The procedural skills of rural hospital doctors

Objectives. To describe the spectrum of procedures performed by general medical officers in South African rural hospitals, and the attitudinal issues associated with these tasks. Design. A descriptive study combining quantitative and qualitative methods: a quantitative audit of operating theatre records of 15 rural hospitals in KwaZulu-Natal and 4 rural hospitals in Northern Province, and a qualitative analysis of 8 focus group discussions in which rural hospital doctors discussed their procedural work. Outcome measures. Quantitative results included patient age, type of anaesthetic, type of procedure, and whether a separate anaesthetist was present or not for each recorded procedure performed in the operating theatre. Qualitative results comprised major and minor themes that arose from the focus group discussions. Results. Quantitative results revealed a high proportion of obstetric and general surgical procedures, often performed by a single doctor acting as anaesthetist as well as surgeon. The range of surgical procedures undertaken varied widely between hospitals. Anaesthetic usage patterns revealed extensive use of ketamine and spinal anaesthetics, with relatively more general anaesthetics being administered in the Northern Province. Qualitative results revealed two scenarios in the rural hospital situation: one where doctors felt that they were coping and learning from the work under the supervision of peers or senior colleagues, and the other where they felt stressed by being alone and having to deal with emergencies, especially when short-staffed. Conclusions. The broad range of skills demanded in rural hospital practice requires specific preparation and ongoing support. Without it, a vicious cycle is established leading to poor output and morale. The phenomenon of the single-handed anaesthetist-surgeon that emerged from this study deserves specific attention, particularly with regard to staff shortages in rural areas. Under circumstances of adequate staffing and support, the rural hospital is an ideal learning site for generalists. This study has significant implications for the proposed introduction of obligatory vocational training for all medical graduates.