|Year : 2007 | Volume
| Issue : 1 | Page : 22
Making a Difference: An Interview with Khaya Mfenyana
University of Colorado, CO, USA
|Date of Web Publication||25-Jan-2013|
7840 SW 86th Street - # 23, 33143-6862, Miami - FL
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Westberg J. Making a Difference: An Interview with Khaya Mfenyana. Educ Health 2007;20:22
Khaya Mfenyana is a leader in family medicine and in community-based education and service in Africa. He is First Professor and Head of the Department of Family Medicine at Walter Sisulu University (formerly the University of Transkei) in Mthatha, South Africa. Currently, he is also Interim Vice Principal of Walter Sisulu University. This edited, abridged interview is based on my interview of Dr. Mfenyana, October 2006 as well as subsequent communications.
Associate Editor, Education for Health
What was your journey into medicine?
After receiving my two-year teacher's diploma at the University of Fort Hare, I taught mathematics and science in a high school for a year. I wanted to be a scientist, though, so I returned to Fort Hare to do my bachelor of science degree. In my final year, I successfully applied for the honor's degree program in chemistry at my university.
I hadn't really considered medicine, but towards the end of my final year in the bachelor of science program, a friend said, "Why don't you apply for medicine?" So I filled out and submitted a form. But I went ahead with my plan to be a scientist.
In January my trip to my university to begin the honor's degree in chemistry was delayed when I had to visit a doctor about a stomachache. When I came back from the doctor, there was a telegram admitting me to medical school at the University of Natal. Over a period of 6 hours I decided to do medicine.
What caused you to change your mind?
When I was young, my father used to say, "Not too many people are doing medicine." I grew up in a rural setting where the two common professions were teaching and nursing. We saw teachers who were men and women, and nurses who were women. I didn't know anyone at that time who was a doctor, except the local doctor in the nearest town whom we saw only occasionally.
So you realized that there was a need for doctors. Had anything gotten in the way of your considering medicine earlier in your education?
I had an impression that my friends in medicine had to do a lot of memorization. In science I enjoyed being challenged to think and to solve problems. Those of us in science used to look down on our colleagues in medicine, saying they were rote learners and not real scientists.
What was medical school like for you?
The first two or three years were not very nice. We were taught by basic scientists who didn't know much about clinical medicine. There wasn't much stimulation.
But when I got into the clinical years, I realized that, no, I hadn't made a mistake. In the basic sciences, you were right or wrong, but in clinical medicine you start seeing things more broadly.
Starting in my fourth year, during holidays, I worked at a small, nearby mission hospital. By the end of the fifth year, I was able to do most of the minor procedures. I was even able to do C-sections and give anesthetics under supervision.
Following medical school, did you go right on to your internship?
Yes, at Umtata General Hospital, a small institution that was still new in internship training. I enjoyed my internship because we got to do hands-on. At the big hospitals, you more or less followed the consultants around.
Was it then that you decided to pursue family medicine?
I didn't want to go into private practice. When I was in my internship, I started doing medicine. It was so interesting that at the end of my rotation, I said, "I want to be a physician [internist]." Then I went to surgery. Surgery was so enjoyable that I said, "I want to be a surgeon." From there I went to obstetrics and gynecology. The same thing happened. I didn't want to go into private practice because all of the disciplines were equally interesting.
What did you do?
A physician friend of mine tricked me, [laughs] so for the next 3 years I had to take care of his private practice in Mount Frere while he did specialty training.
I presume it was a good trick. What was that experience like for you?
I enjoyed it, and actually in 1980 shortly after beginning work there, I began my master's degree in family medicine at Medunsa - Medical University of Southern Africa.
How did that happen?
Earlier, while I was still at Umtata General Hospital, Sam Fehrsen, who later became my mentor in family medicine, visited a group of doctors in Mthatha and asked. "Don't you want to do family medicine?
"What's family medicine?" I asked.
When he described family medicine I realized his recommendation made sense because I wouldn't lose touch with all the disciplines that I enjoyed. I could also be more thorough, and I could get into behavior issues and other things that normally aren't covered in those disciplines.
In 1982, I left Mount Frere to run my own practice and rendered service in the local hospital in Cala, another small town. I completed my master's degree in 1984 and continued working in Cala until the end of 1986.
In 1987 Sam Fehrsen got me involved with his Department of Family Medicine at Medunsa in Pretoria as a senior lecturer. I was also the Senior and later Principal Medical Officer in the Department of Family Practice at Garankuwa Hospital in Pretoria.
Towards the end of 1988 I was recruited to create a Department of Family Medicine back at Umtata General Hospital and University of Transkei (now Walter Sisulu University). I reluctantly agreed. I didn't think I was ready, but my mentor, Sam Fehrsen, thought I was.
So I became Professor and Head of the Department of Family Medicine from January 1989. Then many other things happened.
What are the highlights for you?
