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Background:  Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability., Aim:  To assess patients' perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine., Setting:  Private sector PC clinics in Nairobi., Methods:  A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants., Results:  Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%)., Conclusion:  Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.

Context: The Royal College of General Practitioners in partnership with the South African Academy of Family Physicians obtained funding to run a series of 'Training the Trainers' courses for trainers of family medicine registrars, with a view to strengthening clinical supervision of postgraduate registrars. The authors wanted to establish whether it was worthwhile for the course to be provided on an ongoing basis after the funded project was completed., Intervention: Development of a pilot tool for evaluation visits after a faculty development course., Methods: The authors developed a pre-visit pack and conducted five site visits to registrar trainers who had been on the course between 12 and 24 months earlier. Before the series of visits and after each visit we debriefed and modified our approach., Results: Optimising the use of the pre-visit pack will require greater orientation of the trainer. Administrative support for the visits will be vital. The visits were experienced very positively. However, in a context in which these visits are not the norm, the trainers need support and encouragement to participate in an activity which made them feel quite vulnerable., Conclusions: The tool enabled course participants to show evidence of their behaviour change, enabled their colleagues to report on the impact on their own teaching practices, and enabled registrars to voice their opinions of their trainer's supervision skills. A post-course formative evaluation visit has the potential to catalyse the impact of the training course. It will be necessary to train the family physicians who conduct these visits.

Background: Integrated team-based primary care is an international imperative. This is required more so in Africa, where fragmented verticalised care dominates. South Africa is trying to address this with health reforms, including Primary Health Care Re-engineering. Family physicians are already contributing to primary care despite family medicine being only fully registered as a full specialty in South Africa in 2008. However the views of leaders on family medicine and the role of family physicians is not clear, especially with recent health reforms. The aim of this study was to understand the views of key government and academic leaders in South Africa on family medicine, roles of family physicians and human resource issues., Methods: This was a qualitative study with academic and government leaders across South Africa. In-depth interviews were conducted with sixteen purposively selected leaders using an interview guide. Thematic content analysis was based on the framework method., Results: Whilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role and 'specialist' status. National health reforms were creating both threats and opportunities for family medicine. Three key roles for family physicians emerged: supporting referrals; clinical governance/quality improvement; and providing support to community-oriented care. Respondents' urged family physicians to consolidate the development and training of family physicians, and shape human resource policy to include family physicians., Conclusions: Family physicians were seen as critical to the district health system in South Africa despite difficulties around their precise role. Whilst their role was dominated by filling gaps at district hospitals to reduce referrals it extended to clinical governance and developing community-oriented primary care - a tall order, requiring strong teamwork. Innovative team-based service delivery is possible despite human resource challenges, but requires family physicians to proactively develop team-based models of care, reform education and advocate for clearer policy, based on the views of these respondents.

Background: In South Africa the submission of a portfolio of learning has become a national requirement for assessment of family medicine training. A national portfolio has been developed, validated and implemented. The aim of this study was to explore registrars' and supervisors' experience regarding the portfolio's educational impact, acceptability, and perceived usefulness for assessment of competence., Methods: Semi-structured interviews were conducted with 17 purposively selected registrars and supervisors from all eight South African training programmes., Results: The portfolio primarily had an educational impact through making explicit the expectations of registrars and supervisors in the workplace. This impact was tempered by a lack of engagement in the process by registrars and supervisors who also lacked essential skills in reflection, feedback and assessment. The acceptability of the portfolio was limited by service delivery demands, incongruence between the clinical context and educational requirements, design of the logbook and easy availability of the associated tools. The use of the portfolio for formative assessment was strongly supported and appreciated, but was not always happening and in some cases registrars had even organised peer assessment. Respondents were unclear as to how the portfolio would be used for summative assessment., Conclusions: The learning portfolio had a significant educational impact in shaping work-place based supervision and training and providing formative assessment. Its acceptability and usefulness as a learning tool should increase over time as supervisors and registrars become more competent in its use. There is a need to clarify how it will be used in summative assessment.

Background: Since 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio's acceptability, educational impact, and perceived usefulness for assessment of competence., Methods: Two structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software., Results: Half of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning., Conclusion: This first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized.

Background: The World Health Organization encourages comprehensive primary care within an ongoing personalised relationship, including family physicians in the primary healthcare team, but family medicine is new in Africa, with doctors mostly being hospital based. African family physicians are trying to define family medicine in Africa, however, there is little clarity on the views of African country leadership and their understanding of family medicine and its place in Africa., Aim: To understand leaders' views on family medicine in Africa., Design and Setting: Qualitative study with in-depth interviews in nine sub-Saharan African countries., Method: Key academic and government leaders were purposively selected. In-depth interviews were conducted using an interview guide, and thematically analysed., Results: Twenty-seven interviews were conducted with government and academic leaders. Responders saw considerable benefits but also had concerns regarding family medicine in Africa. The benefits mentioned were: having a clinically skilled all-rounder at the district hospital; mentoring team-based care in the community; a strong role in leadership and even management in the district healthcare system; and developing a holistic practice of medicine. The concerns were that family medicine is: unknown or poorly understood by broader leadership; poorly recognised by officials; and struggling with policy ambivalence, requiring policy advocacy championed by family medicine itself., Conclusion: The strong district-level clinical and leadership expectations of family physicians are consistent with African research and consensus. However, leaders' understanding of family medicine is couched in terms of specialties and hospital care. African family physicians should be concerned by high expectations without adequate human resource and implementation policies.

