On ComServe, and the Desroches Case

My friends and I have this joke among ourselves. We say that medical school is like slavery. But then we say, it’s actually WORSE than slavery, because we PAY to work ridiculous hours in ridiculous conditions. As you can see it’s kind of more of a tragedy, but we’ve chosen to make it a joke. For our sanity’s sake.

So in light of that you might be surprised to find that my overwhelming feeling towards the Miguel Desroches case is not a good one.

comserve

Here’s a quick rundown of Community Service Years (also known as ComServe or Zuma Years*):

All South African healthcare practitioners have to complete a compulsory year of community service in a public, usually rural, setting. Allied healthcare workers do this year straight after graduation, pharmacists after first completing a year of internship, and doctors after completing two years of internship.

If they do not complete said year, they will not be recognised by the HPCSA, and cannot practice in South Africa.

Here is a disclaimer: I don’t know this doctor. Some of my colleagues know and have worked with him, and say that he is a real swell guy, with really good arguments. At any rate, those good points do not come across in the article above, mostly because it vilifies the parties involved to excess.

First: Working Conditions

This is the part where I think Desroches has a good point, albeit an incorrect approach.

Truth: junior doctors do work way too much unpaid overtime. There is really good article explaining that here. That is one of the things I look forward to least: because I know how hard it is to put one’s foot down and refuse to work unpaid overtime. As the most junior doctor at an institution, it’s pretty impossible to put your foot down about ANYTHING.

But firstly, that case belongs in the Labour Court. Not in the Constitutional Court (at least, not yet).

And even before it goes to the Labour Court, there needs to be proof that due process has been followed to air grievances – that the correct channels were followed, and that they failed. You can’t just take an employer to court before following the internal procedure in an attempt to resolve the problem! Now that would be wasting tax payers’ money.

JUDASA (Junior Doctors’ Association of South Africa) is supposed to speak for all young doctors. I’m pretty disappointed that they are not taking this to Labour Court, instead of this one doctor, who seems to think he should speak for the profession.

I don’t blame him for wanting to speak for us. I know what it’s like getting annoyed because NOBODY’S DOING ANYTHING about a situation! I just can’t help thinking that there should be a way of involving us, and making it a group thing.

As for JUDASA not doing anything: it IS an association run mostly by junior doctors. The association doesn’t have too much clout when you plot it against a Head of Department or some famous professor.

Second: Community Service being Unethical

As for ComServe, Desroches seems to make a good point about the justifiability and humanity of a forced community service. The earlier article, by Erasmus, also has a good explanation of forced labour by the International Labour Organisation.

Essentially, for labour to be forced, it must be coerced and involuntary. The coercion in this case is that doctors may NOT practice in South Africa if they do not complete the year. The involuntariness comes down to the fact that by far the majority of placement sites are in rural and under-resourced hospitals, and are really not a pleasure for young doctors to work in.

I’ll skip over the obvious, “But you KNEW this when you decided to study medicine!” because that’s pretty flawed even though it is kind of true.

Here is why I don’t think that the compulsory Community Service year is unconstitutional or unethical:

Medicine and Health Sciences are HEAVILY subsidised by the South African government. Our class was once told that, if not for subsidies, our tuition fees would be double what they are. And what they are is ALREADY a lot of money.

Internship is our chance to learn more. It is essentially part of your studies, but at least a paid part (finally). Community Service is also salaried, but now that we are “more experienced”, this is our turn to give back. To return the favour for the heavy subsidies that were paid for our studies.

Is it really fair to have all those resources poured into your qualification, and then by the end of it, you just up and leave to private sector or worse, abroad? It means the country ultimately loses out. I can see the attraction in those options, I really can, but maybe you owe the country just a little bit before taking to the hills.

Decided not to use an emotional picture of suffering children.

It is true that the reason ComServes are required is because public health is in a shambles and nobody wants to work at the rural sites, despite rural allowances. So it’s true that this is a bit of a forceful solution to the problem, and that the Department of Health really should be finding a more sustainable solution (because maybe after a year of being the only doctor at a deeply rural site, you would never ever ever want to go back into rural medicine, even if as a student you were interested in it).

