BasedEducation
in a SouthAfrican
Community
WasSocrates
Right?
Gontext:
Abstract
Cameron, D
MB,ChB(UCT),MPraxMed
(Medunsa)
Departmentof FamilyMedicine,
Universityof Pretoria
PrivateBagX449
Hammanskraal,
0400
Tel: (0 12)7 17201| - Pager427
Fax: (0 12)7 177404
E-mail:
[email protected]
Keywords: Medicaleducation,
Communitybasededucation,
Undergraduate
medicaleducation,
qualitativeanalysis
Overseeing medical students
working in small rural clinics
challengesboth the students and
the lecturers. How does one
evaluatea learningexperiencethat
does not involve memorisingfacts?
Socrates(470-399 BC) maintained
that the teacher's role was not to
impart knowledge but rather to
expose ignoranceand encouragea
process of
self-discovery.
According to Socrates, the
outcome of this processwas a new
understandingof oneself,a sense
o f e m o t i o n a l b a l a n c ea n d a n
increasedconsciousnessof onel
socialresponsibi
lities.
This study evolvedas I participated
in the processofteachingstudents
and becameforcefullystruck by
their commentsin their rotation
reports.A qualitative
analysis
of 150
studentrepoftswascarriedout and
the majorthemeswerehighlighted.
T h o s e t h e m e si n c l u d e d b
: eing
overwhelmed
bythe difficulties
and
f r u s t r a t i o n so f a n i n a d e q u a t e
service,beingchallenged
by cross
cultural issues,comparingnotes
with traditionalAfrican medicine,
reassessing
compulsorycommunity
serviceanda changedvisionabout
oneselfand one'sfuture career.A
community-based
experience
in a
rural clinicis definitelyone wayof
preparingfuture doctors to meet
the challenge
of healthcarein South
Africa.
SA FamPraa2000;22(2):
l7-20
Introduction
A f t e r | 6 y e a r s i n s u b u r b a ng e n e r a l
practiceI felt asthough I had beenthrown
into the deep end when I loined the
Department of Family Medicine at the
University of Pretoria. I was given the
taskof overseeingsmallgroupsof 4'hyear
m e d i c a ls t u d e n t sw h i l e t h e y s p e n t 2
weeks working at a primary care level in
rural clinics.
metaphors to illustrate this role. The
teacher was the "god\ of the rhoughts".
B y m e a n s o f p r o b i n g q u e s t i o n st h e
student became aware of his/her
ignorance. This awarenessstimulated
curiosity and encourageda process of
self-discovery.
The teacher also became
the"intellecarclmidwife" as he/she assisted
in the birth of consciousunderstanding
out of unconsciousignorance.According
This article attempts to capture the to him,the outcome of this processwas
experiencesof thesestudents.In addition a new understandingof onesell a sense
it explores my own journey in looking of emotional balanceand an increased
for waysof makingthis time a meaningful c o n s c i o u s n e s s o f o n e ' s s o c i a l
learningexperiencefor them.
responsibility.
In the lightof allthe current discussionsr-7 What happensto medicalstudentswhen
about training medical students I was they are removed from the comfort of a
fascinatedto come acrossSocrates'ideas largeurbanAcademichospitaland placed
about education.s
in small rural clinics? How does one
evaluatea learningexperience,which
does not involvememorisingfacts?Can
Socrates (470-399 BC) maintained that
the teacher's role was not to impart o n e m e a s u r e c h a n g e o f a t t i t u d e ,
k n o w l e d g e b u t r a t h e r t o e x p o s e increasingmaturity, a greater awareness
i g n o r a n c e . H e s u g g e s t e d2 v i v i d of the needsof others?Are these things
importantl Shouldone even be trying
to evaluate20'hcentury studentsin this
way? Are the outcomes that Socrates
suggestedstill validtoday?
