The self-reported learning needs of primary care doctors in South Africa: a descriptive survey

Figures & data

Table 1: Future roles and competencies of primary care doctors

Role	Competencies
Competent clinician	The primary care doctor should be able to practise competently across the whole quadruple burden of disease They should have the clinical and procedural skills to fulfil this role in primary care.
	They should be a role model for holistic patient-centred care with the accompanying communication and counselling skills.
	They should be able to offer care to the more complicated patients that primary care nurses refer to them.
	They should support continuity of care, integration of care and a family-orientated approach.
	They should be able to offer or support appropriate health-promotion and disease-prevention activities in primary care.
Capability builder	The primary care doctor should be able to engage in learning conversations with other primary care providers to mentor them and build their capability.
	They should be able to offer or support continuing professional development activities.
	They should help to foster a culture of inter-professional learning in the workplace.
	As part of a culture of learning they should attend to their own learning and development.
Critical thinker	The primary care doctor is one of the most highly educated/trained members of the primary care team and as such should be able to offer a level of critical thinking to the team that also sees the bigger picture.
	They should be able to help the team analyse and interpret data or evidence that has been collected from the community, facility or derived from research projects.
	They should be able to help the team with rational planning and action.
	They should have IT and data management skills and the ability to make use of basic statistics.
Change agent	The primary care doctor should be a champion for improving quality of care and performance of the local health system in line with policy and guidelines.
	They should be a role model for change – people need to see change in action.
	They should know how to conduct a quality improvement cycle and partake in other clinical governance activities.
	They should provide vision, leadership, innovation and critical thinking.
	They may need to support some aspects of corporate governance.
	They may need to assist with clinically related administration, e.g. occupational health issues, medical record keeping, medico-legal forms.
Collaborator	The primary care doctor should champion collaborative practice and teamwork.
	They should use their credibility and authority to assist the team with solving problems across levels of care (referrals up and down) or within the community network of resources and organisations.
	They should help develop a network of stakeholders and resources within the community.
Community advocate	The primary care doctor should exhibit a community-orientated mind-set that supports the ward-based outreach teams, understands the community’s health needs and social determinants of health in the community and thinks about equity and the population at risk.
	They should be able to perform home visits in the community when necessary.

Table 2: Distribution of respondents between provinces

Province	Total (n = 170)	GPs (n = 90)	MOs (n = 80)
	n (%)	n (%)	n (%)
Gauteng	27 (15.9)	15 (16.7)	12 (15.0)
Western Cape	15 (8.8)	0 (0.0)	15 (18.8)
Northern Cape	12 (7.1)	12 (13.3)	0 (0.0)
KwaZulu-Natal	32 (18.8)	14 (15.6)	18 (22.5)
Free State	32 (18.8)	12 (13.3)	20 (25.0)
Limpopo	26 (15.3)	11 (12.2)	15 (18.8)
North West	14 (8.2)	14 (15.6)	0 (0.0)
Mpumalanga	12 (7.1)	12 (13.3)	0 (0.0)

Figure 1: Age distribution of primary care doctors

Figure 2: Distribution of medical officers (MOs) and general practitioners (GPs) by year of graduation

