Walter Sisulu University PROFESSORIAL INAUGURAL LECTURE 20 April 2010
25 years of training doctors at WSU: how have we responded to the 1983 UNITRA Council Guidelines?
Professor E. N. Kwizera Department of Pharmacology School of Medicine Faculty of Health Sciences Walter Sisulu University Eastern Cape South Africa
Auditorium, Nelson Mandela Drive Campus, Mthatha, Eastern Cape
Walter Sisulu University (WSU) Department of Pharmacology School of Medicine Faculty of Health Sciences
Topic
25 years of training doctors at WSU: how have we responded to the 1983 UNITRA Council Guidelines?
By
Enoch Nshakira Kwizera
Date: 20 April 2010
Venue: WSU Auditorium
3
The Vice-Chancellor of Walter Sisulu University, Professor Balintulo; The Deputy Vice-Chancellor, Academic and Research, Professor Obi; The Deputy Vice-Chancellor, Planning, Quality Assurance and Development, Professor Buijs; the Registrar, Professor Tau-Mzamane; Executive Deans of Faculties; the Director, Research Development, Professor Ekosse; Directors of Schools; Heads of Departments; University Teaching and Administrative Staff; Students; Distinguished Guests; Friends and Family; Ladies and Gentlemen
As I stand before you this autumn afternoon, I cannot think of a single adjective to describe how I feel. For starters I am anxious and nervous about delivering this once in a life time Lecture. I have given classroom lectures and read papers at conferences for thirty years or so, and I am pretty much used to that. Not a Professorial Inaugural Lecture though, and I thus hope that my anxiety and nervousness are understandable. But then again, as my colleague, Professor Iputo observed when delivering his Professorial Inaugural Lecture just over 10 years ago, I am also relieved that these occasions do not provide for ‘question time’. My anxiety is also at least partly countered by the excitement of finally delivering this Lecture, which should have been delivered 6 years ago, and which over the last 2 years has been postponed so many times. I am proud that my University is, today, formally recognising my lifetime academic achievements; but I am at the same time humbled by the awareness that this is actually being done while I am still alive, and not posthumously; and I am thankful to the Almighty God for that and for everything else.
Over the past 20 years my career path has been dichotomous. My primary and principal speciality is Clinical Pharmacology, but I also consider myself a Health Professions Educationalist. As far back as 2004, I had intended to give my Inaugural Lecture on a clinical pharmacological topic, the fortuitous discovery of medicines, which has interested me since my early medical school days 40 years ago. Towards the end of 2009, however, I decided to change to a medical education topic, partly because 2010 would be the 100th Anniversary of the Flexner Report which revolutionized and standardized medical education in North America, and by extension, in the rest of the world; but mainly because the WSU Faculty of Health Sciences would be celebrating its Silver Jubilee this year. I therefore thought (and hopefully rightly so) that a medical education topic would be a more appropriate and, indeed, a more interesting one.
OVERVIEW OF THIS LECTURE Mr VC, Sir, I propose to deliver this, hopefully relatively brief Lecture, under the following six themes: 1. Dedication 2. Brief history of medical training in South Africa and in Transkei
5 3. UNITRA Council Guidelines 4. Our response to UNITRA Council Guidelines 1985 - 2010 5. Concluding remarks and the road ahead 6 Acknowledgements
Dedication In the first of his 3-volume Autobiography series, “Unreliable Memoirs”, Clive James, the Australian / British writer, begins: “I was born in 1939. The only other big event of that year was the outbreak of the Second World War”1. When I first read this opening 30 years ago, I was so impressed that even before I had really read the book, I started telling my mates: “I was born in 1950, and the only two other significant events of that year were the outbreak of the Korean War, and the imprisonment of Kwame Nkrumah”. I certainly said that in jest and in mere emulation of Clive James, whose satire as TV critic for “The Observer” I also admired at the time. For Clive James, however, the outbreak of the Second World War was indeed a big event, because his father enlisted and was killed in war. By contrast, neither the Korean War nor Nkrumah’s imprisonment was of any direct consequence for me, so to speak. For my parents, however, my birth was remarkable in more ways than one. When I was born, they had been married for just over 8 years, and already had three children, all of them daughters. And by then my father was at the receiving end of ridicule from his male peers who, in their ignorance of the genetic basis for the determination of an offspring’s gender, would taunt him: “Your wife is stronger than you and that’s why you are producing girls only”. But my father took it all on the chin and told them repeatedly and with confidence:“I have faith that God will give me sons”. That is how, when I was born that Tuesday night in the second week of June 1950, I came to be named Kwizera, because the word ‘kwizera’ in my mother tongue means ‘faith’.
But there is even more to this. Those of you familiar with the Bible (and if I may beg the indulgence of those who are not), might recall that Hebrews 11.1, in the King James Version, reads: “Now faith is the substance of things hoped for, the evidence of things not seen.” Thus, by naming me ‘Kwizera’, my father was in a way foretelling, among other milestones in my life, this special day when I would stand before you to deliver my Inaugural Lecture as Professor of Pharmacology at Walter Sisulu University. Indeed, had this Lecture been scheduled as soon as I was belatedly promoted to Full Professor effective January 2004, and in any case for a date before 11 October 2004, the day when my father was called to rest, he would have been there to witness further fulfilment of his Faith in God, and his faith in me. I, however, have faith that right now he is looking down at what is happening in this auditorium, and that he is warmly smiling, and nodding proudly at his first of 3 sons in whom he had faith; and whom he fondly gave the nickname: ‘Successor’.
I dedicate this Lecture, first and foremost, and with my eternal gratitude, to my parents: to my father, the late Rev. Canon Ernest Mizerero Nshakira, and to my 86-year old mother, Edreada Nshakira, who both imparted to me not only their powerful genes, but also brought me up with love, sacrifice, leading by example, and ever-present encouragement. Being the dedicated Church workers that they were, in those days before religion became the lucrative enterprise
6 it is for some today, my parents did not have much materially. However, when they utilized whatever little they had, my siblings and I were always given priority. More importantly, what they did not have materially was more than compensated for by their many virtues, including spirituality, hard work with their own hands, honesty, modesty, and humility; all of which they instilled into me, and which were instrumental in shaping the man I am today.
One great lesson I learned from my parents while growing up in those materially skinny (but spiritually and morally very rich) surroundings was to make do and to be contented with whatever I had, and not to waste any energies, thoughts or emotions being consumed with envy. For example, when I first went to High School in January 1965, I was barefoot (one of the 3 or 4 ‘barefooters’ in my class of ca. 30 boys) and I remained so for the First Term. I did not even have ‘slippers’, and after taking a shower I would walk back to the dormitory barefoot! In fact, I was so different in appearance from the mainstream, that a common question about me, was: “Ogu nawe n’omwana w’eishomero?” (i.e. “Is this one also a schoolboy here?”).
But all that did not deter me from working hard and finishing Second Term 5th in my class. And this was notwithstanding the fact that besides two or three Americans, nearly all of our teachers were from the UK, and they had such confusing accents (e.g. Yorkshire, Irish, Scottish, Welsh, Geordie, and of course Cockney) that for the first few weeks we (the village boys who were being taught by ‘Wazungu’ for the first time) would sit through lesson after lesson and get out of them all with no understanding whatsoever of what the teacher had been talking about! For my very promising start High School (and against all those odds), my father rewarded me with my first pair of shoes (the make was, I recall ‘Manhattan’ -of course they do not make them anymore…), and I will leave for another day the description of how so difficult and painfully uncomfortable it felt walking in shoes for the first time, at the grand age of 15! Needless to say, I did not have any long trousers either -my first pair of trousers was in 1966 (in grade 10), and I still recall the uncomfortable scratchy feeling I had around my legs when I put on and walked in those brand new long trousers also for the first time -and to make matters worse, on an evening school visit to Bweranyangi Girls High School! I will not digress going into the ‘Ntare-Bwera’ story at this stage; and nor will I reveal today when I adorned my first real underpants (and not the PE shorts that the school provided as part of our uniform)!
Perhaps -and more importantly, growing up in those materially lean surroundings taught me to be innovative, an attribute which has served me very well in diverse aspects of my dichotomous career. For example, before commencing my research studies at the University of Bradford (UK) in the late 1970s, I had to build apparatuses from a scratch so I could isolate and incubate rat liver cells for my experiments. Besides the usual laboratory glassware, the only ‘standard’ equipment my University gave me (besides the tiny laboratory space) were: a water bath, a Watson-Morley pump, oxygen-carbon dioxide gas cylinders, and the routine consumables. For everything else, I simply had to improvise2, 3.