So, frankly, I don’t see ComServe being declared as unconstitutional anytime soon. And, frankly, I don’t WANT it to be. I’ve just been to a deeply rural hospital, and it’s one of the better ones, and it was HARD. I know ComServe is going to be hard. But I also know it is going to be a year of intensive learning. And I want to serve my country, for the taxpayers’ money that went into my studies. (Read this article by a doctor about why she is grateful for her ComServe. Guys, that piece makes me excited!)

The only possible solution I see to this, is that allowance will be made for doctors who refuse to do community service, to pay their studies in FULL – i.e. not be subsidised by the government in any way. I’m sure there is a small handful of people willing to do that. I’m not sure what their career prospects will look like, though, because I suspect that prospective employers would like their doctors to have that year of intensive experience.

Third: “Unfair” Placements

This part is hard. It’s also the part about the article that annoyed me most because it sounds really bitter, and maybe Desroches isn’t even bitter. Journalism has its own biases. Anyways. We all want to be placed at the “nicer” hospitals. We all want to be near our families and near the nice big cities. The fact of the matter is, some places are way more popular than others. If you WILL apply ONLY to sites in the Western Cape, there is a pretty good chance that you won’t get any of them, and that the government will place you in a place of their own choosing.

That is why most students know that you should be aware of nice places outside of your preferred city, and apply to at least one of those. It is a method I plan to use when I apply this year.

I’ve had quite some interaction with people involved with placements of junior doctors (mostly because I’m good at networking and getting involved in places). And this I know: placement officials try REALLY hard to place junior doctors somewhere that is good for them. They try especially hard not to uproot people who are married with children. And then they look at other factors too. But sometimes, especially with super-popular places like Cape Town, they just can’t give everyone their first or second or third choice.

And that’s reality. It’s a reality I have to deal with too. And it’s probably a reality I will want to kick and scream and cry against if I don’t get MY preferred placement.

But what do you do? Surely we cannot expect every single person who requests a Cape Town placement to get it, while rural sites go severely understaffed?

I don’t know guys. It’s hard, right?

In Summary

1. Desroches is really brave to challenge the system. I can say that I am impressed by that, because so many medical students and junior doctors just ACCEPT unfairness, and sit back and complain without DOING anything.

2. His complaints about working conditions are valid, but that case should be formally logged with the Department of Health and if unresolved, go to the Labour Court – then taken from there. If you are a South African lawyer or otherwise well-versed in Law and don’t agree with my assessment, I really would value your feedback.

3. I strongly disagree with Delroche’s take on Community Service. However, I hope that he will speak at my campus soon, and that I can hear his argument from him, rather than through the pen of a journalist.

4. I welcome any feedback and criticism – constructive, and keep it clean, please. Disagreement is welcomed.

References:

1. “Doctor Challenges HPCSA ‘Slavery'”, Angelique Serrao, The Star, 30 January 2014, http://www.iol.co.za/news/crime-courts/doctor-challenges-hpcsa-slavery-1.1639369#.UuvcdRC1ZcQ

2. Slaves of the State – Medical Internship and Community Service in South Africa, Nicolette Erasmus, The South African Medical Journal, Vol 102 No 8 (2012), http://www.samj.org.za/index.php/samj/article/view/5987/4343

3. “I’ll always be grateful for my Zuma Year”, Karen Milford, 31 January 2014, https://medium.com/p/8013b9a8b060

*Named after Nkosazana Dlamini-Zuma, Minister of Health at the time of implementation, and not, according to popular belief, after President Jacob Zuma.

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18 thoughts on “On ComServe, and the Desroches Case”

  1. I agree with you – comm serve is a huge learning experience and a way to really feel like you’re making a difference. Isn’t that why most of us chose the health professions?
    In my opinion the Western Cape is over rated 😉 I went to Port Elizabeth, still a city, and although their hospitals aren’t nearly as nice as Cape Town ones, you get way more experience.

  2. Great article, and the references are very useful. Thank you.
    I am a public health researcher, and when I last checked out the stats (2009/2010) they were as follows:

    Number of doctors who graduate each year in South Africa: 1200
    Of these 1200,
    – 600 end up in the Private sector
    – 300 emigrate immediately (before ComServe)
    – 300 end up in the Public sector

    Of the 300 that end up on the Public Sector, 89% end up working in urban areas.
    That leaves 33 doctors each year going to work in rural communities.

