CUSTOMER CARE LINE 0860 PHARMA (742 762) / +27 21 707 7000
www.pharmadynamics.co.za
DULTA 30, 60 mg. Each tablet contains 30, 60 mg duloxetine respectively. S5 A46/1.2/0889, 890. NAM NS3 18/1.2/0126,
0127. For full prescribing information, refer to the professional information approved by SAHPRA 29 September 2017.
DAA641/03/2021.
CUSTOMER CARE LINE 0860 PHARMA (742 762) / +27 21 707 7000
www.pharmadynamics.co.za
EXLOV XR 50, 100 mg. Each extended release tablet contains desvenlafaxine benzoate equivalent to 50, 100 mg
desvenlafaxine respectively. S5 A51/1.2/0009, 0010. For full prescribing information, refer to the professional information
approved by SAHPRA August 2020. 1) Colvard, M.D., 2014. Key differences between Venlafaxine XR and Desvenlafaxine XR:
An analysis of pharmacokinetic and clinical data. Mental Health Clinician, 4(1), pp.35-39. EVA642/03/2021
ISSN 2409-5699
AABBOOUUTT ththeeddiscisicpliipnelineFOFROtRhethdeiscdipislinceiplinisesue 27 • MAY 2021
LEGAL CONSIDERATIONS
IN PRACTICING
PSYCHIATRY IN
THE DIGITAL AGE
THE PSYCHIATRIST’S
DILEMMA:
SEXUAL OFFENDING &
PERSONALITY DISORDERS
EMERGING TRENDS
INFLUENCING THE FUTURE OF
PSYCHIATRY IN
SOUTH AFRICA
AN OVERVIEW OF SOUTH
AFRICAN LAW AND ITS IMPACT ON
HEALTHCARE
PRACTITIONERS
PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS
THE BIG MOVE:
FROM PAPER TO DIGITAL
www.southafricanpsychiatry.co.za
TURN
THEIR
WORLD
RIGHT
SIDE UP
“These children are frustrated and bored at school. It’s not that they cannot concentrate, it’s that they
concentrate on every little thing that happens around them. They have a perception that their teachers
don’t like them.”1,2
Unlocking potential
References: 1. Knowles T. The kids behind the label: understanding ADHD. Middle Matters, National Association of Elementary School Principals. June 2009. [cited 2020 June 01]; Available
from: https://www.naesp.org/sites/default/files/resources/2/Middle_Matters/2009/MM2009v17n5a3.pdf. 2. Renata Schoeman, All of these things are important to me. 2017 Goldilocks and The Bear
Foundation.
S6 CONTRAMYL XR 18 mg (Extended Release Tablets). Reg. No. 49/1.2/1137. Each extended release tablet contains 18 mg methylphenidate hydrochloride. Contains sugar (sucrose).
S6 CONTRAMYL XR 27 mg (Extended Release Tablets). Reg. No. 49/1.2/1138. Each extended release tablet contains 27 mg methylphenidate hydrochloride. Contains sugar (sucrose).
S6 CONTRAMYL XR 36 mg (Extended Release Tablets). Reg. No. 49/1.2/1139. Each extended release tablet contains 36 mg methylphenidate hydrochloride. Contains sugar (sucrose).
S6 CONTRAMYL XR 54 mg (Extended Release Tablets). Reg. No. 49/1.2/1140.Each extended release tablet contains 54 mg methylphenidate hydrochloride. Contains sugar (sucrose).
For full prescribing information, refer to the Professional Information approved by the Regulatory Authority.
Mylan (Pty) Ltd. Reg. No.: 1949/035112/07. 4 Brewery Street, Isando, Kempton Park, 1600. Tel: (011) 451 1300. Fax: (011) 451 1400.
www.mylansa.co.za
M3126 Exp 04/2022
Features EMERGING TRENDS
INFLUENCING
THE BIG MOVE: THE FUTURE OF
7 PSYCHIATRY IN SOUTH
AFRICA
FROM PAPER TO
DIGITAL 22
LEGAL
CONSIDERATIONS
IN PRACTICING
PSYCHIATRY IN THE
DIGITAL AGE
25
AN OVERVIEW OF THE PSYCHIATRIST’S
SOUTH AFRICAN
LAW AND ITS IMPACT 34DILEMMA:
ON HEALTHCARE
SEXUAL OFFENDING
31PRACTITIONERS & PERSONALITY
DISORDERS
NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 2
CONTENTS
CONTENTS MAY 2021
5 FROM THE EDITOR
7 THE BIG MOVE: FROM PAPER TO DIGITAL
19 PAPERLESS PRACTICE POINTS TO PONDER
22 EMERGING TRENDS INFLUENCING THE FUTURE OF
PSYCHIATRY IN SOUTH AFRICA
25 LEGAL CONSIDERATIONS IN PRACTICING PSYCHIATRY IN THE
DIGITAL AGE
31 AN OVERVIEW OF SOUTH AFRICAN LAW AND ITS IMPACT ON
HEALTHCARE PRACTITIONERS
34 THE PSYCHIATRIST’S DILEMMA: SEXUAL OFFENDING &
PERSONALITY DISORDERS
40 OF ‘HOW ARE YOUS?’ AND ‘HELLOS’
43 DEPARTMENTS OF PSYCHIATRY
48 THE STREAMS THAT MAKE A RIVER BERNARD JANSE VAN
RENSBURG 12.04.1960 – 23.04.2020
59 ABILIFY MAINTENA AVAILABLE IN SOUTH AFRICA!
64 BREATH: THE NEW SCIENCE OF A LOST ART
66 MOVIES
67 WINE FORUM: RAISING HANDCRAFTED WINES… ALONG WITH
TWO DAUGHTERS
69 MPUMALANGA BEYOND WILDLIFE
73 SASOP
* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online.
Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication.
Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any opinion, loss or
damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed.
© South African Psychiatry This magazine is copyright under the Berne Convention. In terms of the South African Copyright Act No. 98 of 1978, no part
of this magazine may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by
any information storage and retrieval system, without the permission of the publisher and, if applicable, the author.
COVER IMAGE: Tim Mossholder on Pexels
Design and layout: The Source * Printers: Raptor Print
3 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
7/10 PEOPLE STRUGGLE Restored Sleep
TO MAINTAIN SLEEP, AND
NEED MORE REST1
mediate release The Dormonoct Definition:
Im
ended release • An effective hypnotic3
Dual-layer Ext • ‘Intermediate’ half-life (6 – 8 hours)3,4
SLEEP FAST. • Unaltered REM sleep3,5
• Rapid sleep onset and maintenance of sleep3,4
STAY FAST ASLEEP. • Refreshed morning awakening3
• Helps reduce anxiety symptoms associated with
insomnia3,6,7
- Caution should be exercised in patients suffering from anxiety
accompanied by an underlying depressive disorder
Stilnox® MR 12,5 vs placebo showed2:
M RORE APID acceleration of sleep onset2
M RORE EST through sustained delivery of
sleep maintenance, duration and quality2
M RORE EFRESHED days as no
performance deficits occur the next morning2
ZOLPIDEM TARTRATE 12.5 mg
References: 1. Neubauer DN. New approaches in managing chronic insomnia. CNS Spectr 2006;11:1-16. 2. Roth T, Soubrane C, Titeux L, et al. Efficacy and safety of zolpidem-MR: a double-
blind, placebo-controlled study in adults with primary insomnia. Sleep Med 2006;7:397-406. 3. Clark BG, Jue SG, Dawson GW, et al. Loprazolam - A Preliminary Review of its Pharmacodynamic
Properties and Therapeutic Efficacy in Insomnia. Drugs 1986;31(6):500-516. 4. Approved Dormonoct® 2 mg package insert. 04 October 1983. 5. Salkind MR, Silverstone T. The Clinical and
Psychometric Evaluation of a new Hypnotic Drug, Loprazolam, in General Practice. Curr Med Res Opin 1983;8(5):368-374. 6. McInnes GT, Bunting EA, Ings RMJ, et al. Pharmacokinetics and
Pharmacodynamics Following Single and Repeated Nightly Administrations of Loprazolam, a new Benzodiazepine Hypnotic. Br J Clin Pharmac 1985;19:649-656. 7. Botter PA. A comparative
Double-blind Study of Loprazolam, 1 mg and 2 mg, Versus Placebo in Anxiety-induced Insomnia. Curr Med Res Opin 1983;8(9):626-630.
For full prescribing information refer to the professional information approved by the Regulatory Authority.
SCHEDULING STATUS: S5 PROPRIETARY NAME (AND DOSAGE FORM): STILNOX® MR 12,5 (Modified Release Tablet). COMPOSITION: STILNOX® MR 12,5: Each tablet contains zolpidem
tartrate 12,5 mg. PHARMACOLOGICAL CLASSIFICATION: A 2.2. Sedatives, hypnotics. REGISTRATION NUMBER: STILNOX® MR 12,5: A40/2.2/0441.
SCHEDULING STATUS: S5 PROPRIETARY NAME (AND DOSAGE FORM): DORMONOCT® 2 mg Tablets. COMPOSITION: Each tablet contains 2,49 mg loprazolam mesylate, equivalent to 2 mg
loprazolam. PHARMACOLOGICAL CLASSIFICATION: A 2.2. Sedatives, hypnotics. REGISTRATION NUMBER: Q/2.2/355. NAME AND ADDRESS OF THE HOLDER OF THE CERTIFICATE
OF REGISTRATION: sanofiaventis south africa (pty) ltd., Reg. No. 1996/010381/07, 2 Bond Street, MIDRAND, 1685, South Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707.
www.sanofi-aventis.com. SAZA.ZOL.17.11.0824a. SAZA.LOME.16.11.0952
FROM THE EDITOR
Dear Reader,
welcome to the May 2021 issue. It never ceases to amaze me how each
issue takes on a unique character based on the content received, whilst
retaining a consistency of look and feel that together with a core of
material from our regular contributors provides the foundation.
At the time of writing each column there is usually an issue out there that
catches my attention. It is hard at this time for it not to be virus linked…and
without a doubt you (if you are reading this) will know without me being
specific which one I am referring to.It seems we have seen the emergence
of a third wave in certain provinces, whereas others are in anticipation.The
vaccine rollout has commenced, slowly, and to what extent it will mitigate
is not clear.The core approach remains the practical measures adopted to date.
I have also had occasion to read Sean Baumann’s “Madness…” – reviewed in the last issue. I
thoroughly enjoyed the book, and commend Sean for his contribution that weaves case material
together with thoughtful consideration and discussion on a wide range of issues relevant and familiar
to clinical practice. I would highly recommend the book.
Another issue that has resurfaced is the Life Esidimeni tragedy. It appears that an inquest will finally
take place commencing in July. This is long overdue, and will hopefully provide clearer answers on
accountability. It has been a long road for the families of those who died, but it seems they are staying
strong with the recently launched online memorial https://www.news24.com/news24/southafrica/
news/we-have-become-a-family-say-life-esidimeni-families-at-launch-of-online-memorial-20210520 I
am hoping to have a piece in the August 2021 issue related to some of the Life Esidimeni issues that
will provide background to the inquest.The prospective author is under pressure to deliver.