7 (Kwizera, 1977,1980)
More importantly, Mr VC, Sir, some relatively more recent improvisations have been in the roles I have played in the development, implementation, and evaluation of the Problem- based, and Community-based MB ChB curriculum at the then UNITRA (and now WSU) from 1989 to date4-33; particularly my successful introduction of ‘one tutor per tutorial group’ in our programme8,10,12,14. As I will elaborate in due course, one of the secrets of our success as a medical school has been the adaptation of ideas and practices from diverse parts of the world to make them fit in our settings; and needless to say, this has involved a lot of improvisation.
Today we live in a different world to the one I grew up in, and the one in which I made the laboratory improvisations in the late 1970s. But like my parents, I have made every effort to pass to my children the same virtues that I acquired from my parents, and it is my hope -or rather my FAITH- that they, and their children, and grandchildren -ad infinitum, will keep the Nshakira ‘Torch of Faith’ burning.
There are of course other people who have made and left big and positive imprints on my life and career, and I think it proper to include them early in this Dedication, rather than merely acknowledging their input at the end of this presentation. Which this reminds me of a colleague in medical education circles, the late Miriam Ben David (RIP) who famously used to say: “Life is unpredictable. Eat your dessert first”. But I digress.
The first such group is, naturally, my teachers, going way back to the mid 1950s when I used to follow my older sisters to school and got ‘free’ education from the likes of the late John Murwani (RIP) who taught me my first rudimentary English vocabulary long before I could, write, read, or spell anything. Needless to stress here, I did not have any privilege of ‘pre- school; or the nursery rhymes that go with that; but thanks to my children, I learned all of them rhymes in my middle age when the same kids would come home and recite them endlessly
8 every evening! Then there were my ‘formal’ teachers at primary, junior secondary, and High School, my undergraduate and postgraduate teachers and supervisors; and particularly my latter day and very recent teachers: Faculty at the Foundation for the Advancement of International Medical Education and Research (FAIMER) Institute in Philadelphia, USA. Needless to say, this dedication would be incomplete if I did not include my past and present colleagues and my past and present students from both of whom I have always learned a lot, and who I continue to learn something from everyday.
One teacher who taught me Biology in my Grade 10 at Ntare School in the first half of 1966 (and pending his enrolment to Makerere University medical school), was none other than Alex Nganwa-Bagumah, who is and has been Professor and HOD of Anatomy at UNITRA/ WSU since 1985. When Alex taught me Biology at Ntare School, he had just written his A-levels at the end of 1965, and when the results came in early 1966, he had scored the first A-level Biology ‘A-symbol’ in our school’s modest 10-year history. The excellent teacher that he was then –and indeed still is now, he effectively transferred to me the basics of High School Biology, and I did not disappoint. When I wrote my A-levels four years later, at the end of 1969, I, following in his footsteps, recorded the second A-level Biology ‘A-symbol’ in our school’s history! I believe there has since been a deluge of ‘A-symbols’ in Biology from Ntare school, but I know that Prof Bagumah and myself still have our special places in Ntare School’s archives in this regard. Professor Nganwa-Bagumah remains my close friend, teacher, mentor, academic colleague, and confidant. I am indeed lucky and proud to have such a person as Professor Nganwa-Bagumah in my professional and personal life, and I deliberately pinpoint him today, while co-dedicating this Lecture to various people besides my parents.
Much as I would have loved to include all of my teachers here, I am torn between ‘eating my dessert first’ and turning the bulk of this into ‘an Inaugural Lecture of Dedications’. As a compromise, therefore, I will have to settle for mention of many deserving individuals under ‘Acknowledgments’. However, I also wish to deliberately highlight two other special individuals: Andrew Walubo, Chief Clinical Pharmacologist, and Professor and HOD, Clinical Pharmacology, UOFS, Bloemfontein; and Yoswa Dambisya, Senior Professor of Pharmacology, ULIMP, Polokwane. In the very early 1980s, I taught undergraduate pharmacology to these two gentlemen when they were 3rd year medical students at Makerere University, Kampala; and they did me proud not only by choosing pharmacology as a speciality, but also by excelling at it and becoming among the most prominent professors of pharmacology in South Africa today. Andrew and Yoswa, wherever you are as I speak, I salute you! Mr VC Sir, allow me also to salute and recognise the presence here of a few of the more than 2600 doctors that I have helped train in Uganda and South Africa; and who are in this gathering this afternoon.
The Dedication of this Lecture would surely be incomplete without including my extended, and particularly my immediate family. I therefore wish to, at this juncture, also dedicate it to my siblings: Ana (RIP), Blandina, Eleanor, Rusi (RIP), Eriya (RIP), Lydia, and Nathan, who individually and / or collectively profoundly contributed to making me what I am today. To you, ‘bana ba mama’, I say: We had the best parents, we had the best moulding and upbringing
9 as children, and we are the best! And more importantly, thank you for always being ‘your brother’s keeper’ and keep it up! I will do likewise. Last, but most certainly not least, this Lecture is lovingly and emotionally dedicated to my children: Olivia, Walter, Fiona, Timothy, and Clara –for I live only for you guys, and as intimated already, I have FAITH in you carrying that ‘Nshakira torch of Faith’. I also must mention here Ruth and Stella, the mothers my children for the vacuums you individually filled in the respective phases of my life; and for lovingly being part of the propagation of our genes; and Maggie, my source of love, companionship, solace, and all, for the past 5 years.
BACKGROUND TO MEDICAL TRAINING IN SOUTH AFRICA Prior to the establishment of the Faculty of Medicine and Health Sciences at the then University of Transkei (UNITRA) in 1985, there were seven medical schools in South Africa, five (or 71%) of which catered for the Whites who constituted less than 15% of the country’s population34.
70
60 50 40 First year 30 Final year 20 10 0 Black Coloured Indian White
South African first and final year medical students by race (1994) (de Vries and Reid, 2003)
Indeed, nearly 10 years later in 1994, whites accounted for nearly 50% of first year and more than 60% of final year medical students in the country The said five medical schools were at: University of Cape Town (est. 1900), University of the Witwatersrand (1921), University of Pretoria (1943), Stellenbosch University (1956), and the University of the Free State (1969). University of Natal (1951) catered for Indians, Africans, and a sprinkling of Whites, while the Medical University of Southern Africa (MEDUNSA) (1978) trained mainly Africans and Indians, and had the largest undergraduate enrolment of any medical school in the country. In a summary of the Council Guidelines for the Medical School at UNITRA, Kriel and Coles35 noted: “It is clear from international experience that medical schools in developed countries do not produce doctors who are equipped with the relevant skills, knowledge and attitudes to deal with the health care problems of …. communities in ….. developing countries. ….. The reasons for this phenomenon have been elucidated by curriculum research which has shown that the curricular process has a very fundamental impact on the manner in which students perceive their academic and professional tasks.
10 “It is therefore unreasonable to expect the Republic of Transkei to send its students to medical schools in the RSA to be trained as doctors, because they will either not return to practise in Transkei, or, if they do, they will not find (personal and) professional fulfilment in their work.
“For this reason, the medical school at UNITRA has been established in order to relate its medical education to the health care needs of the country. It is therefore clear that this medical school should not follow the traditional medical education patterns of the RSA or western countries, but should study relevant models elsewhere in the world that have sought to address a similar situation to that pertaining in Transkei.”
The Guidelines authors35 were also quick to clarify upfront: “This does not mean a difference in the standard of education and training, but a difference in orientation. The challenge is to present the same basic science and clinical knowledge in such a manner that the graduate will be both motivated and able to work in urban and rural communities in Transkei.”
As I and my colleagues30 recalled in an article published 5 years ago, the establishment of this Faculty had its vehement opponents, like Saunders36 with his (infamous) question: “where will the staff of sufficient academic standing be found?”, his prophecy of doom: “there is a danger of their obtaining fifth rate, First-World medical education”, and his unsolicited suggestion: “surely a school of public health to educate professionals to work in rural areas constitutes a greater need”. In spite of these, and the memorable but highly educative teething pains we experienced at the end of 1989, this faculty has now been in existence for a quarter of a century, has a multinational, highly qualified, efficient and effective academic staff, and with 925 doctors (and still counting) has probably produced more African doctors per year of existence than any other South African medical school, with the obvious exception of MEDUNSA and probably Natal.