    Consider another perspective…
    600 of the 1200 doctors who graduate each year go into the Private sector.
    The private sector in South Africa serves just 15.5% of the population. The public sector treats the other 84.5% – 43 million people.
    Despite this, the Private sector accounts for 42.2% of all health expenditure in South Africa…

    So, 84.5% of the population receive 57.8% of total health expenditure in South Africa and are served by 25% of the graduating doctors.

    The skewed distribution of each of these indicators has gone on for decades and will take decades more to reverse. The incentives aren’t yet aligned in a way that will change this. However, they are a start of the effort to prevent the already sharp divide from widening further.

    I don’t know what the solution is, but I would love to hear your thoughts.

    For my finance references, see:
    http://www.pmg.org.za/docs/2010/100204dbsa.ppt

    For a similar set of stats on healthcare worker stats in rural areas, see Africa Health Placements
    http://ahp.org.za/no-people-no-healthcare

    1. Hi there, thank you so much for this info. It’s actually super interesting. I’m on a really rough rotation at the moment but if you don’t mind I will add your stats as a post-script to this post at a later point. And I don’t know what the solution is either, but it is certainly worth discussing. The skewed distribution is certainly a massive problem and one that needs to be addressed on a long-term basis.

  3. Hi Mariechen

    Thanks so much for relating your opinion on the issue.
    I have generally kept quiet on forums such as these because I want to see how others feel about it, but I decided to respond to this particular post because there are a number of inaccuracies in what you have written which may lead people to believe that this is simply a selfish appeal for placement in Cape Town.

    There are a couple of things that I believe you may have misunderstood re: my appeal to the constitutional court for comm serve. The first and most important is that I DO NOT seek to abolish comm serve! I firmly believe that in principle it is a great idea, and I truly hope that when the dust settles, there is still the possibility of me doing it. I have no argument against the idea that doctors give back to society. I do however question exactly what that “subsidy” you spoke of (which we were all told about at Medical School) amounts to, and where it actually goes. But in that regard, you contradict yourself.
    I quote: ” We say that medical school is like slavery. But then we say, it’s actually WORSE than slavery, because we PAY to work ridiculous hours in ridiculous conditions. As you can see it’s kind of more of a tragedy”.
    Interesting point you make there. You pay to work at a hospital for a number of years, doing work that by rights belongs to qualified doctors. You guys take blood for us, you take histories and examine patients for us, and you even administer medications or assist in surgery. Those are important skills that you will need for the rest of your career, and we all have to start somewhere. But as you well know, being a student at Stellenbosch, if we didn’t have students, our entire system would crumble. We actually NEED you guys to enable us to provide a decent service to people. When you aren’t there, there is a tangible, dramatic increase in the workload for us, and we simply cannot keep up. And your university charges you for that. Now, while I make no comment about the morality of that particular situation, I would like to point out that you are contradicting yourself. The government is apparently sponsoring your education, and yet you claim that you are paying them to work ridiculous hours in ridiculous conditions?
    I do not deny that it may exist, but not once have I seen evidence of this subsidy that we are so often told about. And still the fees to study medicine are higher than most other degrees. You said it yourself in your opening statement, and I could not have said it better. My running joke with my friends when I was at Med School was that I was Spongebob Squarepants- I was paying my boss to work for him.

    Secondly, I wish to address this statement: “And even before it goes to the Labour Court, there needs to be proof that due process has been followed to air grievances – that the correct channels were followed, and that they failed. You can’t just take an employer to court before following the internal procedure in an attempt to resolve the problem! Now that would be wasting tax payers’ money”

    I am therefore glad that I am not employed by the DOH. In fact, I am unemployed so labour court is not even up for discussion is it? Rather, let me put it into perspective for you and for others who read this. Internal procedure in the DOH is a non-existent entity, precisely because of the coercive system we work in. Since you are a medical student yourself, you must know a number of doctors. I suggest you ask them what they believe would be the course of action should they want to lodge a complaint against their employer. I can guarantee that most, if not the overwhelming majority, would tell you that they are either too busy, too scared, or just focused on getting done. And this brings me to my third point.