I came across an advertorial in the April 2021 issue of the South African Medical Journal that I was
wondering – and concerned - about. It was published on behalf of the Health Professions Council
of South Africa (HPCSA) and related to a detailed account of the Maintenance of Licencure (MoL)
Programme.I do not recall any formal communication but the content certainly caught my attention
and I would recommend you familiarize yourselves with it. If you do read the advertorial (pages 20-
22) there is reference to a Figure 5, however aside from a Figure 1, there are no others. Further – is
Licencure a word? I think it should be Licensure – which is a word.
And one more – for the road…for those who access content electronically www.southafricanpsychiatry.
co.za you will notice a registration process has been implemented for access – very simple, and a
one off.
On that note, I wish you all good health. Stay safe and enjoy this issue.
Editor-in-Chief: Christopher P. Szabo - Department of Psychiatry, University of the Witwatersrand
Associate Editor: Renata Schoeman - University of Stellenbosch Business School
Advisory Board: Ugash Subramaney - Head, Department of Psychiatry, University of the Witwatersrand
Soraya Seedat - Head, Department of Psychiatry, Uiversity of Stellenbosch
Dan Stein - Head, Deprtment of Psychiatry and Mental Health, University of Cape Town
Solly Rataemane - Department of Psychiatry, Sefako Makgatho Health Sciences University
Funeka Sokudela - Head, Department of Psychiatry, University of Pretoria
Janus Pretorius - Head, Department of Psychiatry, University of The Free State
Zuki Zingela - Head, Department of Psychiatry, Walter Sisulu University
Bonga Chiliza - Head, Department of Psychiatry UKZN; President South African Society of Psychiatrists
Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading
Design and Layout: Rigel Andreoli
"The views expressed in individual articles are the personal views of the authors and are not necessarily shard by the editor, associate editor, advisory board,
advertisers or the publisher."
5 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
For further product information contact PHARMA DYNAMICS P O Box 30958 Tokai Cape Town 7966 Fax +27 21 701 5898
Email info@pharmadynamics.co.za CUSTOMER CARE LINE 0860 PHARMA (742 762) / +27 21 707 7000 www.pharmadynamics.co.za
ZOXADON ODT 0,5, 1, 2 mg. Each orodispersible tablet contains 0,5, 1, 2 mg risperidone respectively. S5 A46/2.6.5/0362, 0363, 0364.
For full prescribing information, refer to the package insert approved by SAHPRA, May 2019. ZNODTA606/09/2020.
FEATURE
THE BIG MOVE:
FROM PAPER
TO DIGITAL
Renata Schoeman
T he idea of moving to a paperless practice than others. Most of us understand
is daunting – or in any case to me. Our the need to transition, yet we
schedules are hectic, we are all trying to are faced with some barriers –
navigate in the time of Covid-19, we are perhaps financial, perhaps time…
overwhelmed with technological onslaughts (think but most likely, as in all change
endless Zoom consultations, emails, apps, finance initiatives, our biggest barrier is our
software, practice solutions etc.), and yet, we know own uncertainty – born from a lack
we need to take the plunge. Paper documents of knowledge.
and filing cabinets have been the way to organize
information in our practices (and at home) for But what is a paperless practice? Renata Schoeman
decades. But that does not mean that physical, A paperless or paper-free
paper documentation is the best option – although practice is a work environment which uses minimal
for many of us, it is still the preferred way – and physical paper and instead uses primarily digital
convenient. Also, as intimidating as the concept documents. The purpose of the set of articles
may be, going paperless with digital information which follow is to give you some insights and
management systems is a necessity to remain advice from our colleagues who are in the process
competitive in the modern world. of transitioning, or already have transitioned to
a paperless practice. A series of questions were
BUT WHY SHOULD WE TRANSITION? posed in interview format which were answered to
STUDIES SHOW THAT WE CAN LOSE AS help you to make better informed decisions. A big
MUCH AS 40% OF OUR TIME LOOKING thank you to Drs Marcelle Stastny, Chris van den
FOR PAPER FILES AND DOCUMENTS – Berg, Pierre Malherbe, Jow’hara Chundra, Melane
TRANSITIONING WILL MAKE US MORE van Zyl, Shaun Janki and Eugene Allers for sharing
EFFICIENT. FURTHERMORE, UP TO 50% OF their expertise and experience. Also included is an
ALL HARDCOPIES END UP IN THE TRASH – article by Dr Doris Viljoen, a futurist, on the trends
WE SHOULD BE MORE ENVIRONMENTALLY influencing the future of psychiatry in South Africa
CONSCIOUS. (of which tele-medicine is a big one) and an article
with legal advice for practicing psychiatry in the
We also waste money on paper, printers, cartridges digital age by Elsabe Klinck, with commentary from
- going paperless is good for our bottom line. And Tibor Szabo (“Nibbles and Bytes”) – responsible for
finally, the transition to value-based healthcare South African Psychiatry’s IT functions.
requires us to measure outcomes and costs – for
this a strong IT platform is needed. However, creating a paper-free office is an ongoing
The idea behind building a paperless office was first and incremental process, one which should be
conceptualised in 1975 (“The office of the future”, adapted and continually improved over time. It also
Business Week) – and it was a lofty vision! Yet, in requires a team effort – everyone in your practice
2021, it is now within reach of all of us, while some – from receptionist, accountant, and even your
have already transitioned – some more successfully patients, need to be on board. The most important
step? Get started.
7 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
Enjoy the read!
FEATURE
DR MARCELLE STASTNY between your devices and constantly doing Auto
backups, then you need uncapped fibre.
Psychiatrist in private practice, Constantia, What was your setup costs?
Cape Town The downside of Apple products is its initial costs.
What motivated you to transition into a paperless You can go considerably cheaper with android.
practice? My iPad cost about R22000, and the pen another
I needed yet another new filing cabinet. And I was R2000. I cannot remember how much my MacBook
getting so sick of the clutter. cost, but it was in the region of R25000.
How long have you been practicing paperless?
Just under 2 years YOU COULD GO CHEAPER BY JUST
Which hardware do you use (e.g., laptop brand/ BUYING THE KEYBOARD TO PLUG INTO
model, PC, speakers, earphones, screens, tablets, THE IPAD, THE IPAD PRO IS PLENTY
printer)? POWERFUL ENOUGH TO DOUBLE AS A
I use a MacBook Pro and an iPad Pro with iPen (wifi, LAPTOP. I LIKE HAVING BOTH BECAUSE I
256 G, no 3G). My receptionist uses a desktop with CAN DO AN ONLINE CONSULT WHILST
Microsoft, we “communicate" via the google suit. WRITING ON THE IPAD.
Which software do you use? Please motivate your And your monthly costs? (related to the paperless
choice (tell us more about the functionality) system)
The thing about Apple is that they have great Apps. Monthly costs are very low. Once a year or so I need
For my patient notes I use “Notability”. Notability has to buy more cloud space to back up on, but that’s
a good folder/ subfolder system- so it works just like a couple of hundred rand.
a filing cabinet. It is also secure- only opens with my How do you manage power supply (i.e., what
face recognition. It is easy to import and export files, power backups do you have for Eskom…and how
and it has a write to type function. does load shedding affects you?)
What connectivity do you have (fibre, ADSL, etc)? I have a UPS with about 3 hours power to keep my
Definitely fibre. I have my phone lines over VOBI too wifi (and VOBI phones) running. The battery life on
(with Vox). If you want the best of Apple “speaking” my iPad and MacBook is long enough to weather
most load sheds. Load shedding usually does not
bother me.
How do you manage scripts?
I have a script template in Google Docs with my
letterhead and signature. I just copy this, put in
patient details, and script and email off. It’s great,
because for the repeat scripts I just need to change
the date. I also give my receptionist access to these
files, so that she can send them off too if needed.
How do you manage forms and reports? (e.g., PMB,
chronic motivations)
I fill them in online and email back. (You need a
pdf programme to do this). There must be a way
to automate it even more, but I have not gotten
my head around it yet. If anyone knows, they must
please share!
How do you manage lab results/ other results? Can
your receptionist e.g., “export” it from your mail into
the patient’s folder?
I have the Ampath and Pathcare and Lancet apps,
which download results straight onto my phone
and iPad. It is very easy to upload it into your files
(in Notability). I used to do it but realised it is not
necessary at all. Looking it up in an app is like having
it there in the file. Typically, I note down actionable
results in my file, or the fact that I asked for bloods.
The actual results I just leave in the lab apps.
What did you do with your paper folders? Did you
scan it to the online folder? Did you keep your
archive?
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 8
FEATURE
I initially scanned all my old notes and imported What would you consider the biggest drawbacks or
them into the patient’s files (in Notability). Then I got challenges your paperless practice?
clever and asked my receptionist to do it. Now I just I have had to figure out new boundaries. Because
scan my assessment notes and a summary of the everything is at your fingertips at all times, there is
patient’s course. I find it a useful reflection. the temptation to “just quickly.”
Any specific comments re the customer experience
I DO KEEP MY ARCHIVE. IT IS PROBABLY for your patients?
NOT NECESSARY, IT’S JUST GATHERING It was very important for me that the “feel” was
MOULD, BUT I WOULDN’T KNOW HOW like writing on an exam pad, so I did not want it to
TO BEST GET RID OF THEM. PLUS, change the patient experience. But it has changed
PATIENTS TEND TO COME OUT OF THE the patient experience (for the better I think). E.g.
WOODWORK EVEN TEN YEARS LATER my psych education: I have started downloading
AND I DID NOT SCAN MY INACTIVE FILES. floating, rotating brains to explain things to people.
Much more exciting than my primitive pencil
How do you manage emails (do your patients use sketches of the past.
the practice address or your personal address? Any other comments you would like to add?
Does your receptionist screen? Can she file it in the Now is a time of much change. It's the perfect time
necessary folder?) to start doing things differently. I found it easier and
I have an email address and she has an email more fun than I expected it to be. It’s also worthwhile
address. I have a clear bounce back saying email to look at OutcomesIT (Eugene’s system).
is not for emergencies. If somebody insists on trying
to get an email consult, I just zip a note back saying CHRIS VAN DEN BERG
that they need to make an appointment to discuss
further. It is easy to load an email into patient files Psychiatrist in private practice, Stellenbosch
if needed, but I try not to let emails be important What motivated you to transition into a paperless
enough to need to file. practice? How long have you been practicing
How do you manage other queries? E.g., a patient paperless?
calls to check when the follow up is due, or a I wanted to be paperless from the get-go, so I went
colleague calls to check re meds prescribed… paperless when I started private practice in 2010. I
could your receptionist then access the treatment did not want to even start with paper files, as I knew
plan and answer, or do you need to manage each it would be very difficult to make the transition to
and every query? paperless later on. Going paperless meant that I
No- heaven forbid! Going paperless is to make could work from anywhere in the world if I wanted
my life easier, not harder. My admin stuff is shared to - my patient files always accessible. And it's also
with my receptionist in google suites. So, Google the more eco-friendly thing to do.
calendar for appointments, google docs for scripts Which hardware do you use (e.g., laptop brand/
and referral letters. We also share a drop box for model, PC, speakers, earphones, screens, tablets,
intake forms and PMB approvals etc. We have printer)?
worked out a communication system in Google Microsoft Surface Pro (tablet pc); I also have a
Calendar whereby my calendar is for appointments Huawei tablet pc as backup in case my main pc
and hers has little to do notes- like send Mr X’s lets me down (which has not happened yet) But if
script to Meadowridge pharm, or bill 2974. We got it were to happen, I would not be able to continue
this system up because sometimes she has been working until I can access my backup pc. This is
working remotely, or sometimes I see patients after one big downside of being paperless - you are fully
hours.
