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It is important to decide if a patient with diabetes has good glycaemic control in order to guide treatment and to offer behaviour change counselling. Currently, determining random blood glucose (RBG) is usually carried out in primary care in the public sector to make this decision. This study investigates the validity of these decisions. Retrospective data from a district hospital setting were used to analyse the correlation between glycated haemoglobin (HbA1c) and RBG, the best predictive value of RBG, and its predictive properties. The best value of RBG to predict control (HbA1c ≤ 7%) was 9.8 mmol/l. However, this threshold only gave a sensitivity of 77% and a specificity of 75%. Clinicians would be wrong 23% of the time when using RBG to determine glycaemic control. Attempts should be made to make HbA1c more available for clinical decision-making. Point-of-care testing for HbA1c should be considered.

Objective: This study aimed to evaluate the effectiveness of the Making the Difference programme (MTDP), an educationand activity-based intervention for Grade 4 learners at primary schools in the Western Cape.Design: This was a cross-sectional, post-intervention survey of an existing programme, using control schools as a comparator.Setting and subjects: The study involved Western Cape primary schools in the 2009 school year. Schools were randomly sampled from two regions. Four intervention (active in the MTDP) and five control (non-participating) schools (n = 325 learners) were selected.Outcome measures: The following outcome measures were assessed using an administered questionnaire to learners: learners’ knowledge of, attitudes towards, and behaviour in relation to nutrition and physical activity.Results: A small but significant improvement (eating vegetables and taking lunch boxes to school) was demonstrated with regard to self-reported behaviour in relation to nutrition in the intervention group. However, this behaviour was not explained by differences in barriers to healthy eating, self-efficacy or knowledge, which were not different between the groups, or by perceived social support, which was actually significantly increased in the control group. Groups displayed no differences in physical activity or sedentary behaviour. However, the results showed a significant difference between the groups in terms of a reduction in perceived barriers to physical activity and increased physical activity self-efficacy in the active group.Conclusion: While the MTDP only had a modest effect on the self-reported nutrition and physical activity behaviour of the learners, results regarding lower perceived barriers to physical activity and increased physical activity self-efficacy were promising.

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The consultation in family practice is a complex and often unpredictable interaction between the doctor and the patient. No two consultations are ever exactly alike and every patient is unique in the way they experience their illness. One model for making sense of a patient’s illness experience is to consider not only the biological but also the individual and contextual dimensions.

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Background and aims. In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. Methods. The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. Results. Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe nonproliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. Conclusion. Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10 000 patients a year. South African Medical Journal Vol. 97 (12) 2007: pp. 1284-1288

The prevalence of diabetes in Africa is predicted to increase by 80% in 2025 and impact younger working age patients. We increasingly live in an obesogenic society that drives the global pandemic of Type 2 diabetes. The powerful commercial, socio-economic and political factors shaping this society encourage individual choices that lead to a sedentary and unhealthy lifestyle. These factors are increasingly seen in lower income countries. The metabolic syndrome is now an established entity which can be identified and treated prior to the development of diabetes. In sub-Saharan Africa there is an emerging relationship between the HIV and diabetic epidemics. For example HAART leads to a higher risk of diabetes and diabetes increases the risk of infections such as TB. The quality of care in sub-Saharan Africa can be improved with relatively simple measures if they are implemented consistently and guidelines have been developed for this context. A vision for the way forward in Africa has been expressed in the 2006 African Diabetes Declaration. South African Family Practice Vol. 49 (6) 2007: pp. 44-50

Family Medicine training and assessment is becoming more formalized and developed in South Africa. Assessment of competency in relation to clinical skills can involve observation in the clinical setting, but is more usually assessed in an examination. The traditional “long case‿ has been largely abandoned as it lacks reliability and validity. Summative assessment of family physician's clinical skills now usually includes an Objective Structured Clinical Examination (OSCE). Although a well designed and organized OSCE can have reasonable reliability and validity, a pass mark of 50% may in fact be an arbitrary figure, which does not credibly represent the required competency of a family physician. Standardisation of the OSCE is required to define the pass mark above which a candidate performs at the level expected of a family physician. A number of standardisation processes have been described that either judge the test items prior to the exam or judge the individual during the exam. In this paper we report on an example of the latter called the borderline regression method. South African Family Practice Vol. 49 (3) 2007: pp. 5-7

Background Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care, family-orientated care, and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs. Methods A co-operative inquiry group, consisting of two facility managers, an administrator, and medical and nursing staff, met over a period of nine months and completed three cycles of planning, action, observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care can be created within a typical CHC. Results The CHC had established three practice teams, but met with limited success in maintaining the teams over time. The group found that, in order for teams to work, the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors, but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of “chronics”. Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an “assistant” who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation, while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks, thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available, while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs, who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs, however, the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day, to be cognisant of the limitations of the building design, to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered, and not just that for the doctors and nurses. Conclusions Key lessons learnt included the need to engage with a transformational leadership style, to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team, due to their hospital duties, was a critical factor in the breakdown of the teams.. The CHC plans to further develop practice teams, to learn from the lessons so far and to continue with the co-operative inquiry. South African Family Practice Vol. 49 (1) 2007: pp. 17

Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care, family-orientated care, and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs. Methods: A co-operative inquiry group, consisting of two facility managers, an administrator, and medical and nursing staff, met over a period of nine months and completed three cycles of planning, action, observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care could be created within a typical CHC. Results: The CHC established three practice teams, but met with limited success in maintaining the teams over time. The group found that, in order for teams to work, the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors, but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of "chronics". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an "assistant" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation, while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks, thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available, while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs, who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs, however, the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day, to be cognisant of the limitations of the building design, to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered, and not just that for the doctors and nurses. Conclusion: Key lessons learnt included the need to engage with a transformational leadership style, to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team, due to their hospital duties, was a critical factor in the breakdown of the teams. The CHC plans to further develop practice teams, to learn from the lessons so far and to continue with the co-operative inquiry.

The new series, “Mastering your Fellowship”, provides examples of the question format encountered in the written examination, Part I of the FCFP(SA) examination. Examples of these question types (according to a theme) will be given in each printed edition of the journal. “General adult medicine” is the theme for this edition and model answers will be available online, but not in the printed edition.Keywords: FCFP(SA) examination, registrars, general adult medicine