Arthur Setlhapelo's focus is momentarily broken by a person in a bright yellow T-shirt walking past the window. He turns his attention back to the spacious room where he smiles reassuringly at one of his patients, a quiet young woman, awaiting his medical advice.
After graduating with a clinical associate qualification in 2011, Setlhapelo started practising at Tshwaragano Hospital, which is about 20km from Kuruman in the Northern Cape. His duties include helping doctors and nurses with basic tasks and procedures so that time spent with patients is better distributed.
Setlhapelo was part of the initial student intake of the University of Pretoria's clinical associate programme. The University of the Witwatersrand in Johannesburg and Walter Sisulu University in Mthatha have also recently introduced this course into their medical faculties.
"I always had an interest in the medical field and I was lucky I learnt about this course when choosing what to study. Because it was new, I saw it as an adventure and was excited to see what would happen," he said.
"There were challenges, because I had to keep telling people what I was studying and why, but after a year or so they understood what the course was about."
Clinical associates are primarily trained to deal with casualty cases and day patients, but they also perform clinical procedures such as lumbar punctures (when a needle is inserted into the lower spine to collect spinal fluid for analysis) and blood transfusions under a doctor's supervision. Although a clinical associate degree is registered with the Health Professions Council of South Africa (HPCSA), the extent of their responsibilities, which were submitted to the council last year, have not been formally approved.
Cheaper than doctors
"Doctors have traditionally done a range of duties that include taking patient histories, performing physical examinations, carrying out simple diagnostic and therapeutic procedures for common communicable and noncommunicable diseases, as well as interpreting findings for common and emergency conditions. Clinical associates can perform most of these duties," said Dr Martin Bac, a lecturer in the University of Pretoria's clinical associate programme.
Other procedures that clinical associates can assist with include cardiopulmonary resuscitation (CPR), uncomplicated vaginal births and adult circumcisions.
The profession is similar to that of a physician assistant in the United States and other mid-level health professionals in African countries such as Tanzania, Kenya, Mozambique and Ghana.
In 2013, 227 clinical associates were registered with the HPCSA.
"We think that clinical associates can play an important role in strengthening the health system. A clinical associate cannot go abroad like doctors and nurses and practise in Europe or Australia because their qualification does not allow them to register there, so there will be less of a brain drain," Bac said.
"It is also very attractive to the department of health because employing clinical associates is cheaper than doctors and they are the most likely solution to reinforce the rural medical teams in South African district hospitals."
HPCSA inefficiency blocking progress
Dr Audrey Gibbs, the co-ordinator of the clinical associates programme at Wits University, said clinical associates are not allowed to prescribe medicine without a doctor's counter-signature because the HPCSA has not passed legislation to approve them as authorised prescribers.
She said this creates a bottleneck for doctors who are forced to leave their work to sign off the prescriptions.
Doctors must supervise clinical associates but this does not mean "that a doctor has to hold their hand and watch everything they do," said Dr Ben Gaunt, the clinical manager at Zithulele Hospital in the rural Eastern Cape.
The hospital employed a number of clinical associates when the profession was introduced.
"In the casualty setting they should be able to assess the triage of patients [by which patients are assigned an urgency status]."
Gaunt said clinical associates have assisted doctors at the hospital "to do basic procedures like putting on drips and chest drains. In other hospitals they work primarily in the outpatient department, seeing a mixture of emergency cases and mostly chronic diseases such as diabetes, tuberculosis and HIV.
"They can also help to manage and review hypertension and epilepsy cases as well as assist in theatre, [for example] giving basic spinal anaesthesia during a caesarean section with the doctor present," Gaunt said.
More accessible career
Because it is offered as an elementary clinical course, Gaunt said it presents an ideal opportunity for students who are interested in a career in medicine, but don't have matric results that are good enough to get them accepted into medical school.
A university exemption and a 60% pass rate in English, a life science subject (biology or physiology), mathematics and physical science are required for the three-year bachelor's degree in clinical medical practice.
"The degree is a bit more accessible as a career than studying medicine. A lot of students are unable to study medicine because they don't achieve high enough academic results. However, they can undertake a clinical science course to become a clinical associate – and come back and serve their community," said Gaunt.
Edwin Leballo, chairperson of the Professional Association of Clinical Associates in South Africa, said that clinical associates can also assist women in labour.
"If you look at the history of clinical associates in other countries you will see that they are mainly used in maternity cases. This is beneficial because South Africa has high rates of maternal deaths. The profession was introduced to close a gap for medical doctors and help [to] speed up patient waiting time.
"Previously, a doctor had to do all the procedures alone and that would waste a lot of time for other patients because the medical practitioner would be spending so much time with one patient," he said.
The association advocates for the profession to become officially re-cognised and that salaries of clinical associates be adjusted according to their capabilities.
"Clinical associates earn about R14 000 a month before deductions. We've asked the department to review this. We are the least-paid mid-level medical healthcare workers. In some other countries clinical associates earn up to R40 000 a month. Clinical associates don't get rural allowances either," Leballo said.
According to the medical and dental board of the HPCSA, entry-level public-sector doctors in South Africa earn over R40 000 before deductions. An entry-level nurse earns the same salary as a clinical associate.
Back at Tshwaragano, Setlhapelo's ready to end his day. He takes off his stethoscope and locks it in the drawer of his table.
"The best part about being here is seeing the difference that my work has made to patients' lives. I help them to heal. That is enough for me."
Lenadine Koza, from the Medical Research Council, was a fellow with Bhekisisa from September to October 2013.