How do you manage back-ups?
I back up my iPad, MacBook and phone on Apple
cloud, because this helps them all sync, and if my
iPad breaks, I can immediately set up with another
without breaking my stride. But I also use Google
and Dropbox.
How do you communicate with your receptionist
re instructions re patients (e.g., paper notes or in
person/email?)
Via Google calendar. She then changes the colour
as she does them, or leaves notes for me to do too.
What would you consider the biggest pros of your
transition to a paperless practice?
Everything. I cannot imagine going back.
9 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
dependant on technology! I also use my iPad for forms are completed electronically, but I find this
questionnaires, HealthID. to be more time consuming.) Chronic medications
Which software do you use? Please motivate your applications are done via HealthID (Discovery) or
choice (tell us more about the functionality) sending a copy of the prescription to the medical
CGM - PMO and MedEDI. I had a look at a few aid via email. Occasionally, when patients bring
products back in 2010, but PMO was the best one me the forms, I will do it by hand.
for me at that moment. Initially I only used the PMO How do you manage lab results/ other results? Can
product and outsourced the billing but started your receptionist e.g., “export” it from your mail into
doing my own billing when CGM integrated the the patient’s folder?
PMO and MedEDI functionality. There are probably Emailed reports are "printed" (exported) to the
better/cheaper products on the market now, but I patient's OneNote file. (The PMO software does
do not consider them, as I do not think I'll be able allow for importing lab results directly into the
to do a smooth transition. I guess I am left with no patient file at additional monthly cost)
option than to stick with them even if they might What did you do with your paper folders? (did you
not be the best. (Almost like sticking with Apple scan it to the online folder? Did you keep your
because you are used to and even dependent on archive?)
their system and switching to Samsung would be a I don't have paper folders. Paper documents that
huge disruption). need to be kept, are scanned in.
What connectivity do you have (fibre, ADSL, etc.)? How do you manage emails (do your patients use
LTE with WebAfrica the practice address or your personal address?
What was your setup costs? Does your receptionist screen? Can she file it in the
The tablet pcs are quite pricey - The Microsoft necessary folder?)
Surface Pro was around R20k; the Huawei a bit I have 2 email addresses: one for reception and
cheaper. one for me. The former is for admin related queries
And your monthly costs? (related to the paperless (appointments, script requests, etc.) and the latter
system) for clinical matters (questions about side-effects,
The CGM packages cost about R1800/month (incl. etc.) Emails can also be exported to the OneNote
MedEDI switch fees). LTE internet about R500-700/mo. patient files.
How do you manage power supply (i.e., what How do you manage other queries? E.g., a patient
power backups do you have for Eskom…and how calls to check when the follow up is due, or a
does load shedding affects you?) colleague calls to check re meds prescribed…
My office building has generators. I have an external could your receptionist then access the treatment
power supply (to give enough time for the computer plan and answer, or do you need to manage each
to save and shut down safely and to protect against and every query?
power surges. But with the generator, power supply
has never been a problem.) THE RECEPTIONIST CAN ANSWER
ADMIN RELATED QUERIES (E.G., NEXT
WORKING FROM HOME IS A DIFFERENT APPOINTMENT SCHEDULED, DATE OF
ISSUE HOWEVER - THERE I CAN'T REALLY LAST SCRIPT ISSUED, ETC.) BUT CANNOT
DO ONLINE CONSULTATIONS WHEN ACCESS THE CLINICAL FILE (WITH
THERE IS LOAD SHEDDING BECAUSE TREATMENT HISTORY, MANAGEMENT
OF POOR CELL PHONE SIGNAL. I AM PLAN, ETC.)
CONSIDERING A SOLAR SYSTEM AT
HOME THAT WOULD BE ABLE TO SUPPLY Queries are then sent on to me via the PMO internal
POWER TO MY PCS AND INTERNET messaging system. I also have a Business WhatsApp
ROUTER. account where patients could ask admin related
questions, but patients also see this as a very quick
How do you manage scripts? and accessible way of contacting me for clinical
Computer generated prescriptions via PMO. It is queries. With the business account, one can at
a quick process and can be emailed quickly. For least set up an automatic reply directing patients
schedule 6 scripts, I write the number of tablets in to the best communication channel for their query
words in my own handwriting and stamp it too. and conveying the message that a WhatsApp can't
How do you manage forms and reports? (e.g., PMB, be used in emergencies.
chronic motivations) How do you manage back-ups?
Unfortunately, it is easier for me to complete My computers back up automatically to the server
forms by hand than electronically so PMB forms as scheduled, but I do an additional backup on
are printed out. (When I do online consultations, an external hard drive once a week, which I take
home with me (to have it off site). I have tried Cloud
backup, but experienced technical problems with
it, so I reverted to good old external hard drives.
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 10
FEATURE
How do you communicate with your receptionist I primary use my iPad and desktop computer.
re instructions re patients (e.g., paper notes or in We have a printer in the practice that can do
person/email?) duplex scanning (scan both sides of a page
PMO internal messaging system or via email. simultaneously), which is fast. As our practice’s
What would you consider the biggest pros of your software is web-based (it works as a website, not
transition to a paperless practice? a programme) and optimised for any size screen,
Not needing space to store paper documents; any device that is connected to the internet can
having easy, quick access to all patient files wherever be used.
I work from (home, holiday, etc.); eco-friendliness, Which software do you use? Please motivate your
being better organized increases efficiency (getting choice (tell us more about the functionality)
more things done in less time), easy integration with
an already-online world; making telepsychiatry and OUR PRACTICE SUBSCRIBES TO CLINIKO
online consulting much easier. (CLINIKO.COM). AS MENTIONED, IT
What would you consider the biggest drawbacks or IS WEB BASED, SO YOU NEED VERY
challenges your paperless practice? LITTLE IN TERMS OF HARDWARE AND
Cost (especially monthly fees for software). Total NO SOFTWARE IS NEEDED EXCEPT AN
reliance on a pc working well; technical problems INTERNET BROWSER, LIKE CHROME,
(programs crashing, slow processing speeds, FIREFOX, SAFARI OR MS EDGE.
connectivity issues) could bring you to a total
standstill! (You cannot see the next patient if you
can't access their file!)
Any specific comments re the customer experience
for your patients?
They are usually impressed by the efficiency of the
service they receive.
Any other comments you would like to add?
No
DR PIERRE MALHERBE We prefer Cliniko because of the following features:
• Really easy: no training necessary and helpful
Psychiatrist in private practice, Pretoria
training videos available on almost all functions
What motivated you to transition into a paperless • It manages our diaries, and you can make
practice?
The management of masses of paper, not having bookings for different types of appointments,
files available between hospital and the rooms, not just certain time slots
files getting lost, etc. frustrated me. Paper files are • It reminds patients of their appointments
also vulnerable to being lost, misplaced or filed automatically via email and SMS
incorrectly. • It keeps a (paperless) paper trail of
How long have you been practicing paperless? communications with patients
Four years • It stores clinical notes and has customisable
Which hardware do you use (e.g., laptop brand/ note templates for each type of appointment. I
model, PC, speakers, earphones, screens, tablets, type my notes directly onto the template in the
printer)? patient’s profile, but my colleagues write their
notes and scan it to the patient profile. I’ve not
found that any writing-to-text conversion really
works well enough on any device, in my opinion.
• Easy to search and peruse old notes whilest
making new notes.
• It offers online bookings
• It has a built-in video-chat facility, for which
patients need no software and no training to
use
• It works on any size screen or device, not just a
PC
11 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
• It can generate and send invoices and keeps How do you manage scripts?
stats on practice income, appointment A major drawback of Cliniko is that it does not have
volumes, numbers and types of patients seen an integrated formulary. We therefore cannot auto-
etc. and generates instant charts / graphs of generate scripts. My scripts are typed with the first
these contact and stay on the patient’s profile as part of
their notes. I load a copy of the previous script with
• It sends out forms that patients can complete each visit and tweak / change it, if necessary, print
online before appointments e.g., Covid it out and sign it. Emailing of scripts depends on the
questionnaires, consent forms pharmacy — some accept emailed scripts, others
do not.
• It discerns between users e.g., reception staff
cannot see clinical notes, billing staff can’t I KNOW THAT OUTCOMESIT INCLUDES A
make appointments FORMULARY TO GENERATE SCRIPTS AND
AUTOMATICALLY ADDS A QR CODE THAT
• Cliniko support-staff usually respond very THE PHARMACIST CAN USE TO VERIFY
quickly to queries via built-in chat help function. SCRIPTS IF THEY ARE EMAILED.
Because data is stored in the cloud (on a server
somewhere off-site), it is instantly accessible How do you manage forms and reports? (e.g., PMB,
wherever there is access to the internet chronic motivations)
Letters are drafted on Cliniko, sent from Cliniko and
• A portion of Cliniko’s profit is donated to charity. saved to the patient’s profile. I have several letter
For email, communication, and other document templates in place. Chronic applications and
storage, we use G-suite. This is a product by Google PMB forms are mostly still completed by hand and
that gives you access to email, word processing, scanned and saved on a patient’s profile. I think
spreadsheets, cloud storage and backup. this is more a function of the medical aids not really
What connectivity do you have? (fibre, ADSL, etc) being paperless-friendly.
We have fibre at the rooms, and I use LTE/5G on How do you manage lab results/ other results? Can
mobile devices. your receptionist e.g., “export” it from your mail into
What was your setup costs? And your monthly costs? the patient’s folder?
(related to the paperless system) Emailed lab results can be stored in a patient’s
The first month of Cliniko is free and thereafter it’s a profile, or one can “drag and drop” from the lab’s
USD45.00 fee per month for a solo practice, e.g., app. Lab results are not automatically loaded onto
me, two receptionists and billing agency. Our the patient’s file like with other systems.
G-Suite subscription costs EUR47.00 per month. These What did you do with your paper folders? (did you scan
subscriptions are monthly and can be cancelled at it to the online folder? Did you keep your archive?)
any time. We have no other software except antivirus New patients do not have paper folders. The
software. For hardware, I use an iPad with a keyboard consent forms that they sign are uploaded onto their
during consultations and the receptionists use PCs profile in Cliniko. Older files, as they are needed, are
with an internet connection. We have a practice scanned, and saved to the patient’s Cliniko profile.
printer and I have my own in my office, because I print The old file is then shredded.
scripts. No servers, or back-up drives are necessary. How do you manage emails (do your patients use
How do you manage power supply? (i.e., what the practice address or your personal address?
power backups do you have for Eskom…and how Does your receptionist screen? Can she file it in the
does load shedding affects you?) necessary folder?)
If the power is out, I keep working on my iPad. I do All emails come to the practice reception. From
have a small UPS under my desk for the printer. The there, the receptionists direct queries to myself or
hospital has a backup-generator. billing, if they can’t attend to the query. With G-Suite
we have four email addresses and our own domain-
name (the part after the @ sign). All emails ever sent
and received are stored indefinitely, off-site and can
be searched. As an administrator, I have access to
all email, but staff only have access to their email
name. We also use the chat function 'Hangouts'
to communicate between reception, rooms, and
billing, which is also backed up automatically
forever. G-Suite is HIPAA compliant, which means it
adheres to privacy and confidentiality requirements
for health care in the US.