So, how have we made it? More importantly, how have we responded to the UNITRA Council Guidelines over the past quarter Century, and how have our responses contributed to our successes (or in rare instances, to our shortcomings)? First though, a look at those eight Guidelines:
11 UNITRA COUNCIL GUIDELINES “The goals of medical education at UNITRA (is / should be) to produce doctors and other health personnel who: a) are equipped with the necessary scientific and professional knowledge, skills and attitudes to deal with the health care problems of urban and rural communities, families and individuals in Transkei; b) are motivated to work in both urban and rural primary health care settings in Transkei, and who can find professional and personal satisfaction in such work; c) are able and motivated to work in health care teams to the benefit of the people of the country; d) are able to educate and motivate communities, families and individuals to take personal responsibility for their health and their own health care; e) can think critically and creatively to deal with the health care problems of communities, families and individuals and have the necessary knowledge and skills to do research appropriate to the needs of Transkei within the various health care settings un the country; f) are equally committed to the prevention as to the management of illness and are capable of understanding health care problems in their biological, psychological and socio-economic context; g) are self-directed and life-long learners who will be able to adapt to changing circumstances in Transkei, keep up with developments in their professions and have the necessary motivation and background to acquire relevant specialised qualifications to fulfil the needs of the country and to advance their own careers; h) exhibit high levels of ethical and administrative insight, skills and integrity.”
In the first instance, it was clear from the outset (and indeed, from the Council Guidelines) that new this medical school would, unlike the majority of the then existing medical schools, not go into the business of training doctors for export to the US or to the UK and the old Commonwealth (of Australia, Canada, and New Zealand).
4000 3500 3000 2500 2000 1500 1000 500 0 australia Canada new UK USa Zealand
South African-born practitioners in OECD countries (2001) (Breier and Wildschut, 2006)
Nor were we, indeed, even going to train doctors for export from the Transkei to Cape Town, Johannesburg or similar. The prevailing political, market, labour, and other forces at the time were already taking good care of that aspect of the South African labour export market. So, Mr Vice-Chancellor, Sir, allow me now to make a ‘blow by blow’ report back as to whether and how we, as the WSU the Faculty of Health Sciences, have, over the years, responded to each of the above Guidelines, and the impact of those responses to our successes. This being a sort of introspective exercise, however, I will also mention areas where we perhaps have
12 fallen short of those Guidelines / expectations; and propose strategies for remediation and / or improvement. a). Equipped with the necessary scientific and professional knowledge, skills and attitudes to deal with the health care problems of urban and rural communities, families and individuals in Transkei
Let me begin by observing that this was a ‘double-barrelled’ Guideline (as were most of the others). Council expected us not only to impart the requisite tools (knowledge, skills, and attitudes) to the nascent doctors under our care, but to also ensure that they would use these said tools “to deal with the health care problems of urban and rural communities, families and individuals in Transkei”
The Eastern Cape Province (ECP) is basically a rural, and with an urban : rural population distribution of 35 : 65%, it is the third most rural province in the country after Limpopo (11 : 89) and KZN (39 : 61)37;
100 90 80 70 60 50 Urban 40 Rural 30 20 10 0 GP FS NC EC LP
Urban-rural ratios in South African Provinces (de Vries and Reid, 2003)
with relatively poor (even by South African standards) healthcare services, particularly the doctor population ratios. For example, of the 9 Provinces, the ECP has the third lowest number of doctors per 100 000 population (27) after Limpopo (18) and North West (23)38, 39. And if that is the case today, one can confidently say that the ratio was eve lower in the Transkei of 25 years ago under apartheid and homeland rule.
13 16 14 12 10 8 6 4 2 0 WC GP FS KZn nC MP EC nW LP
Number of medical practitioners per 10 000 population by region (2004) (Breier and Wildschut, 2006)
Our first strategy to address the need for serving rural communities was to deliberately select majority of our medical students from rural areas, mainly from the Transkei, but also from ‘Border’ and KZN.
WSU medical graduate demographics (Kwizera and Iputo, 2010)
% at W SU % 2001 census Black 71.67 79.00 Asian 26.06 2.50 Coloured 1.48 8.90 W hite 0.81 9.60 Female 51.14 52.18 Male 48.86 47.82
This policy was based on the belief and expectation that medical students with rural origin were more likely to serve rural communities after qualification40-42. International studies have since demonstrated strong rural origin-rural practice correlation43-46, and a similar trend was reported from South Africa a few years ago by de Vries and Reid47. At WSU, we are still analysing the relevant graduate data, but preliminary findings indicate that our strategy of rural recruitment has worked very well. For example, out of the 571 WSU-trained doctors
14 who, as of 2009 were in independent practice (i.e. were neither in Community Service nor in Internship) 242 (42.38%) were practicing in the Eastern Cape. At least a third of these were in rural areas and the majority of those in or near large urban areas had their practices in the townships48. This preliminary finding not only shows that we are meeting a cardinal UNITRA Council Guideline, but it also vindicates us on our policy of deliberate rural recruitment. More excitingly, I am almost certain that once the data has been fully analysed, we are going to report one the highest provincial and national graduate retention rates by medical schools in this country.
Another curriculum factor that has been propounded as promoting medical graduates’ choice of rural careers is their rural exposure during undergraduate training49-53. In our settings, we are a rural institution, and our training is therefore, intrinsically a continuous rural exposure28. We however, did not want to complacently make this assumption, and we deliberately incorporated a significant (rural) community-based component into our undergraduate curriculum; which has been amply described in various publications from this institution54-58. Unlike the strong correlation between rural origin-rural career choices, however, the impact of rural placement or exposure per se is less prominent and more variable, partly because the practice is relatively recent and there is no standardised implementation among different institutions59, and partly due to the presence many confounding variables, some of which can not be easily controlled for53, 59. Nonetheless our experience from Exit Surveys of final year students in 2001, 2002 and in 2005, 2006 (6 and 5 year programmes, respectively), is that 37.7% reported that community- based clinical training was better than in other settings (e.g. tertiary teaching hospitals), 18.4% thought it was somewhat better, 30.6% felt it was about the same as other settings, and 4.1% and 2.0% said it was somewhat worse, and worse, respectively24.
Regarding the equipping our medical undergraduates with “the necessary scientific and professional knowledge, skills and attitudes”, we were the first medical school in sub-Saharan Africa to implement an innovative curriculum based on the ‘SPICES’ model60 –i.e. Student-centred, using Problem- based learning (PBL), Integrated, Community-based, with provision for Electives and planned so as to be Systematic. When developing this curriculum, we drew different aspects from different medical schools in Australia, Middle East, Europe, and North America which were already practitioners of innovative curricula, and we adapted these aspects to suit and serve our settings and needs, respectively. In the process, we also forged useful and lasting partnerships with some of these institutions, e.g. the University of Newcastle in Australia and Bowman Grey University in USA.
Our PBL curriculum has been extensively described4, 7, 61-64, monitored8, 10-12, 65, reviewed66 and evaluated9, 11, 24, 29, 65, 67-71; the latter including rigorous accreditation visits by the Health Professions Council of South Africa (HPCSA)71, 72. In addition, we have followed-up all our graduates meticulously9, 48, and the clear picture that has emerged from these processes is that, notwithstanding our considerable constraints, we have produced, and we are producing well-trained, holistic, competent, and confident doctors, who have made a big contribution to healthcare in this region, province, and country at large.
15 6
5
4
3
2
1 confidence collaboration management p < 0.05
UNITRA cf Other SA doctors (1998) (Rolfe et al 2000)
More importantly, our graduates are comparable to graduates from any other medical school locally and internationally, as attested, at least in part, by the fact that as of 2009, 5% (n = 28) of our 1990-2005 graduates were practising overseas in North America, Europe, Australia and New Zealand. It is also heartening to note that whereas for 15 years we were the lone travellers on the PBL road in this country, we have since been joined by at least three other medical schools38, 73 which are older and more well-established, but which have directly or indirectly benefited from our experience as PBL pioneers in the country.
Besides successful accreditation visits by the HPCSA71, 72, one exciting finding from programme evaluation of our PBL curriculum was that it improved student performance and throughput rates48. For example, comparing our ‘traditional’ and our PBL curricula, the latter significantly brought down the attrition rate from 23% to 10.3%, while the mean throughput rate fell from 6.7 years to 6.4 years48. On the other hand, exit surveys of final year students24 and some External Evaluator reports69 have helped us to identify and attend to areas of the curriculum where students needed further exposure (e.g. family dynamics, family violence, medicine and the law, and practice management). b). Motivated to work in both urban and rural primary health care settings in Transkei, and who can find professional and personal satisfaction in such work
We have compiled a complete Alumni Database, and among the entries are particulars of where each graduate attended High School and where they are practising currently. As noted earlier, 242 (42.4%) of the 571 WSU medical graduates over the 1990-2005 period were, in 2009, practising in the Eastern Cape, which is largely rural. Another 24.5% (n = 140) were in Kwa Zulu-Natal, and this figure tallies with the percentage of our graduates that are Indian (26%) and who are recruited mainly from KZN. Gauteng had 11.7%, and the Western Cape
16 had 5.8% of our graduates, while Free State had 2.4%. These three provinces are, in that order, the most highly urbanised in the country (with urban : rural ratios of 95:5%, 87:13%, and 71:29%, respectively), and the numbers of our graduates practising in these provinces are disproportionate to the very few students we recruit from there. It can therefore be concluded that as per above Council Guideline b), our programme is also producing doctors who are attracted to work in urban settings! What is more gratifying, however, is the apparent absence of an exodus of our graduates of rural origin to the cities, with all their bright lights and other tempting attractions.
