To watch this interview, please follow this link

Hello, I’m Domhnall MacAuley, and welcome to this BMJ leader conversation, where we talk to the key opinion leaders and health in medicine around the world. Today we’re in South Africa and I’m talking to Shrikant Peters. Let’s go back to the very start. What got you interested in medicine?

Shrikant Peters: You get to the end of your schooling career and you’re good at some subjects, you’re bad at others, and you try and engage for yourself where you would like to be. For some people, it’s following what their parents would like them to be and, for others, it’s their innate passion. Like many medical students, the question I wanted to ask myself was, in what professional space would I use my abilities in sciences and biology, as well as my empathic side, to help people. And, with medicine, there wasn’t really anything else that could come close to the combination of science and the humanities, and the utility you could get from a medical degree. So, that’s how I came to medicine. And then it was a long and winding approach to get into public health and management.

DMacA: Let me bring it back to medical school, because I’ve been very privileged to visit South Africa and indeed your University of Cape Town. Tell me about the medical school and the community. Is there integration, is there discrimination? What is the current situation?

SK: I speak as someone under the age of 40, but feeling quite old because of the rapid changes in financial flows and cultural psyche of students and practitioners in our country. I came of age, turned seven, when we had our first democratic elections, which meant I was in the last group of kids that could remember becoming a democracy. I finished my undergraduate medical school in 2010 and, at that stage, the question we had in our minds is where we would be sent for internship and community service. It was just after the financial crisis of 2008, and we were yet to feel those effects fully. Since then the economy of the country has been a bit listless and we failed to grow as much as we had in the first 15 years of our democracy. For that reason we have less money to throw behind the education and health departments.

Now, 14 years out of medical school, the question confronting our young doctors is not, ‘where I will get placed?’, it’s ‘will I get a post?’. And that is something we’re seeing replicated for interns, for registrars, and consultants. We have 300 people applying for one post, we’ve got a heavily constrained budget, and it’s quite difficult. And in that competition for spaces and for career progression opportunities, the noise does get quite loud. That being said, in 2008, when I was still an undergraduate, I made the conscious decision to stay and be a South African medical doctor because I felt that there was nothing else of higher regard in my professional undergraduate brain. I had the opportunity to travel to the States if I wanted to, but I wanted to be a South African doctor. We have an ideology in this country that focuses on a preferential option for the poor, for decentralized care, for the primary health care approach, and for district health systems, and that comes through quite strongly in our undergraduate curricula. I’m sure it’s one of those driving, hidden aspects of the curriculum that that drove me towards public health – the idea that medical care was not simply about biomedicine and technical accuracy, it was about providing the most utility for the most number of people and using the budgets we have efficiently.

South African doctors are equipped to take a history, to examine, diagnose, and manage, sometimes in the most constrained of circumstances, without access to any fancy modalities and sometimes, unfortunately, without ICU, or even high care beds. We’re aspirational and we’d love to move towards a national health system of our own, but are very aware of the constraints that such a system brings to beds, to access to care, to waiting times. It’s an interesting space to be in, South Africa has never been an easy place to be in. We have a quadruple burden of disease that all our junior and senior doctors manage on a daily basis and we’ve been through quite a bit in the last 15 years with a fracturing of our political space between left and right, similar to the rest of the world. But, in the most recent elections the way forward does seem to be coalition building and consensus building, and we’re hoping to bring together those warring factions, the political ends as well as the clinical, medical, and public health spaces, to create a functional system for our patients and doctors.

DMacA: Lets move briefly back to your education because, after you did your medical degree, you did an arts degree…

SP: Throughout the medical degree, they slowly peel open the clinical spaces to medical students. Our first introduction to clinical medicine was percussing and palpating in the mock wards. But very early on in our careers, we were able to go out onto the mobile clinics. We run the largest student run free clinic in South Africa called SHAWKO (https://shawco.org/) where medical students go out on busses into the communities to assess patients, present to doctors, and see for themselves how care is delivered in communities. For me, that really showed me the importance of people working on the back end of the health care system; people that would make sure that busses had petrol, that pharmacies had drugs, that locum doctors were available for their shift because, in as much were training classes of 200 student doctors to go and deliver care, if we insert them into dysfunctional systems, we will have burnt out doctors and patients with poor outcomes. So, the concept of needing a functional system was very relevant from an early time in the medical school. Whereas some places do allow doctors to go straight into specialty programs after their degrees, we have at least three years of clinical practice time where you do two years of internship, and you rotate in everything from anesthesia, orthopedics, family medicine, obstetrics and gynae, medicine, surgery, over a two year period, and then you do another year of community service, generally in a smaller facility with a lot more responsibility, managing your own ward or emergencies centre, sometimes doing a caesarean section and an anesthetic together on a patient by yourself. You are kind of locked in where you can’t really specialize, and you’re both a full time student and a full time worker in that final year. And I didn’t want to lose that opportunity.