How do you manage other queries? E.g., a patient
calls to check when the follow up is due, or a
colleague calls to check re meds prescribed…
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 12
FEATURE
could your receptionist then access the treatment practice more transparent to patients, provide ease
plan and answer, or do you need to manage each of access and offer greater access to care (within
and every query? strict parameters).
Receptionists and billing people do not have access Any other comments you would like to add?
to clinical data, so all clinical queries are handled I use an old iPad during consultation for rating
by a clinician. For phone queries, reception will scales and questionnaires, that I hand to the
send me a message on our chat, and I’ll respond patient to mark on with their finger (after properly
to the chat. sanitising it) — then you do not need to print them
How do you manage back-ups? out or use a tear-off pad. For iPad or other tablet
Back-ups are not necessary, as all Cliniko- users, I can recommend Goodnotes: a good, free
data is stored in the cloud and all email data is app for your tablet or phone to write on documents
automatically stored forever. A concerning issue and edit PDFs, then drag and drop into a patient’s
with using international products such as Google, profile
Cliniko, Microsoft etc., is that patient information will
inevitably be stored overseas. This is in contravention DR MELANE VAN ZYL
of the POPI-act. Although I am very happy with
the security of patient information stored at our Psychiatrist in private practice, Vanderbijlpark
practice, I am not sure how to manage the POPI What motivated you to transition into a paperless
issue in a paperless practice. practice?
How do you communicate with your receptionist My main motivation to go paperless was to be able
re instructions re patients (e.g., paper notes or in to access patient notes wherever I am. I am also
person/email?) interested to be able to collect data (e.g., rating
As mentioned above — we use Hangouts that is scales and treatment given- in other words measure
part of our G-Suite. We have chats between me and outcomes). In my previous office I have also started
reception, myself and billing, billing and reception to run out of space for my 11 000 plus files- not a
and reception and reception. As an administrator problem however in my new office.
I have access to all chats, but other staff only their How long have you been practicing paperless?
designated chat. It is a work in progress. I have been using Outcomes
What would you consider the biggest pros of your IT for nine months.
transition to a paperless practice? Which hardware do you use (e.g., laptop brand/
model, PC, speakers, earphones, screens, tablets,
IT’S MUCH EASIER TO SEARCH THROUGH printer)?
DIGITALISED RECORDS THAN PAPER Lenovo Thinkpad Yoga X1 (laptop), Ipad Pro, Ricoh
RECORDS AND BECAUSE THERE IS MP C307 (copy machine)
ALWAYS A DIGITAL TRAIL, ONE CAN Which software do you use? Please motivate your
MORE EFFECTIVELY DEAL WITH QUERIES choice (tell us more about the functionality)
OR DISPUTES. Outcomes IT
What connectivity do you have (fibre, ADSL, etc)?
Many processes in the practice can be automated ADSL
and this saves time and energy. Personally, I like What was your setup costs? And your monthly costs?
feeling that I have a handle and a bird’s eye view (related to the paperless system)
on things, and this decreases my anxiety at work. Outcomes IT monthly subscription of R900 per
What would you consider the biggest drawbacks or month
challenges your paperless practice?
As I mentioned above, my ideal would be for Cliniko
to have a formulary on board for e-scripting. Cliniko
does offer 3rd party “plug-ins”, so it is possible. I
have just been too lazy to ask a software creator
to help with a plug-in. I would like to see the allied
professionals that we often work with to use the
same system, to streamline MDT functionality, but
they have not yet bought in.
Any specific comments re the customer experience
for your patients?
Many patients comment on how helpful the
automatic reminders are and how modern the
practice appears. Our online presence has just
started, and I hope to gain some traction with
info available on our website and online booking
of appointments. My hope is that it will make the
13 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
How do you manage power supply (i.e., what plan and answer, or do you need to manage each
power backups do you have for Eskom…and how and every query?
does load shedding affects you?) Straightforward queries are managed and noted
I have an inverter, so power supply is sorted. in the dairy or accounts system. All clinical queries
However, in the one hospital I work there is usually e.g., medication side-effects are written in the
no wifi or cell phone signal so I cannot take digital patient’s file and it is given to me. I also write notes
notes on Outcomes IT whilst I am there. I write all my regarding my answers in the file. I have protocols in
notes with ordinary pen and paper and scan it in. place for requests for reports, emergencies, other
How do you manage scripts? doctors who want to speak to me, admissions etc.
In my office I write scripts on Outcomes IT. When I How do you manage back-ups?
am in the wards or do not have a printer available, Outcomes It and my billing system (GoodX) is cloud
I write on a script pad (always make a hard copy based. I back up all the computers on a hard drive
with carbon paper for the file) and scan it in into weekly.
Outcomes. How do you communicate with your receptionist
How do you manage forms and reports? (e.g., PMB, re instructions re patients (e.g., paper notes or in
chronic motivations) person/email?)
Most reports I write in Word (on my letterhead), Communication with my staff is either verbal (when
print a hard copy for the file and save a pdf to I am in the office) or on WhatsApp (if urgent)
Outcomes. For PMBs and chronic forms I do hard or email. All instructions and the outcomes are
copies (mostly- Discovery I do on HealthID) and recorded in the patient’s file.
save a hard copy in the patients file (with a note of What would you consider the biggest pros of your
the date it was sent in). transition to a paperless practice?
How do you manage lab results/ other results? Can Pros include to be able to access notes wherever
your receptionist e.g., “export” it from your mail into I am, and a good feeling that I am on track with
the patient’s folder? falling in line with the ”digital future”. I really like the
All my lab results are hard copies that are filed in the timer function on Outcomes IT.
patient’s file. What would you consider the biggest drawbacks or
What did you do with your paper folders? (did you challenges your paperless practice?
scan it to the online folder? Did you keep your
archive?) DRAWBACKS INCLUDE THAT I OFTEN
I have all my files available (from starting my WORK WHERE I DO NOT HAVE INTERNET
practice in this area in 2007). RECEPTION OR A PRINTER AVAILABLE, SO
How do you manage emails (do your patients use MUST RE-DO THIS WORK SO IT REFLECTS
the practice address or your personal address? ON MY SYSTEM. THIS INCLUDES NOTE
Does your receptionist screen? Can she file it in the TAKING DURING THE MDT MEETINGS.
necessary folder?)
I have a practice email (Outlook) which my two I also seem to do work for which there are no
receptionists screen continuously. All emails that templates or separate filing “space” for in Outcomes,
are not straightforward (e.g., about appointments so I must scan this with the patient notes. (This
or accounts) they print out for me and show it to includes EMDR, psychoanalytic psychotherapy
me ASAP. sessions and DBT outpatient groups- when I start
How do you manage other queries? E.g., a patient them)
calls to check when the follow up is due, or a Any specific comments re the customer experience
colleague calls to check re meds prescribed… for your patients?
could your receptionist then access the treatment My patients seem to be impressed with the printed
scripts with the bar code. Consultations take
longer, but nobody has complained yet. I have
read reviews on the internet where patients seem
to dislike it when the psychiatrist types during the
interview.
Any other comments you would like to add?
I like the physicality of writing with a pen on paper. It
might be the way I work now, but my consultations
have space that patients can talk freely and “all
over”, and I have learned through the years how
to write notes that that are still structured and
comprehensive in the end. It might be possible to do
it this way digitally in the future, but I have found no
app, device, or program yet that fits my note taking
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 14
FEATURE
style. I like to handle the patients’ files. If I have it About R900 a month. No set-up costs except for
in my hand, I can judge how long the patient has Apple pencil (though one can use a cheaper
been in my practice and how “complex” they might stylus) and a small printer for my office.
be. Sort of a bird’s eye view/ instinctive feeling that I How do you manage power supply (i.e., what
will not get by looking at a computer screen. power backups do you have for Eskom…and how
Because my practice is extremely busy, I like to does load shedding affects you?)
organise piles of files with specific tasks, e.g., scripts,
reports, feedback reports, etc. I do the same with my GENERATOR AT THE OFFICE, UPS AT HOME.
billing- I make the flow of the accounts through the LOAD SHEDDING AFFECTS SYSTEM AS
months visible by printing it out and moving it through WELL AS ONLINE CONSULTATIONS. AND
30, 60, 90 days etc. (Almost like a Kanban system) THE PRINTER OCCASIONALLY.
When I must write a long report or think of myself in
court, I do prefer having a physical file. So, I think my How do you manage scripts?
patient notes are a bit like a security blanket! Electronic scripts are emailed to my receptionist, who
then gets me to re-sign and stamp. They are then
DR JOW’HARA CHUNDRA collected, or sent to the pharmacy, from our practice
email address. In face-to-face consultations, scripts
Psychiatrist in private practice, Saxonwold are printed in office and given directly to patient
What motivated you to transition into a paperless How do you manage forms and reports? (e.g., PMB,
practice? How long have you been practicing chronic motivations)
paperless? Still paper. Reports are done using the programme.
I had been thinking about it for quite a while, as files How do you manage lab results/ other results? Can
were cumbersome, and it was difficult to remember your receptionist e.g., “export” it from your mail into
details of medication in an emergency. During the patient’s folder?
hard lockdown in 2020 with limited access to files, Yes
I decided to make the change, but it has been What did you do with your paper folders? (did you
gradual. scan it to the online folder? Did you keep your
Which hardware do you use (e.g., laptop brand/ archive?)
model, PC, speakers, earphones, screens, tablets, For the meantime, we still have the paper files, and
printer)? are not uploading all the old files
Ipad pro, Macbook pro- both older models. How do you manage emails (do your patients use
i-pencil, a new printer in my office- old printer was the practice address or your personal address?
in reception. Does your receptionist screen? Can she file it in the
Which software do you use? Please motivate your necessary folder?)
choice (tell us more about the functionality) Emails are sent to the practice or directly to my work
Outcomes IT- I initially used Office OneNote-but email address. The receptionist tries to remind me
then was worried about the privacy settings and to get back to them, if I miss them. She can upload
was looking for something that would make admin to folder but does not.
a little easier. Outcomes It seems to do that How do you manage other queries? E.g., a patient
What connectivity do you have (fibre, ADSL, etc.)? calls to check when the follow up is due, or a
Fibre- at home and at the office. At the hospital, I use colleague calls to check re meds prescribed…
3/4G. At the office- speed is sometimes a little slow could your receptionist then access the treatment
What was your setup costs? And your monthly costs? plan and answer, or do you need to manage each
(related to the paperless system) and every query?
My receptionist deals with appointments, I deal
with colleagues. Letters and summaries can be
accessed on the system by the receptionist, and
forwarded on if needed
How do you manage back-ups?
System guarantees back-ups
How do you communicate with your receptionist
re instructions re patients (e.g., paper notes or in
person/email?)
In person or by email or WhatsApp.
What would you consider the biggest pros of your
transition to a paperless practice?
15 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
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I can access notes whenever I need. Scripts are ADSL. We’ve just installed fibre so I can’t tell you how
easier to do. The templates make letter and report that’s working out. But the ADSL is temperamental
writing quicker and there were nerve wracking days when I needed
What would you consider the biggest drawbacks or to run a Zoom based consultation service without
challenges your paperless practice? reliable WiFi.
Speed of internet. Also, my receptionist no longer What was your setup costs? And your monthly costs?
checks if I signed off my notes- so now I have (related to the paperless system)
to check. The internet speed is an issue, and I paid about R20 000 for the iPad. The internet service
sometimes, it takes a while to access online files, or is approximately R800/month. I pay approximately
change screens within the app. R1400 a year for access to Microsoft office (which I
Any specific comments re the customer experience use mainly for medicolegal reports). Evernote costs
for your patients? a similar amount for the pro version.
