22 Maart 1980

SA MEDIESE TYDSKRIF 461

Family Practice as a Part of Undergraduate Medical
Training in South Africa
C. J. REITZ
SUMMARY
Undergraduate tuition in family practice was fully insti-
tuted for the first time in South Africa at the University
of Pretoria in 1977. Students in the 2nd - 5th years of
study are taught the various aspects of family medicine
and practice management by means of formal lectures
and practical clinical work. The teachers are all general
practitioners, most of whom hold a higher degree in family
practice. In addition, each student spends at least 1 week
with a practitioner in general practice.
In Pretoria the outpatient and casualty departments of
the two teaching hospitals are run by the Department of
Family Practice. Large numbers of patients who would
not be seen in the wards are thus made available for
teaching purposes, and the standard of service to patients
is improved.
Until recently, medical teaching was confined to the
various specialties and only patients admitted to teach-
ing hospitals were available for teaching purposes. As
less than 1% of persons reporting sick are admitted to
hospital, inpatients are not representative of the disease
profile seen in genera! practice.
Undergraduate medical training in family practice could
be further improved by more participation in the teaching
programme by experienced general practitioners in active
practice.
S. Afr. med. l., 57, 461 (1980).
Ever-increasing scientific advances in all fields of medicine
during the past 3 decades have resulted in a tendency t?
specialization and subspecialization. The general practi-
tioner seemed about to disappear from the medical scene,
particularly in highly developed countries such as the
USA but the exorbitant costs of specialized services make
it im'possible to provide them for the whole community,
even in the richest countries. In addition, there remains
a need for the family doctor who knows the patient
intimately and can treat him as a whole. In most Western
countries it has been realized that special training is
required to produce a competent general practitioner.
Countries such as the USA and UK, Canada and Austra-
lia have taken the lead during the past 20 years in esta-
blishing departments of family practice at universities to
provide undergraduate and postgraduate training. In South
Africa the first training programme in family practice,
offering a postgraduate course for a Master's degree in
Department of Family Practice, University of Pretoria
C. ]. REITZ, M.B. CH.B., M. PRH. 1>1ED., Associate Professor
Paper presented at the 52nd Congress of the Medical Association of South
Africa, Durban, J6 21 July 19?9.
family practice' and making a limited start in under-
graduate teaching was instituted by the University of
Pretoria in 1967. This was gradually expanded, and in
] 977 the Department of Family Practice was fully esta-
blished and is now integrated into all facets of under-
graduate teaching.
In 1978 departments of family practice were established
at the University of the Orange Free State and at
Medunsa. The Faculty of General Practice of the College
of Medicine of South Africa has also promoted teaching
and examination in family medicine.
The Teaching Programme in Family Practice at
the University of Pretoria
Since 1977, undergraduate teaching in family practice
has been incorporated into the curriculum from the 2nd
to the 5th years of study. The professors and senior
lecturers in the Department were previously either general
practitioners in private practice or were engaged in other
forms of primary medical care. They are in possession of
higher degrees in family practice. The casualty and out-
patient departments of the two teaching hospitals have
been staffed by lecturers from the Department of Family
Practice, who are mainly concerned with practical teach-
ing in the clinics, since 1977. Although many of these
doctors have not been in private practice, several of
them are engaged in postgraduate study if family practice.
General practitioners in active practice are occasionally
invited to lecture to the students on subjects such as the
general practitioner's daily routine and the typical disease
profiles encountered.
Theoretical Teaching
A total of 110 lectures is gi ven during the 2nd - 5th
academic years. Lectures in the 2nd year start with an
orientation course which includes the definition and scope
of family medicine, followed by a course in applied first
aid. The course is completed within the first semester.
Lecture subjects in the 3rd year include ethics, com-
munication with the patient the doctor-patient relation-
ship and sports medicine. are co-ordinated with
lectures in the basic subjects. When students have com-
pleted lectures in the anatomical pathology of a specific
system, they are taught how to recognize and deal with
the relevant diseases in their early stages. Early recog-
nition of disease, early treatment and preventive mea-
sures by general practitioner are stressed, and the com-
monest diseases seen in general practice are discussed.