Being public health and systems minded, I wanted to know more about politics. I wanted to know more about economics. And I wanted to understand philosophy, especially the philosophy of science. And that’s stood me in good stead. The fact that when we take a history and we diagnose, we’re actually coming up with a scientific hypothesis and testing that hypothesis.

So, it was very interesting for me as a junior doctor seeing patients on the wards, and then being a humanities student post on-call, going to write my examinations, sometimes while taking anti retrovirals for post-exposure prophylaxis. It was a very interesting experience.

DMacA:  As part of your education, you also went to Yale, in the US. Tell us about that.

SP: I did go to Yale. I was on a remote program. I’d also been to LA and Chicago and New York. But the Yale program was the Advanced Health Management program, mostly taught remotely. It was led here by a group called the Foundation for Professional Development, which is part of the South African Medical Association. I was in the inaugural class and it was an opportunity as an intern, who had absolutely no hard power, to assess a system as they would a patient.

We’re used to being painted into a clinical corner where we’re told  “this is your degree”, these are the patients you can see, ‘you see them, and we will sort everything else out. And if something goes wrong or if the system fails, this is what you tell the family, and this is how you apologize and say- I did as much as I could.” The problems that a lot of junior doctors face is that they see problems in the system that are impacting patient care and they’re apologizing for them, but they have no power to change them.

The health management program taught us this concept of hard power and soft power. And it took us through the concepts of management and leadership and project management. So, I used the Yale program to conceptualize a triage program in our emergency centre in the small hospital where I was working because we simply didn’t triage. It wasn’t done and it’s still not necessarily done in a standardized way across the country. Here you had patients coming into a facility without a standardized operating procedure on how to manage the flow through the unit, how to track them into high acuity or low acuity, and how to deliver efficient care to those that needed it. It wasn’t a question of resources. We had the resources, but it was whether we were using them most efficiently to get the best outcome for the most number of people. Using that Yale program, we put in place a manual triage system in that casualty department and we monitored what we did. We did PDCA cycles and test-retest, to see how long it was taking us to categorise patients as red, orange, and yellow priority. We’ve done similar things in casualty, in the theatre, and we’re looking to apply similar methodologies to the rest of the hospital that I’m currently in.

DMacA: Before we move on to the public health, I’d like you to talk about medicine in the community, because you also did some work in general practice and I’m really interested in is primary care within the community and particularly within the townships. How does that work?

SP: Its quite difficult. For the year after my community service, and before I started in full time public health, I was allocated to the Johannesburg Metro clinics. Johannesburg is a massive city and those clinics are far flung. On any day of the week, I could be in clinics 100km apart. Some days I might be in the ARV  division in an inner city metro clinic, looking at renal functions and with access to a working laboratory. Other days I might in a casualty department in the middle of town where most of our patients were foreigners who had come straight across the border looking for health care, some of them in active labour.

And then on other days, I would be out in the far flung reaches, which could be classed as rural, where we were operating out of container clinics and where we had fewer resources than the undergraduate students at UCT would have had in their mobile clinics. For example, you had to make do with dipsticks, a little fridge and a pharmacy. Understanding acute care and understanding how to treat the undifferentiated patients and treat them appropriately and stream them appropriately was very important. Those three years of supervised junior practice really came in handy. Sometimes you would have to take kids in your car at the end of a clinic and rush them through to a casualty if you were worried because ambulances don’t necessarily go into townships. And the distances are quite far. The system is fundamentally broken in certain aspects. And junior doctors do make up for that. It was very interesting because we’re aspirational around primary health care, around the district health approach, but the numbers just don’t add up on the floor. It’s very good for a junior doctor to see that and see where they can be inserted into that dysfunction to make a maximum return on investment for the country. But we need to start getting smarter in how we upskill and network our professionals in rural areas to be supported and provide a better care for our patients. That’s becoming all the more relevant now with modalities like tele medicine and other outreach services.