They were initially a little perplexed, as I had to look How do you manage power supply (i.e., what
at the screen much more. power backups do you have for Eskom…and how
Any other comments you would like to add? does load shedding affects you?)
I still have not transitioned fully, but it gets easier the We have a UPS for WiFi but this wasn’t very reliable.
longer you stay with it. Fortunately the iPad has a reasonably long battery
life. More recently I needed to bring my MacBook
DR SHAUN JANKI into work to use as a device for consultation whilst
typing my notes on the iPad.
Psychiatrist in private practice, Umhlanga How do you manage scripts?
What motivated you to transition into a paperless This is very difficult. I tried Outcomes IT but it was too
practice? How long have you been practicing cumbersome. So I reverted to handwritten scripts.
paperless? How do you manage forms and reports? (e.g., PMB,
It seems to be a more efficient way of archiving chronic motivations)
the immense amount of data we collect. Also, I These are prefixed and I add in the patient specific
tend to note quite a lot of verbatim responses and details. We email them. This works well. Unfortunately,
electronic notes are less onerous. we still store a copy in the patient’s file.
Which hardware do you use (e.g., laptop brand/ How do you manage lab results/ other results? Can
model, PC, speakers, earphones, screens, tablets, your receptionist e.g., “export” it from your mail into
printer)? the patient’s folder?
My primary device is an iPad Pro. I have a windows This is also problematic. For now, it is largely paper
10 Asus desktop, primarily because the billing based.
software I use (MEDIS) only runs on windows What did you do with your paper folders? (did you
computers. I have an HP printer. scan it to the online folder? Did you keep your
Which software do you use? Please motivate your archive?)
choice (tell us more about the functionality)
Evernote. It’s multi platform and multi device and THEY STILL EXIST. THEY CONTAIN
cloud based. It also allows the use of templates. CONTRACTS, PAPERWORK FROM
I can make notes even when there’s no internet THE MEDICAL AID, PHQ-9S, GAD-7S,
access and it synchronises when there’s an internet MOCAS AND OTHER MISCELLANEOUS
connection. DOCUMENTS.
What connectivity do you have (fibre, ADSL, etc.)?
How do you manage emails (do your patients use
the practice address or your personal address?
Does your receptionist screen? Can she file it in the
necessary folder?)
There is a practice email. My secretary screens
them and prints them for the folders.
How do you manage other queries? E.g., a patient
calls to check when the follow up is due, or a
colleague calls to check re meds prescribed…
could your receptionist then access the treatment
plan and answer, or do you need to manage each
and every query?
We have a query book. She takes the messages and
asks me about specific things. Unfortunately for now,
it seems that the queries are better captured than
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 16
FEATURE
my responses. The latter seems to be something we I have been “paperless” for the past 5 years. My
can retrospectively piece together but this rarely motivation always has been to work at the cutting
becomes necessary. edge of technology. As a scientist and interested
How do you manage back-ups? in data and science to be a good practitioner and
The billing data is backed up daily. My clinical notes run a successful business and working on paper
are not ever “backed up” as it is all cloud based. was just too cumbersome and out of date for me
How do you communicate with your receptionist to provide me with information I needed to practice
re instructions re patients (e.g., paper notes or in and do business.
person/email?) Which hardware do you use (e.g., laptop brand/
A combination of all three. I’ve asked her to record model, PC, speakers, earphones, screens, tablets,
as much as possible in Evernote but I believe many printer)?
of these are managed on an ad hoc basis. Apple iPad Pro 12.9”, laser printer on a network.
What would you consider the biggest pros of your Which software do you use? Please motivate your
transition to a paperless practice? choice (tell us more about the functionality)
It’s easy to find notes, trace the factors that led to
certain decisions, communicate with colleagues ELECTRONIC HEALTH RECORD:
on referring or handing over. OutcomesIT. IT IS A FULLY SOUTH
What would you consider the biggest drawbacks or AFRICAN PLATFORM WHICH HAS THE
challenges your paperless practice? USUAL FUNCTIONALITY INCLUDING:
There are several kinks that need to be ironed MAKING NOTES, PRESCRIPTIONS, SICK
out. I’m still looking at ways to create a unified NOTES, MOTIVATIONS AND PROGRESS
patient folder with all their documents so that I can FORMS FOR MEDICAL SCHEMES,
completely eliminate the paper. AUTOMATICALLY POPULATING REPORTS
Any specific comments re the customer experience AND REFERRAL LETTERS, GIVING YOU
for your patients? THE OPTION TO TYPE, WRITE OR TEXT
Patients sometimes need to be explained that the CONVERT YOUR NOTES, IMPORTING
iPad is for notes. Some people seem confused PATHOLOGY RESULTS AND TRACKING
and I’ve even had the odd patient complain that EVERY ENTRY AND PLACING IT INTO A
“the doctor wasn’t paying attention, he was on his DATABASE.
tablet the whole time!” I also orientate new patients
by showing them that I’m working from a general It has a fully web-based calendar with full
template and that my questions are fairly standard. functionality. It has a full set of outcomes measures
Any other comments you would like to add? for the entire psychiatric team and connects all
I’m interested to see how others are managing their the members of the psychiatric team into one
practices and what technology they are using. I platform, to enable co-ordination of care. We
tried Outcomes IT but it was very cumbersome and can thus read each other’s notes and follow the
I’m not ready to give that up. treatment and check the patient’s compliance
to treatment. It has a functionality to privatise
DR EUGENE ALLERS your note if you so wish. It gives you real time live
feedback on your data. It is value based enabled
Psychiatrist in private practice, Benoni and easy to use. It has a telepsychiatry facility and
Director and shareholder of OutcomesIT communication platform for SMS and emails to
What motivated you to transition into a paperless patients and members of the psychiatric team.
practice? How long have you been practicing It gives notifications to patients of appointments
paperless? and can accommodate multiple users in one
practice. It has a built-in facility for auditing all your
interactions with patients, so if you get audited by
a medical scheme, it will take minutes to supply
them with the required data. It has excellent
support.
What connectivity do you have (fibre, ADSL, etc.)?
I use LTE as I have no fibre in my area and all
hardware is on a network.
What was your setup costs? And your monthly costs?
(related to the paperless system)
The most expensive item was the iPad Pro, costing
around R30 000. The rest of the wifi and hardware
was in place in the practice anyway. The monthly
cost of OutcomesIT is R899.00 per month.
17 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
How do you manage power supply (i.e., what information or limited information. I give them full
power backups do you have for Eskom…and how access (they had full access to files anyway), with
does loadshedding affects you?) a confidentiality agreement in place. They can
Battery power bank that can supply power for up to then answer those queries, they can even send the
2 hours and a backup 3KW generator that supplies prescription to the doctor or pharmacist that phones
power to the lights, computers, electric gate and about what medication the patient is on. Therefore, I
fridge (not the geyser) am spared to answer each and every query.
How do you manage scripts? How do you manage back-ups?
Electronic scripting. It remains a problem with some
pharmacies though. In my area I have spoken to all YOU DO NOT HAVE TO BACK UP THE
the pharmacies and after 5 years now, they accept SYSTEM. THE SYSTEM IS WEB BASED AND
my electronic faxed scripts. For those pharmacies SAVES EVERY ENTRY ON THE CLOUD.
that are not well informed about the legislation or THE SYSTEM IS POPIA COMPLIANT AND
remain problematic we supply printed electronic HAS ALL THE NECESSARY SECURITY
paper scripts which the patient get at the time of the MEASURES IN PLACE. YOU CAN WORK
consult, stamp them with an original stamp and sign ON THE SYSTEM ANYWHERE IN THE
in red pen. OutcomesIT has an electronic verifiable WORLD IF YOU HAVE WIFI.
signature which can be checked with a bar code
next to the signature, but some pharmacies still How do you communicate with your receptionist
have problems. I do no handwritten prescriptions. re instructions re patients (e.g., paper notes or in
How do you manage forms and reports? (e.g., PMB, person/email?)
chronic motivations) Depends on the communication, directly, phone,
OutcomesIT generates these virtually automatically email or WhatsApp.
from your input during your consult. You only have What would you consider the biggest pros of your
to add some detail here and there and I then email transition to a paperless practice?
them to the case managers, my office or whomever I have everything at my fingertips, and it spares me
needs these. to do things for the patient afterwards, like writing a
How do you manage lab results/ other results? Can letter or some other admin. It is all done during the
your receptionist e.g., “export” it from your mail into consultation as it is so easy. I even do referrals to, say
the patient’s folder? a specific psychologist on the system, whilst I see
OutcomesIT imports them automatically into the the patient. All patient files with all their information
patient’s folder in excel format and pdf which also are always with me at any given time when I have
means that my pathology data gets analysed and I my tablet with me.
receive a report on my test results, how many done What would you consider the biggest drawbacks or
and what and how many positive or negative. challenges your paperless practice?
What did you do with your paper folders? (did you I am still waiting to find out after 5 years. The only
scan it to the online folder? Did you keep your drawback, which was solved easily was the stability
archive?) of the internet. We solved it by having two service
OutcomesIT allows you to scan the active files onto providers, if the one goes down, it automatically
the system on each patient’s file. This is done the switches to the other. If everything goes down, which
day before a patient has an appointment. The non- it has not until now, it would be a major problem.
active files are archived. Any specific comments re the customer experience
How do you manage emails (do your patients use for your patients?
the practice address or your personal address? They enjoy doing the outcomes self-rating scales
Does your receptionist screen? Can she file it in the on the tablet and seeing their graphs and progress.
necessary folder?) As the tablet is so easy to use, more so than paper
Emails are sent to a central office email to the as it is not floppy or you have to page, you have
receptionists and placed onto the patient’s file on more eye contact with your patients. They prefer the
OutcomesIT. Emails are forwarded to my personal electronic prescriptions as it also enables them to
email which I have to respond to, to enable me read the prescription (as they cannot read doctors
to respond to them. Other emails to which the handwriting). They can easily receive emails and
reception can respond to is not dealt with by me. reminders of their appointments. They think you are
How do you manage other queries? E.g., a patient really advanced, and it improves your image. I have
calls to check when the follow up is due, or a not had any negative comments from patients,
colleague calls to check re meds prescribed… only positive ones.
could your receptionist then access the treatment Any other comments you would like to add?
plan and answer or do you need to manage each I cannot think of going back to paper. It would be
and every query? like living without a cell phone and only using a fax
OutcomesIT has a functionality where you can machine in my office
decide whether to give your staff full access to
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 18
PERSPECTIVE
PPARPAECRTLIECS SE
POINTS TO PONDER
Tibor Szabo
G oing paperless – this is a commonly heard consultation). The end result is
phrase nowadays in the medical field. a far more slick data-gathering
The idea of moving away from reams process. Captured information
and reams of patient notes, to a virtual is therefore automatically saved,
platform where data is stored in digital form, can be without the need for additional
particularly daunting for some professionals. scanning of physical paper
After all, there is certainly something to be said for sheets post-consultation.
having a physical copy of a document on hand
to work with – it’s definitely “old school”, yet proven SECURITY:
and effective.
Why then, should one even begin to consider going Data stored in a digital format Tibor Szabo
paperless?
