Trust and entrustability in medical specialist training in South Africa: An Ubuntu-inspired pedagogy

The medical specialist training landscape in South Africa (SA) is grounded in a tradition of learning in the clinical workplace for at least four years, with a single exit examination assessing clinical competence, knowledge and complex clinical reasoning. However, given the broad scope of specialist practice, it is impossible to assess all aspects of training in this single assessment. Consequently, it is not possible to make a categorical statement on the holistic clinical competence of trainees using the data derived from the current assessment model.

A rational solution to this dilemma could be the introduction of formal continuous assessments within the workplace, aptly called workplace-based assessments (WBA). As the name implies, this is based on the overall performance of trainees in real-life situations. These assessments need to be well planned, implemented by appropriately trained supervisors, reported in a manner that facilitates defensible progression decisions about trainees and allow faculty to make final decisions about trainees’ clinical competence across a range of domains that characterise the specific discipline. The evidence for the impact of this type of complex intervention on trainee performance, assessment quality and impact on skills development has been well documented in high-income countries, but less so in low-middle-income countries globally and even less in Africa.

This book addresses the crucial gap within the literature on WBA in medical specialist training in the context of African and low-middle-income countries. The primary aim was to present a socially accountable praxis of WBA in SA by bringing together locally generated research that described early initiatives at implementing WBA, key elements from the global literature and the lived experiences of the authors who are all deeply involved in various aspects of specialist training. 

Using a realist perspective, the authors foreground data that describes the SA context, given the stark inequality across training sites and the attitudes and capabilities of supervisors and trainees who labour under immense clinical workloads. They employ an Ubuntu perspective to frame their reflections on the local and global literature, infused with their own experiences, which necessarily elevates the role of workplace relationships and social dynamics as these impact the learning and teaching environment.

What emerges from each chapter is a uniquely African proposition for medical specialist training, offering new ways of teaching and learning that are sensitive to the emotions, hierarchies, sensitivities and cultural dynamics that are typical of a diverse demographic context, without departing from the high-stakes technical competence required for medical specialist practice. This has implications for how health educational systems are configured and how faculty are trained. The hypothesised impact in the short term would be more accurate assessments of clinical competence, in the medium term, a positive change in the socio-cultural dynamic of the clinical learning spaces and in the long term, the emergence of clinical services that produce better holistic outcomes for staff and patients.