DMacA: Lets return to public health, your current career. Tell me about your career progression and what you’re doing now.

SP: After four years in clinical, including some time in the Metro, primary care clinics, and in locum practices around Johannesburg and back in Cape Town, I started the Masters of Public Health at my old undergraduate university. That program gives you a wide theoretical base including some of the things that you disliked in medical school, including epidemiology and biostatistics, the things that wafted over your head while you thought about getting back into the wards and being on call. To be fair, those classes, when simply theoretical, can be quite dense, and you sometimes do fail to see their relevance to the clinical practice of someone who is paid to see sick people and bring them back to health.

But, after that first year on the MPH program, I applied to the public health residency training program. This meant that I joined a rotation of doctors who were all specializing in public health medicine and we were being paid, not to treat sick people anymore but, to reimagine the service as it should be including everything from non-communicable to infectious diseases, occupational to environmental health, health economics, policy and development, and looking at health organization, and management and systems design. On the first day of my project looking at medical referral systems in the Metro that I had worked in Cape Town as a student, the medical consultant to whom we were now seconded, said to my public health consultant. “Yes, I’m very interested in in medical referrals. And I want to improve the efficiency of the system and this is my lifeblood. I’m a clinician. This is what I do. But why do you care as someone in public health and what are you paid to do?” And my consultant, on that first day, thought to himself and he smiled. And then he said, “I get paid to think about the problems that we have”.

There are some public health competencies that are so important that they shouldn’t be limited to the specialty of public health, they are things we should be teaching to our undergraduates. And that’s how to diagnose and manage systems in the way that we are taught to diagnose and manage patients. It’s a big frustration of clinicians, as well as myself as a manager, when we don’t bring our clinicians into these problem solving spaces, because they are inherently able to diagnose and manage and plan. That’s why you see clinicians getting into policy spaces, talking about global surgery, talking about global health, speaking at the W.H.O., and having this this impact because it’s medicine. As Virchow said, politics is medicine writ large. And so that’s the space that I found myself in. I didn’t see myself in ‘Politics’ with a big P. I wanted to be focused on health, and that’s where public health has taken me.

We have rotations in quality of care, in health care data management, in district health services in metro and rural, and then finally back to facility management, which was one of the last rotations I did as a public health registrar. It really was a privilege to come back to my old tertiary hospital, where I never thought I would end up as a trainee manager, as a public health registrar, to manage and work with and coordinate clinical heads of departments, whilst being very junior in my career, still being a trainee, but applying the same principles of good quality medicine and utility of care, to consensus building, taking us through the pandemic, escalating our ICUs, de-escalating our theatre services, and coming out of the pandemic with a team of specialists and subspecialists around me putting together a surgical recovery project where we put on 4000 extra procedures, over a period of a year.

And they were skills that I learned that I could not have gotten anywhere else because I was a public health medical doctor on rotation; being taught how to manage and lead and be vulnerable in the spaces, together with clinical heads of department at the top of their game. It really was a privilege.

DMacA: I also hear that you can work miracles. You’ve done something really quite remarkable. You’ve made a 1500 person waiting list disappear…

SP: How long is a piece of string? When we started the surgical recovery project at the end of COVID, people were asking us how many theatre slates did you lose in the pandemic? How many patients couldn’t get their procedures? And we had said, based on our previous volumes, we should have done an extra 20,000 procedures that we’ve lost over the last two years. And they said, “Okay, we want to help you., we’re donors, we’ve got the money, we’d like to go 50:50 with you and the Province. And they said, “Show us your waiting lists.”

And we showed them the numbers that added up to 6000. And they asked us, “where are the 20,000?” The problem with the healthcare system is that if the need isn’t met, patients die on waiting lists and people go on to have incurable diseases. Being on a waiting list today doesn’t mean you’re going to be on the waiting list tomorrow and still a candidate for surgery, or even alive the next day. And so it really is for us to advocate for our patients. We could have done more. I wish we did do more surgical procedures, but that wasn’t possible. We maximized what we could do and I know for those 1500 people, 4000 people over the full time frame, we made a difference in their lives and the lives of their families. We brought them back to an economic ability to feed and clothe themselves. And, that’s something that’s fundamentally important in clinical care; the fact that we can boost the economy of a country. The health care system is always thought of as a drain on the economy- but, it’s a fundamental capability, health, towards development and the Human Development Index.