While the ultimate decision will vary from practice can be secured and backed up in a number of
to practice, it is certainly worth considering some of ways.
the benefits that current IT trends bring to the table:
CONVENIENCE: We are now spoilt for choice in terms of how we
The ability to access any historical data at the are able to use encryption, password protection,
touch of a button, is a huge value add to any local backups and cloud backups, in order to
practice. ensure that sensitive data is kept as secure as
When compared to the alternative of having possible.
to seek out a single physical file from among
thousands of others (all while stored in a physical ACCESSIBILITY:
cabinet), the benefit here becomes obvious.
SIMPLICITY AND TIME-SAVING: Historically, information would be physically stored
Going paperless enables professionals to capture at a single location and accessed as needed
information directly onto a digital medium (e.g. during the working day.
by jotting down notes on an iPad during a
THE EXPONENTIAL GROWTH OF
CLOUD STORAGE SERVICES HAS
TRANSFORMED THIS ARCHAIC MODEL
INTO ONE WHERE PATIENT DATA CAN
BE SECURELY ACCESSED AT ANY TIME,
FROM ANYWHERE IN THE WORLD WITH
INTERNET ACCESS.
19 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
PERSPECTIVE
Having noted some of the obvious benefits of going For this reason, anybody accessing data on
paperless, it would be remiss to omit some of the a practice system should be well trained to
other considerations involved, which need to be recognise and correctly handle any potential
taken into account: emails, links or even telephonic scams which may
STABLE NETWORK INFRASTRUCTURE: be an attempt at compromising practice data or
systems in any way.
I use this term broadly, as it encompasses both
the internal network (LAN) of a practice, and the SOFTWARE:
internet connectivity in use by the practice.
A paperless workflow demands a stable platform Older medical software packages might need
upon which to function. An unstable network can to be upgraded or migrated to newer solutions,
result in lost productivity and downtime, which in order to fully support the move to a paperless
ultimately affects the bottom line of the business. workflow. This would involve cost considerations
With this in mind, networks should be well-planned (Once off? Monthly subscription?), as well as
from the ground up prior to implementation, appropriate training for practice staff on the new
and include relevant failovers and redundancy software package.
measures in order to accommodate for
unforeseen outages that may occur. ECO FRIENDLINESS:
Such measures might include redundant power,
redundant switches, the use of both cabled and There are pros and cons to consider in terms of
WIFI networks, as well as the availability of an the eco friendliness of a paperless practice. On
alternate internet connection, should the primary the face of it, using less paper is a good thing. On
connection fail (think LTE). the flip side, what if you were already recycling all
SECURITY: of your paper anyway?
SECURITY IS SOMETHING WHICH IN ADDITION, ONE NEEDS TO CONSIDER
NEEDS TO BE WELL PLANNED IF GOING THE ISSUE OF E-WASTE, WHICH IS A
PAPERLESS. SENSITIVE DATA NEEDS SEPARATE TOPIC ON ITS OWN.
TO BE PROTECTED BY MEANS OF
ACCESS CONTROLS, PASSWORDS AND The massive influx of electronic devices into
ENCRYPTION IF REQUIRED. our lives and workplaces brings with it a new
challenge - what happens to these devices when
There is also the very real threat of data corruption they reach end-of-life? Do we simply toss them in
or theft at the hands of ransomware or malware. the bin? Do we re-purpose them or donate them
To some degree, this can be circumvented to a worthy cause, and if indeed they are truly
through the use of effective security software and dead, do we then seek out their correct means of
multiple layers of backups (local, offsite, cloud). disposal / recycling?
THE HUMAN FACTOR HOWEVER, ALSO I hope that I have provided some thought-provoking
COMES INTO PLAY HERE. SO CALLED points to ponder, to assist with your decision to
“THREAT ACTORS” WILL USE SOCIAL move into the world of the paperless practice.
ENGINEERING IN ORDER TO PREY ON
POTENTIAL VICTIMS, BY GETTING THEM TO CONTACT US
OPEN MALICIOUS LINKS OR SUSPICIOUS Tibor Szabo
EMAILS, WHICH IN TURN CAN DEPLOY Nybbles & Bytes cc
MALICIOUS CODE ON A TARGET SYSTEM. 084 959 2515
help@tibor.co.za
www.tibor.co.za
Tibor Szabó is an independent IT Consultant and Support
specialist. He founded Nybbles and Bytes cc in 2004, and
provides specialised IT services to small businesses and
individuals, in and around Johannesburg, South Africa.
Correspondence: help@tibor.co.za
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 20
FEATURE
EMERGING TRENDS
INFLUENCING
THE FUTURE OF PSYCHIATRY
IN SOUTH AFRICA
Doris Viljoen
Many factors could influence the future 2. More older people Doris Viljoen
of psychiatry in South Africa – eight South Africa could see a
emerging trends are discussed here. rapid increase in the number
Since we live in a complex and adaptive of people aged 80 and
system, each of these trends could influence and older. The graph in Figure 2
be influenced by the other. Furthermore, each of indicates how the numbers
the trends could create both exciting opportunities are projected to increase from
and disruptive risks, for individual practitioners as its current level of around 500
well as for the field as a whole. 000 to around 1.5 million by
8 EMERGING TRENDS 2050 and 3 million by 2070.
1. More people
3. Boundaries between disciplines are fading
At the moment, STATS SA estimates that there The past 200 years saw the ‘branching off’
are around 59.62 million people in South Africa. of disciplines and the growth of areas of
The 2017 projections by the UN Population specialisation. But now the trend seems to be
division were used to create Figure 1, illustrating reversing, with boundaries between disciplines
how the numbers of people within different age and areas of specialisation getting more diffuse
groups are changing. and interesting things happening on the edges
where they connect.
THE 0-19 YEAR OLD AGE GROUP
GREW RAPIDLY BETWEEN 1950 AND IN THE NEAR FUTURE, THE CONFLUENCE
2000, BUT SINCE THEN, GROWTH HAS OF PSYCHIATRY, NEUROLOGY,
TAPERED DOWN AND THE NUMBER INFORMATION COMMUNICATIONS
OF PEOPLE IN THAT AGE GROUP IS TECHNOLOGY AND DATA SCIENCE
PROJECTED TO DECREASE SLIGHTLY WILL PROBABLY BE AN AREA OF
TOWARD 2060. THE TRAJECTORY OF SIGNIFICANT INNOVATION.
THE 20-29 YEAR OLD AGE GROUP
SHOWS A SIMILAR TREND. A scene from the further future: You are
appointed as the Consciousness Custodian
The group of people aged 30-59 has been of your client, Samantha. As such, you are
growing fast since 1980 and is projected to show the one that will make decisions about the
significant growth toward 2060. The yellow line appropriate time to ‘upload’ her consciousness
on the graph shows how the number of people (knowledge, memories, thoughts as well as the
aged 60 and older increased slowly from 1950 thought patterns behind it) onto a device to
until now, but is projected to grow faster over create a digital replica of her brain; her legacy
the next 40 years. that will remain available after the death of her
physical body.
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 22
FEATURE
4. Increased focus on wellness trouble working with the collaborative robots
Wellness is becoming a lived value for many on their teams, and a recent wellness survey
people. Organisations (read employers) are indicated that people struggle with the notion
increasingly concerned about the wellness of of what it means to be human.
their people. Psychiatrists should play a leading 5. Neuro-imaging technologies
role in shaping wellness initiatives, assisting Although these technologies created a big
to create an ecosystem of initiatives, tools, hype and were the focus of a number of recent
techniques and treatment. studies, it seems as though it still requires further
A scene from the future: You are contracted development. One of the obvious next focus areas,
by a large organisation to consult on their two is the need for more continuous monitoring and
main topics of concern – people are having imaging. At the moment it just gives a ‘snapshot’.
Figure 1: South African population by age group, 1950-2060
Source: Compiled from data in the UN World Population Prospects, 2017 update
Figure 2: Number of people aged 80+ in SA, 1950 – 2070
Source: Compiled from data in the UN World Population Prospects, 2017 update
23 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
As this technology and the insights derived within a certain area on a continuous basis or,
from it develops, a situation may emerge where for individuals, give an indication of increasing
consistent patterns are matched to certain or decreasing risk of relapse, suicide or other
behaviours. Enter ethics and questions like behaviour. An application, developed for
‘Should we regulate what is allowed to be done people with bipolar disorder, collects metadata
with this information?’ and ‘How responsible are from their mobile typing kinematics (variability
people really for their behaviour?’. in typing dynamics, pauses, using backspace)
6. Adoption of tele-medicine to monitor mood changes.
Advances in video-communication technologies,
combined with wider digital access created the IN THE NOT-TOO-DISTANT FUTURE,
potential for tele-medicine. Since the lockdowns MACHINE LEARNING ALGORITHMS
as a result of the Covid-19 pandemic, earlier MAY BE ABLE TO WORK THROUGH
barriers against the adoption of tele-medicine MASSIVE AMOUNTS OF DATA AND
are broken down – doctors and patients are IDENTIFY PATTERNS TO SUCH AN EXTENT
changing their views about the usefulness THAT IT ENABLES INDIVIDUALISED /
thereof, and more medical insurance providers PRECISION PSYCHIATRY.
are paying for it. Many medical practitioners
pointed out an interesting trade-off – there is a Moreover, it could support a systems approach
loss in intimacy from not being face-to-face with where data from diverse sources such as
the patient, but there is a gain in intimacy from brain scans, behavioural and physical data
seeing the patient in his/her own environment. from wearable devices, geolocation tracking,
genomic information, and data from the
FOR THE NEAR FUTURE: ALTHOUGH microbiome are analysed in real time to not
EARLY INDICATORS ARE MOSTLY only support the process of diagnosis, but also
POSITIVE, RESEARCH IS NECESSARY optimise the treatment plan and individual
TO ASSESS THE REAL EFFICACY AS mental health on a continuous basis.
WELL AS THE DIRECT AND INDIRECT
COSTS OF TELE-MEDICINE. FOR NOW: Psychiatrists should actively
contribute to and participate in research in this
To consider: Tele-medicine could enable a area, ensuring that the products developed are
psychiatrist to treat anyone, anywhere in the evidence based and ethically sound.
world – is that preferable?
7. Advances in sensor technologies CONCLUDING THOUGHTS
Sensor technologies, wearable by humans
or embedded in structures, are making rapid South Africa’s realities of unequal access, shortages
progress. Sensors themselves are getting of medical professionals and failing social systems
smaller and more sophisticated, and it is may require psychiatrists to think of innovative ways
enabled by increased connectivity, allowing to serve the mental health needs of our nation in
for constellations of connected things sharing a responsible manner. Timeous consideration of
massive amounts of data. the opportunities (and risks) presented by the eight
For example, a combination of wearable and trends highlighted here, could contribute to this
other sensors, connected through mobile effort.
devices, could enable the psychiatrist to
establish a person’s true baseline and daily RECOMMENDED READING
fluctuations.
8. Development of machine learning algorithms Artificial intelligence and the future of psychiatry:
Machine learning algorithms (and eventually Insights from a global physician survey.
AI) will probably not ‘take over’ the activities ht tps://w w w.sciencedirect.com/science/ar ticle/pii/
performed by psychiatrists, but could influence S0933365719306505
it in a significant manner. Predictive text and
similar applications driven by machine learning Psychiatry of the Future – 2030 and Beyond
algorithms could increase the efficiency of h t t p s :// j o u r n a l s . s a g e p u b . c o m /d o i/
recurring activities, like capturing data and full/10.1177/2055207620968355
writing reports.