Table 3: Awareness of key primary care guidelines amongst primary care doctors

Guideline	All mean score (CI)	GP’s mean Sscore (CI)	MO’s mean score (CI)	p value
Standard Treatment Guidelines and Essential Medicine List for Primary Health Care in South Africa, 2012	2.67 (2.53–2.81)	2.44 (2.23–2.66)	2.92 (2.77–3.07)	<0.001
PC 101 (Primary Care Symptom Based Integrated Approach to the Adult in Primary Care) 2013/2014	1.72 (1.57–1.86)	1.76 (1.55–1.96)	1.67 (1.47–1.88)	0.66
South African COPD treatment guidelines 2011	1.82 (1.68–1.96)	1.77 (1.58–1.96)	1.87 (1.66–2.08)	0.56
South African Hypertension Society Guidelines 2012	2.34 (2.19–2.49)	2.28 (2.06–2.49)	2.41 (2.20–2.63)	0.37
Guidelines for the Management of Type 2 Diabetes. SEMDSA 2012 (Society for Endocrinology, Metabolism and Diabetes in South Africa)	2.27 (2.11–2.42)	2.22 (2.00–2.43)	2.32 (2.09–2.55)	0.51
Guidelines for the Management of Chronic Asthma in Adolescents and Adults 2007 (South African Thoracic Society)	2.26 (2.10–2.42)	2.30 (2.07–2.53)	2.22 (1.99–2.45)	0.65
Guidelines for the Prevention and Treatment of Malaria (NDOH 2009)	2.01 (1.85–2.16)	2.04 (1.84–2.25)	1.97(1.74–2.20)	0.50
SA National Tuberculosis Management Guidelines (NDOH 2009)	2.65 (2.51–2.79)	2.47 (2.26–2.68)	2.83 (2.65–3.01)	0.01
Management of Drug-resistant Tuberculosis: Policy Guidelines (NDOH 2011)	2.16 (2.01–2.31)	2.01 (1.80–2.21)	2.32 (2.11–2.53)	0.03
National Contraception Clinical Guidelines (NDOH 2013)	1.73 (1.58–1.88)	1.68 (1.47–1.88)	1.79 (1.57–2.01)	0.42
Sexually Transmitted Infections Clinical Guidelines (NDOH 2009)	2.69 (2.54–2.83)	2.67(2.47–2.87)	2.70 (2.49–2.92)	0.67
Guidelines for the Management of HIV in Children (NDOH 2010)	2.49 (2.34–2.64)	2.44 (2.23–2.64)	2.55 (2.33–2.78)	0.48
National HIV Counselling and Testing Policy Guidelines (NDOH 2010)	2.50 (2.35–2.66)	2.44 (2.23–2.65)	2.57 (2.35–2.79)	0.37
The South African Antiretroviral Treatment Guidelines (NDOH 2013)	2.82 (2.67–2.96)	2.68 (2.47–2.89)	2.96 (2.75–3.16)	0.07
Prevention of Mother to Child Transmission of HIV – PMTCT Clinical Guidelines (NDOH 2010)	2.78 (2.64–2.92)	2.68 (2.47–2.88)	2.89 (2.70–3.09)	0.13
IMCI – Guidelines for the Integrated Management of Childhood Illness (NDOH 2009)	2.36 (2.20–2.52)	2.18 (1.94–2.41)	2.54 (2.32–2.75)	0.02
Guidelines for Maternity Care in South Africa (NDOH 2007)	2.07 (1.91–2.23)	2.19 (1.95–2.43)	1.94 (1.73–2.16)	0.18
Guidelines for Basic Antenatal Care (BANC)	2.04 (1.89–2.20)	2.09 (1.86–2.33)	2.00 (1.77–2.22)	0.63
Guidelines for Post Natal Care (EPOC)	1.81 (1.65–1.97)	1.92 (1.69–2.15)	1.69 (1.47–1.91)	0.16
Guidelines for Basic Intra-partum Care (BIC)	1.85 (1.69–2.01)	1.90 (1.66–2.13)	1.80 (1.58–2.02)	0.67
Essential Steps to Manage Obstetric Emergencies (ESMOE) 2009	2.20 (2.03–2.37)	2.12 (1.86–2.37)	2.29 (2.07–2.51)	0.23
Immunisation Schedule for South Africa 2013 (EPI)	2.41 (2.25–2.56)	2.30 (2.08–2.53)	2.51 (2.31–2.72)	0.17
Ethical and professional rules of the Health Professions Council of South Africa 2008	2.04 (1.90–2.17)	2.13 (1.95–2.32)	1.93 (1.73–2.13)	0.16
National Complaints Management Protocol for the Public Health Sector of South Africa (NDOH 2013)	1.35 (1.24–1.46)	1.44 (1.27–1.61)	1.26 (1.13–1.39)	0.26
Primary Health Care Supervision Manual: A Guide to Primary Health Care Facility Supervision (NDOH 2009)	1.36 (1.24–1.48)	1.52 (1.33–1.72)	1.18 (1.05–1.30)	0.03
Guidelines for Basic Life Support (BLS) –(Academy of Advanced Life Support)	2.13 (2.00–2.25)	1.80 (1.63–1.96)	2.49 (2.32–2.65)	<0.001
ATLS – Advanced Trauma Life Support (Trauma Society of SA)	1.65 (1.53–1.77)	1.45 (1.32–1.58)	1.87 (1.67–2.06)	<0.001
ACLS – Advanced Cardiovascular Life Support (Academy of Advanced Life Support)	1.74 (1.61–1.87)	1.47 (1.32–1.61)	2.05 (1.84–2.25)	<0.001
PALS – Paediatric Advanced Life Support (Academy of Advanced Life support)	1.39 (1.29–1.50)	1.36 (1.22–1.49)	1.43 (1.26–1.60)	0.85
ANLS – Advanced Neonatal Life Support (Academy of Advanced Life Support)	1.20 (1.11–1.28)	1.19 (1.07–1.30)	1.21 (1.09–1.33)	0.86