Three years ago, I was privileged to host and co-supervise a medical student from the UK who had taken a gap year to study for an intercalated degree in International Health. He interviewed our medical graduates about their motivation for, and experience of studying medicine, their reasons for practising in the Eastern Cape, and their views on doctor migration74. Our graduates had been equally motivated to study medicine by role models (38.5%), and by guaranteed job security (38.5%), but mainly by altruistic values (to help people) (84.6%). Although monetary gains were admittedly considered to be important, they were not high on the list of the graduates’ motivating factors (30.8%). Most graduates (61.5%) had chosen the then UNITRA mainly for its comparatively lower, and more affordable training costs, and partly because of the PBL curriculum (38.5%) and “good preparation for practice” (30.8%). A few (7.7%) came to UNITRA because other medical schools had either kept them waiting too long for a response, or had turned down their application; while some graduates’ choice was also because they “would be working with and around people of my own culture and language”, a statement that says a lot. As to the quality of their medical schooling, the report’s author says, and I quote: “ ….. all … were unequivocal in stating that they had received equal, if not better training than their counterparts”74. The main reasons for working in the Eastern Cape were: because it was home (100%); to help fulfil the community’s health needs (61.5%); or the moral obligation to plough back into the province that had financed their education and training (46.1%); while just under a quarter (23.1%) had been lured by the ‘Rural Allowance’ (which surely is one of the worthier legacies of the late Dr Manto Tshabalala-Msimang (RIP). Even those in private practice emphasized they were not in it primarily for financial gain, but rather to provide better services than what obtained in the shortages-riddled public sector, and to find job satisfaction instead of frustration arising from the aforementioned shortages. The majority (61.5%) were working in the public sector, 30.8% were in the private sector, and 7.7% provided services in both sectors74. Interestingly (and thankfully) only 23.1% of the UNITRA/WSU graduates interviewed had considered temporary or permanent emigration from South Africa, although they were unanimous in observing that emigration was a right to which doctors, like any other professionals, were individually entitled.
Mr Vice-Chancellor, Sir, from the above Student Project research findings, and from the data generated from analysing our Alumni Database, it is abundantly clear that we have successfully fulfilled the requirements of UNITRA Council Guideline number two.
17 c). Able and motivated to work in health care teams to the benefit of the people of the country
The inculcation of teamwork into our graduates starts right early in their undergraduate training where the primary setting for learning is in small group PBL tutorials62, and where students are also required to undertake group work on community-based health research projects58. Thus, our students are imbued with a cooperative rather than a competitive spirit very early in their training, and this is expected to endure. During their early and subsequent clinical exposure, students experience team work, vicariously initially, but directly subsequently64; and they, in particular learn from their experience in clinics and district hospitals that this teamwork is more symbiotic than hierarchical. Thus, by the time they graduate, our students are capable of being effective and efficient members of healthcare teams. Ability to work in teams is, however not a characteristic unique to our graduates, but one that is expected of, and is actually acquired by all medical undergraduates. Unless one is practising traditional medicine deep in some rural village, healthcare is, by its very nature, a teamwork effort, irrespective of whether it is in the public or in the private sector. Thus, this was probably the least demanding of the UNITRA Council Guidelines, and yes, we have fulfilled it too.
d). Able to educate and motivate communities, families and individuals to take personal responsibility for their health and their own health care
Nearly 20 years ago, the UNITRA Faculty of Medicine and Health Sciences pioneered community engagement and empowerment as an arm of health professions education by the formation of the UNITRA Community Health Partnership Project (UHCPP) with the Department of Health, and with the Communities of: Ngangelizwe, Baziya, Mbekweni, and Mhlakulo54. One immediate offshoot of this project was the building of four Health Centres for the partnering communities, which also became the epicentres of education (for both students and communities) and community empowerment, e.g. by establishment of demonstration vegetable gardens (Mbekweni) or as rallying points for a self-help water supply project (Baziya).
Students also use these Health Centres for facilitation of their group community-based health research projects and for home as well as school visits, all of which activities involve ingrained community health education55, 58. In addition to the foregoing specific instances, this Council Guideline is fulfilled on a daily basis, irrespective of the student’s level of study, ortheir study settings. In the PBL tutorials, students are required to identify and discuss non-medicinal management of patient problems including education and counselling61, 62, while in the clinical setting they get to learn that a consultation is incomplete if patient education and provision of information are omitted64.
We have plans, now in advanced stages, to implement multi-professional learning in the Faculty66, and it is envisaged that the presence of the School of Allied Health Professions in our midst, incorporating, inter alia, the Departments of Health Promotion, and of Social Work, will not only boost this approach to our education programmes but that it will also help 18 us refine our fulfilment of the above Council Guideline. Two other developments expected to be even bigger boosters for the community health outcome-based fulfilment of this Guideline are the recent introduction the Master of Public Health programme, and more significantly the “Adopt a Community” project by the Department of Community Medicine75. e). Can think critically and creatively to deal with the health care problems of communities, families and individuals and have the necessary knowledge and skills to do research appropriate to the needs of Transkei within the various health care settings in the country
Mr VC Sir, we introduced our first and ill-fated version of PBL in 198930, ill-fated because for various reasons which I won’t go into here, the students toyi-toyed against it at the end of that year and we had to re-design the version that was subsequently implemented successfully in 1992. In one of the weekly Tutors meetings76 we held early in 1989, I remember a colleague (who will be familiar with those colleagues involved at the time, but who this afternoon will remain anonymous) asking: “How can I tell if a student is thinking critically in a tutorial, when I cannot read his or her thoughts?” This particular colleague was not terribly fond of the innovative PBL curriculum, and he never concealed his very conservative ideas about this, nor did he conceal his determination to make the innovation fail –reportedly going to the extent of advising some students to spearhead the rebellion, with promises of helping them get admitted to other South African Medical Schools! By asking the above rhetorical question, our dissenting colleague was perhaps using it to highlight what he considered to be unclear or unrealistic items on the checklist we were using for continuous student assessment, and he remained unimpressed when someone gave him the dictionary meaning of ‘critical thinking’ in our context, viz. “containing careful or analytical evaluations”77.
Mr VC, Sir, given the above dictionary definition, allow me to submit that clearly, anybody whose work includes making decisions -and that is perhaps everybody- has got to be a critical thinker. I thus consider critical thinking to be a generic skill, and not one that is confined to doctors or to WSU medical graduates for that matter. However, this skill has to be learned, and as with all skills, the best way to learn it is through repeated practice78.
In the training of our undergraduates, students acquire critical thinking skills in nearly all their learning settings. In the small group PBL tutorial62-64, a real world, real life problem is presented to the students by sequential revelation of information, in a bid to trigger learning by helping them identify what they do not know, and therefore need to learn; before they can understand the problem, let alone attempt to solve it. They formulate hypotheses, and suggest ways to test them. Then, as they are given further information, they continually revise and and/or re- rank their hypotheses until they come to a likely diagnosis, suggest management strategies, and reach closure. In other words, they learn and constantly practise: analysing components and relationships in a system; comparing and contrasting options; making inferences and interpretations from data; and evaluating the relative worth of options79. Thus, in our context, PBL not only enables students to formatively acquire critical reasoning skills, but they also
19 use PBL to learn how to make evidence-based diagnostic and / or therapeutic decisions80. That our students are, as early as their second or third year of study, able to critically analyse a patient problem scenario to the extent of suggesting diagnoses and management strategies is one aspect of our curriculum that never ceases to impress External Examiners from sister institutions in South Africa, and from as far north as Uganda4, 81. Typical comments by the External Examiners have been: “My 3rd year students would not be able to tackle the patient problem the way yours do”; or “If your pre-clinical students and my pre-clinical students were to encounter this scenario in real life, your students would be able to do something about it whereas my students probably wouldn’t”81
Mr VC, Sir, the second requirement of Council Guideline e) was for us to train graduates with skills and knowledge to conduct health research relevant to local community needs. We have fulfilled this Guideline by introducing our students to basic health research methodology as early as year 1 when they learn statistics and statistical methods. In year 2, when they go for a month-long Community-based Experience and Service (COBES) exposure at selected District Hospitals in the Eastern Cape, they learn and practice such skills as gathering and recording of vital statistics (birth rates, neonatal mortality rates, maternal mortality rates, infant mortality rates, child mortality rates, morbidity and mortality rates, disease burden, crude death rates, cause-specific death rates, etc.), as well as taking anthropometric measurements in school children55. More focused community-based research training and practice takes place in year 3, wherein students spend each term time Wednesday in communities where they learn clinical skills in the mornings and research methodology in the afternoons. The latter, which involves early ‘know your clinic’ and ‘know your community’ themes, culminates in student group community-based health research projects, the results of which are presented by the students, on a dedicated day, to (besides their year 3 peers) a diverse audience that includes: University Management, Health Sciences Faculty; fellow WSU students, staff from the Health Centres, representatives from all the involved communities, and from local and provincial service providers58. The lasting impact of this exercise has been not only the acquisition of research competences by our students82, but also the use by the communities of the data generated from these researches to convince government and local municipalities to deliver services identified as critically lacking by the student-conducted research 69. I thus wish to observe at this juncture that by training in the communities, our programme and our students have, through relevant community-based research, had a positive impact on the health of these communities. We, however, still need to rationally and scientifically evaluate this impact, in view of some obvious and some not so obvious confounders. Having thus said, though, Mr VC, I wish to observe that we have pretty well fulfilled this Council Guideline, and that we are on our way to doing so even better, as I will illustrate shortly.
