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Background: Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District. Method: Following an initial audit in 2008, the researchers and a new audit team introduced interventions, and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals, one regional hospital, and one tuberculosis hospital) were audited. Results: Spinal manometry was performed more consistently in the regional hospital, than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths, drug stock problems, and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling was better in the district hospital setting. However, both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART. Conclusion: Deficiencies in the quality of care remained. Between the prior and current audit cycles, there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed, and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future. [ABSTRACT FROM AUTHOR]

There has been an increasing awareness of the importance of physician mental health. Several South African studies show a high prevalence of burnout among doctors. Burnout is characterised by three components: exhaustion, depersonalisation, and a sense of a lack of efficacy. Burnout is a result of both external and internal pressures. While lifestyle modification is essential, mindfulness-informed programmes promote self-regulation and resilience. Mindfulness programmes comprise three components: present moment awareness, perspective-taking and wisdom, and compassion. Physician wellness begins with individuals recognising the need of self-care and giving themselves permission to prioritise this. Ongoing identification of self-care needs and acting compassionately to address these needs is essential.

Background: Burnout among doctors negatively affects health systems and, ultimately,patient care., Aim: To determine the prevalence of burnout among doctors working in the district health system in the Overberg and Cape Winelands districts of the Western Cape Province and to compare the findings with those of previous South African studies., Setting: Rural district hospitals., Methods: During 2013, a validated questionnaire (Maslach Burnout Inventory) was sent to 42 doctors working in the district health system within the referral area of the Worcester Hospital, consisting of the Overberg health district and the eastern half of the Cape Winelands., Results: Response rate was 85.7%. Clinically significant burnout was found among 81% of respondents. High levels of burnout on all three subscales were present in 31% of participants.Burnout rates were similar to those of a previous study conducted among doctors working in the Cape Town Metropolitan Municipality primary health care facilities. Scores for emotional exhaustion (EE) and depersonalisation (DP) were greater than those of a national survey;however, the score for personal accomplishment (PA) was greater. EE and PA scores weresimilar to that of a study of junior doctors working in the Red Cross Children's Hospital;however, EE was smaller., Conclusion: This study demonstrates high burnout rates among doctors working at district level hospitals, similar to the prevalence thereof in the Cape Town Metropolitan primary health care facilities. Health services planning should include strategies to address and prevent burnout of which adequate staffing and improved work environment are of prime importance.

Introduction: Medical education across the globe is in a state of flux influenced by a number of drivers for change. In response, institutions are seeking to re-align their curricula to address the prevailing imperatives. Against this backdrop, the training of practitioners for practice in rural communities was identified as an educational priority, and led to the establishment of a rural clinical school (RCS) within a Faculty of Medicine and Health Sciences in South Africa in 2011. This article describes the students' experiences in the first year that this innovative educational model was implemented and explores the extent to which it influenced their thinking and practice., Methods: A qualitative, formative evaluation study of the first year of implementation was undertaken. Data was generated from in-depth interviews. This article focuses on individual interviews conducted with the eight students at the RCS, which explored their experiences during a year-long clerkship. Transcripts of interviews were thematically analysed., Results: Four themes emerged from the analysis: a learning experience that differed from what was experienced at the tertiary training hospital, an enabling clinical environment in the district and regional hospital, the positive role played by the specialists, and the influence of the community immersion. Underlying all of the responses was the building of relationships over time both with supervisors and with patients. Evident from the responses was that students' confidence in their clinical skills and decision-making abilities was heightened while their approaches to their own learning were enhanced., Conclusions: To respond to the call for educational reform and a heightened awareness of social realities, innovative approaches to the training of medical students, such as those adopted at the RCS, are indicated. It is argued that the learning facilitated by these rural medical education models has the potential to offer learning experiences that can lead to transformation through a change in practice and attitude among the students, and ultimately also enable curricular renewal at the institutional core.

Introduction: It is well-recognised that medical students whose training exposure is largely limited to tertiary-level training hospitals may be inappropriately equipped to deal with the most relevant health issues affecting rural communities. This article evaluated the perceived educational value of a 2 week clinical rotation undertaken by senior undergraduate medical students at rural district hospitals and health care centers in the Western Cape Province, South Africa., Methods: Students completed a daily log diary to provide an overview of time spent on specific academic activities, ranking the educational and enjoyment value of each activity. At the end of the 2 week rotation students completed an open-ended questionnaire capturing the main positive and negative aspects of their experience, followed by focus group discussions with a randomly selected subgroup. In addition, a formal feedback seminar was arranged with the academic supervisors at each of the training sites to triangulate the information received and to document their perspective., Results: Thirty-seven students consented to study participation and 25 (68%) adequately completed the log diaries and questionnaires, rating the following activities as most educational: 'assisting in theatre', 'teaching by doctor', 'seeing patients in clinic/health centre/OPD' and 'mobile clinic excursions'. The rural experience allowed practical application of their theoretical knowledge, which improved their levels of confidence and enjoyment. The most enjoyed activities were: 'mobile clinic excursions', 'performing medical procedures' and 'teaching by doctor'. The students were critical of some aspects: (i) the rural rotation was not structured efficiently; (ii) compulsory written reports and additional projects prevented them from maximizing the rural experience; and (iii) a time period of 2 weeks was felt to be too short for optimum benefit from the rotation., Conclusion: The feedback obtained from this log diary study demonstrates that well-functioning rural health care centers provide excellent opportunities for students to develop the most relevant practical skills required of generalist doctors working in resource-limited settings. In addition to a more efficiently structured rural program, students requested an increase in the length of the rotation and a reduction in the written academic workload.

Growth monitoring, oral rehydration, breast-feeding and immunisation--female education, family spacing and food supplementation (GOBI-FFF) are a selective package of World Health Organisation primary health care strategies recommended by UNICEF. Changes over a 1-year period in the implementation of the components of GOBI-FFF were investigated in a rural village in Ciskei to detect any changes associated with a newly modified village health-worker (VHW) programme. A baseline survey was conducted before the introduction of a modified VHW programme and a second survey took place a year later. The principles of GOBI-FFF were already familiar to and have since been increasingly practised by the community and health personnel. Breast-feeding is widespread, most carers know how to make oral rehydration solution and most children have a 'Road to Health' card and are being weighed regularly. However, malnutrition remains a major problem and the food supplementation programme is operating poorly. The high coverage of the community by the village health-workers and the clinic suggest that these two channels should be used more intensively to strengthen the GOBI-FFF programme in the area.