The physical campus may be tucked behind the Tygerberg Hospital, but the clinical reach of Stellenbosch University’s Faculty of Medicine and Health Sciences (FMHS) extends beyond municipal, district and even provincial borders to cover the range of complex health needs of the country.
Undergraduate medicine and health sciences students receive clinical training at approximately 120 different facilities in the Western Cape, Eastern Cape and Northern Cape. This large network of clinical training facilities, known as the FMHS’ Distributed Training Platform (DTP), exposes future doctors, nurses, dietitians, physiotherapists, occupational therapists and speech-language and hearing therapists to the variety of clinical environments they might encounter in their careers as healthcare professionals.
“Our curricula are aligned to the health needs of the country, and our graduates are equipped with the skills set they need to deliver on the strategic intent of government to provide healthcare services to the people of South Africa,” explains Dr Therese Fish, FMHS Vice-Dean: Clinical Services and Social Impact.
Clinical training of FMHS students is distributed across the entire range of healthcare facilities, offering every level of care – from modern private hospitals and large provincial hospitals in urban areas through to basic primary care clinics and rehabilitation facilities in rural areas.
Says Prof Julia Blitz, FMHS Vice-Dean: Learning and Teaching: “The learning opportunities we offer our students have to prepare them for the real-world practice that they are going into after they graduate – which is across the breadth of health in the country.”
Healthcare is not limited to a single facility, and therefore nor can healthcare training be. A patient’s disease journey usually follows a care path starting at a primary care facility, and steps up a rung as the disease progresses and treatment becomes more specialised.
“We want our undergraduates to understand the care paths for managing various diseases,” says Fish. “Our curricula are underpinned by the social determinants of health, and we want our students to understand both the social and health-related factors of disease.”
“The DTP provides students the opportunity to be trained closer to the communities from which their patients come and to obtain a better understanding of the patients’ context and circumstances, which could be factors causing them to get sick,” explains Prof Ben van Heerden, former coordinator of the MBChB programme.
According to Blitz, the impetus for the DTP is to meet the health sector’s human resources needs. “The health system requires broadly trained clinicians that understand the breadth and scope of the platform and the health needs of the country,” she says.
Van Heerden agrees that the wider exposure better prepares students for the world of work. “It gives them a better understanding of how the health system and levels of care within the system work and what the challenges within the health system are.”
A large provincial hospital, such as Tygerberg, handles many complex medical cases that have been referred from district centres not equipped to deal with advanced cases. This can create a skewed perception of disease among students if that is all they are exposed to. “As a medical student on orthopaedic rotation you need to know how to manage an arthritic joint or a minor fracture, and not only deal with shattered bones from a gunshot injury,” explains Fish.
Limiting students’ clinical exposure to a single central healthcare facility also means large groups of students have to be accommodated on ward rounds, which minimises the individual attention they can get from trainers. Dispersing students over a number of centres takes pressure off central facility resources, and affords students more individual attention. “Students say they feel like a fly on the wall during big ward rounds, but at one of the distant sites they may be one of only two students with a consultant, a nurse and a medical officer, and they feel as if they are part of the team,” Fish explains.
Healthcare facilities benefit from student training
Placing students at healthcare facilities can also have a positive impact on the level of care at the facility. In the process of training students, healthcare workers’ own skills are also sharpened, and teachers often update their own knowledge in order to field questions from inquisitive students. Centres where training takes place are also supported by physicians and other experts from the central facilities.
“The idea of placing students across the spectrum of healthcare facilities is also a way of improving health care throughout the entire system, and not only at one or two central facilities,” says Blitz.
Ongoing programme renewal
In order to stay current, all undergraduate curricula are continuously renewed to stay abreast of advances in health care, as well as developments in teaching and learning. “You constantly need to be judging the programme against what your graduates will need to do in a couple of years’ time, and stay ahead of that,” says Blitz.
The MBChB programme is currently undergoing renewal to further align the curriculum to the health needs of the country. The renewed curriculum is expected to be rolled out in 2021, and will introduce new trends in health professions education (HPE) to the programme, one of which will be to expose students to patients at an early stage. “The sooner students can put their learning into context of real patient care, the easier it is for them to learn,” says Blitz, who has been leading the MBChB renewal process.