In this way an attempt is made to upon the
student the importance of the basic sciences and their
relation to the patient's problems.
462 SA MEDICAL JOURNAL 22 March 1980
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During their 4th year students are taughr .J10W to deal
with unselected patients. The lecture programme includes
history-taking, clinical examination and evaluation, re-
ferral of patients and clinical record systems. Students are
taught the principles of practice management, which in-
clude entrance into practice, practice organization, the
planning of consulting rooms and the choice of equipment,
the value of ancillary personnel, book-keeping and finance,
and management of a dispensing practice. Students are
also expected to be cognizant of the composition and
functions of the South African Medical and Dental
Council, the Medical Association of South Africa, and
ethical principles and legal aspects of importance to the
general practitioner.
From 1980 the first group of 5th year students will be
included in the lecture programme. Lectures will deal
with problems encountered in private practice, counselling
skills, patient management, problem-solving and family
care.
Practical Instruction
Practical instruction is provided by the following
services:
The casualty and outpatient departments of the two
teaching hospitals. Instruction at the casualty and out-
patient departments is started in a limited way during
the 2nd and 3rd years of study. During the 4th year
groups of students rotate through the morning clinics of
the various disciplines, including family practice. At the
casualty and outpatient departments one or two students
work with each doctor. They are instructed in history-
taking and the physical examination of unselected patients
and are taught how to record the relevant facts concisely
according to a specially designed, problem-orientated,
clinical record system. In addition they are taught practi-
cal procedures, and are invited to discuss the choice of
special investigations and therapy. They are encouraged
to become familiar with the trade names of drugs in
general use. At the one hospital students also see patients
admitted to the short-stay ward of the Department of
Family Practice.
Small groups of students. are required to attend 3-
hourly sessions during weekends at the casualty depart-
ments and the Family Practice Clinic where non-trauma
patients are treated after hours. In the casualty depart-
ments students practice mouth-ta-mouth or mouth-to-nose
ventilation, external cardiac massage and intubation on
life-sized models.
The suburban polyclinic. This clinic was established by
medical students and is administered by a student com-
mittee. It operates on week nights. Medical students in
the 4th and 5th years of study examine and treat the
patients under the supervision of a medical practitioner.
Second-year students are responsible for immunizations,
while 3rd year students perform laboratory examinations
and dispense medicine under the supervision of a pharma-
cist.
Preceptorship. During the 4th year of study each
student is required to spend at least a week with a
general practitioner in private practice. The practitioner's
services are voluntary. The student is required to submit
a report and commentary on his experiences.
Homeland hospitals. Students are encouraged to work
in homeland hospitals during vacations. This valuable
practical training is, however, purely elective.
Evaluation of Students
During all 4 years of study, written tests are used to
assess the student's theoretical knowledge. In addition
marks are assigned for practical work and for the report
submitted on the preceptorship.
. DISCUSSION
In the past, undergraduate medical education was under-
taken exclusively by specialists in particular fields, and
only patients admitted to hospitals were available as
teaching material. Patients admitted to hospital comprised
less than 1% of all people reporting sick and were there-
fore not representative of the disease profile seen in
general practice! Such patients usually have advanced
disease, and students do not become familiar with the
early signs and symptoms which they will encounter in
general practice. In addition, the tendency in under-'
graduate teaching has been to place undue emphasis on
rare and unsual diseases which, if encountered in private
practice, would automatically be referred to specialists.
As most students will eventually go into gener,al practice,
provision must be made for this by including the subject
in the teaching programme. An attempt is being made
to correct this previous deficiency; students are taught
how to deal with unselected patients, and the importance
of good history-taking is stressed. An investigation in the
UK showed that the correct diagnosis could be made' in
about 80% of new patients on a good history alone:
Attendance at clinics at the outpatient departments
brings the students into contact with unselected patients
such as will be encountered in general practice. They are
made aware of the need for accuracy and speed in order
to arrive at the correct diagnosis in the shortest possible
time. Special methods of history-taking and examination
are required when coping with a large number 'of
patients in a limited period of time. Students are malie
aware of the expense of special examinations and medi-
cines and are taught how Jo be selective in choosing
them. When groups of students are kept small in these
clinics, it is also possible for the student to become aware
of the importance of the doctor-patient relationship and
how to communicate with patients.