More sophisticated models could estimate The WPA-Lancet Psychiatry Commission on the
the number and categories of beds needed Future of Psychiatry.
ht t p s://w w w.re s e a rc h g a te.n et/p u b l i c a t i o n/319 9 916 62 _
T h e _W PA - La n c et _ P syc h i a t r y_C o m m i s s i o n _ o n _ t h e _
Future_of_Psychiatry
https://www.biaffect.com/
Doris Viljoen is Senior Futurist, Institute for Futures
Research, University of Stellenbosch Business School.
Correspondence: doris@ifr.sun.ac.za
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 24
FEATURE
LEGAL CONSIDERATIONS
IN PRACTICING PSYCHIATRY
IN THE DIGITAL AGE
Elsabé Klinck
W ith the Health Professions Council and scientific healthcare and
of South Africa (HPCSA) allowing research, particularly to the under
“telehealth” in its response to the serviced areas in the Republic of
realities of the Covid-19 pandemic, South Africa”.
there has been renewed interest in the use of
technology in the rendering of healthcare services. It includes video-conferencing
The application of technology in the rendering of and data-transfer, whether “off- or
healthcare services can be as uncomplicated as online”, and formally or informally.
a video-call, to the complexities of involvement of
artificial intelligence to diagnose or even treat or The above definition is far narrower Elsabé Klinck
operate on patients. Such technologies become than what is currently possible in
medical devices, and unlike physical devices terms of the use of software to diagnose, or artificial
requiring importation, can be downloaded from intelligence used in the diagnostic- and treatment
anywhere in the world and fulfil its purpose as processes.
software.
Technology as a data-collection method can also THE HPCSA PREVIOUSLY1 PROHIBITED THE
help to build applications by creating algorithms RENDERING OF HEALTHCARE SERVICES,
that could fulfil certain services instead of a AS DEFINED ABOVE, REMOTELY. IT
healthcare professional. REQUIRED ANOTHER PROFESSIONAL TO
Within this changing environment, the question is BE WITH THE PATIENT (THE “CONSULTING
which legal principles apply, and whether there HEALTHCARE PROFESSIONAL”), AND
is, or could be, an increased medico-legal risk for THE PROFESSIONAL WHO IS BASED
healthcare professionals. Below we unpack some REMOTELY (THE “SERVICING HEALTHCARE
of the legal aspects, and the pitfalls that may be PROFESSIONAL”).
more pronounced when technology is used as a
mechanism to render healthcare services. On 20 March 2020 the HPCSA issued a “Guidance
TELEHEALTH AND TELEMEDICINE on the Application of Telemedicine Guidelines
The HPCSA’s relaxation of its previous prohibition During the Covid-19 Pandemic”, which it updated
seemed to specifically single out the field of on 8 April 2020, as part of general guidance on
mental health as a possible area of application of the HPCSA’s response to the pandemic. The HPCSA
telehealth. had already updated the term “telemedicine” to
The HPCSA defines telemedicine as: refer to “telehealth”, and also made it possible for
“the practice of medicine using electronic a healthcare professional – patient relationship to
communications, information technology or other come into existence by means of telehealth. This
electronic means between a healthcare practitioner meant that such a relationship could come into
in one location and a healthcare practitioner in existence with new patients. The only condition
another location for the purpose of facilitating, attached to it is that it must be in the interest of the
improving and enhancing clinical, educational patient.
25 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 The HPCSA also cautioned that although
professionals may charge for services rendered,
practitioners must not engage in practices
amounting to over-servicing or perverse incentives.
1 General Ethical Guidelines for Good Practice in Telemedicine, 2014.
FEATURE
CONSENT of a digital platform may enter in some financial
As with any healthcare service, and/or the use of any deal with the professional using the platform.
goods in the processes of diagnosis and treatment, CONFIDENTIALITY & SECURITY
informed consent is required when embarking One of the greatest considerations in relation
on telehealth, and/or the use of digital tools. The to digital healthcare is the confidentiality of the
obligation to obtain informed consent is contained information.
in the National Health Act, 2003, the HPCSA Ethical The National Health Act’s section 14 states:
Rules, 2006 and the Consumer Protection Act, 2008. “All information concerning a user, including
What is different when digital modes of healthcare information relating to his or her health status,
service delivery is used, is to ensure the application treatment or stay in a health establishment, is
of the principles of informed consent to the specifics confidential.”
of the mode of service delivery, namely: The confidentiality therefore extends to all aspects
• Discussing the treatment options available to of the care, whether it was, for example, online-,
or face to face, or even just the fact that care was
the patient, which would include, for example, rendered. This confidentiality may only be breached
rendering the care as face to face or as as is permitted by the National Health Act, namely:
telehealth, or using software as a diagnostic • With the written consent of the patient.
tool instead of a traditional method. The choice This is important in the digital age, as it implies either
remains that of the patient, provided they an Electronic Communication and Transactions Act
understand the options and the implications. (ETCA)-compliant consent, or a scanned-in version,
• Discussing the benefits, risks and implications of or some written format that would be proven as
the treatment options. that of the patient. A verbal consent is therefore not
The patient should therefore understand not only enough.
the positive and negative aspects of the digital Examples of consents not usually thought about,
mode, or digital diagnostic, but also what it is where a person, such as a chaperone or a
would take from them e.g. in ensuring a reliable family member, is also digitally present during a
video connection, ensuring confidentiality, or not consultation. The non-patient’s presence, and that
feeling comfortable to interact over a video link. person accessing the confidential information of
Or, in the case of a software diagnostic test, not the patient, must be consented to by the patient.
having immediate support once the diagnosis is The patient must also understand what the
made could be problematic for the patient. These implications of such person’s presence might be,
implications may also relate to issues of third- and it is therefore recommended that the consent
party access to information, or the further use of be obtained without such third party being present.
information in artificial intelligence development. It • If a law authorises the disclosure.
is within the disclosure of these implications, and the The 2017-Regulations relating to Notifiable Medical
considerations thereof, that the HPCSA reference to Conditions makes the reporting of notifiable
the patient's “best interest” applies. conditions, such as Covid-19, mandatory. This
• Discussing the cost of care. In a digital area, the does, however, not mean that information thus
cost of rendering services may be different, as shared with the National Institute of Communicable
cost bases may be different. Diseases (NICD) can be shared with any third party,
or that an employer must inform the employee’s
HOWEVER, THE REALITY IS THAT, EVEN medical scheme.
IF PRACTICES MOVE MORE INTO A Under the Protection of Personal Information Act,
DIGITAL AREA, CERTAIN FIXED PRACTICE 2013, the lawfulness of processing of personal
COSTS REMAIN, WHICH MAY LIMIT information, namely the collection, sharing
THE POSSIBILITY TO REDUCE THE and use, must be clearly authorised by a law, or
COSTS OF RENDERING HEALTHCARE consented to. The further use of information is easy
SIGNIFICANTLY. IT IS IMPORTANT TO when information is digitally stored, it can simply be
DISCUSS WITH PATIENTS THE COSTS OF forwarded, extracted or changed. If this is the case,
HEALTH RENDERED DIGITALLY, AND ALSO such further processing must also be consented to,
IF THERE WOULD BE ANY COSTS FOR THE or must be authorised by a law.
PATIENT’S ACCOUNT, SUCH AS THE COST In some cases, the storage of records digitally, or by
OF AN INTERNET CONNECTION AND using a specific platform or system, is mandatory.
DATA, OR IF A SOFTWARE APPLICATION This mandatory nature should best be legislated. If
MUST BE DOWNLOADED.
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 26
Below we discuss as one of the potential pitfalls
relating to the cost of healthcare, where the provider
FEATURE
offered to patients as an option, the implications of health issue with their psychiatrist, may be targeted
such storage must be explained and agreed to. If with advertisements on some self-help technique or
the patient’s information will be collated with other a complementary medicine, for example.
patients’ information and used to make for example, Both practitioner and patient should be aware of
estimations on future treatment requirements, or to these strategies when choosing an appropriate
build artificial intelligence around diagnostic and messaging or video-conferencing service.
treatment protocols. • Specially-developed platforms
• Non-disclosure represents a serious threat to There are also services that have been developed
in other jurisdictions to facilitate the provision of
public health. healthcare by digital means. Before using an
This is a limited statutory authority to breach international-developed platform, one should
confidentiality, and only relates to public health consider whether such a platform would align with
instances, along the lines of notifiable medical local laws and ethical rules.
conditions. In constitutional law, the authority by a A service where a patient merely enters a description
law to disclose does not mean that the law passes of their condition and symptoms, and obtains a
constitutional muster – it has to also be reasonable, prescription in return, is unlikely to be compliant with
rational and proportional, amongst other criteria. South African law, even if there is an opportunity for
If there is a less intrusive way to achieve the same the practitioner to ask further questions. Ethical rule
outcome, e.g. to protect others, namely to not 23 of the HPCSA Ethical Rules of 2006, as amended,
disclose confidential information, that course of requires a physical examination of a patient prior to
action must be followed. any treatment being recommended.
SO, WHOSE INFORMATION IS IT ANYWAY? The fee arrangements are also important, and
The information relating to a patient, belongs to that must be in line with anti-corruption legislation, and
patient, even if it is digitally stored, and consents the HPCSA Ethical Rules. Fee-sharing with such a
to be stored and used in a particular way. It is this platform would be impermissible under the Health
ownership in one’s personal information that is Professions Act, 1974 – the platform not being
controversial – consent to use, and further use is registered to render, and hence bill, for healthcare
often construed as giving such processing entities, services and could also amount to a perverse
the right to, for example, commercialise that incentive, in contravention of the HPCSA’s 2016 Policy
information. Should personal information be used on Over-Servicing, Perverse Incentives and Related
for commercial purposes, this must be disclosed Matters, and its 2016 Business Practices Policy.
and consented to – even if the information thus Paying a flat fee for the service rendered by the
commercialised are anonymised – it started out Platform owner or licensee, would be permissible.
as personal, identifiable information that is owned Care must also be taken that any platform being
by that person and becomes subject to further used, does not limit the treatment choices of the
processing. healthcare professional. For example, where the
The principle of openness in the POPI Act, also platform is designed so as to limit choices for
necessitates such disclosure, even where a law prescription to products of companies that paid
authorises further processing. for sponsorship, or which prioritises such sponsor’s
products in the hierarchy of available products, the
THE POPI ACT ALSO COMPELS THE professional participating in such a platform, and
HOLDER OF ANY PERSONAL INFORMATION choosing such products, will in all likelihood not only
TO ENSURE THAT REASONABLE violate ethical rule 23 by endorsing or preferring a
MEASURES ARE IN PLACE TO PREVENT product in exchange for the benefit of the platform,
UNAUTHORISED ACCESS OR USE OF but also run the risk of violating the Prevention and
SUCH INFORMATION. Combatting of Corrupt Activities Act, 2004. This is
as the professional is in a position of trust, and the
PITFALLS monetary benefit to the system may be seen to be
• Messaging services & video-conferencing swaying the judgement in favour of the sponsor,
and not what is in the best interest of the patient.
services • Prescriptions
Not all messaging- or video conferencing services Regulation 33 of the 2017-General regulations
are the same. Various online platforms and to the Medicines Act, allows for prescriptions to
applications link a person’s presence on one, with be digitally-issued and signed, in line with the
the other, through log-in details. ETCA. The mandatory, and more extensive list of
When these shared platforms trawl information to information required on prescriptions also makes
target one with “appropriate” advertisements, there digital capturing and further processing of personal
is a risk that a patient who has discussed a mental information more feasible.