DMacA: I’d like to finish up by asking you about something very personal. And that is about your mother. Perhaps you could tell us that story.

SP: In the middle of that pandemic, between escalating ICU services and escalating surgical services, my mother came back from Australia. She came back to South Africa because after six months of lockdown, she had a recurrence in her cancer. For me, she was the archetypal clinician who we all want to be. She was a 75 year old family physician doing clinical shifts till 10:00 at night at age 75. And her cancer recurred, and it made me remember that we’re doctors until we’re patients. We got her back to South Africa after six months, and she was given a ten year prognosis by her oncologist. In the chaos of the pandemic, I took her around to two different private hospitals. We were shunted from post to post simply because there were no beds available. The referral system, on which I had worked previously, was upended by COVID and nobody was able to tell us where there were beds. She was crying on my shoulder in the casualty department because people had turfed her out of the ward. And that was very difficult to hear.

In the end she had the surgical procedure that she needed on an elective basis, a minor procedure. I remember the day because I was post call when the surgeon called me to say she’d got a post-operative haemothorax, she’s on adrenaline, she’s in ICU. It just made me realize that it’s very easy in private medicine to add a case to your list. You get paid money for this, and a bill was sent our way, but you don’t necessarily get the outcome that you want. And in the private sector in South Africa, we don’t have academic spaces. And I would love to see that develop and help that process develop. But it rounds out my learning and my understanding.

My mother stood there with me when I graduated medical school and she was very proud. My final lesson from my mother was when I walked into that ICU and I saw doctors doing CPR on her and I told them to please stop- there was nothing else to be accomplished.

Value based care is so important to understand and to live and to thread through our systems because, it wasn’t simply about doing a procedure, about receiving income for a procedure, it was about understanding for us as a country, what is the volume of services that we can deliver, at what cost and what quality of outcomes are we getting.

For those first 1500 procedures that we had done in the surgical recovery project, we had a balancing measure. We looked at readmission, we looked at 30 day mortality rate, to make sure that the people that we were pushing through what was not sardines through a factory. It was patients with lived experiences, with prognoses, some of them with chronic diseases that still needed to be managed after a procedure. And so, forced into this holistic understanding and concept of medicine and public health and health systems thinking, I’ve learned a lot. It’s not easy. It hits home very, very closely. I’ve got a stack of adverse incidents on my desk at any one time of the day. The ability to see things from a clinician’s point of view, take them through a complaints process, with what we call a ‘just culture’ approach to making sure that patients and their families are treated with dignity and respect at the end of the day, is important. And, I’ve grown as a manager and as a clinician, and as a person because of my personal and professional experiences. It’s not easy, but it encourages us to be vulnerable, and to accept our vulnerability and to lead through that vulnerability as managers and as doctors.

And, I do have a lot of faith in the junior doctors that are coming through because they understand that they’re not superhuman. We do have a holistic group of doctors graduating but I don’t think that the systems they’re working in are conducive to health for themselves or their patients. I think we can do a lot better with what we have, and I think we need to grow both ourselves, the current generation of seniors, and then the millennials, the Gen Z’ers, the Alphas – people that are highly connected and unwilling to accept the system for how it is.

We need to teach them, what models to use, what thinking frameworks to use, how to apply the clinical method to improving problems in the system, in the public, in the private sector, for how we generate utility and dignity and respect. And I say that as a clinician and as a bereaved family member of someone who should have been had that too.

DMacA: Shri, thank you very much for sharing so much of your life, your education, your career, and of course, your very personal experience. Thank you very much indeed.

Dr. Shrikant Peters

Shrikant Maurice Peters is a medical doctor from Pietermaritzburg, South Africa. He completed his junior years of internship, community service and medical officer time in primary and district hospital rotations in the major metropolitan cities of Durban, Johannesburg and Cape Town. After developing a keen interest in health systems management and strategic planning, he completed residency training and qualified as a Public Health Physician in 2019. He has previously been  Medical Manager of Peri-Operative Care, Critical Care and Transplant Services at Groote Schuur Hospital, and is now Chief Clinical Information Officer at the facility. As an honorary lecturer in Public Health Medicine at the University of Cape Town and as a Council member of the South African College of Public Health Medicine, he is responsible for advancing the professionalization of medical management, both in South Africa and throughout the wider continent.

Professor Domhnall MacAuley

Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.