Another trend in HPE that programme managers at the FMHS are trying to incorporate into curricula is inter-professional learning – where students from different programmes/disciplines work together. (Increased inter-professional education and collaborative practice were also recommended in a recent ASSAf report on HPE, see section on Strategic Intent of the DTP below).
“Take the example of a stroke patient,” explains Fish. “There are learning opportunities for students from speech-language and hearing therapy, physiotherapy, occupational therapy, human nutrition, medicine and nursing. Interdisciplinary training helps them understand the roles of different professions, and how they can work together to assist the patient.”
One of the main challenges of inter-professional training was for different programmes to coordinate clinical rotations at specific facilities to allow for combined activities. Up until now, the different undergraduate programmes managed the placement of their students using separate operating systems. Recently the Faculty introduced a custom-built online platform, called Placement+, that manages the clinical placement of students across all programmes, and that can identify synergies between programmes where interdisciplinary training can take place (more on Placement+ below).
Supporting students away from campus
Clinical rotations for medical and health sciences students currently start in their second year, increasing as they progress through their studies. These range from short visits to a hospital to two-, four- or six-week rotations, and in some cases even a year-long stay at a specific site. Students on clinical rotation in and around Cape Town are shuttled between the healthcare facility and campus, while students on rotation outside Cape Town stay at university-arranged accommodation for the duration of their clinical training block.
“Regardless of where they are, they are still our students, and they are still within our curricula,” says Blitz. The university provides a number of logistical and other support services to students on rotation away from campus. The FMHS established a specific unit, SUNLOC (Stellenbosch University Logistics for the Clinical Training Platform), that provides transport, accommodation and ICT support to students receiving training off campus (more on SUNLOC below).
Academic support at distributed sites is provided by, amongst others, healthcare professionals that have been accredited as lecturers by the University. Students have e-mail access to lecturers, and online access to podcasts of lectures and other study material.
Student learning centres have been set up at certain sites where students stay for long periods. These centres, where students have access to computers, the internet and other resources that can aid their studies, are in Ceres, Upington, Helderberg and Hermanus.
Despite many advances, reliable internet access remains a challenge, particularly in very distant sites. However, the University is working on solutions to provide remote students with the exact same opportunities as those at the Tygerberg campus via virtual platforms.
SU was the first South African university to place medical students at a rural site (Worcester Rural Clinical School) for their entire final year rotation, and currently has year-long longitudinal placements for final-year medical students at Worcester, Ceres, Robertson, Hermanus, Upington and Swellendam hospitals.
The FMHS’ human nutrition and occupational therapy programmes were also the first to offer year-long placements in Worcester, and nearly all programmes have six- and four-week placements in Worcester or Upington.
“The notion behind longitudinal placement is to embed students in a place for a length of time so that they start to feel like they are part of the team. The value of that for students is that it helps to develop their identity as a healthcare professional, and their transition into more independent clinical care,” explains Blitz.
Strategic intent of the DTP
The FMHS DTP is based on the strategic vision of the University and Faculty, and geared to the outcomes required by the national Department of Health, which aim to address the health needs of the country.
The rationale for the DTP is underpinned by three core strategic themes of the university: (1) offering students a transformative student experience; (2) creating purposeful partnerships and inclusive networks; and (3) offering networked and collaborative teaching and learning.
A 2018 report by the Academy of Science of South Africa (ASSAf) specifically called for the strengthening of health professions education (HPE) for practice in rural and underserved areas. The report, entitled Reconceptualising Health Professions Education in South Africa, was compiled by a panel of HPE experts, led by FMHS Dean Prof Jimmy Volmink, to explore the country’s challenges in HPE, and to offer recommendations to address the issues.
In 2017, the FMHS’ Committee for Undergraduate Teaching (CUT) assigned a task team to review all activities on its DTP, and to make recommendations for improvement and expansion. In 2018 the task team produced a comprehensive report on DTP activities, and made a number of recommendations that were all adopted by the Faculty Board. Subsequently, the FMHS established a DTP committee to oversee training sites and facilitate training activities on this platform. A central online system has also been developed to consolidate all DTP activities on a single platform (more on Placement+ below).