The University of Transkei was the youngest medical school in South Africa. (It was inaugurated in 1985.) They wanted to be sure that the first graduates had the opportunity to do family medicine, so we introduced family medicine at undergraduate level in 1989. I also introduced a postgraduate program in family medicine in 1990 in partnership with Medunsa. Students registered with Medunsa but were located at our university. We did joint teaching with Sam Fehrsen and Ron Henbest, a Canadian whom Sam recruited to help establish his Department of Family Medicine. In 1992 we registered the postgraduate students at our university. Our first postgraduate student graduated in 1995.
What about the UNITRA Community Health Partnership Project?
Because of my interest in communities and community development, I was also asked to start that project in 1991. Our goal was to improve the quality of health care in underserved areas. The project brought together the university; the health sector (providers, policy makers etc.); and the community.
The Kellogg Foundation funded us for 10 years. They helped us build four community health centers with small libraries in Mthatha. We built a skills lab in our institution and established community-based education and also community projects, like water projects in the surrounding areas. Students in medicine, nursing and health promotion were involved.
The university liked the model and asked us to expand it from health sciences to the rest of the university. So in 1999, we phased in service-learning in what we call Community Higher Education Service Partnerships. We broadened the community involvement. I was asked to lead this because of my previous experience with the Community Health Partnership project.
Our university has 6 faculties. The 5 faculties that joined health sciences in this initiative are law, humanities, science, education, and economic sciences. Out of the 6 faculties, we've had 10 pilot service-learning programs.
How do you and your colleagues define service-learning?
There should be learning and service on an equal basis. The service must be determined by the community based on their needs, so there are benefits for both the students and the community. Time must be built in for students to reflect on the learning and service, individually and in groups.
In 1992 I was asked to develop and direct a unit for health personnel education within the faculty of health sciences. This unit coordinates all the learning in medicine, nursing, and health promotion. This was helpful because we had reintroduced community-based education [CBE] and problem-based learning [PBL].
The medical school had been set up in 1985 in the traditional way, but in 1989 there was a move toward CBE and PBL. They started discussing this even before I got there. PBL was introduced in 1989. Although the students initially were excited, after some months they were concerned and asked, "Why are we the only institution in South Africa doing this? Is this a good thing? We are the youngest school. We're in the homeland."
We suspended the program at the end of 1989 and reintroduced it at the beginning of 1992. In 1990 and 1991, we did more spade work, more selling and we attended more conferences. We worked in the community, along with nursing and health promotion departments. We organized workshops and put together a curriculum for the 3 groups of students.
For PBL, medical students were organized into small group tutorials of 8 to 10 students. It was labor intensive. People had to leave their comfort zones of teaching biochemistry, internal medicine and other disciplines and go and be a tutor.
We held lots of faculty workshops. For the first five years we had regular workshops two times a year so we could review what had been done and plan for the future. Now we continue to hold workshops but not quite as frequently. We have staff development workshops for all new faculty.
That's wonderful. How early and how much are medical students exposed to family physicians, community-oriented primary care and service-learning?
At Walter Sisulu University, we have a continuum of exposing students to the community. Year 1 students spend 2 weeks in the community. The focus is on how you enter the community. You don't just go there. You have to go to the chief or whoever is the community leader. Community liaison officers accompany the students into the community and make sure that they are baptized in a correct manner.
Year 2 students spend 4 weeks at a district hospital with its health centers and clinics. Ward rounds include the psychosocial dimension, so students participate in these rounds. Most important is what they learn when they go with the nurses to the clinics.
Year 3 students spend 7 weeks in the community. They are accompanied by a tutor who makes sure there is continuity with what the students are learning in their tutorial groups. There is also a family physician, who maintains a constant presence in these clinical situations.
In the morning, under the supervision of the family physician, the students examine patients, putting into practice the skills they learned in the skills lab in Year 2.
In the afternoon students go with the tutor to the community to do what the community and the community liaison offer have decided needs to be done. Mostly the students do surveys and community diagnoses. The students later present their findings to the community and the medical school.
Who are the circuit riders and what do they do?
Circuit riders are academic staff members (faculty) that accompany students to the community, health centers and district hospitals. Circuit riders can be from any discipline, including the basic sciences. We encourage all faculty members to go out into the community to see how their disciplines are being taught. It's not enough to teach students something in the first or second year. You need to go out to make sure that students understand your discipline. An anatomist, for example, may want to go to a clinical setting to be sure that the students still know the anatomy they were taught.
Our curriculum is integrated so faculty must be comfortable with areas that are outside of their areas of specialization. When the students are in the skills lab being taught the cardiovascular system, we have a family physician and a physician (internist - cardiologist). When students are examining the abdomen, the family physician, as a constant, is there, but a surgeon will also be there because surgeons deal primarily with abdomens.
When students are examining the eyes, the family physician is there and also an ophthalmologist. Sometimes that doesn't work out, but we try for this. This way the specialists don't wait until the clinic years to start teaching the students the clinical skills that are specific to their area of expertise and make them unlearn what they were taught by other people. We want faculty to be involved from the beginning.