    When you finish Med School, you will stand up and speak the words of an Oath as old as the profession itself. The Oath to protect not only the physical, but the holistic interests of those who come to you. We are charged with something that is so important- to protect those who cannot protect themselves. I challenge you, as I would challenge Dr Milford, to tell me that the way things stand at the moment is in the best interest of doctors and patients. And happily, the majority of doctors are starting to speak up about this.
    It isn’t as simple as “giving back a year of your privileged existence”. It is a question of constitutionality, of freedom, and of choice. How many of the patients you have taken blood from or performed procedures on know how inexperienced you are? Some may, but they too are coerced because they simply feel that they aren’t allowed to request that someone else take their blood. How many times have we as medical students and junior doctors performed procedures we aren’t comfortable with under duress, under threat of persecution or disciplinary action, or without true supervision?
    Again, just because we can keep things the way they are, and most eventually recover from it, does that mean we should leave things the way they are?

    I never wanted to abolish community service. If you had been following the groups on Facebook and other social media, you would have read this in a number of my posts. Nonetheless, the process is what needs reviewing. My challenge to the DOH and HPCSA is to allow the constitutional court to review whether the process and enactment thereof are truly in line with our constitution. As a medical student, you may not have had the experience yet, but it is not only in my interest that I have taken this matter up.

    And besides, if I am wrong, and the process is really constitutional, what does the DOH and HPCSA have to fear?

    I could respond to each of your points here, but I think that perhaps having covered the most glaring inaccuracies, I have shown that this case runs deeper than a simple gripe I have with the DOH for not placing me. I should think that if someone were willing to remain unemployed and unemployable for two months (and counting) that he might have a VERY good reason to do so. Many of my colleagues who also decided not to be blackmailed eventually capitulated and are now placed far away, but I believe firmly in what I have written in my affidavit and supporting documents, and it is for that reason that I refuse to just keep quiet and let the year go by. Trust me, it is definitely the easier course of action to just DO comm serve wherever you get placed and under whatever conditions, and come back to CT afterwards. We are toughened by a terrible system that teaches us (incorrectly) that one has to be able to function perfectly without sleep and under a crushing workload. While those are wonderful qualities to possess, the process of acquiring them is what endangers our lives and the lives of our patients. Just because I CAN function without sleep, does not mean I SHOULD. And all it takes is one mistake and a simple C-section turns into a bladder injury. So too with working under such unhappy conditions.

    We are not supermen and superwomen. We would love to believe so, and in many cases hubris leads to that very conclusion. But inevitably, every doctor is humbled by a death barely prevented, either his/her own on the N1 after a long shift, or that of his patient, who narrowly misses having the wrong digit amputated.

    Yes, we are doctors. We hold such a privileged position in the world. But before we were doctors, we were human. I refuse to lose my humanity for the sake of plowing through a year with my eyes and heart closed.

    I hope that I get the opportunity to meet with your classes and hear your opinions. To be quite honest, I very rarely speak of my own particular situation (the affidavit should be on the ConCourt website as it is now in public domain) and my own specific reasons to remain in Cape Town. I am far more interested in sorting out what really matters than allowing people to derail this case into a personal gripe.

    I hope that those who read this are encouraged to browse the article and affidavit with its supporting documents (almost 300 pages in total!) and voice their own opinion. I would like nothing more than healthy debate with all the facts out in the open.

    1. Hi Miguel
      I do appreciate your input here. Since this was written more than two weeks ago, I might actually post a summary of your comment (and some others) in a new post so that they are viewed.

      I think it is fair to say that I did misunderstand your intention re: community service. Suffice to say it is best to get information “from the horse’s mouth”. (As for your comment in re: social networking, I do frequent these, and even spoke to peers of mine who worked with you during your internship, and none of them corrected me on the ComServe “assumption”. Many of them were very eager to “agree” that it should be abolished. So I am sure you can see that these forums only strengthened my impression that you are against ComServe, and I am certainly relieved to hear that it is not the case. Notably I never saw any of your posts, and so in addition I must be following the wrong groups.)

