HEAD OF DIVISION - Professor Gail Todd
The Divisions training programme includes undergraduate teaching of 2nd to 6th year MBChB students. Postgraduate students include 8 registrars, 1 MRC fellow and 2 PhD fellows. Despite limited staff our division supervised 15 second year students in 5 research projects and 2 fifth year students during their electives in 2010.
The core undergraduate dermatology module is taught as part of the mixed specialities block of the 5th year of the new curriculum Students in the dermatology 7 day block benefit from intense small group, facilitated problem orientated, patient-based tutorials and receive in course assessments based on case presentations. An OSCE, held at the end of each block, and a final scenario-based examination using slides and short answers completes the assessment and appears to offer a discriminatory student assessment. Course evaluation (one station of the OSCE) highlights the time constraints students experience with a unanimous request for more time to be allocated for the teaching of these specialities. A favourite student and staff component of this 8 week block continues to be the monthly two-day field trip to outlying clinics. Here students see and manage dermatology and ENT cases under the supervision of consultants and registrars from both divisions, giving them a taste of clinical practise. These clinics are a perfect example of how service can be linked with teaching at all levels of health care as up to 200 patients may be seen on any trip.
Our e-health and distance-based teaching platform, a joint project with CHED, assesses participants ability to identify morphology, use it to reach a diagnosis and then implement appropriate therapy. The course is designed in such a way that a limited number of attempts are allowed to answer each set of questions, after which participants are asked to read given literature before starting again. To prevent rote learning subsequent attempts make use of different case scenarios randomly selected from a central bank. It was hoped that the service would relieve the pressure on our small department for teaching both locally and nationally. Although our first module has been designed and piloted on Vula it awaits additional case scenarios for completion and new modules need addition. The project remains stalled due to lack of finances and key CHED staff resignations
Postgraduate dermatology training is continuous and intense. Our division remains active in facilitating a unified national dermatology examination platform as 3 of our consultants are on the committee of the College of Dermatology. In recent years the training base of these registrars has been slowing undermined. Problems with National Health Service appointments have meant that dermatopathology, which is an integral component of our HPCSA approved curriculum, has been gradually reduced. Teaching has to be provided by private pathologists on a sessional basis paid with Departmental of Medicine DOE funding. In recent years medical consultations for skin problems within the hospital complex has declined decreasing the medical and infectious skin disease exposure of the registrars. A resurgence in the spirit of academic learning and knowledge sharing is soely needed. A portfolio of in-course training, including clinical competency in procedures essential to the practice of dermatology will be required from 2011 as will a research component. The additional time and supervision needed for both these additions to the MMed will severely stress the 4 consultant staff equivalents in our Division.
The division contributes significantly to the occupational health curriculum. Occupational Health registrars spend 6 months in our Division rotating through the occupational skin clinic and general clinic. They provide a service and do regular work place visits writing a review article based on a case seen for publication.
Ten nurses successfully completed the Dermatology Nurse Course run in collaboration with the Division of Nursing, including a candidate from Kenya. This brings to 150 the total number of nurses trained to date. PN Patricia Kelly is the course convenors. Dermatology nurse run services are offered throughout southern Africa and local clinics are being incorporated into our teaching platform as primary health care teaching nodes. The first formal dermatology day care centre will open in Mitchells Plain in 2011. A post graduate diploma in Dermatology Nursing will start in 2012. The course and nurses continue to be supported by Rotary with the awarding of annual Rotary bursaries and prizes. The International Federation of Anti-Leprosy Associations lists the course as approved for leprosy field worker training internationally.
Interns rotate erratically through the division for periods of one week. The rotation helped to address the lack of undergraduate exposure identified by the HPCSA and national primary health care units especially with outreach sessions at dermatology nurse-led clinics in Hout Bay. Dr Rannoeke Lehloenya provides annual dermatology refresher courses for the intern group.
