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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574





Following his passion is 'life-changing' rural award winner



Most doctors can recall a career-defining moment of choice when events combined to offer divergent paths. For Kelly Gate, this year's Rural Doctor of the Year, it was, he declares dryly, 'either fame and fortune, or peace and tranquillity'.

Today's medical manager of the rustic Bethesda Hospital in far northern KwaZulu-Natal (no guessing his choice) is describing a moment two years ago when, fed-up with 'catching fainting patients' in Britain to pay off his student loan and on the verge of a registrarship at McCords Hospital in Durban, that that telephone call came.

It was Mrs P S Khumalo, the CEO at the 222-bed Bethesda Hospital, begging her stalwart former community service officer (comserve) to 'come help-out' after her solo medical officer fell ill, leaving three wide-eyed comserves stranded in a sea of needy patients. Gate, then 32, consulted his dietician wife Mary-Jane, whom he met at Bethesda during her community service year. 'I asked her what do we want ... fame and fortune or peace and tranquillity?' It was a 'no-brainer' - Bethesda was their rustic romantic idyll, it posed a wide variety of exciting clinical challenges (a fixed-wing medical outreach air service was also based there), plus it was in the heart of an internationally famous ecotourism area, and was safe (they sleep with doors unlocked). Socially, Wednesday nights at the local Mkhuze Cricket Club (sporting an 'awesome restaurant') were legendary among the local game rangers, sugar cane farmers and doctors.


Synchronicity of events boost Bethesda

That initial professional pledge by the Gates and its evolution into a 5 - 10-year commitment, was initially built on some serious serendipity. 'Just as we arrived in November that year, four foreign-qualified Brits were dumped in the deep-end with us, followed by some strong comserves in January'. Things unexpectedly began to look up for the tens of thousands of mainly low-income or indigent Zulus that depend on Bethesda District Hospital for their healthcare.



Says Gate: 'Numbers [of doctors and nurses] make a massive difference. It's not just the medical care that deteriorates, but the nursing care, wards start getting neglected and people seem to forget their responsibilities. Nurses do stuff they're not qualified to do. Just having a team leader [doctor] supporting, teaching and talking to them makes a huge difference to morale and the level of patient care. We try to make the work environment as conducive, as informal as possible, attractive to the young guys coming here for a bit of adventure. We listen to them. Support their projects. We've built a fantastic group of doctors, all singing the same tune and really dedicated. Our comserves stay. At present we've got 10 doctors [including Gate], with another four due before the end of September (2012), and a further three before the end of October [his out of 30 medical officer posts available].'

When numbers are up (and a 50%-plus doctor complement in a rural South African hospital is rare), Bethesda can implement decent policies and protocols, 'not just chip away, trying to put out fires'. Says Gate: 'You can then actually take an hour or two to get to the root of a problem and find out why the results are not in the files. I go on and on about getting back to basics but really, things have become way too complicated. I mean we still have kids dying of dehydration because they aren't referred early enough . and kids dying of malnutrition. Now we're getting our doctors out to the clinics with the dieticians, teaching nurses to fill out growth charts and recognise the signs. It's about basic manners, basic ethics, basic health care, basic everything,' he adds.

Bethesda has over 6 500 patients on a nurse-initiated antiretroviral therapy programme (from a base of just a few score in 2004), and 70% of its nursing posts are filled. 'We're still grossly short-staffed but I think staff shortages can often be a lame excuse for the mistakes being made ... a lot of what we're working with has nothing to do with staff shortages. Fair enough, the patient waiting times are way too long . but bed sores have nothing to do with staff shortages - that's about getting back to basics, doing things properly the first time. Our nursing training is not up to scratch so our doctors spend as much time as possible with them,' Gate adds.


Tackling the 'night shift syndrome' head-on

Another innovation is introducing night shifts for doctors - after he noticed patients being neglected at night. Gone are the sapping 24-hour and 36-hour shifts. Added is a single, week-long night shift (19h00 - 07h00, Thursday to Thursday), every 10 weeks for each doctor, with a daytime colleague on night-time stand-by (for infrequent emergency caesarean sections or major highway accidents).

'It seems to be working. Previously nurses felt they couldn't call tired doctors and doctor response times were also pretty unacceptable. Now there's no ways the doctors want to go back to the old system. When they're called, they come and we've no longer got patients overnighting in the Outpatients Department [OPD]; if they come in at 20h00, they're seen that night.'

Gate is proud of the new clinical outcomes, the most impressive of which is a perinatal mortality rate that has dropped from 30 per 100 000 to 13 per 100 000, just over the past year. When he got to Bethesda there was one working incubator, one SATS machine in theatre and one Ambu Bag in the entire hospital, and all the ET tubes had expired. Now there is a resuscitation trolley in every clinical unit and a multi-parameter monitor in every ward with a fully stocked emergency resuscitation room and high-care unit.

Resuscitation training is obligatory. Their newly diagnosed diabetic inpatient programme is world class and their next ambition is to start up a home peritoneal dialysis programme and inpatient peritoneal dialysis.


'Good clinical fun' -Gate

'Clinically I reckon we're one of the strongest district hospitals around. We're doing things normally done in the academic centres. This is good clinical fun. It's what everybody becomes a doctor for. We're doing all our own obstet emergencies. If a comserve stays on here, basically they get snapped up in reg posts because of the confidence they've gained. As a junior you're seldom left on your own. There are no horror stories of unsupervised junior doctors over weekends. We've got a fantastic group of strong, dedicated, vibrant young doctors who are having the time of their lives,' he adds.

The proof of the pudding is in the eating. Bethesda's OPD numbers and bed occupancy rates have shot up dramatically, with some patients travelling from over 100 km away. On average the team sees 100 -120 outpatients per day. Bed occupancy rates are up to 80%. Paediatric inpatient mortality is down to 3% per month. Adult inpatient mortality has dropped to about 10% and maternal mortality has been eliminated while obstetric-related maternal mortality is down by 150%. Before, it was a hospital to avoid. No longer - it's now a beacon of hope and a magnet for healthcare professional recruitment agencies like African Health Placements (AHP), who actively seek it out for their overseas and local prospects.





Some of Gates' observations are supported by research at the University of the Witwatersrand Medical School's Rural Health Advocacy Project (RHAP). The project identified governance and leadership and human resources for health as the top two challenges for rural healthcare. In his citation for the 2012 prestigious Pierre Jacques Rural Doctor of the Year Award (a joint award by the Rural Doctors Association of South Africa (RUDASA), the RHAP and AHP), Gate is praised for his 'inspiring story of how a good medical manager turned services around ... resulting in patients voting with their feet. He should be celebrated for his remarkable contribution to rural healthcare in South Africa.'

It seems fame (and good fortune) are inescapable, especially when you follow your heart's desire, and peace and tranquillity are the bonus.


Chris Bateman