f). Equally committed to the prevention as to the management of illness and are capable of understanding health care problems in their biological, psychological and socio- economic context
Allow me to observe, Mr VC, Sir, that fulfilment of this Guideline is again inherent in any medical undergraduate curriculum anywhere in the world, and that differences (if any) are in
20 how this is done. I am sure that every Health Professions practitioner (and hopefully, every Health Professions student) will by now be aware that in 1978, an International Conference on Primary Health Care was held under the auspices of the World Health Organization (WHO) in Alma-Ata in the then USSR; and that this Conference adopted the 10-point Declaration of Alma-Ata83. This Declaration was, for the next 22 years known by the slogan ‘Health for all by the year 2000’, although the careful wording of the Declaration in this regard was simply that: “A main social target of governments, international organisations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”. Incidentally, the WHO definition of health84 was (and is): “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity”; a definition that has not only attracted interesting debate85, 86, but also one which perhaps was not in the minds of those (me included) who were, over those 22 years, bombarded with the “Health for all by the year 2000” slogan, and who instinctively thought of health simply as the absence of disease and/or infirmity! Additionally, I daresay that the architects of the Alma-Ata Declaration must have been a bunch of optimists who not only thought that 22 years was a long time, but who also implicitly expected ‘plain sailing’ over the said period of time. In the words of a Dean of a medical school in a Central African country, which he uttered, rather cynically (I must add) in 1995 at an All Africa Conference on Medical Education in Cape Town: “….. they might as well have declared: ‘AIDS for all by the year 2000!’ ”.
Mr VC, I am perhaps now digressing a bit, and to come back to how we have responded to Council Guideline e), let me put it in a nutshell and say that it is all in our Faculty Prospectus87. More specifically, our PBL curriculum is integrated both horizontally and vertically, to ensure that nothing is learned by our students in isolation, or in a vacuum; and to make sure that their learning and assessment takes place in a real life, rather than a theoretical context. And when it comes to diseases, the training for fighting which is one of our main core businesses, we emphasize not only cure, prolongation of life, or palliation, but also primary and secondary prevention. One way of ensuring the latter two, has been the deliberate inclusion of Population Medicine in all the three phases of our curriculum (viz. Phase 1: Normal Structure and Function, Phase 2: Abnormal Structure and Function, and Phase 3: Clinical Practice), wherein, as COBES and / or as Community-based Clinical Clerkships (COMCC), this vital theme (together with Clinical Skills training) provides the ‘golden threads’ that link the different phases of our curriculum. We also emphasize holistic care in the training of our undergraduates, by priming them to address the wellness of the patients’ body, mind and spirit –or the physical, emotional and spiritual aspects of an individual. And by ‘spiritual’ I do not mean any religious aspects of a doctor-patient interaction, but rather the ‘essence of who one is’, or the ‘core of self’. To address the latter, we have, over the years, sought support from the UNITRA/WSU departments of Anthropology, Psychology, and Sociology in the module of ‘Human Behavioural Sciences’; but we believe we could be of better service to our students if we had our own department of Human Behavioural Sciences (may be under the watchful eye of the Department of Psychiatry). This department would also provide a more efficient and effective service to our sister (no pun intended) Schools of Nursing Sciences, and of Allied Health Professions. Mr VC Sir, I am thus calling for the incorporation of the other Human Behavioural Sciences (i.e. Anthropology, Sociology & Population Studies, Psychology) into the WSU Faculty of Health Sciences, so 21 that we can exploit the resources available therein for the common good of our students, our academic staff, and (most obviously) our communities.
Mr VC, Sir, before I digress even further, let me reassure you that we are fulfilling this Council Guideline, although there is still room for improvement.
g). Self-directed and life-long learners who will be able to adapt to changing circumstances in Transkei, keep up with developments in their professions and have the necessary motivation and background to acquire relevant specialised qualifications to fulfil the needs of the country and to advance their own careers
Mr VC, Sir, I am sure you will agree that of all the UNITRA Council Guidelines that I have referred to thus far, this is probably the most ‘loaded’, in that it is a composite of at least 5 ‘sub-guidelines’: self-directed learning, life-long learning, adaptation to local changing circumstances (no specifics), keeping up with developments in the profession, and specializing to fulfil national needs and to advance own careers. At the same time, however, I believe that this is one UNITRA Council Guideline where we have excelled, thanks to our innovative PBL and CBE SPICES-model curriculum11, 29, 65, 88.
The PBL aspect of our curriculum implies that our students’ learning is not only self-directed89, 90, 91 but that it is also stimulated by their encounter with real life problems. Because their future professional life is expected to be full of patient problems, we want to believe that the curriculum turns them into life-long learners. It may be argued that every individual is a life-long learner in one way or another, and I have no problem with this sentiment. I however wish to submit that the life-long learning which we believe PBL promotes is purposive and that the life-long learning which every individual goes through is by default or accidental. In this regard, it is interesting to note a close relationship between our PBL curriculum and the features of life- long learners, viz. they plan their own learning; they assess their own learning; they learn in informal settings; the learning is active; there is peer learning; they integrate knowledge from different disciplines; and different learning strategies are used in different situstions92. There are compelling reasons for imparting life-long leaning skills to our graduates, and examples are: explosion of knowledge and of technology; economic restructuring, organisational reform, and changes in the workplace and career patterns; need to find more cost-effective ways of teaching and learning within constrained resources; shift to an information society; emergence of new occupations and careers, and rapid transformation of others; and the need to meet expanding educational needs and expectations of larger numbers of students from increasingly diverse backgrounds92.
Our students’ career intentions have been researched93 and preliminary findings suggest that these are matched by the actual career paths followed by the graduates94, 95. More excitingly, although medical postgraduate training in South Africa is, like many other prominent professional and/or managerial positions, still dominated by white males96, we at WSU have not done badly motivating our students to specialise as per the above Council Guideline; and
22 in this regard the two gender groups appear to be fairly equally represented.
80 70 60 50 B 40 C I 30 W 20 10 0 1999 2000 2001 2002 2003 2004 2005
Male M Med enrolment by race at UCT (1999-2005) (Breier and Wildschut, 2006)
70 60 50
40 M 30 F 20 10 0 1997 1998 1999 2000 2001 2002 2003 2004
UNITRA PBL PGs: Gender (Kwizera, 2009)
As of 2009, there were just over 570 WSU medical graduates that were post-Community Service, and of these, 43.5% had either obtained a postgraduate qualification or they were undergoing postgraduate training for one48. The clinical disciplines preferred by our graduates for specialisation are: Paediatrics (14.1% of the 43.5%), Obstetrics & Gynaecology (11.7%), Anaesthesiology (7.3%), Internal Medicine (5.7%), General Surgery (5.2%), Family Medicine (4.4%), Psychiatry (4.0%), Ophthalmology (3.6%) and Orthopaedics (3.6%). Interestingly in exit surveys31, final year students consistently identified Obstetrics & Gynaecology and Paediatrics clinical clerkships as the top two with which they were most satisfied, a perception
23 that is also reflected in their postgraduate training preferences. Gender preferences for the different specialities are similar to what one sees elsewhere, both nationally and abroad, with females going for Paediatrics and Family Medicine, and males dominating General Surgery as well as the surgical sub-specialties of Ophthalmology and Orthopaedics. The two genders are equally represented in Obstetrics & Gynaecology and in Internal Medicine95.
