South Africa’s Clinical Associate (Clin-A): The PA Model Around The World

This is part seven of a nine-part series by documentary filmmaker Adam Halbur on the PA model around the world.

Today we take a fascinating look into the real-life of South Africa’s pioneering PA-like clinical associates.

South Africa’s Clinical Associate (Clin-A)

Starting with programs at Walter Sisulu University and the University of Pretoria (2008) and at the University of the Witwatersrand, or WITS (2009), South Africa’s clinical associate (Clin-A) is one of the more recent to join physician assistant-like professionals around the world.

I visited the Bachelor of Clinical Medical Practice (BMCP) at WITS in Johannesburg, where I found the students and teachers as refreshingly current as any student in the United Kingdom or the United States.

I hesitate to make overarching generalizations, but perhaps there is a more-established middle class in South African cities, imbued with a different attitude growing up in a pluralistic, politically liberated society under Nelson Mandela, than students and educators in countries like Kenya and India that gained independence early on and still suffer under a hierarchical ideology lingering from colonial Britain, even though that empire’s physical infrastructure went into decline long ago.

Instead of “sir” and “madam” following up every phrase in overt reverence to faculty and administrators, I found a more collegial, if-not irreverent, atmosphere one would find among players and their coach.

An Interview with Clin-A Educators

Academic head Scott Smalley, a U.S. physician assistant, and Clin-A educators Victor Mokokotlela and Aviwe Mgobozi sat down to talk with me in 2017.

Both Mgobozi and Mokokotlela were among the first graduates of the WITS program.

“I didn’t really know what it was about,” recalled Mgobozi when considering the program. “And I just thought, ‘OK, let me do it because it’s still within health care and it’s still within medicine.’ And so I thought because I want to help people because I want to work in the hospital, I still sort of in the same field. And then we just started. And we were a very small class of 25.”

Later, while driving me to another interview, Mgobozi told me more in-depth about how she was inspired by her mother, who is a physician in Port Elizabeth:

"I grew up in an environment where I would go and sit at the surgery and greet the patients and just run around there—she’d have to chase me away. So I think that the environment influenced my decision to apply for medicine. But I was interested in just how you would help a sickly patient, the medicine or biology behind it. And I just saw the relationships she had with her patients. It was more than just a strictly formal, ‘OK, I’m the doctor. You’re the patient.’ And so I grew up really wanting to be part of that. And she loves community work. And she’s really, she’s more into community health. And I was inspired by that and so applied for medicine."

Things didn’t go well the first year and Mgobozi transferred into the clinical associate program, but she said that she’s happy and doesn’t regret her decision.

She also continues to share her interest in medicine with her mother.

“Even now, when I go back home, I’ll be there with her,” she said. “And we’ll have conversations about patients and, you know, what’s prevalent in the community now. She’s like an HIV specialist, so we still have those conversations. Not many daughters and their mothers have these conversations, but we really do. Like we talk about guidelines and HIV, so it’s nice to have that.”

A Day in the Life of a Clin-A Student

I found similar passion in a first-year student from Limpopo, one of the most rural areas, where HIV infection is high but where there is a clinic only every 60 km.

“It's very difficult to get people to engage, to donate and voice out if you're on the outside,” she explained about choosing to become a Clin-A, “but from the inside, people actually take you seriously. So it's more about me getting people to be helped than me helping—two hands are not really much, but if I get more people to engage, it can really benefit a lot of people's lives.”

Others in her group agreed, but they all appeared more interested in the latest episode of Game of Thrones they were discussing before the interview, and more worried about meeting the higher standards of university academics.

“It’s pretty difficult," the Limpopo woman said, “because if you look at the South African education system level in high school and you compare it to the education level that we have here, there’s a really broad gap, so we have to do a lot of work to catch up and understand when you get to university.”

Another woman found it difficult navigating the BMCP’s integrated curriculum.