Table 4: Performance of key clinical skills by primary care doctors

Skill	All: mean score (CI)	GP’s mean score (CI)	MO’s mean score (CI)	p value
General:
Femoral vein puncture	2.95 (2.80–3.10)	2.70 (2.48–2.92)	3.21 (3.02–3.40)	<0.001
Intra-dermal injection	3.03 (2.88–3.17)	3.04 (2.85–3.23)	3.01 (2.78–3.23)	0.95
Intra-muscular injection	3.41 (3.31–3.50)	3.37 (3.24–3.50)	3.45 (3.30–3.59)	0.39
Subcutaneous injection	3.32 (3.21–3.43)	3.36 (3.22–3.50)	3.28 (3.11–3.46)	0.79
Interpret chest X ray	3.42 (3.30–3.53)	3.27 (3.10–3.45)	3.57 (3.43–3.71)	0.02
Interpret abdominal X ray	3.26 (3.13–3.38)	3.08 (2.87–3.28)	3.45 (3.30–3.59)	0.02
Abdomen:
Proctoscopy	1.64 (1.51–1.77)	1.7 (1.51–1.89)	1.57 (1.40–1.74)	0.46
Chest:
Set up, record and interpret a stress ECG	2.30 (2.15–2.45)	2.36 (2.14–2.57)	2.24 (2.03–2.44)	0.44
Set up, record and interpret a resting ECG	2.92 (2.78–3.06)	2.64 (2.45–2.83)	3.22 (3.03–3.41)	<0.001
Pleural tap	3.12 (2.99–3.26)	2.90 (2.70–3.09)	3.36 (3.19–3.53)	<0.001
Measure PEF (peak expiratory flow)	2.73 (2.59–2.87)	2.74 (2.54–2.93)	2.73 (2.52–2.93)	0.85
Nebulise a patient	3.30 (3.18–3.41)	3.14 (2.97–3.31)	3.46 (3.32–3.61)	0.01
Demonstrate use of inhalers and spacers	3.28 (3.15–3.40)	3.11 (2.93–3.29)	3.46 (3.30–3.62)	<0.001
Antenatal care:
Plot and interpret antenatal growth chart	2.93 (2.80–3.07)	2.91 (2.72–3.11)	2.96 (2.76–3.15)	0.76
Assess foetal movement/well-being	2.87 (2.74–3.01)	2.91 (2.73–3.10)	2.83 (2.62–3.04)	0.62
Perform an obstetric ultrasound	2.43 (2.27–2.59)	2.55 (2.32–2.79)	2.30 (2.07–2.52)	0.13
Intra-partum care:
Examine progress during labour, plot and interpret partogram	2.7 (2.56–2.85)	2.62 (2.42–2.82)	2.79 (2.58–3.00)	0.26
Apply and interpret CTG (cardiotocograph)	2.68 (2.52–2.83)	2.52 (2.32–2.73)	2.84 (2.62–3.06)	0.05
Normal vaginal delivery	2.66 (2.52–2.79)	2.61 (2.42–2.8)	2.7 (2.51–2.89)	0.52
Assisted vaginal delivery	2.58 (2.45–2.71)	2.56 (2.37–2.75)	2.6 (2.42–2.78)	0.76
Episiotomy and suturing	2.53 (2.40–2.66)	2.55 (2.36–2.73)	2.51 (2.32–2.69)	0.78
Repair of third-degree tear	2.29 (2.14–2.43)	2.47 (2.27–2.67)	2.08 (1.90–2.27)	0.01
Post-partum/new born care:
Resuscitate a newborn	2.73 (2.59–2.87)	2.71 (2.49–2.93)	2.75 (2.57–2.93)	0.80
Teach a mother Kangaroo Care	2.44 (2.28–2.59)	2.34 (2.10–2.57)	2.54 (2.33–2.75)	0.21
Well newborn check	2.71 (2.56–2.86)	2.62 (2.40–2.83)	2.82 (2.60–3.03)	0.23
Women’s health:
Insert IUCD (intra-uterine contraceptive device)	2.14 (1.99–2.30)	2.2 (1.97–2.42)	2.08 (1.88–2.29)	0.56
Cervical smear	3.00 (2.88–3.13)	2.92 (2.75–3.01)	3.08 (2.91–3.26)	0.26
Drain a Bartholin cyst	2.68 (2.54–2.82)	2.67 (2.48–2.85)	2.70 (2.49–2.92)	0.81