      I think your point about contradiction may be a little pedantic, but serves to illustrate that we are probably on the same side of the fight. My intention is quite clearly that ComServe is a repayment of said subsidy; thus working in hospital as a medical student cannot ALSO simultaneously be considered repayment. But then why should one work in hospital at all and not be paid? Why should I be running around in hospital carting patients to lung functions and ECGs when that is quite CLEARLY not my job? When my JOB is to get patient contact and learn for very important exams around the corner? I’ve been on vascular. I digress.

      I don’t have proof of the subsidy either, apart from the fact that I never imagined a tertiary institution to have any reason to lie about government involvement. As an aside, I wonder how easy or difficult it will be to get to the bottom of that.

      Regarding internal procedure: as a student who has made it my job to complain as much as possible for the past six years, I hear you (and if you read carefully, you will see that I refer to this same flaw in my original post). I submitted a complaint about overflowing sharps bins posing a health risk, and was summarily told that I was lying and in any case that I should complain to the matron in every particular ward. Since then I have submitted photographic evidence, and I have been told it is too bad because there is a set schedule for replacing bins and too bad for us if a bin fills up before the replacement date.

      I’ve served on my student council two years in a row, I’ve requested (and been denied) meetings with the hospital CEO and the provincial MEC for Health, and I agree entirely that it is DIFFICULT and close to IMPOSSIBLE to launch a proper complaint. My belief is that the reason for that is that too few doctors are willing to do it. And too few students. The reason that I can be victimised by a Prof for complaining is because I am one of the only ones complaining. He couldn’t victimise half of my class. Probably the same reason that you are garnering so much interest. Hence my reference to JUDASA. I don’t think you should have to do this alone, and I do think that matters like working conditions should be addressed by a professional GROUP rather than an individual. But then, I am replying to your comment before I read your affidavit (as I said, exam prep) and because of the complacency in our profession it is perhaps not surprising that so few are joining you.

      I still think that, however a waste of time it may seem, powers that be may still request proof of an ATTEMPT at due process/due diligence being followed in terms of the nonexistent internal procedure, and that this may cast a shadow of doubt, but I understand your POV.

      [Just as a matter of interest, I always offer my patients the opportunity to opt to have a more senior individual do their procedures. For this reason I only got to place my first male catheter in fourth year while many of my colleagues did so in their third year (the patient in question was not comfortable with the fact that I appeared sixteen). For the same reason I was kicked out of gynae theater several times because I refused to be one of six students PVing an anaesthetised individual as she had not consented to it.]

      In any case, I would like to point out that our belief system in terms of medicine and humanity seem to have a lot in common. It may not be clear from my OP, but then again I do not profess to be very proficient in making clear my beliefs through writing or any other medium. I too carry the sentiment that “just because we can keep things the way they are, and most eventually recover from it, does that mean we should leave things the way they are?” In fact, it is the source of a lot of my misery at med school. As I said, I’ve just completed Vascular Surgery. While other students sing praises that they are done, I’m filing complaints (which is a long story not fit for a blog comment).

      Suffice to say, I appreciate hearing this straight from you. I appreciate that your are NOT trying to abolish ComServe and your desire for a review of the process – which I am sure, as many processes in this profession, is flawed. So behind that, I can stand.

  4. I have a small, but pertinent, comment from the patient’s perspective. IF doctors performing Community Service are expected to work these ridiculous hours – how can you expect me to believe that patient care isn’t compromised? This equates to dereliction of duty and in terms of Labour Laws of this Country is a form of slavery! How do these doctors function for these long hours – with the aid of drugs? I certainly wouldn’t be able to cope. As for placement in certain hospitals – there is a dire need ALL over this country – I’m sure that a doctor who has a specific and valid request could be accommodated (with the will to advance medicine in this country). I am not seeing much willingness to uphold the oath that doctors are required to take and quite honestly, do not feel safe with the level of care offered by overworked, under-staffed hospitals!!

    1. Hi Tessa, thanks for your comment.
      On the first matter, I completely agree, and I certainly think that patient care IS compromised if one works such long hours. It is not healthy and it is not acceptable, and it speaks to much greater scope of the problem in South African public health. This being one very good reason for all doctors to demand solutions.

