre-colonial records of the area and its previous inhabitants were difficult to come by.

Today the town located in the Dr Pixley ka Seme Local Municipality in the Gert Sibande District of Mpumalanga Province is roughly midway between the towns of Volksrust and Ermelo. A previous census⁴ lists 3652 households, population 12 335, split between the township of Ezamokuhle with an area of 6,2km²  [and density of 1 657 people per km² ] and the town proper with an area 10,8km² [and density 187 people per km²].^4,5 The hospital aptly named in honor of its donor serves the town’s population, surrounding farms and some sections of the nearby town of Daggakraal.

Major Adjustment: With the art of medicine

I would go on to spend the last six months of CS primarily rotating in the HIV/TB wellness clinic, a space that created an out of the ordinary meaningful experience when caring for patients. A typical day would involve reviewing patients collecting their chronic medication and addressing any acute conditions or concerns that may arise.  

Not so typical however was the additional time one would be able to spend in a consultation with a patient that working in a rural, smaller community provided. Unlike urban larger academic hospitals, I rotated in as a student or the bustling regional hospital during internship; where queues for consults stretched beyond what the eye could see [sometimes] and the resultant time per patient available very limited. There would be ample time in a consult to get to engage with patients, build rapport and foster open dialogue without worrying too much about ‘pushing the queue’ compared to my previous experiences during medical training. At the end of the clinic, I would usually assist colleagues/CSMOs in their departments as and when the need arises. Equally not so typical however were days at the facility short staffed.

Understaffed: How bad could it be?

Although there were initially two permanent medical officers (MO) for the entire facility, supplemented by five sessional MOs and four CSMOs at the beginning of my CS. There would be a total of ONE working permanent MO for the entire facility during my final six months. Though shortage of doctors and nurses is a common phenomenon across SA.⁶ The shortage at my facility was critical, and not stable as vacancies for permanent medical officers remained unfilled throughout my CS. At the same time, clinical service delivery continued; leaving CSMOs like myself performing additional overtime outside contracted hours agreed on appointment. 

Turning a bad situation even worse were there few weeks when asynchronous CSMOs would complete their twelve months of CS and their replacements only joining at later intake cycles. What I never imagined occurring however, was being the ONLY doctor present in the facility. Not once! Not twice! Spinning around different departments where I would be needed the most to assist the brilliant nursing staff keeping clinical service delivery going. I am glad the Lord heard my prayers for maternity and the emergency room on those days. Human resources unfortunately were not the only resources that were limited.

Limited resources: Being the bearer of bad news

The most difficult task I had initially thought would be, during my CS year in rural SA; would be working in conditions with limited resources. Even more difficult of a task I began realizing however, was having to constantly communicate to patients and their families these limitations, in shared frustration, whilst simultaneously being the face and the bearer of the bad news. The bad news that the medication needed is out of stock; the pharmacy will not be open today [again]; the CT machine at our referral centre is not working; the advanced life support ambulance is completing a separate transportation and on and on and on… No matter how many times I had to explain ‘due to…’ it never became easier, instead it became increasingly difficult to continue to do so. Even when the resources are limited due to systemic failures, the experience always felt like a personal failure. The weight that came with the comprehension of the repercussions constrained health services had on patient outcomes due to limited resources was crippling.

Constrained health services: Lessons learnt

Despite all the challenges, I witnessed how the staff at the facility kept services going, working with what we had to obviate poor outcomes. The conditions however did necessitate the constant [over]reliance on referral centres. The number of hours spent on the telephone consulting, advocating, and referring [urgently & non-urgently] was considerable; possibly more times than both years of internship combined. While referral institutions themselves face their own unique challenges, as had been repeatedly told copious times by clinicians on the other side of the line; their mere existence provided some consolation for patients, the community and for us healthcare workers at our facility.

So… my final six months and a year later

In conclusion, the experience of the first six months & the last six months as a CSMO in a rural South African district hospital, with constrained services, limited resources and critical staff shortage was completely extraordinary from my journey in medicine thus far. While a smaller community and facility afforded me the opportunity to build distinct rapport with patients, it was incredibly difficult not to feel personally responsible for shortcomings that were so often out of my control. Undoubtedly, systemic failures like the availability of essential medical technologies; or the challenge of understaffed [albeit dedicated] health workforce undermine efforts to deliver quality healthcare services, and therefore necessitate [over]reliance on referral centres. Although policies to address underserved areas [like the CS programme] exist, healthcare providers on the ground, coping or not, continue to work with what they have.

---