Paediatrics:
Plot and interpret Road To Health Booklet	2.88 (2.74–3.03)	2.67 (2.46–2.89)	3.11 (2.92–3.30)	<0.001
Assess child abuse: sexual/non-sexual	2.47 (2.33–2.62)	2.39 (2.18–2.59)	2.57 (2.35–2.78)	0.28
Capillary blood sampling	2.63 (2.49–2.77)	2.55 (2.35–2.75)	2.72 (2.51–2.92)	0.35
Developmental assessment	2.71 (2.57–2.85)	2.62 (2.42–2.81)	2.8 (2.60–3.01)	0.24
IV access in a child	2.96 (2.83–3.10)	2.70 (2.51–2.90)	3.25 (3.09–3.41)	<0.001
Intra-osseous line	2.47 (2.31–2.63)	2.28 (2.06–2.50)	2.67 (2.45–2.89)	0.02
Surgery/general adult health:
Wound care dressings	3.04 (2.91–3.17)	2.97 (2.78–3.17)	3.11 (2.93–3.28)	0.39
Suturing of laceration	3.31 (3.20–3.41)	3.21 (3.05–3.37)	3.41 (3.27–3.56)	0.10
Insert urinary catheter	3.23 (3.11–3.34)	3.08 (2.91–3.24)	3.39 (3.25–3.54)	0.01
Debride wounds and burns	2.83 (2.69–2.97)	2.86 (2.66–3.05)	2.81 (2.60–3.01)	0.69
Perform a circumcision	2.69 (2.53–2.85)	2.77 (2.56–2.99)	2.6 (2.37–2.83)	0.28
Administer a ring block	2.91 (2.77–3.05)	2.77 (2.57–2.98)	3.06 (2.87–3.25)	0.08
Administer a regional block	2.59 (2.43–2.75)	2.65 (2.42–2.88)	2.52 (2.29–2.75)	0.38
Incise and drain an abscess	3.13 (3.00–3.26)	3.04 (2.86–3.23)	3.23 (3.04–3.41)	0.17
Orthopaedics:
Aspirate and inject a knee	2.59 (2.44–2.74)	2.55 (2.34–2.75)	2.64 (2.42–2.86)	0.56
Inject a tennis/golfer’s elbow	2.03 (1.87–2.18)	2.15 (1.92–2.38)	1.89 (1.69–2.09)	0.14
Inject into the sub-acromial space	1.93 (1.78–2.09)	2.13 (1.91–2.35)	1.73 (1.52–1.93)	0.01
Apply finger and hand splints	2.70 (2.55–2.85)	2.60 (2.39–2.80)	2.81 (2.60–3.02)	0.18
Apply POP (plaster of Paris)	2.90 (2.76–3.05)	2.76 (2.55–2.97)	3.06 (2.87–3.25)	0.07
Reduce shoulder dislocation	2.78 (2.64–2.92)	2.73 (2.52–2.94)	2.84 (2.64–3.04)	0.54
Immobilise suspected fracture for transport	2.93 (2.80–3.07)	2.82 (2.62–3.02)	3.06 (2.87–3.25)	0.10
Emergencies:
CPR – adult/child (cardiopulmonary resuscitation)	2.95 (2.82–3.09)	2.66 (2.46–2.85)	3.27 (3.11–3.44)	<0.001
Manage choking	2.55 (2.42–2.69)	2.49 (2.29–2.68)	2.62 (2.44–2.81)	0.37
Primary/secondary survey	2.89 (2.73–3.04)	2.85 (2.36–2.81)	3.21 (3.01–3.40)	<0.001
Intubate and manage airway appropriately (LMG or ET tube)	2.81 (2.67–2.96)	2.51 (2.30–2.72)	3.14 (2.96–3.32)	<0.001
Cricothyroidotomy	2.12 (1.98–2.25)	2.04 (1.84–2.24)	2.20 (2.03–2.37)	0.13
Administer oxygen	3.16 (3.03–3.29)	2.86 (2.67–3.06)	3.48 (3.34–3.62)	<0.001
Insert a chest drain	2.89 (2.74–3.03)	2.67 (2.46–2.87)	3.12 (2.93–3.31)	<0.001
Relieve tension pneumothorax	2.55 (2.41–2.69)	2.45 (2.24–2.66)	2.65 (2.47–2.84)	0.17