This article attempts to answer these
questionsas well as assessing
whether
the experienceof working in rural clinics
helps to prepare medicalstudentsfor
facingthe challengeof the health care
needsof SouthAfrica. lt is interesting
to read how colleagueshavegrappled
with similar issuesand have come up
w i t h e x c i t i n g i d e a s f o r s o l v i n gt h e
difficultiesencounteredin Community
BasedEducation.e-rl
Teaching methods
During their 4'h year of training (old
c u r r i c u l u m ) ,g r o u p s o f 3 0 m e d i c a l
studentsspend 2 weeks livingat the
University'ssatellite campus near
Hammanskraal 50km north of
Pretoria. In the mornings they work
in variousvillageclinicsin the Moretele
District assistingthe nursingstaff with
their primary healthcare tasks,such as
immunisation,antenatal care, family
planning,the D.O.T.S.program for TB,
healtheducation.and the treatment of
so-calledminor ailmentsand common
At the end of this time the students
had to write a report in which they
had to criticallyevaluatethe District
Health Systemas well astheir personal
experience.Theywere encouragedto
write "from the heart" rather than to
follow any formal guideline.
chronic illnessessuch as hypertension,
asthmaand diabetes.In the afternoons
they participatein discussions,
debates,
role-play,quizzes,slides and videos on
topics related to primary health care
presentedby variouslecturersfrom the
Facultyof Medicine.
Methods
A qualitative
analysis
of 150 reports This studywas not originallyplanned
w a s c a r r i e do u t . M a j o r t h e m e s at the beginningof the year.As I
especially
thoserelatedto the process participatedin the processmyselfand
of self-discovery
in a cross-cultural, w a s s o f o r c e f u l l y s t r u c k b y t h e
ruralsettingwere highlighted.
comments
of the studentsI decided
to
try to analysetheir responses.
My own
reactionsand personalbiasesprobably
heavilyinfluencethis analysis.
Despite
this, I felt the voices of the students
need to be heard.
MajorThemes
l. An overwhelming experience
Many students expresseda feelingof
helplessnesswhen confronted by the
harsh realities of life - the realisation
that the problems many people face
every day cannot be fixed with a simple
prescription. Problemssuch as
u nemployment,d isabiIity,dysfunctional
f a m i l i e s ,a l c o h o l a b u s e & H I V / A I D S
appearinsurmountable.
'/
wos so he/plessond incompetenLWhat
struck me was that this wos reol life,
nowhereto hide'
'Medicine
doesnt cure poverty'
'l
'
felt os if my hondswere chopped off'
I felt more like on undertoker thon o
medicolstudent'
thoughts thotwere ungrounded. I om
the poor one. I om the one who is
going to be helped'
2. The difficulties and frustrations
of an inadequate service.
T h e m a n y d e f i c i e n c i e so f t h e r u r a l
district health system causedmuch
frustration. Inefficientadministration
and managementresultedin recurrent
shortages of medical supplies,
stationeryand cleaningmaterials.On
inquiringthe staffmerely shruggedtheir
shoulders.
deliverywomen ore giventhe plocentasto
toke home for disposol."
"The most shocking thing of oll is thot
women ore sent home after deliverywith
the placento in o plosticbog."
3. Another culture - conflict or
opportunity.
Working in a cross cultural setting
c o m p o u n d e dt h e s t u d e n t sp r o b l e m s
especiallyas most of them have little
o r n o u n d e r s t a n d i n go f t h e l o c a l
languages.Staff shortages meant that
the nursing staff were also not always
available
to help interpret,asthey were
'..
. the depletedsupp/iesin the dispensary b u s y w i t h o t h e r a c t i v i t i e s . l t i s
ond the possiveway thisis occeptedis o/so interesting how different the reactions
o problem'
of various students were. A few were
very unhappy.
The lack of telephonesand transport
m a d e d e a l i n g w i t h e m e r g e n c i e sa "The experiencewos notolwoyspleosonL"
nightmare.The overcrowding and lack Aportfrom the limitedsupplies,the nurses
of privacyespeciallyon familyplanning were mostly ontogonistic,unhelpful ond
day was also disturbing.
unfriendly.One wos deliberotelymode very
Those students who come from more
affluent urban backgroundsexpressed
s u r p r i s e a t s e e i n gs u c h a p p a r e n t
poverty so close to home. Some
'Potients
ore often herded like sheepinto
expressedfeelings of guilt at having
fotd;
been'spoilt'and havingtaken so much
for granted. A few students went one
'At
the fomily planning clinic the women
step further. They realisedthat it was
woiting in o row with their dress
stond
actuallythey themselveswho were the
'poor
pulled
up while you jump oround like o
ones'. lt was they who were
receivingmore than they were giving. jock-in-o-boxtryingto rememberwho gets
which injeaion.'