There are, however, two aspects of postgraduate training by our students which give rise to major cause for concern. The first is that, whereas we are retaining in rural Eastern Cape those of our graduates who are generalists, the same is not the case with those who have specialised. Either they stay in the big Metropolises where they specialised (Durban, Cape Town, Pretoria, Johannesburg), or if they return to the Eastern Cape at all, then they prefer the bigger cities of Port Elizabeth and East London. While it is true that hospitals in these two cities are part of our teaching platform, the bulk of clinical teaching still takes place in the Mthatha Hospital Complex, and we need to attract our graduates who have specialised to come back to Mthatha and play an active and much needed role in the medical education and training of their younger brothers and sisters. With the relatively recent introduction of Registrar training in the Mthatha Hospital Complex, we are, hopefully, going to use this opportunity to ‘grow our own timber’; although this is more of an intermediate-to-long term solution than an immediate one. The immediate solution is the return of our graduates who have specialised to their alma mater. If one looks at other medical schools in South Africa and elsewhere, or indeed at other Faculties in WSU, it becomes abundantly clear that Universities and their Faculties are built and sustained by their own graduates; and there is a limit as to how much or how long the WSU School of Medicine can rely on an expatriate academic staff component of more than 95%. And these are not words of a turkey voting for Christmas (or Thanksgiving). I, God willing, will reach retirement age 5 years from now, and the outlook for succession in my department remains dim. I am sure the same could be said of many other departments in the School of Medicine, and we need to urgently find ways of attracting some of our soon to be 1000+ medical graduates to return to us.
The second area of major concern is that hardly any of our graduates have, or are specialising in the basic biomedical sciences. We have recently tried to address this by introducing a Bachelor of Medical Sciences degree in a bid to, again, ‘grow our own timber’ but we have to be very careful to ensure that majority of the graduates from this programme do not end up studying medicine (which seems to be the strategy of most), because then we will simply be ‘scoring own goals’ More importantly, there is need for reflection and introspection on our part in a bid to answer some important questions: Why are WSU medical graduates not pursuing careers in the basic biomedical sciences? Is it lack of mentoring and / or motivation? Have basic medical sciences been misrepresented in our curriculum so they have become unattractive to our graduates as careers? Or do they (probably rightly so) equate being a medical graduate with clinical practice, and not teaching and researching basic biomedical sciences in a laboratory? As the FASEB Journal Editor wrote recently, may be it is time for another Flexner Report “and the return of medical education to the basic biomedical sciences”97.
24 My grumbling aside, Mr VC Sir, I think we have executed this Council Guideline superbly, and since the ‘Transkei’ referred to in the UNITRA Council Guidelines has since again become part of the Republic of South Africa, then we derive satisfaction in knowing that our medical graduates who have specialised are providing sterling service to their country, even if they are not in rural Eastern Cape, and / or even if they have not specialised in the basic medical sciences. In addition, we have a Radiologist in Australia, a Psychiatrist in New Zealand, a Gastroenterologist in Canada, a Paediatrician in New Zealand, a Surgeon in the UK, to cite but a few of our ‘ambassadors’ abroad, of whom we can be truly proud! h). Exhibit high levels of ethical and administrative insight, skills and integrity
On perusal of the 157-page WSU Faculty of Health Sciences Prospectus 201087, the discerning reader will notice that it begins on page 2 with a ‘Student Declaration’ which is ‘sworn’ by new students at the start of their training in our Faculty. Then, towards its end on page 155, there is an adaptation of the Hippocratic Oath which is ‘sworn’ by successful final year medical students in December, before they commence Internship in January, pending their graduation in May. Both these documents emphasize ethical behaviour of our students and graduates, respectively. However, we have not stopped at ‘declarations’ and ‘oaths’, but have deliberately taught our students Ethics and Professionalism from year one, and by means of different approaches including lectures98, as well as hands on training in research ethics58, 99. One could also submit, anecdotally, that the requirements of this Guideline have been fulfilled through mentoring and role modelling. In my 21 years at UNITRA/WSU, I have not come across or heard of a single instance where any one of us was found guilty of unethical behaviour, negligence or misconduct by their employers, the HPCSA, or any Court of Law. By the same token, I am not aware of any of our more than 925 (and still counting) medical graduates who has fallen foul of the law, or the HPCSA, as a result of unethical or criminal behaviour. In addition, though again I say this anecdotally, some of our graduates currently occupy positions of responsibility and high accountability as Medical Superintendents in various government hospitals, and in government Departments of Health (both provincial and national) countrywide. Many are highly respected members of their communities wherein they are providing ‘generalist’ services, some have joined the country’s Defence Forces and are proudly wearing their uniforms both at home or in AU Peace-keeping Missions (e.g. in Darfur and the DRC); and others –albeit few, have joined us in Academia. The bottom line, Mr VC, is that we have, unequivocally, fulfilled this UNITRA Council Guideline to the core; and if anyone in this gathering has any information to the contrary, I am very keen to be brought in the know. And, in any event, if there have been any mishaps that I am not aware of, let us remember that our graduates are, like the rest of us, only human!
In summary, Mr Vice-Chancellor, Sir, I wish to submit that the Faculty of Health Sciences at WSU has, by and large, positively and successfully responded to the Council Guidelines outlined by the then UNITRA Council just before this Faculty was established 25 years ago; and that those positive and successful responses have borne results of which we as WSU can collectively be proud.
25 Concluding remarks and the road ahead Mr VC, Sir, as I near the end of my Inaugural Lecture, allow me to make the following observations, conclusions and recommendations: -the WSU Faculty of Health Sciences has really come a long way from 1985 and a total enrolment of 12 in the MB ChB programme, to today, 25 years on, when the enrolment is more than 600 (i.e. more than a 50-fold increase in 25 years). This has happened against all odds, and with appropriate support from the University, I hope it is not unreasonable –especially if our Faculty is considered to be the WSU Flagship- to expect at least a similar increase over the next 25 years. -we (again against all odds) pioneered medical PBL and CBME in the country, not unlike ‘Star Wars’: ‘Boldly going where no other South African medical school had gone before’; and not only did we survive the venture, but we also proved to the country and to the medical education community worldwide, that in so-doing, “Yes We Can!” Furthermore, changes in the Medical Education scene, and in government health policies in South Africa after 1994 have demonstrated that we were way ahead of our time, and that the antagonism we encountered at the beginning was perhaps another example of what is written in The Bible (King James Version), in Luke, 4:24: “ …..Verily I say unto you, No prophet is accepted in his own country”. And interestingly, none of the local sister institutions which have adapted a similar approach to the training of their medical undergraduates came to us directly for assistance, preferring instead to ‘import’ bigger chunks of curricula from Australia or The Netherlands, and behaving as if we were ‘invisible’. In the words of one Pathologist from one such medical school, “A myocardial infarction in Sydney is no different from a myocardial infarction in Johannesburg!” –another statement that says a lot. And although they give us anecdotal reports of how good our students / graduates are, they seem to consciously make it a point not to want to learn from our rich experience. Of course this might partly be due to important distinctions regarding our different historical perspectives, but I also see an effort on the part of these ‘Johnny come lately” medical education ‘innovators’ to hijack our pioneer legacy, and to claim their latter day clones as ‘the first in South Africa’ –or similar. We have to be vigilant and jealously protect our pioneer status as the medical education innovators in this country and on this sub-continent.
Mr VC Sir, I wish to further strongly suggest that our University’s response to this putative development, or rather to the potential (or may be real) threat to our legacy as pioneers of innovative medical education in this country should be your unequivocal support for our programmes, our plans and our strategies; so we can retain our vanguard position. I need not overemphasize this, and not simply because of the emerging ‘competition’ on an apparently still uneven playing field, but mainly for the sake of our heritage as pioneers in innovative medical education in this country.
Mr VC Sir, in the February 2010 Issue of Academic Medicine, the Editor, Steven L Kanter, writes a virtual ‘capsule’ message for the Journal’s readers in 2110. And he concludes his message thus: “And so, as you prepare to celebrate the 200th anniversary of the Flexner Report, I wish you a rational, ethical, and satisfying equipoise in dealing with the most important challenges of your time.” Mr VC Sir, without appearing to be plagiarising, allow me to borrow from Steven Kanter, Editor in Chief of Academic
26 Medicine, and say: “To those of you who will be celebrating the 50th Anniversary (Golden Jubilee) of the WSU Faculty of Health Sciences in 2035: I hope that you will add richly to this Inaugural Lecture or should I say ‘self report’, and that you will have found lasting solutions to the two problems bugging us now: specialising graduates who do not return, and the paucity of specialisation in the basic biomedical sciences among our graduates.”