The curriculum is integrated. There are no lines of demarcation. There are no areas that are out of bounds.
What do students do in Year 4?
Students, accompanied by circuit riders, go again to learning complexes (i.e. district hospitals together with their health centers and clinics), this time for 6 weeks in groups of four to eight. Family physicians, again as constants, also become additional circuit riders to ensure integration and application of principles of family medicine.
In Year 5 (the students' final year), students spend 6 weeks in a district hospital that is close to the university. There are also health centers, a hospice and an old age home, so it's a learning complex as well.
Your work in family medicine goes well beyond your school. You've been instrumental in trying to strengthen and unite family medicine in South Africa.
In 1997, 8 departments of family medicine from the 8 medical schools in South Africa joined together as FaMEC - Family Medicine Education Consortium. I was made chairperson of this group in 2004. I've been asked to continue because at the beginning of 2006 we began the process of merging FaMEC with the South African Academy of Family Practice.
Jan de Maeseneer, Head of the Department of Family Medicine, and his colleagues at Ghent University, Belgium, have been supporting FaMEC as we've been learning to talk the same language and share the same values. Recently, with funding from the Flemish Government, this project was extended to include the departments of family medicine in East Africa. We call it the FaMEC Africa Project.
How would you characterize family medicine in Africa?
That is our task. We want to go deeper in defining family medicine within the context of Africa. Our first goal is to be on the same page in the African context.
Secondly, we want to influence the world in terms of focusing on horizontal rather than vertical programs. For example, there are a lot of vertical programs for AIDS and TB, but family physicians need to look at the individual within the context of his surroundings - family and community. We want to make sure that we all understand the role of community-oriented primary care and service-learning. All this must be understood in the context of the district health system. If you do this, then you see the value of horizontal integration.
Our third goal is to examine family medicine education in Africa. In contrast to the specialties that do their training in tertiary care facilities, family physicians have to be educated in the community. We're trying to develop teaching complexes made up of the district hospital, the surrounding clinics and health centers, private practitioners, hospices and old age homes.
What about the postgraduate programs in family medicine?
Family medicine has finally been accepted as a specialty, so now the government is working toward regularizing the posts for registrars. We are evolving toward accrediting complexes where a family physician will always be present. There will be learning away from tertiary hospitals so these physicians won't have to be taken out of their work areas. The complexes will have libraries and students.
We don't want accredited learning complexes just for Walter Sisulu University. We want them all across South Africa. That's why in our family medicine education consortium (FaMEC) we are trying to help each other develop these complexes. Also, we want this to happen in East Africa. And we want a uniform curriculum and a uniform exit exam.
What is the role of family medicine in Africa?
It is the only discipline that has fully adopted the philosophy of primary health care. We feel that if we are going to really improve the services to the majority of people in Africa, we must emphasize primary health care. Only about 5% of the population need the services of the specialist. We want to make sure that there are more properly trained family physicians, so they can take care of 90% of the problems in the community and minimize the referrals to the more expensive tertiary care levels of care.
You've been working in HIV/AIDS.
It's problematic in South Africa. All disciplines can have something to do with HIV. We think that family physicians are the proper coordinators. We need to develop a comprehensive program that includes TB because HIV/AIDS and TB go together. We need to include nutrition.
We're proud that Walter Sisulu University is one of 6 sites that have been chosen for the South African AIDS Vaccine Initiative (SAAVI). We've also been developing health centers for comprehensive care including HIV/AIDS. In a year or two we hope that we'll have what we're calling a Wellness Village, which will again have a focus on HIV/AIDS in its totality. I'm also leading this effort.
What is your vision for this Wellness Village?
In the village we will make sure that the principles of wellness are adhered to. One unit will take care of the medical aspects, including palliative care. Palliative care is a continuum, so it can be appropriate for someone who is not dying. I'm also involved in the local hospice. I'm the chairman.
When do you sleep?
[laughs] Our local hospice is focusing on home-based care. Hospice workers, who are nurses, take our fifth year students with them for home visits. Students say that this is one of the most wonderful experiences in their training.
Our current hospice program doesn't have any in-care so in the Wellness Village we're planning to have an in-care unit. We'll also have other things that go with holistic care, such as occupational therapy, physiotherapy, a nutritional unit, and a sports facility. We also want a unit that will focus on primary health care research with a focus on HIV/AIDS. We think this will be the home for the vaccine.
We're also going to promote both subsistence and commercial agriculture. And there will be a training center for youth who want to run small businesses.
Where will the Wellness Village be located?
We have identified an unoccupied farm that is next to the university and we are leasing this from the department of land affairs. Next year we'll have a big launch to start raising funds.
The Wellness Village could become a model for the world. So when do you sleep?
Ask my wife. She says that when I retire, I will still get in my car and drive to work [laughs].
You clearly are making a significant difference. Thanks for sharing your activities and dreams. Best wishes in all your current and future projects.