      On the second matter, I’m not a spokesperson for the department but I think you may underestimate the popularity of certain sites for ComServe, and the magnitude of “specific and valid” requests. To this effect those requests have been prioritised, and it is very difficult for someone who does not say that they are either married or have children in a specific city/town, to have a strong case. Whether this be right or wrong is a new can of worms. Some might say, for example (myself included), that being offered free accommodation with family in a specific locale, which thus enables one to pay off huge student loans more quickly, should also be considered specific and valid.

  5. Hi again

    I must say I was impressed by your ethic when it comes to complaining and taking up these issues and other issues which face us every day. Notably, while I was an intern, not once did I manage to sort out issues like overflowing sharps containers either- partly because I was just too tired or because no one listened when we actually spoke. As you say, you start to upset the Profs and the matrons who think you’re trying to be difficult, when actually, you are trying to improve something.

    In terms of support, I must say that there is actually a huge support base for the case I am taking to court. It exists and it is growing every day. The newspaper article helped tremendously, but very soon there will be another article published in a more official journal that will also expose the issue further. On my side, I am busy discussing and researching these issues, and meeting with people in the know, to get our argument to the standard required.

    With re: to the due process, the affidavit does go into the reasoning behind bypassing the high court and labour courts, but that said, there has been a complaint lodged twice at the SAHRC which was rejected as well as an investigation currently going on with the public protector’s office. The official response from the DOH to the public protector so far has been that doctors are not working more than their commuted overtime- which I think we all know is absolute nonsense (I’m thinking vascular here for example – 6am to 10pm is a normal day for an intern and isn’t counted as overtime). Those processes have been put into action, but will move at a bureaucratic pace. For that reason, and because it is a constitutional issue, we felt that the issue warranted urgent attention by the ConCourt.

    It’s great to have that kind of fighting spirit that won’t give up. Keep speaking up and encourage your peers to do the same. As you say, we should be doing this as a group!
    Miguel

    1. Hi,
      Sorry, I didn’t mean to say that you didn’t have support for the case. I was more referring to the paucity of doctors willing to go to the extents that you are; willing to take big risks. But it’s great to hear that more and more people are supportive of your moves.

      I certainly am. I appreciate your explanation about circumventing the high court and labour courts. Certainly agree that the DOH’s statement that commuted overtime is not exceeded is a blatant lie. I know of one or two hospitals that are very strict about it, but certainly not the majority.

      Thanks for clearing up my misconceptions, I apologise for my presumptions. There are still a lot of people who believe in completely abolishing ComServe, and so I think (hope) my arguments still stand, but in terms of your case I’ll post a follow-up to clear things up a little from my side.

      Good luck and thanks for the encouragement. I just had a bureaucratically-paced meeting regarding students in hospital today and it was frustrating, so I sure do hope that your case moves faster.

  6. Thank you for replying to my comment. However once again, I am a little confused by the illogical reasoning. Hospitals ARE, according to your reply, understaffed. With compromised patient care due to humanly impossible hour requirements on their working day. Yet you say that these hospitals, understaffed, are not able to accommodate another doctor, able and willing, just because he/she doesn’t fall into the specified area of assignment. I don’t believe this!! Put them ALL to work…if rural areas don’t have enough doctors – create INCENTIVES for them to go there. it’s standard business practice the world over. Let’s stop thinking and behaving like we’re dealing with an insurmountable issue! Its not – where there’s a will, there’s a way. I’m not seeing the will! I’m reading excuses for a system that’s failing the PATIENT.

    1. No, Tessa, I think you are either misunderstanding me or making assumptions about my stance – or maybe I am just not making myself clear.

      I am not making excuses for a system that is failing the patient. Why would I make excuses for it when I too am suffering under it? The reason willing and able doctors can’t always work at the sites they so desperately want to work at, is because those aren’t always the sites in the direst of needs.

      In fairness and just distribution of resources, it would not be fair to let EVERYBODY who wants to work at a nice hospital in Cape Town (just as an example) to work there, because then there won’t be enough
      ComServe doctors to work at rural and under-served hospitals!