The incorporation of the oJJtpatient and casualty de-
partments into the Department of Family Practice has
practical advantages for the patients as well. The service
to patients is improved because of higher academic
standards and better organization.
In order to educate students in the art and science of
family practice, experienced and competent general prac-
titioners must be available to give ler:tures and practical
instruction. This will of necessity be on a part-time basis.
In the future planning of undergraduate teaching in
family practice special attention should be paid to the
22 Maart 1980 463
inclusion of general practitioners in active practice in the
teaching programme:" Experience in countries such as
the UK and the Netherlands, where general practitioners
are employed part-time to instruct students, can provide
useful future guidelines. Our experience in Pretoria has
indicated that the preceptorship system is very valuable.
We should aim to produce family practitioners of the
calibre defined by Rutledge
6
as follows: 'A general practi-
tioner is one who has a high degree of competence in the
practice of medicine over a broad field and in sufficient
depth to treat his patient and/or keep him well in all
situations. He must always recognize and acknowledge
Geneial Pl'actice
the need for consultation or advice from his specialist
colleagues whenever, in his judgement, such a course is
desirable in the best interest of his patient.'
Undergraduate instruction in family practice is a
modern trend in medical training in South Africa directed
at achieving these aims.
REFERE 'CES
J. Reitz, C. J. (1978): S. Afr. med. J., 54, 923.
2. Schmidl, D. D. (1977): J. Fam. Pract., 5, 401.
3. Hampton, J. R., Harrison, M. J. G., Milcbell, J. R. A. el at. (1975):
Brit. med. J., 2, 486.
4. Van Wyk. F. (1966):: S. Afr. med. J., 33, 744.
5. Relief, F. P. (1978): Ibid., 54, 889.
6. RUlledge, N. (1971): Med. J. Aust., 2, 212.
Clinical Anatomy of the Umbilicus
T. COETZEE
SUMMARY
The diagnostic value of the appearance of the umbilicus
in a wide range of conditions is discussed. Umbilical
sepsis, tumours, fistulas, developmental anomalies and
hernias are described, and the embryology of related
structures is outlined.
S. Afr. med. l., 57, 463 (1980).
'Every time an abdomen is examined the eyes of the
clinician, almost instinctively, rest momentarily on the
umbilicus.'
Hamilton Bailey
POSITION AND APPEARANCE
Typically the umbilicus is at the same level as the highest
point of the iliac crest, i.e. at the 3rd - 4th lumbar disc.
This point is almost equidistant along the line joining the
Department of Anatomy, University of Cape Town
T. COETZEE, M.D., CH.M., F.R.C.S., F.C.S. (S.A.), M.R.C.P.,
D.P.H., D.l.H.
Date received: 6 August 1979:
tip of the xiphoid process and the top of the symphysis
pubis. The position is, however, variable and unreliable as
a landmark. The umbilicus is normally above the mid-
point between the top of the head and the soles of the
feet; in achondroplasia it is below this point. If the
abdomen is distended as a result of a pregnant uterus, the
umbilicus is displaced up\vards; ascites will cause down-
wards displacement (Tanyol's sign).
The skin in the umbilical area drains upwards to the
lymph nodes in both axillae, and downwards to both
groins.
The prominence of the umbilicus and the depth of the
umbilical pit (cicatrix) are extremely variable. A bluish
tinge may be noticeable at the umbilicus and the sur-
rounding skin in cases of ruptured ectopic pregnancy
(Cullen's sign, umbilical 'black eye'), while a yellow
tinge is sometimes observed in acute pancreatitis. Intra-
peritoneal rupture of a hydatid cyst may result in a dirty
greeni h stain of the umbilicus. Visible veins are often
seen, arranged radially from the umbilicus. Normally the
blood flow is upwards in the veins above the umbilicus,
downwards in those below. In portal vein obstruction this
direction of flow is unchanged, but in obstruction of the
inferior vena cava the flow in veins below the umbilicus
is reversed (i.e. l)pwards) to shunt blood to the superior
vena cava.