As a volunteer with the American International Health Alliance, Volunteer Healthcare Corps, I had been working for several months with students from the clinical associate program at the University of Pretoria, South Africa. I was precepting second-year students who were continuing their training in the patient wards of the underresourced government hospital in the impoverished township of Mamelodi, east of Pretoria. The students were part of the bachelor of clinical medical practice degree program and would become clinical associates after 3 years of education and intense hands-on training. This health profession is very similar to the physician assistant (PA) profession in the United States, and because of my 14 years of experience as a PA in family practice, my assignment fit me well.
On a warm day in April 2013, I met 16-year-old Themba. He was a young patient in the adult medical ward of the Mamelodi District Hospital, where there were four patients per room and more patients than rooms available. Around him were three grown men who were quite ill, two of them cachectic and coughing, riddled with miliary tuberculosis. My student, Katlego, called me to Themba's bedside.
Katlego was concerned about Themba. He was exceedingly weak and thin. His legs were swollen and mottled in appearance, and his arms were thin as reeds. His head seemed too large for his small body, but his swollen, pleading eyes were the most haunting.
Themba was so weak that he could only whisper, making it hard for us to hear him. As we stood by his bed, his irregular pulse, decreasing BP, and slowing respirations caused us concern. Being touched on his cool lower extremities brought him discomfort, though he never whimpered.
He had no tubes, no IV lines, no pumps or alarms. He was shifted down in the bed and looked uncomfortable. Katlego adjusted him further up in the bed and stroked his arm. The chart was at the table below his bed. Themba's laboratory values were there in black and white, and the numbers were telling.
He was an orphan. His parents had both passed from AIDS-related pneumonia. As we reviewed the chart, a small group of people came to the room. They were from a nearby church. They had been looking after Themba and his younger sister. They were smiling at him, sitting close by, and later started to sing.
Katlego and I slipped out of the room and added our findings to Themba's chart. That day we discussed many aspects of Themba's illness and, together with the ward physician, we developed a plan. I returned to Themba's bedside after the students and physicians had left for the day. Themba was desperate to speak but could not, either because of physical difficulties or because of a language barrier. We were able to communicate only through our eyes. He knew he was dying, and I tried to comfort him through soft eyes and a warm touch.
When I returned to the hospital the following day, Themba had passed. His body had already been removed and replaced by another equally ill patient. Themba succumbed to AIDS, which his sister, his only remaining sibling, suffers from as well. I will always remember Themba's courage and strength in his final day and the important role he played in teaching human dignity, respect, and love to Katlego.
Clinical associates, the profession Katlego hoped to join, are well trained to provide excellent quality healthcare for South Africans like Themba who are not fortunate enough to have private insurance. Students like Katlego are identified in matric (high school) as intelligent, sharp in sciences and math. When they are accepted into the university, they are often supplied with a bursary from the government to cover costs, with an agreement that they will work a year for the government for each year of bursary received. They are grateful for the opportunity.
As a medical provider, I am grateful for the time that more experienced providers—physicians, nurses, and PAs—gave me in my training. In turn, I tried to pass that gift on to Katlego. Part of my job with the Volunteer Healthcare Corps at the University of Pretoria clinical associate program is to see patients at the wards with the students. Together we perform a thorough and appropriate physical examination, make an assessment, and craft a management plan—all key steps in patient care.
The students in the clinical associate program are hard-working and self-driven, and the curriculum is rigorous. They are responsible for a large amount of work at the hospital wards and on-call hours in the casualty department. They are forced to learn quickly and develop diagnostic acumen as well as practice many procedural skills. They frequently perform spinal taps, insert chest tubes, and remove drains, for example. They know that even though they are training to work under the supervision of a physician, the reality is there are not enough physicians. The clinical associate students are preparing to be able to work in rural clinics with physicians available only remotely.
In Themba's eyes, I saw hundreds of young men just like him, resigned yet courageous. In Katlego's eyes, I saw determination and compassion, striving to make a difference to her patient. In my eyes, I saw resolve to continue my commitment to be a strong leader and teacher for the students of Mamelodi and the University of Pretoria, humbly guiding them through this important phase of their education. These clinical associates are the pioneers in their field, as PAs were 50 years ago. What an honor to be able to mentor and encourage them, and to help them develop confidence that they will make a difference in their communities.
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