      We have a shortage of doctors. They ARE “put to work”; the problem is there ARE NOT ENOUGH OF THEM to solve the problem. And that is why so many young doctors find themselves placed in under-resourced sites where they don’t want to be. And YES, I completely agree that THAT problem needs to be solved. More medical schools, more graduated doctors, more of everything – all things that will only really happen when the government begins to spend funds efficiently, and THAT is a whole issue that is way beyond my debating/assessment capability.

      You seem to think that we are on two opposite sides of a situation/argument. We are not.

  7. Completely agree with the necessity of ComServe, it is the only thing holding up the healthcare system at the moment. But is it fair to the patients to have inexperienced doctors doing their procedures (especially procedures they are still uncomfortable doing) just because they don’t know any better or are too afraid to speak up? Are we not, in essence, practising on them?

    And if the above is considered acceptable, then the issue of terrible conditions in the rural areas can easily be addressed with incentives, as Tessa mentioned. If the rural doctor is paid quite a bit more than the city doctor, surely it will increase the appeal of rural setting and more doctors will flock to the rurals. It should put the skewed distribution of doctors back into balance. After all, we have student loans to pay off. Having a system that would help us pay them off quickly, while we giving back to the community and improving the state of our healthcare system, would be ideal. Seems like a win-win to me.

    1. Hi Megan,
      Thanks for your comment. I’m not going to address the issue of “practicing” on patients mostly because I don’t think I’m qualified to answer it. It is an ethical debate all over the world. Nobody wants to be “practiced” on, but someone has to be your first IV line. Someone has to be your first C-section.

      As for rural allowances: they exist. I just think that evidently people don’t realise it. Doctors (and teachers!) who work in rural areas in South Africa do get a rural allowance. Is it enough to justify their discomfort and isolation? I don’t know.

      Furthermore, I don’t think that rural allowances “solve” the issue of terrible conditions in rural areas. Just because I get a rural allowance, does that make it okay that I work under immense pressure with poor resources? I don’t think so.

      Definitely agree that rural allowances should a) be increased or b) be better “advertised”; but more than just that needs to be done. Terrible conditions need to be solved directly, and getting more doctors at a rural site is A step in the right direction, but not the ONLY step.

  8. Thanks for clearing up the issues surrounding the Desroches case. A lot of media reporting gives the impression that Desroches is acting on a personal gripe but I really value your true motivation for pursuing this case.
    I too have gone through Comm Serve a few years ago and felt like all my complaints about terrible working conditions fell on deaf ears. It is time that we as a medical community stand up to try and change the system for the better for ourselves and our PATIENTS.
    The solution does not lie with training more doctors, but with retaining them in the public sector, especially senior staff that can teach and supervise new docs. The biggest reason I hated Comm serve was that I was expected to do procedures that I was not comfortable doing just because there was no-one else to do it or show me how (and that after 30hours straight of working!). I am not sure the patients were always better off with my care although I had all the best intentions to help and relieve suffering.
    Up to now most people working in appalling conditions did their ‘time’ and got out of there as quickly as possible only to leave the situation in that under serviced area as it was before.This does not help or fix the broken system. I know this court case will also not fix the system but at least we can try and open people’s eyes about what is really going on in the healthcare system.
    Another reason I hated Comm serve was that I spent about 40%+ of my time doing other people’s jobs: being a porter, nurse, porter, phlebotomist, porter, etc. If we can try and change the way healthcare is delivered to our patients, one small step at a time, then maybe Community service will be a great learning experience and a way to get people to go to rural areas. (As it is intended to be in theory). But first we as doctors, nurses, med students should start by standing up and saying what is broken and push for change. If we don’t do it nobody else at the top will. And in the meantime thousands of patients are paying the price…

    1. Thank you, Mickey. I appreciate you stopping by and sharing your experience too. I agree with your reference to people getting out as fast as they can – it is not sustainable. Retention is the way to go, and the way in which the system is currently broken is NOT helping with that retention.
      Honestly, I’m not really looking forward to my Com Serve anymore. I really hope we can fix it soon.
      And I feel you 100% in terms of doing other people’s jobs. Even as a medical student, I spend so much of my time – which should be spent getting patient contact and experience and LEARNING things – porting patients around and doing work that is not mine.
      I hope that things will change soon. Our wellness is at stake, as is that of our patients.
      Thanks again for sharing your views.

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