Background: Within the 52 health districts in South Africa, the family physician is seen as the clinical leader within a multi-professional district health team. Family physicians must be competent to meet 90% of the health needs of the communities in their districts. The eight university departments of Family Medicine have identified five unit standards, broken down into 85 training outcomes, for postgraduate training. The family medicine registrar must prove at the end of training that all the required training outcomes have been attained. District health managers must be assured that the family physician is competent to deliver the expected service. The Colleges of Medicine of South Africa (CMSA) require a portfolio to be submitted as part of the uniform assessment of all registrars applying to write the national fellowship examinations. This study aimed to achieve a consensus on the contents and principles of the first national portfolio for use in family medicine training in South Africa., Methods: A workshop held at the WONCA Africa Regional Conference in 2009 explored the purpose and broad contents of the portfolio. The 85 training outcomes, ideas from the WONCA workshop, the literature, and existing portfolios in the various universities were used to develop a questionnaire that was tested for content validity by a panel of 31 experts in family medicine in South Africa, via the Delphi technique in four rounds. Eighty five content items (national learning outcomes) and 27 principles were tested. Consensus was defined as 70% agreement. For those items that the panel thought should be included, they were also asked how to provide evidence for the specific item in the portfolio, and how to assess that evidence., Results: Consensus was reached on 61 of the 85 national learning outcomes. The panel recommended that 50 be assessed by the portfolio and 11 should not be. No consensus could be reached on the remaining 24 outcomes and these were also omitted from the portfolio. The panel recommended that various types of evidence be included in the portfolio. The panel supported 26 of the 27 principles, but could not reach consensus on whether the portfolio should reflect on the relationship between the supervisor and registrar., Conclusion: A portfolio was developed and distributed to the eight departments of Family Medicine in South Africa, and the CMSA, to be further tested in implementation.

Introduction: A 'competence' model of CPD using facilitated small groups covering a range of clinical topics is an alternative model to lecture-based CPD. The aim of this study was to evaluate a new small group CPD programme and to determine whether the anticipated improvements in the quality of learning were realised., Method: A nominal group technique (NGT) was used to compile two questionnaires for participants and facilitators, respectively, seeking quantitative and qualitative information. The NGT is an effective tool and particularly useful in developing questionnaires to evaluate an educational intervention., Results: The results of the participants' survey indicated broad agreement with the NGT responses. For small group participants personal time constraints was the main reason given for not attending. 91% of the respondents indicated that the small group programme improved their knowledge, 73% indicated improvement in their patient care and 61% that their clinical skills had improved. Learning practical skills and the ability to identify and focus on specific learning needs of participants were strengths of the small groups. Participants valued the ability to deal with one theme in-depth over a number of weeks rather than many topics superficially in didactic lectures., Conclusion: The introduction of the small group CPD enabled an important shift from an update to a competence model of CPD, which has been shown to be more likely to lead to useful change in clinical practice. This approach to CPD should be encouraged. The main challenge for future research in this area is to assess the impact on clinical practice and health outcomes.

Setting: The purpose of this research was to adapt the World Health Organization's educational programme Mental Disorders in Primary Care for South African general practitioners., Aim: This paper describes how to organise and facilitate a co-operative inquiry group as a form of participatory action research aimed at developing or adapting educational materials. Specific quality criteria for this type of action research are defined. The experience of our own co-operative inquiry and the lessons learnt are discussed., Conclusion: In the field of medical education participatory action research methodology is relatively new. This article shows how the co-operative inquiry group can be used effectively to develop educational materials. It is intended to encourage and support others in using similar methods of action research in their own settings.

Setting: This innovative educational programme was developed in the South African context for general practitioners (GPs)., Aim: This short report describes the process of designing an Internet-based distance education programme Mental Disorders in Primary Care., Learning Methods: The article discusses relevant educational principles and then describes four stages in the instructional design process: design, development, evaluation and revision., Conclusion: The design and development of an Internet-based distance education programme for GPs in South Africa was a potent learning experience for me as an academic family physician with no prior experience in this area. I hope that this short report will assist other people and contribute to an ongoing dialogue on this topic.

Introduction: Community-based education is an important strategy for training students appropriately for delivering primary health care services. A community-based training rotation in Family Medicine and Primary Care was introduced at the University of Stellenbosch, South Africa, in January 1998., Objective: The aim of this study was to explore the perceptions of final year medical students about the new rotation and to provide feedback on the value of this experience to the Faculty. In this article we explore the influence of differing world views held by biomedically oriented training institutions and the systems view of life adhered to by the discipline of Family Medicine on attempts to reform medical education., Method: Quantitative and qualitative curriculum evaluation methods, including a questionnaire and focus groups discussions, were used. Students rated the value of the block as 7.8 out of 10., Results: Eighty-eight percent of students felt that there should be an earlier exposure to Family Medicine and Primary Care in their training. The main themes identified from the qualitative results supported the literature findings and included the difference in type of practice between tertiary and primary levels of care and the value of learning a new approach to patient care. Despite the fact that the results emphasized the importance of including community-based training in Family Medicine and Primary Care at an early stage in the medical curriculum, resistance to implementation was encountered. This led to reflection on possible reasons on why the recommendations of the study were not immediately adopted into the curriculum.