“It gets a bit messy at times because it has your anatomy, your physiology, your pharmacology all together,” she said. “Whereas other degrees perhaps will have anatomy, physiology separately. But when it’s all mixed, it’s just that the workload is so much.”

While first-year students have a lot of memorizing to do, they also begin to learn problem-solving skills.

“They taught in a symptom-based way,” recalled Mgobozi. “So you would just write ‘cough’ on the board, and then we started brainstorming what could the possible causes be for the cough.” “At first it was very difficult to get the hang of that,” Mokokotlea added, Can’t we just study, just read our books? Tell us the various different causes for a cough, and then we’ll memorize those and when you ask us tomorrow in class as to what the causes of a cough are, we’ll just list them off like that. But it wasn’t like that. It was just ‘cough,’ let’s think about a cough. What is affected when a person coughs? It’s the lungs. You just write ‘respiratory.’ It could also be the heart, ‘cardiovascular.’ So we thought, well, at the time, I thought, ‘It’s really difficult.’

Rotations and Objective Structured Clinical Exams

These mapping skills are important as second-year students are already beginning to have hands-on experiences, mainly at Chris Hani Baragwanath Academic Hospital, in Soweto Township, the third largest hospital in the world.

“Today we’re going to do work on child health, and we’re teaching them integrated management of childhood illness, which is a protocol process to help treat children under 5 years old,” said Smalley on the way to lead a group of second-year students at Chris Hani. “There are five big mortality diseases that affect children, and this is one way we can identify that early so we can get the child the help they need before problems become too challenging, and it often becomes too late.” Third-year students also get experience at Chris Hani, such as in the ER. “The emergency department is very busy,” said Smalley.

It sees lots of trauma patients. South Africa seems to have an undercurrent of quite a bit of violence that they say is often hanging over from the Apartheid days. So on any given day, there’ll be gunshot wounds, there’ll be stabs, a lot of domestic violence, intimate partner violence.

So our students are exposed to some opportunities here of really tremendous learning —to do some emergency medicine work, also in the wards, and HIV clinics, in the obstetric wards.

Third-year students preparing for their OSCE (objective structured clinical exam), including doing lumbar punctures, said they focus on those common cases.

“We deal with a lot of relevant things in class,” said one. “We deal with a lot of conditions we are guaranteed that we will see as opposed to your once in ten.” “So yeah, you become very good, very good,” added another.

Chris Hani, a public hospital, caters mainly to a local population that has risen economically post-Apartheid but still cannot afford the private care many wealthier people can buy. Smalley said there are efforts to implement a national health scheme to rectify these inequalities:

Inequality and South Africa's National Health Insurance

There’s this big inequity of health provision in South Africa. If you have money to afford medical aid, which is like health insurance, or if you work for an employer that can provide you that, then you can go see the private doctors and pay substantially more but also get deductions through the medical aid scheme. But if you don’t have either of these, then you can go to any government health facility and receive free care or for very minimal charges for certain procedures. But there’s a real inequity in that distribution and what’s provided because the government health sector has very little money and resources to hire and retain doctors, to hire clinical associates, to hire nurses, to hire and to staff it, and to have the resources available—you’re always running out of medicines quite often, of sterile packs quite often.

"You’re not able to run your theaters. Whereas the private sector gets all of the resources, but only 20 percent of the population. So then in the last six years, there’s been a movement to try to equalize this with the national health insurance scheme, NHI. And so that all South Africans will be provided with health coverage, and they can go to the private sector or the public sector, and the idea was to bring up the public sector so it meets the same provisions as the private. And so they’re going to have to redistribute these resources. You’re talking about pulling money away from private and putting more into the public. And they’re going to have private doctors starting to work more in public, and private facilities accepting what were public patients."

Reading online comments on news sites, I encountered some skepticism the NHI would work, leading to additional fleecing of citizens; only if properly funded and implemented, with the citizenry truly in mind and not private interests, can it succeed.