Dr Rannakoe Lehloenya leads a study of the clinical, molecular and genetic aspects of severe cutaneous adverse drug (SCAR) reactions as a PhD fellow in the division. Intrinsic to this will be the development of a predictive model for ascribing causality to ensure safe drug reintroduction especially for antituberculosis treatment reactions. Several other closely related clinical studies include a follow up of patients to assess long term sequelae, evaluation of placenta and newborn following SCAR in pregnancy and the use of clobetasol to prevent nail sequelae of SCAR. The division has become the only African member of the international group, RegiSCAR, contributing cases to the group database, essential as the cause of these reactions in Africa is very different from Europe and Asia.
Our work in atopic eczema has brought further collaboration with overseas researchers and the role of filaggrin gene mutations in local Africans with atopic eczema is the basis of a PhD project for Dr Fatems Esmail, a joint project with the University of Dundee, Scotland, University of Dublin, Ireland and Zurich University, Switzerland.
Professor Nonhlanhla Khumalo and Dr Laduma Ngwanya continue to research African hair disorders. A study on cytokine profiles of the scalp after hair straightener use together with Dr Rene Beach, a visiting registrar from Canada, has been completed. The management of acne keloidalis a uniquely African problem is the MMed project for Dr Nomphelo Ganthso.
Dr Motsepe completed her ALLSA funded study of the relevance of a positive latex specific IgE result in a non-medical occupational setting. She will submit the study for her MMEd in 2011.
Dr Thuraye Isaacs is comparing the clinical patterns of Kaposis sarcoma relative to HHV8 clades in a joint project with the Dr Arieh Katz of the Division of Medical Biochemistry
Dr Anita Bonthys, our current MRC research fellow, is currently completing her MSc evaluating epidemiology and molecular aspects of pigmented naevi in collaboration with the Department of Human Biology. Disorders of pigmentation including the molecular basis of vitiligo, the role of khellin in repigmentation, and the low incidence of cancers in vitiligo patients remain an important focus of our collaborative research work together with Professor Sue Kidson, Dr Lester Davids and Dr RRobea Ballo of the Department of Human Biology.
Service and outreach
Divisional teamwork has made the substantial contributions of 2010 possible, as, in addition to teaching, our small staff is responsible for in excess of 90,000 patient contacts per annum. The selfless efforts of the supernumerary staff and many visitors to South Africa are acknowledged. Visitors and unpaid staff who deserve special mention include our willing supernumerary registrars, Dr Fatema Esmail, Dr Didi Motsepe, Dr Thuraya Isaacs and Dr Ilana Steenkamp.
In line with the 2010 health plan for the Western Cape we continue to try and improve community based dermatology patient care. Following a land mark meeting with Dr Keith Cloete and regional directors from the Provincial Government of the Western Cape, Tygerberg, Groote Schuur and Red Cross Hospitals administrators, nurses and dermatologists, a platform of care for dermatology for the Western Cape was proposed and accepted. Pilot, nurse-led day-care centres at key community health care centres will be supported by direct contact and telemedicine backup from tertiary care centres. The first facility is being built at Michels Plain for commissioning in 2011. Integral to this nurse-led service is the requirement that the nurses receive appropriate training and recognition. A diploma in post graduate nursing for registered nurses has been approved by UCT and the Department of Education and will start in 2012.
Outpatient attendances remain unchanged despite a relentless reduction in state funded staff and represent an enormous increase in divisional and individual output. The demand for dermatology services continues to be fuelled by the HIV epidemic and increasing population in the Cape Town area. Patients with HIV disease present the biggest challenge as the recalcitrant nature of the skin diseases often leads to increased inpatient admissions. Inpatient numbers thus remain unchanged with bed capacity at above 85%. The burden on the nursing staff has increased beyond what a simple analysis of figures shows. Skilled core staff, who leave the service for a variety of reasons, are not replaced and reliable skilled relief staff is seldom available. Severe drug reactions are a daily challenge to the small group of loyal nursing staff. These reactions are usually caused by antituberculosis therapy, cotrimoxazole or nevirapine. Each patient requires high care, barrier nursing, the cornerstone of management, and this must be accommodated in a busy routine daily schedule. The need for high care beds to manage these patients was formally acknowledged in 2010 but acceptance of the need for appropriate nursing remains a stumbling block despite a patient charter of rights. PN Wallace, PN Kennedy and the nursing staff of Ward G23 need to be acknowledged for the huge burden they shoulder, the sterling care they render and the extremely low mortality and morbidity record achieved.