'My
ftrst impressions were thot we
"Most clinics do not hove o proper
were going to leorn about delivering a
incinerotor.
At those clinics with an
seryice to /ess fortunate people thon
incinerotor
there
is no cool or wood. After
ourse/yes. I now find it wos my
conscious of differences in culture ond
opportunitiesond at everyopportunitythis
wos rubbed in. Communicationwith
potients was very difficult os o result of
the longuogeborrier.
For others the experienceas well as
their own reactions were totally
different.
'l
enjoyed
workingot Mokoponstod
Clinic
verymuch.Thenursingstaffwossofriendly
peopleconsult
ond willingto teachme voriousski//s. / thereosons
o GP,then
one
it
very
stimuloting
to
work
with
cannotjust
drsmiss
the
volue
such
o
of
found
peoplewho were so differentto me person."
especially
regordingculture,languoge
ond
opportunities.'
A secondopinion.
relationships,
the reolityof life ond the
possibility
of olwoysremoiningo thonkful,
potientperson,generouswith whot you
hove- thot is ofteroll whot life,isobout'
'Withinme o smoll
flomewos re-ignited.
'lt modeme reolise if I
'IHURSDAy
thot wontedto be
todoywe did notgo to the ln all honestyI was afroid thot it wos
o gooddoctorI woulddefinitelyneedto clinicbut insteodwe visiteda troditionol olreodycompletely
dead.'
leornonotherlonguoge.'
heoler. My first surprisewas thot the
'doctor'wos
a woman,especiolly
oswomen 'lt wos there that I rememberedwhy I
'l mustmention
ot this stogethot Sister don'tenjoymuchesteemin blockculture. beganstudying
medicinein the firstploce'
Deborohwent out of her woyto moke Secondly,
it wosencouroging
to heorthot
these2 weekso successful
leorning she doesrefer patientsto doctors.The '... sco/es
fellfrommy eyes......'
experience.
Shewoso reol inspirotion
to highlightof the morningwos to find on
me personolly
becouse
shewosolwoysso Afrikoonsbook of old home remedies '... the highlight
of my 4 yeorsof study;
positivedespitehovingso little.Her heort (boererote).Theformer on whoseform
is in herworkondin hercommunity.'
shegrew up gavethe bookto her: She '... allthe'swotting'will
notbefor nothing.'
usesit regulorlyos o referencebookin
4. Traditional
medicine
her flourishingpractice. lt is goodto 'Anotherottemptis modeto destroyour
comparing notes.
knowthot'XXX mints'ondbrokefluid
hove insuloritycomplex.We wereexposedto
o plocein the treatmentof piles.'
rural SA ond we wonderevenmore for
A visit to a traditionalhealerwas a
whomto vote.'
highlightfor manystudents.Though 5.A changedvision
apprehensive
and somewhatsceptical
at first, they enloyedthe opportunity For manythe experienceof working '... And a movingencounter
to compare notes on the different i n a r u r a l c l i n i c o p e n e d a n e w
perspective.After 3 yearsof theory 'Whot will I olwaysrememberobout
approaches
to illness.
theywere at lastgiventhe opportunity Refentseclinic? A greot deol,especially
HerbsandSandton
to put their knowledgeto the test. theimogeof o certoinI7-year-old
mother
'Afroid? Yesindeed,
we thought the Beyondthe skillsof measuring
blood with herhydrocepholus
babyin her orms.
'troditionol
heoler'wouldmokeus drink pressures
andtemperatures,
of listening O yes,the boby as o potientswos very
boneryocidond bewitchus oll. Biosond to heartsand lungs,there was the interesting,especially
the'VP-shunt'and
prejudice!'
to seepeoplein contextand everqhingthotthedoctorexploined
challenge
to us.
to delvea bit deeperinto the hidden Butin myopinionitwastheyoungmother
"He showedus o// his quoliftcotions
ond needsandproblems.