And at this juncture, Mr VC, Sir, allow me to observe -and to express the hope- that I have delivered this Inaugural Professorial Lecture to your standards and expectations, that I have answered the questions I set for myself for this Lecture, and that, -God forbid-! I will not be required to sit for a Supplementary for the first time in my life.
27 ACKNOWLEDGEMENTS I wish to express my gratitude to WSU (and to UNITRA, before it) for providing me with uninterrupted employment for the past 23 years and for giving me the honour to serve as Associate Professor for the first 17 years and as Professor and HOD for the past 6years; and contribute to the training of the nearly 950 doctors produced by this institution thus far. I particularly wish to thank the Executive Management: Prof Balintulo for steering with a such a steady hand this, often times ‘tricky’, ship that is WSU; Prof Obi for his supportive, enthusiastic, and hands-on approach to academic and research affairs at this institution; Prof Buijs for uncompromisingly attending to institutional development and Quality Assurance; and Prof Tau-Mzamane for monitoring the institution’s pulse and other vital signs. Prof Ekosse has been highly supportive, not only in my preparation for this occasion, but also whenever I have approached the Research Development Directorate for sponsorship to national and international conferences; and for this and more, I am grateful to him and to all the staff in the Research Development Directorate.
I must make special mention of the Executive Dean, Faculty of Health Sciences, Prof Mfenyana –and with him all the past Deans in the Faculty: Prof. Xaba-Mokoena, Prof Ncayiyana, Prof Kakaza (RIP), and Prof Mazwai, together with the present and past Vice-Deans: Prof Sokhela, Prof Knight, Prof Nganwa-Bagumah, Prof Lategan, Prof Gibbs, Prof Mkhize, and Prof Surka- for their visionary leadership and their belief in innovation, which qualities have immensely contributed to the successes of this Faculty over the past 25 years. Thank you for all your foresight, and for telling us “Yes We Can” long before the advent of Barack Obama!
Without those who were or have been my formal and peer teachers over the past 53 years, I would not be standing here today. I therefore wish to acknowledge a few of my many teachers whose collective roles in my education and training made me who I am today. Among these are: Yudesi Ndanguza, Yonasani Rwakabingo, Frederick Mugenga, David Rwihandagaza, William Rukara, Paulo Komunda, Cosma Munyarugerero, and John Bitunguramye (different primary schools); William Chrichton, Maurice Reeve, Colin Gregory, Brian Remmer, Francis Kasiragi, Jeb Bangizi, and Ian Tilling (Ntare School); Sultan Karim, Willy Annokbongo, Ian McIntosh, Raphael Owor, John Luwuliza-Kirunda, James Rwanyarare, John Kakitaahi, John Ssali, and Sam Sebikari (Makerere University), David Leach, Roger Hicks, Peter Hulbert, Roger Ash, Robert Naylor, Brenda Costall, Ian Naylor, Diana Woods (University of Bradford); Jeff Bridges, Peter Bach, Martin Wilks, Patricia Ijomah and Neil Gregg (University of Surrey); and William Burdick, Page Morahan, John Norcini, James Hallock, Debby Desirens, Regina Petroni-Mennin, Stewart Mennin, Danette McKinley, Ray Wells, Ralf Rundgren Graves, and Frank Simon (FAIMER). I must also mention the FAIMER Fellows in my class of 2007, together with those from the 2006 and 2008 classes with whom we interacted in Philadelphia –and subsequently on Mentor-Learning (M-EL) webs.
I have also, over the past 20 years, learned a lot from my UNITRA/WSU colleagues and mentors, and I wish to mention but a few namely: Marina Xaba-Mokoena, Alex Nganwa-
28 Bagumah, Dan Ncayiyana, Khaya Mfenyana, Ortrun Meissner, HSS Kakaza (RIP) Jehu Iputo, Augustine Kafuko, James Byaruhanga, Dan Kayongo, Grace George, David Mugwanya (RIP), Dan Mkhize, John Byarugaba (RIP), Charles Kamanzi, Sylvia Kamanzi, Andrew Stepien, Lech Banach, Geoffrey Buga, Banwari Meel, Ernesto Blanco-Blanco, Mirta Garcia- Jardon, Orlando Alonso, Julio Aguirre-Hernandez, Foyaca Humberto Sibat, Myra Gari, Gisela Milanes, Amalio del Rio, Jose Martinez (RIP), and many, many more who I am unable to name here and now due to time constraints –but who, I am glad to note, I ‘know who they are’ to me.
Mr Vice-Chancellor, Sir, I must also make special mention of colleagues in my Department, the Faculty Office, the Directorate of the School of Medicine, and the FHS Undergraduate as well as the Postgraduate Training Units for their support in various circumstances relating to my work and research, and their dissemination locally and abroad.
Mr Steyn Swanpoel has always been there for me, not only for photographic services (e.g. relating to this occasion), but also by his preparation of excellent posters that I have, over the years, presented to conferences, not only as near as Mthatha and East London, but also as far as Canada, USA, Spain, Holland and Australia. Thank you, Steyn, keep up the good work, and may you prosper! My wishes for Steyn are extended to all other MultiMedia gurus involved in this presentation.
I contritely wish to thank Bishop Mzamane of the Diocese of Mthatha and based at the Cathedral of St John the Evangelist. As The Right Rev Mzamane might attest, I am not a regular at St John’s Cathedral; but I am sure he can also attest to my spirituality, and to our friendship. My Lord Bishop Mzamane, I thank you for gracing this occasion with your [presence and your blessings.
To the WSU Choir for all those sweet melodies, what can one say, except that may your voices become even sweeter, and may your music bring joy to the entire creation!
To all the guests from far and near, and to the entire congregation, thank you for sparing a bit of your precious time to honour this occasion, and to share my ‘big’ day!
Last but not least, to my good friend Rev Philemon Mathenjwa for his most able MC role, and to the Caterers for ‘what we are about to receive’ and for which I am sure we shall be truly grateful.
But before we are ‘truly grateful’, Mr Vice-Chancellor, Sir, please allow me to point out that I have, over the years, also had the opportunity and honour of meeting, learning from, and/or interacting with South African (-and not so South African) colleagues outside UNITRA / WSU who I wish to acknowledge here; and I they are many … but I can think of Dek Sommers (RIP) and CP Venter (RIP), Ben Potgieter, Bernhard Myer, Wimpie du Plooy, James Syce, Peter Folb, Gavin Steele, Pierre Mugabo, George Amabeoku, Athol Kent, Marietjie de Villiers, Roy
29 Henbest, Max Price, Vanessa Burch, Bongani Mayosi, Wendy McMillan, Francois Cilliers, Ben van Heerden, Juanita Bezuidenhout, Elizabeth Wasserman, Jacky van Wyk, Gboyega Ogunbanjo, John Tumbo, Dianne Manning, David Cameron, Christina Tan, and Marietjie van Rooyen; as well as all the SAFRI Fellows to-date. Other (international) medical education colleagues to whom I am fondly grateful include: Gwendie Camp, John Hamilton, Isobel Rolfe, Sally-Anne Pearson, Frances Kaye, Elizabeth Kachur, Deborah Murdoch-Eaton, Brian Jolly, Sue Whittle, Michelle McLean, David Cook (RIP), Janet Grant, Ahmed Fahal, Sir Ronald Harden, Ian Hart, Sam Leinsten, and James Ware.
It is when I get to think about my Clinical Pharmacology and Medical Education colleagues, both near and far, that I realise how much we value each other, and how much we mean to one another –and by extension, what we, as a network, are to those whom we train, be it in South Africa, USA, Australia, UK, Sudan, Malaysia, or the Middle East. At the end of the day, Mr Vice-Chancellor, Sir, whether we are Clinical Pharmacologists or Medical Educationalists, I guess the bottom line is, to borrow from the late Michael Jackson: “We are the World”!
Mr Vice-Chancellor, Sir, Ladies and Gentlemen; I thank you!