"The NHI would also benefit the clinical associate and vice versa as the scheme would offer 16 services of health care needs from pediatrics to maternity to surgical to etc. etc.,” said Smalley. “But the opportunity for us as clinical associates is that we can get in on this national insurance scheme and our clinical associates can be employed at either place because they’ll be flexible enough to be here or here.” Mokokotela added, “Of those 16 goals of the NHI, clinical associates satisfy 10 of them.”

A Lack of Growth and Recognition Cause Many to Leave the Profession

Clinical associates are already working both in private clinics and private hospitals. And while Clin-As seemed more autonomous in private practices, there was a sense of restlessness among both camps. Zenande, a Clin-A in internal medicine doing cesareans at Bertha Gxowa, a public hospital in Germiston, Johannesburg, said,

"Honestly, I’m looking to leave the field. I’m happy doing my work. I’m just not happy about all the other things—salary, lack of appreciation, you know, there’s so much. There’s no growth. There’s no academic growth currently. There’s only that one program at WITS for emergency medicine. What about the rest of us that don’t want to do emergency medicine but have other specialties? So there’s no growth academically. There’s no growth financially. There’s no recognition from our health department. So that pains me. As much as I love what I’m doing, but when I go home, you know, and I want to grow; I’m not getting any younger."

Nhlanhla working in general practice at a private clinic expressed a similar desire to advance:

"I love family practice. If in the future there would be maybe an honors in internal medicine, then I think I would go for that because I love internal medicine. And in the future, actually, recently I applied with Adventist Health in California. The only challenge was that I had to register as a qualified certified physician assistant from the states, whereby I have to go for two years to a PA school in America. So that was a bit of a drag, which means I would have to quit working and go back to school fulltime, and then the responsibilities take a toll."

Clinical Associate Professional Demographics

According to Smalley, of those students that had graduated before 2017 about 5 percent typically wanted to go on to further studies, even in new professions, about 4 percent went to academics, 6 percent went into nonprofit work, and another 6 percent went into private work, whereas 80 percent went to the government. Mgobozi added many leave because they are not finding the stability they seek since the clinical officer is such a new profession and still establishing itself.

Mokokotlela and Mgobozi are among the 4 percent who were able to leave practice to go into academics.

“There’s a whole lot of gratification from teaching,” said Mokokotlele, but stressing the need for role models for this new profession. “I’m hoping that a lesson is better learned from a role model than a person who’s not.”

Why do You Want to be a Clinical Associate?

When I asked why he became a Clin-A, Mokokotlela said he gives a different story every time

"There are just so many reasons. I think what I first said…. At home, we had chickens. We had outside rooms and there was a toilet outside. We used to sleep in there, in the outside rooms, in the staff quarters; it was traditional old housing. There was a toilet outside, so one of the chicks, a couple of chicks actually fell in the toilet, in the bowl there. And some of them drowned. I used to watch Baywatch with Pamela Anderson back then. And I saw CPR for the first time on Baywatch. And I did CPR on a chick, or chicks—one survived, one died. One died, one survived. I’m made for this."

As with the chicks, his first CPR on a human subject wasn’t successful but the second was.

“But I thought, ‘I was made for this,’” Mokokotlela said. “And I realized this when I was seven years old. So that’s why I’m here because of a chick I did CPR on.” “You save lives,” replied Smalley, while Mgobozi laughed.

Perhaps, in the end, a good sense of humor is the best quality Clin-As could hope as they move forward into the next decade.

About the Author

Adam Halbur is a writer and teacher living in Tokyo, Japan. A short version of his film As Good As You Can, As Professionally As You Can premiered at the 11th annual conference of the International Academy of Physician Associate Educators. Watch the “American Cheese” segment of the longer version here. Watch a short of the 50th AAPA Conference with interviews from Ruth Ballweg and David Kuhns here. Halbur is entirely self-funded, so if you appreciate his work, please consider making a small contribution to his feature documentary on the Kenyan clinical officer.

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