Measure GCS (Glasgow Coma Scale)	3.18 (3.05–3.31)	2.96 (2.78–3.14)	3.41 (3.24–3.58)	<0.001
Insert naso-gastric tube	3.15 (3.02–3.28)	2.97 (2.78–3.16)	3.34 (3.16–3.52)	<0.001
Immobilise the spine	2.73 (2.58–2.89)	2.51(2.29–2.72)	2.98 (2.78–3.19)	<0.001
Certify a patient under Mental Care Act	2.79 (2.64–2.94)	2.55 (2.34–2.76)	3.06 (2.86–3.26)	<0.001
Ear nose and throat:
Remove foreign body from the eye	2.68 (2.53–2.82)	2.58 (2.38–2.78)	2.78 (2.57–2.99)	0.20
Remove foreign body from the ear	2.93 (2.80–3.05)	2.88 (2.70–3.05)	2.98 (2.81–3.16)	0.54
Remove foreign body from the nose	2.82 (2.69–2.95)	2.76 (2.57–2.95)	2.88 (2.69–3.07)	0.50
Manage epistaxis – pack the nose	2.96 (2.83–3.09)	2.89 (2.71–3.07)	3.03 (2.85–3.22)	0.30
Wash out the eye	2.80 (2.66–2.93)	2.68 (2.50–2.86)	2.92 (2.70–3.13)	0.09
Skin:
Excise sebaceous cyst	2.52 (2.37–2.68)	2.55 (2.34–2.76)	2.50 (2.26–2.73)	0.64
Cryotherapy/cauterisation	2.41 (2.26–2.56)	2.47 (2.24–2.70)	2.35 (2.14–2.56)	0.42
Trucut/punch biopsy	2.38 (2.23–2.53)	2.37 (2.14–2.60)	2.39 (2.18–2.59)	0.79
Fine-needle aspiration biopsy (FNAB)	2.77 (2.63–2.91)	2.72 (2.53–2.92)	2.82 (2.61–3.02)	0.54
Forensic:
Assess/manage and document sexual assault	2.53 (2.38–2.69)	2.57 (2.35–2.80)	2.49 (2.27–2.70)	0.60
Assess, manage and document drunken driving	2.53 (2.38–2.68)	2.48 (2.26–2.70)	2.58 (2.36–2.80)	0.60
Clinical administration skills:
Complete a J88 form	3.12 (3.00–3.23)	3.02 (2.85–3.19)	3.22 (3.07–3.37)	0.13
Complete a Death Notification Form (BI 1663)	3.08 (2.97–3.19)	2.94 (2.77–3.11)	3.24 (3.10–3.38)	0.02
Complete a WCA form (injury on duty)	2.89 (2.76–3.02)	2.86 (2.69–3.04)	2.92 (2.72–3.12)	0.57
Communication and consultation skills:
Patient-centred consultation	3.17 (3.06–3.28)	3.09 (2.92–3.26)	3.25 (3.11–3.39)	0.29
Brief behaviour change counselling	2.98 (2.85–3.11)	2.91 (2.72–3.10)	3.06 (2.88–3.24)	0.30
Break bad news	3.17 (3.06–3.27)	3.02 (2.85–3.18)	3.32 (3.20–3.45)	0.02
Counsel for HIV prevention or test	3.15 (3.03–3.26)	3.06 (2.89–3.24)	3.24 (3.08–3.39)	0.25
Counsel patient after sexual assault	2.60 (2.46–2.75)	2.64 (2.44–2.85)	2.56 (2.35–2.78)	0.58
Counsel patient before and after termination of pregnancy	2.49 (2.34–2.63)	2.55 (2.35–2.75)	2.41 (2.20–2.62)	0.35
Mini-mental examination	2.76 (2.63–2.89)	2.66 (2.47–2.85)	2.87 (2.70–3.04)	0.14
Use a genogram	2.21 (2.05–2.36)	2.06 (1.84–2.28)	2.37 (2.15–2.58)	0.04
Work effectively with an interpreter to overcome language barriers	2.76 (2.62–2.90)	2.65 (2.44–2.86)	2.88 (2.70–3.06)	0.17
Include family members appropriately in the consultation	3.04 (2.94–3.14)	3.02 (2.87–3.17)	3.06 (2.92–3.20)	0.72