who wosa heroine.Shewossoowkword
then we realisedthot he wos a type of
wheneveryone
endemborrossed
cometo
"Herbolist". At first he was suspicious 'lf just for onceyou con exchongeyour exomineher littledoughter.Loterwhen
nfident,oll knowing,better-tho n-you- wewereoloneondI toldherwhoto pretty
becousehe thoughtwe were from the self-co
police. (l wonderwhy?). I hove never attitude,for thot of o teochoble,flexible bobyshehodondhowmuchthechildloved
person,
seensomeone
whocouldloughsomuch- ondunderstonding
theneverything herond olsohowmuchshelovedthechild;
n o t e v e n t h e n u r s e so f B o s p l o o s .doesnt/ookso strongeonymore. If you she blossorned
into o beomingloving
Something
ond mother.As innocentas a child,in reolity
thot wosremorkoblewoshis tokeoff yourjudgmentalspectocles
good clinicolknowledge.Biosond looko bit deeperthon the not so shiny whotsheherselfstill
is,she kissedherbaby
prejudice!
surface,you
willseewhotyouorefomilior repeotedlyon her foreheodond spoke
with. Youwill seethe broveeffortsof the softlyto her. lt is unbelievoble
how
Althoughhe works within a different staffwhoore tryingto copewithsomuch importontthe odvicea lecturergoyeus
to morethontheywereoriginollytrainedto one doyjust in possingthot oneshould
fromeworkofstoriesond explanotions
the westerndoctor,he definitelyhoso lot do.Theyhoveto hondlethingsthotothers rememberto encourage
the porensof o
of experience.
wouldnot be willingto do. It is oll in on deformedchild by ottochingo senseof
effortto bringprimoryheolthcoreto os volueto the child. I wosomozedot this
Evenhereone con see thot thereore mony peopleos possible.And olthough young girl - she /ooks ofter this
differences
omongst
troditionol
healers.
For thiscareis notoccordins
to the stondords hydrocepholus
bobyso nicely,she brings
guideline,itis
exomplethisheolerto/d us thot he wos of on ideolistic
otthe moment her to the clinicregulorlyond checksto
not in fovourof treotingpeoplewith oll thereis,the bestthot we con deliver.' seethot the shuntdoesntblock.Shehos
illnesses
whichhe knewthe"whitedoctors"
to corry oll thoseheavy responsibi/ities
couldcuremorequickly.
ln the two weeks/ wos exposedto this oloneot sucho youngoge- is thissimp/e
lf onethinksabouttheplocebo
effectand system,I leornt more obout humon personnot so much betterthan we who
orealwoyscomploining
ondtryingtoovoid communityservicehad beenchanged moregratefulperson.
I am evenpositive
responsibilitywhen life becomeso bit and that they were actuallylooking oboutCommunityService.'
pressurisedT'
forwardto thisopportunityof service.
'After
the visittoTlholwe,lhaveo new
'l
6. Community service
mustbe honestond odmitI hod very perspectiveobout underdeveloped
negotiveideos about compulsory communities.For the first time in my
'spoilt'life,lrealised
On occasions
the studentshadcontact Community
howo lorgeport of
Seryice
thot owoitsus,butnow
people
with doctors doing their compulsory I hoveo differentperspeaive.
must
moke
our
do with so few
I am oauolly
privileges.
y e a r o f c o m m u n i t ys e r v i c e .T h e i r lookingforwordto the opportunity
Now I understondthe
to moke
positiveattitudeandwillingness
to help a positivecontributionin Primary Heolth importonce
of o goodprimoryheolthcore
the studentswas greatlyappreciated. Core.'
servicein the development
ond welfore
Manystudentscommentedon how 'Thetwoweeksot Hommonskrool
did not of o country.'
their previouslynegative
feelingsabout onlyteachme a lot"it modeme o better,
Discussion
Thirty years ago the American
educationalist,Frederick Mayer; said:
'Education
is measuredby its impact'.
It is evident from those repofts that
many students coped well with the
experienceof working in a rural clinic.
As predicted by Socratesthey gained
a new understandingabout themselves,
they were able to resolvesome inner
conflicts and achieved a sense of
emotional harmony and an increased
I
w i l l i n g n e s st o f u l f i l t h e i r s o c i a l
responsibilities. As can be expected,
however a small minority remained
entrenched in their original attitudes
and prejudices.
Obviously this study has many
limitations and it may not fulfil all the
r e q u i r e m e n t so f a f o r m a l s c i e n t i f i c
study yet I feel that the views of the
studentsprovidesvaluableinsightinto
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