Internal Medicine: Global Perspectives
Dr. Adri Kok, MBBCh, Dip.PEC, FCP, MMed, FACP (Hon)
President, Faculty of Consulting Physicians (FCPSA), South Africa
Life in South Africa can be perilous, fast, and unfortunately for many, short, and practicing health care in a country plagued by HIV/AIDS is a daily challenge. But there are many reasons—the people, the culture, a sense of duty, a need to help—why Adri Kok happily calls it home.
South Africa At-A-Glance
- Population: 48 million
- Motto: “Unity in Diversity”
- Number of official languages: 11
- Number of specialist physicians: 516*
- Life expectancy for men: 47
- Life expectancy for women: 49
Percentage of deaths for all ages from HIV/AIDS: 52
Source: World Health Organization
*A specialist physician is the equivalent of an internist or primary care physician in the U.S.
What inspired you to become a physician?
I believe it is what God wants me to be. I have been incredibly blessed with my work, my patients, and my colleagues. I enjoy the challenge of internal medicine as a specialty—it is never boring. I love the interaction with people, to be able to chat with them, to make a difference simply by listening. The work in intensive care is a challenge, and challenges me on a different level. It requires dedication, long hours, physical endurance and mental sharpness. I enjoy it! The interaction with the families is very important to me and as critical as looking after the patient, sometimes maybe even more.
What motivated you to take this role with the FCPSA?
I’ve been in private practice for 18 years, so I have the experience to share. I felt as though I could contribute on many levels to the future of the profession. While it is a great challenge to coordinate everything that goes along with being a physician in South Africa, there are many times where I make headway and a situation is resolved, and it motivates me to continue doing it. I took the role because I feel that we need strong leadership in medicine to draw students and young doctors to our specialty. We need to make it attractive to them, and we also need representation on all levels—academic, private practice, within the funding industry, with pharmaceutical companies and with the Department of Health. By taking this position, I felt I could contribute to this.
How does the AIDS/HIV epidemic in your country affect you as a physician on a daily basis?
We see a fair number of AIDS patients in private practice. In the private sector, people are on medical AIDS funding medication, blood tests and hospitalization, so we are able to look after them. It is the public sector that bears the brunt of this epidemic. This is due to the initial mismanagement by the Department of Health and the public statement by the Health Minister at that time that HIV/AIDS is not a problem and that a “good diet” was the best treatment. This resulted in a belated distribution of anti-retroviral therapy, and the unnecessary deaths of thousands. This spilled over into private practice as people came in too late to see us. The low life expectancy in our country has nothing to do with incompetence and everything to do with late presentation to our practices. The tide is turning slowly, as people see the benefits of getting tested and starting ARVs, but it is a slow process.
Violence is the fifth leading cause of death in South Africa. How does that affect the health care system?
It is extremely costly, very depressing, and uses up enormous volumes of resources. The violence even confronts you personally, which has resulted in many doctors making the decision to safeguard their families by leaving the country.
Are there enough young people choosing internal medicine and if not, what are the barriers?
Not at all. We are lucky if we get 10-15 to qualify through our College of Medicine. Community service is in place of a normal internship, a two year enforced service in whatever hospital the Department of Health places you. These hospitals are understaffed and many are below par as far as academic cover is concerned. Their remuneration is stipend only – wage negotiations have recently broken down with a threatened strike by doctors in the public sector. At the end of this time, many young physicians emigrate instead of specializing in internal medicine or other specialties. The few who do are quickly absorbed into the medical services of both public and private health care to supplement the dire shortage.
Are there other countries you admire for their health care system and what can other countries learn from yours?
Countries like Sweden seem to have great results and also produce amazing research, but home seems best to me. South Africa has such diverse cultures and fantastic people as patients. We know how to work hard! Medicine is a fascinating field in South Africa—we face an amazing spectrum of disease with high tech facilities and very competent doctors. It makes for a very interesting mix.
Does access to electronic information or products have any influence on what patients want from their doctors in South Africa?
Yes, especially in private practice, but for the better. It is great to deal with a well-informed patient. However, South African patients still trust their doctor totally and rarely question a decision. They accept what we say very easily—it is simply the culture of “trust me, I’m a doctor.” It places the responsibility on us to ensure we keep ourselves updated, to be trustworthy, and to be deserving of trust.
What have you accomplished during your tenure that you are proud of?
We have successfully challenged the government on the fees we are allowed to charge. We are in the process of developing a South African–based coding system especially for procedures, but it still requires a huge amount of work. We have successfully challenged decisions of the Council for Medical Schemes on funding issues, and we also have been able to establish a positive relationship with the hospital groups, the funding industry and the pharmaceutical companies.
What has been the most challenging part of leadership? The most rewarding?
It is very challenging to do this while running a busy private practice. Time is precious. You need a lot of energy to keep believing you can make a difference. It is difficult to find people who are committed to help, and the change of ministers in our Department of Health continues to present a challenge, as each person starts all over again. However, the recognition that you receive at times is rewarding. For example, an unexpected reward I received from the American College of Physicians is something that will sustain me throughout my career. But most of all, it is rewarding to see the results that make a difference in the lives of every physician in our country.
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