Table 5: Confidence of primary care doctors to perform roles across the full scope of practice

	All: mean score (CI)	GP’s mean score (CI)	MO’s mean score (CI)	p value
Competent clinician:
Using a bio-psycho-social approach to the assessment of the patient	2.89 (2.75–3.03)	2.84 (2.63–3.05)	2.94 (2.76–3.12)	0.78
Use a systematic, stepwise approach to solve ethical or professional dilemmas	2.71 (2.58–2.85)	2.79 (2.61–2.97)	2.63 (2.43–2.83)	0.27
Clinical governance:
Improving the organisation of your practice, e.g. patient’s access to care	2.95 (2.82–3.07)	3.06 (2.87–3.24)	2.83 (2.64–3.01)	0.07
Leading a quality improvement cycle for your team of primary care providers	2.46 (2.30–2.63)	2.59 (2.35–2.82)	2.33(2.10–2.55)	0.13
Leading a meeting to critically reflect on deaths or significant adverse events in your practice	2.40 (2.23–2.57)	2.48 (2.23–2.73)	2.32 (2.10–2.53)	0.35
Critical thinker:
Critically appraising and making recommendations for the incorporation of new evidence in your primary care practice	2.47 (2.31–2.62)	2.59 (2.36–2.81)	2.33 (2.11–2.55)	0.14
Helping staff in your team to interpret and use health indicators from your facility	2.74 (2.59–2.90)	2.84 (2.61–3.06)	2.64 (2.42–2.86)	0.20
Capability builder:
Using referrals from clinical nurse practitioners as an opportunity to give them feedback and provide supportive education	2.96 (2.83–3.10)	3 (2.81–3.18)	2.93 (2.73–3.12)	0.61
Providing continuing professional development or training to other primary care providers	2.77 (2.61–2.92)	2.78 (2.56–3)	2.76 (2.53–2.98)	0.84
Community advocate:
Helping community health workers to prioritise and respond appropriately to issues discovered during home visits	2.25 (2.09–2.41)	2.36 (2.13–2.58)	2.13 (1.90–2.35)	0.17
Make sense of information on the population served by your practice and share with others in the primary health care team	2.41 (2.25–2.58)	2.59 (2.36–2.82)	2.21 (1.98–2.44)	0.02
Collaborator:
Working collaboratively with other people in a multi-professional health care team	3.12 (2.99–3.26)	3.09 (2.88–3.30)	3.16 (2.99–3.32)	0.87