Professor Nonhlanhla Khumalo was appointed to a full time senior consultant position at Red Cross Hospital. This has meant an improved and sustainable skin service for children again. SEN Williams in the Oasis Crescent Trust day care unit treats and educates up to 200 children with severe skin diseases monthly. The approximately 5000 outpatients, inpatients and consultations managed during the past year require a team of health care workers. The paediatric service and its outputs represent the combined effort of the Division of Dermatology as a functional single unit.
Specialist problem clinics have grown in recent years. The occupational skin disease clinic has been running since 2000 and is increasingly used as a tertiary referral for occupational doctors and nurses. A specialised clinic for problems of the hair and scalp, run by Dr Nonhlanhla Khumalo and Dr Ngwanya remains a service in demand. Outpatient tertiary specialised clinics for children with specific, complicated skin diseases such as disorders of keratinisation, epidermolysis bullosa, and vascular anomalies have improved care for children with these problems. Phototherapy clinics are run twice monthly and a recently introduced infectious skin disease clinic managing increasing numbers of patients with leprosy and other tropical infectious provide unique opportunities of learning for registrars. Combined clinics for the management of skin cancer and lymphoma are held in collaboration with the Department of Radiation Oncology. A problem patient clinic is held monthly with dermatologists in the private sector.
PN Lynne Kennedy and ENA Athena Israel handle a steady patient load of 400 to 500 patient visits per month in the dermatology day-care centre, including children as it is the referral unit for Red Cross Hospital. It is the only training and referral centre of its kind in South Africa drawing patients from all over southern Africa for management of difficult skin conditions. New bed phototherapy equipment acquired in 2010 means that the service will be improved.
The teledermatology service and distance-based teaching platform continues with daily teledermatology clinics being a regular features of both registrar and consultant rotations (firstname.lastname@example.org). The acceptability of the programme to provider and patient and its educational value has been accepted for publication. The suitability of a cell phone based network approach forms the basis of a research project for Dr Samantha Eisman. She was awarded the Dermatology Society of South Africa research award for their project. In 2009 we became one of a team of international referral centres for Medicines Sans Frontiers and have received 50 requests from all over the world.
Southern African outreach remains a significant part of divisional service and teaching. Professor Gail Todd serves on two subcommittees of the International Federation of Dermatology to establish global patterns of skin disease and develop a curriculum for all levels of health care allowing for local adaptations. Dr Rannakoe Lehloenya and Dr Fatema Esmail were guest speakers at the annual continuing medical research meeting at the Regional Dermatology Training Centre in Moshi Tanzania. Monthly outreach teaching clinics to rural areas in the Western Cape as part of undergraduate teaching are increasingly popular for patients and staff who benefit from on site appropriate training. Registrars and consultants from the Division provided popular monthly teaching session for health care providers at Kayelitsha. PN Pat Kelly runs a weekly dermatology clinic in Hout Bay and is the African representative of the International Skin Care Nursing Group.
The private and public service delivery divide of recent years continues to deprive our registrars of exposure to a sector of health care that the University of Cape Town, Skin & Hair Centre at the UCT Lung Institute provides. This complementary service for colleagues in private practice continues to grow as a specialist referral facility for outpatient management of private patients with skin diseases. It is an essential postgraduate teaching resource. Dermatology registrars participate in specialist clinics, phototherapy and research conducted at the centre.The first public skin laser unit that was commissioned in 2008. Despite increasing numbers of referrals it was unilaterally closed in January with the withdrawal of the sister appointed to run the service by the Nursing administration. This left the hospital and division in the embarrassing position with the donor, Oasis Crescent Trust. The unit has since been re-opened in the spirit of the public private partnership that underpinned the donation. The unit and facilities will be maintained by Groote Schuur and revenue generated from cosmetic hair removal will be used to fund PN Hilary Lochner, the nurse-tutor employed to run the service and provide training for registrars via a UCT research fund. The unit is available to all hospitals in the Western Cape and it is hoped that it will develop into a national training centre.