The FMHS established the Ukwanda Centre for Rural Health in 2001 to coordinate and support training and research initiatives in rural and underserved communities. The aim of the centre is to equip healthcare professionals with skills and hands-on experience to help them address the challenges faced by rural communities in South Africa. “Rural communities, which make up 35% of South Africa’s population, are generally underserved,” explains Prof Ian Couper, Director of the Ukwanda Centre for Rural Health. “The centre is a means by which the FMHS demonstrates and drives its commitment to address the rural healthcare needs of South Africans.”
The Ukwanda Rural Clinical School is a sub-section of the centre that oversees the placement and training of undergraduate students in rural areas in Worcester, the Overberg and the Cape Winelands.
Ukwanda recently expanded its portfolio to the Dr Harry Surtie Hospital in Upington in the Northern Cape. In 2019, four final-year medical students completed a modified longitudinal integrated model (LIM) programme there. “These students are trained by local healthcare staff and supported by consultants from Tygerberg Campus, as well as the Ukwanda Centre for Rural Health team,” says Couper. The Occupational therapy and Physiotherapy Divisions also started sending final-year students for four- and six-week rotations. “The plan is to move towards longer longitudinal programmes in 2020, with speech-language and hearing therapy possibly also joining the programme,” Couper says.
Private sector partnerships
Since 2014, a number of fourth- and fifth-year medical students with the FMHS have also been doing their four-week clinical placements in internal medicine at certain private sector hospitals.
“This experience gives students a good idea of what medicine is like in both the public and private health sectors, and what the advantages and disadvantages of both environments are. It ensures the students are very well rounded by the time they graduate,” says Prof Rafique Moosa, executive head of the Department of Medicine at the FMHS, who initiated the project.
Since its inception, the project has been rolled out at numerous hospitals in the Mediclinic group and in 2019 the Melomed group also joined. The facilities and training doctors are accredited by the University before students are placed there.
According to Moosa, the feedback from students, doctors and patients has been overwhelmingly positive. Students enjoyed the private facilities and the one-on-one interaction with doctors, while patients appreciate the extra attention they receive from students. The doctors involved said they enjoy mentoring students and that it made them brush up on their own knowledge in order to answer students’ questions.
For a number of years, human nutrition students have also been doing their eight-week food services rotation at private hospitals.
The FMHS developed a software programme, called Placement+, to manage the clinical placement of all undergraduate students in the Faculty. “We custom-built a platform that specifically speaks to the needs of our Faculty, and the South African context,” says Mr Stefan Engelbrecht, FMHS Deputy Director: Business Management.
Student placements were previously managed by each academic programme on individual operating systems. These are now consolidated into a central platform that automates the placement process and can find synergies between programmes.
In addition to the online platform where student placement data is captured and managed by Faculty staff, students can also access the system via a cell phone application that shows them where the healthcare facility where they are doing their clinical rotation is situated, and can even direct them to the facility in real time.
“This software will allow our Faculty to go to the next level in the placing of students in terms of data analysis and communication to students – it is changing the way the Faculty functions,” Engelbrecht concludes.
Stellenbosch University Logistics for the Clinical Training Platform (SUNLOC) provides logistical support to FMHS students on the DTP. The services include transport facilitation with shuttle services and vehicle provision, distant accommodation arrangements, and information and communication technology (ICT) support.
“The SUNLOC team vets all student accommodation to ensure that sites are safe and convenient for students to make their stay away from campus as comfortable as possible,” says Ms Georgenia Stam, Manager: Clinical Training Platform.
SUNLOC is also in regular contact with students in transit or those on rotation in remote sites, and is on hand to assist in case of any incidents.
‘Our curricula are aligned to the health needs of the country, and our graduates are equipped with the skills set they need to deliver on the strategic intent of government to provide healthcare services to the people of South Africa.’ - Dr Therese Fish, FMHS Vice-Dean: Clinical Services and Social Impact
Photo credit: Nardus Engelbrecht and Stefan Els