30 References 1. JAMES C. Unreliable Memoirs. London:Picador Books, 1980 2. Kwizera EN. The preparation of adult rat hepatocytes and the study of the metabolism of para-nitroanisole and para-nitrophenol in the system. MSc Dissertation, University of Bradford, UK, 1977. 3. Kwizera EN. Effects of hepatotoxic drugs on the glutathione content of isolated rat liver cells. PhD Thesis, University of Bradford, UK, 1980. 4. Kwizera EN, Potgieter B. A problem-based learning approach to medical studies. Journal of Modern Pharmacy 1994; 1(6)Suppl:S19. 5. Kwizera EN. Continuous student assessment in PBL tutorials. Faculty of Medicine Orientation Workshop for PBL Tutors. University of Transkei, Umtata, South Africa, March 1997. 6. Kwizera EN. Comparison of tutor and peer assessment in MB ChB III PBL tutorials. Faculty of Medicine Orientation Workshop for PBL Tutors. University of Transkei, Umtata, South Africa, March 1998. 7. Kwizera EN. An African model of problem-based learning (PBL) in Medical Education. The Internet and Telemedicine in African Health Care and Education. Durban, South Africa, 19-24 July 1999. 8. Kwizera EN, Dambisya YM, Aguirre JH. Tutors’ subject-matter expertise does not influence student achievement in problem-based learning. 9th International Ottawa Conference on Medical Education. Cape Town, South Africa, 1-3 March 2000. 9. Rolfe I, Pearson S, Ringland C, Mazwai EL, Kwizera EN, Mkosi BN. South Africa’s first medical graduates from an innovative problem-based curriculum: are they ready for practice? 9th International Ottawa Conference on Medical Education. Cape Town, South Africa, 1-3 March 2000. 10. Kwizera EN, Dambisya, Aguirre JH. Does the subject-matter expertise of tutors influence student achievement in pharmacology learned under an integrated problem-based curriculum? VII World Conference on Clinical Pharmacology and Therapeutics. Florence, Italy, 15-20 July 2000. 11. Kwizera EN, Iputo JE. The impact of the problem-based learning / community- based medical education curriculum on the cognitive functions of UNITRA medical students. 8th International Cochrane Colloquium. Cape Town, 25-29 October 2000. 12. Kwizera EN, Dambisya YM, Aguirre JH. Tutors’ subject-matter expertise does not influence student achievement in problem-based learning. South African Medical Journal, 2001; 33:514-516. 13. KWIZERA EN, Mazwai EL. The training of doctors at the University of Transkei: facts, figures, and relevance. 3rd Eastern Cape Health Research Conference. East London, South Africa, 16 –18 August 2001.
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37 38 CITATION Professor Enoch Nshakira Kwizera was born on 13 June 1950 in Bufumbira, South-Western Uganda. He was the fourth child and first son of Ernest and Edreada Nshakira, and he grew up in a happy family, with five sisters and two brothers.
Kwizera started formal schooling in 1957 at Seseme Primary School in Bufumbira, and he did his grade 3 at Kabindi Primary School, grades 4 and 5 at Nyaruhanga Primary School and grade 6 back at Seseme in 1962. His Junior Secondary School was also at Seseme, where he passed with flying colours, and qualified for a place, with a full scholarship, at Ntare School, Mbarara, Uganda. In 1966, the school headmaster decided to use the entire 1967 Senior 3 (Grade 11) class in an experiment dubbed ‘Acceleration’, where they would write the Cambridge School Certificate Ordinary Level Examinations (‘O-level’) at the end of Senior 3, instead of the usual end of Senior 4. When the results were released in January 1968, Kwizera was one of the 3 top achievers in the school, all from the ‘Acceleration’ class, and each with distinct aggregate in six subjects. In March 1968, he enrolled at Ntare School for ‘A-levels’ in Physics, Biology, and Chemistry; and passed these at the end of 1969 with excellent symbols.
Between January and June 1970, Kwizera served at a private Junior Secondary School where he taught every subject except History. In June 1970 he enrolled at Makerere University Medical School; and while there, he again excelled, scoring special merits (‘Credits’) in: Anatomy, Physiology, Pathology & Microbiology, Pharmacology, Preventive Medicine, Obstetrics & Gynaecology, and Paediatrics; and he was joint second best finalist in March 1975. It was also at Makerere that Kwizera met his Pharmacology mentors: Dr William W Anokbonggo, and Professor Sultan Karim (of the prostaglandins in obstetrics fame) in whose laboratories he was employed as a Student Research Assistant during holidays between 1971 and 1974. He was ‘Circulations Manager’ of the student-run Makerere Medical Journal in 1973/74.
Dr Kwizera’s professional working life started in April 1975, as an Intern in Mbale Hospital in Eastern Uganda, where his rotations were in Obstetrics & Gynaecology and in Internal Medicine. He was also Chairman and Spokesperson of the Mbale Hospital Interns’ Committee. On completion of Internship in May 1976, he was appointed Tutorial Fellow in the Department of Pharmacology & Therapeutics, Makerere University Medical School. Three months later, in September 1976, he commenced studies toward a Masters of Science in Experimental Pharmacology at the University of Bradford, West Yorkshire, UK. This was successfully completed in September 1977, and for his MSc research project, he pioneered the isolation and use of liver cells in experimental research at the University of Bradford.
In November 1977, he was awarded a scholarship by the World University Service (UK) to study towards a PhD degree in Pharmacology at the University of Bradford, which he went on to complete (research, write-up and all) in record time of just under 3 years. In December 1980 he returned to Uganda to take up a position of Lecturer in the Department of Pharmacology and Therapeutics at Makerere University. He was promoted to Senior Lecturer in 1983.
39 In 1985, Dr Kwizera was offered a Commonwealth Medical Fellowship in Clinical Pharmacology and Toxicology, at the Robbens Institute of Industrial and Environmental Health and Safety, at the University of Surrey in Guildford, UK. There, attached to the Nephrotoxicity Unit, he researched and published on drug and chemical-induced kidney damage. And while in Guildford, Dr Kwizera was appointed Associate Professor of Pharmacology at the then UNITRA, a position he took up in December 1988. After a frustratingly long moratorium on promotions at the institution, Professor Kwizera was promoted to Full Professor, effective January 2004. He has also been HOD, Pharmacology, since 2004.
At WSU, not only has Professor Kwizera taught, researched and published in Clinical Pharmacology, but he has also served on Eastern Cape Provincial Drug and Therapeutics Committee, as well as on the National Essential Drugs Committee. He has also put in Sessional clinical work at Mthatha General Hospital in Family Medicine (1989 – 2002) and in Forensic Medicine (2003 – to date), contributing to the clinical care of patients in these facilities.
Over the past 20 years, Professor Kwizera has developed deep interest in Health Professions Education which has become his second academic passion. In 1993, he was elected to the Council of the South African Association for Medical Education (SAAME) to represent UNITRA and the Border Region. SAAME has since morphed to SAAHE (South African Association for Health Professions Educationalists), and he represents the Eastern Cape on the SAAHE Council. More recently, Kwizera was, in 2007, awarded a Fellowship of the Foundation for the Advancement of International Medical Education and Research (FAIMER) based in Philadelphia, USA, which he completed with distinction in 2008. As an offshoot to his FAIMER Fellowship, he is currently on the Council and is Faculty at SAFRI (Southern African FAIMER Regional Institute) which aims at propagating FAIMER activities in sub- Saharan Africa.
Professor Kwizera has widely published locally and internationally on pharmacology, toxicology, and on health professions education; and he has attended and presented papers at numerous local and international conferences. The last two of the latter were in Malaga, Spain and Khartoum, Sudan in August and October 2009, respectively, and the next one is next month in Miami, USA, where he will make a presentation on a novel way of evaluating the learning of Pharmacology at WSU. He is Associate Editor of two international peer-reviewed online journals: BioMed Central Clinical Pharmacology, and BioMed Central Medical Education, and he is on the Editorial Board of the African Journal of Health Professions Education. He is also a reviewer for Medical Education, and for the European Journal of Radiography.
In his illustrious academic career as a Pharmacologist, Professor Kwizera has directly participated in the training of more than 2600 doctors (in both Uganda and South Africa) and more than 500 biomedical scientists in the UK. In addition, he has been involved in the external moderation and/or examination of a further 300 doctors and 150 pharmacists in Tanzania, as well as 200 Pharmacists and 300 dentists in South Africa.
40 In recognition of his past, present, and potential contribution to Pharmacology in this country, Professor Kwizera was, in 2009, invited to join the Colleges of Medicine of South Africa as an Associate of the College of Clinical Pharmacologists. This recognition has ramifications which go beyond his CV, in that there is now a real possibility for WSU to train Clinical Pharmacology Registrars within the Mthatha Hospital Complex.
Professor Kwizera is also a past First Vice President of Mthatha Lions Club, and he is a keen stamp collector, scrabble player, gardener, and amateur golfer. Kwizera is also an experimental braai master, and he hopes that when he retires, he will earn a living ‘braaing for profit’!
41 42 43 44 45 46 47 Design: Mthatha Health Resource Centre 48