27 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
However, the HPCSA’s ethical rule 17 still requires • Defamation, harassment / bullying
a “personal and original” signature for schedules
1 to 4 prescriptions (the prescription itself may be The digital age makes persons feel anonymous,
printed), and schedules 5 to 8 medicine cannot be even if they are not. Some are bolder, and may say
printed at all – and all aspects thereof must be done and do things they would not do in person. People
in the practitioner’s hand and under “personal and also tend to use social media to blow off steam.
original” signatures.
• Identity and hidden participants The laws relating to defamation, bullying and
A practical consideration when rendering harassment apply as much to digital platforms, as
healthcare by digital means, is that it may be it does in “real” life. Patients should be warned that
difficult to verify the identity of a new patient, or to the same standards apply to their behaviour when
know whether there may be a third-party present in engaging a professional personally and/or face to
a video-consult. face, than if the engagement is by digital means.
ALTHOUGH IT MAY BE IMPOSSIBLE • Medico-legal risks
TO ESTABLISH THE PRESENCE OF A
THIRD PARTY, THE COMPLETION OF As with harassment and defamation, the law
PATIENT INFORMATION PRIOR TO A relating to “being sued” by a patient applies
CONSULTATION, AND THE SETTING OUT equally to digital engagements with patients.
OF THE TERMS ASSOCIATED WITH SUCH Digital and verbatim recordings may make it easier
A CONSULTATION IS IMPORTANT. for a patient to prove what they allege. The possible
manipulation of these records, or its selective use is
These terms may include that there should be no also a consideration.
third parties present, and if there is, a consent would
be required from the patient. Should the patient CONCLUSION
have hidden the presence of such a person, and
rely on that person in, for example, complaints The digital age presents opportunities for healthcare
against the practitioner, the terms could be used to professional co-operation, better and easier storage
confirm what the patient had agreed to. and retrieval of records, and for the development of
• Verbatim recordings streamlined practice systems. It may allow patients
Although verbatim recordings may be extremely to seek healthcare from the comfort of their homes,
valuable for professionals, any such recording is, but practitioners must adopt these technologies
under the Promotion of Access to Information Act, knowing what they entail, and what the risks may
2000, accessible to the patient. be, and how to mitigate it.
Where, under that Act, the professional believes
there may be a risk to the patient should such Elsabé Klinck is is the Managing Director of Elsabé
recording be disclosed, the provisions of section Klinck & Associates . A B.Iuris, LL.B graduate, who
61 must be followed, and disclosure is made to a also completed a degree in Psychology for Applied
nominated healthcare practitioner who must make Professional Contexts and an Honours Degree in
the necessary arrangements for, for example, German. She started her career in the Department of
counselling, so as to assist the person through Constitutional Law at the Free State University, where
the process of coming to terms with the disclosed she also worked for the Centre for Human Rights
information. Studies, managing amongst others, voter education
• Sharing on social media and paralegal training projects. She was active in the
Two digital mechanisms, namely “cut & paste” and establishment of a Free State Centre on Citizenship
screenshots make it extremely easy for persons to Education and Conflict Resolution. Elsabé also
share information from one platform or application, participated in the training of Magistrates on Diversity
to another. The advice provided by a psychiatrist (with the Law, Race and Gender Unit at UCT) and the
to a patient on a messaging service, can easily training of local government councillors and Free State
be forwarded to others, or placed on social media Peace Committees. This experience in human rights
platforms. and constitutional law stand her in good stead in her
It is critical that the use of digital media be health sector work.
regulated by the patient agreement to the terms
of the practice. Patients should also understand Elsabé has been working in the health sector since 2001,
the implications of sharing of health- and personal gaining valuable experience dealing with medical
information on platforms, even in circumstances practitioners and pharmaceutical issues, as well being
where they may believe the information is secure. a key contributor to a prominent health care consulting
company. She has an international outlook and backs
her services with a broader insight into international and
national policy developments, such as those of the World
Economic Forum and the World Health Organisation
Her extensive knowledge and practical experience in
health care/medical practice issues, medical schemes,
medicines, medical devices and patient rights are
grounded from this perspective, as well as from her
background in constitutional/human rights law. Elsabé’s
specialized expertise assists attorneys to provide
service at the highest level to their health sector clients.
Correspondence: elsabe@elsabeklinckassociates.co.za
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 28
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29 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
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For full prescribing information refer to the package insert approved by the medicines regulatory authority. Sandoz SA (Pty) Ltd. Reg. No. 1990/001979/07. The Novartis Building, Magwa Crescent West, Waterfall City, Jukskei View, Gauteng,
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FEATURE
AN OVERVIEW OF
SOUTH AFRICAN LAW
AND ITS IMPACT ON
HEALTHCARE PRACTITIONERS
Volker Hitzeroth
In this article, the first in a series of medicolegal articles, Dr Volker Hitzeroth, Medicolegal
Consultant at Medical Protection Society will highlight common medicolegal developments
faced by South African Healthcare Practitioners. This article will specifically elucidate the larger
medicolegal arena and emphasize common medicolegal complications arising within this
landscape.
L ike medicine, with its specialties and Only brief lectures covering
subspecialities, the law can also be divided common and general bioethical
(and further subdivided) into specific and dilemmas have been offered. This
well-defined fields, based on the theory and omission raises serious concerns,
practical application thereof. given that robust evidence
To most Healthcare Practitioners (HCPs), however, indicates medicolegal issues
the alien legal landscape often seems intricate have increased significantly
and confusing. Thankfully, involvement with the in the past decade and are
law remains mostly on the periphery of HCPs daily affecting ever more HCPs in both
clinical obligations, at arm’s length to patient care the private and state sector.
and mostly unrelated to their associated practice Anecdotal evidence suggests Volker Hitzeroth
commitments. There will however, unfortunately,
be occasions when a HCP is implicated in a that medicolegal threats are of major concern
medicolegal matter. It is then that the HCP becomes to HCPs. In addition to impacting on clinical
personally embroiled in the legal system, be that as interactions and patient care, they also affect the
a respondent to a complaint, a defendant in a civil health and wellbeing of the practitioner and their
claim or even as an accused in a criminal trial. As the family.
legal issues suddenly become more intimate and
pressing, a HCP, who might already feel somewhat INCREASINGLY HOSTILE MEDICOLEGAL
anxious, concerned, and uncertain, may find that COMPLICATIONS ALSO CREATE A
they have no alternative but to urgently familiarize CLIMATE OF RISK AVERSION WHICH
themselves with an unfamiliar legal landscape. This COULD RESULT IN REDUCED PATIENT
seemingly complex and unchartered terrain often SAFETY.
results in further distress and discomfort.
Furthermore, medicolegal complications fuel
REGRETTABLY, SOUTH AFRICA’S MEDICAL increases in indemnity and insurance subscriptions.
UNIVERSITIES HAVE HISTORICALLY NOT This has resulted in unsustainable costs for some
PROVIDED A COMPREHENSIVE LECTURE high-risk specialties, which also impacts on the
SERIES REGARDING COMMON HCP’s wellbeing and, indirectly, on service provision.
MEDICOLEGAL PITFALLS AFFECTING
HCPS. While South African law is divided into numerous
large sections, a reasonable and common high-
level division is that between public and private law.
31 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
FEATURE
PUBLIC LAW From the above, it should become clear that HCPs
Public law governs interactions between the state can become embroiled in a variety of different
and its citizenry. It is therefore deemed to be acting medicolegal complications after an adverse
along a vertical axis between the state above clinical event.
and an individual below. Examples of different
subdivisions of public law include constitutional, SUCH MEDICOLEGAL DEVELOPMENTS
administrative, environmental, and criminal law. MAY FIND THEIR GENESIS IN SEVERAL
A common medicolegal issue governed by South DIFFERENT LEGAL DIVISIONS AND
Africa’s administrative law includes the Health SUBDIVISIONS, EACH WITH THEIR
Professions Council of South Africa’s (HPCSA’s) OWN SPECIFIC CONVENTIONS AND
disciplinary process, which is initiated when a TRAJECTORIES, PROCESSES AND
complaint of alleged unprofessional conduct PROCEDURES.
against a practitioner is lodged with the HPCSA’s
registrar. Hence, the approach to defending a HCP in such
different scenarios requires a tailored defence
CRIMINAL LAW GOVERNS THE PROCESS strategy in order to reflect the specific field of law
WHEN A HCP IS ACCUSED OF A CRIME and its particular application to the case.
AND THE STATE (VIA THE NATIONAL
PROSECUTING AUTHORITY) PURSUES MULTIPLE JEOPARDY
A CRIMINAL CHARGE AGAINST THE It is also common for an adverse incident to
PRACTITIONER. result in numerous medicolegal challenges
occurring simultaneously. This is conventionally
PRIVATE LAW called “multiple jeopardy” and usually involves a
Private law governs interactions between individuals clinical event that subsequently triggers a variety
(or corporate entities). It is therefore deemed to be of medicolegal developments, including but not
acting along a horizontal axis between various limited to a complaint before the HPCSA, a civil claim
individuals and/or corporate entities. Examples of in alleged negligence, an inquest, or later criminal
different subdivisions of private law include family, charges. Undoubtedly, and understandably, such
property, employment, contract, succession, and multiple assaults on a HCP’s acumen, judgement
law of delict. and professionalism are likely to be deeply
unsettling and could even be career-ending.
COMMON MEDICOLEGAL ISSUES Whilst it is always best to prevent adverse events
GOVERNED BY SOUTH AFRICA’S PRIVATE from occurring in the first instance and hence
LAW INCLUDE A LABOR DISPUTE WHERE avoid any medicolegal repercussions from
AN EMPLOYED HCP IS CALLED TO arising, this is virtually impossible. Medicine is an
EXPLAIN THEMSELVES IN THE EVENT OF imprecise science and patients’ bodies respond
A CLINICAL SCENARIO THAT AFFECTS to medications or surgery in a multitude of
THEIR EMPLOYER. unpredictable ways.
Similarly, it is the law of delict which governs civil DESPITE RAPID ADVANCES IN RESEARCH
claims in alleged clinical negligence between the AND THERAPEUTICS, MUCH REMAINS
HCP and their patient or the patient’s family. UNKNOWN AND CONTINUES TO
Most serious medicolegal complications relate to CHALLENGE EVEN THE BEST HCPS.
one of the following three scenarios: HENCE, WITH THE CONSTANT FEAR
1. A formal complaint lodged with the Registrar AND THREAT OF MEDICOLEGAL
DEVELOPMENTS SHADOWING THE
of the HPCSA which in turn triggers the HPCSA’s HEALTHCARE PROFESSION AT EVERY
investigative, and then possibly disciplinary, STEP THE ONLY CERTAINTY AND
process. REASSURANCE AVAILABLE TO A HCP
2. A claim in clinical negligence whereby the IS TO HAVE ACCESS TO THE BEST
patient or their family institute legal proceedings MEDICOLEGAL INDEMNITY AND ADVICE
against a HCP in order to access financial WHEN THE WORST CASE SCENARIO
compensation for harm or an injury sustained UNFOLDS AND PROFESSIONAL LEGAL
due to alleged negligence on the HCP’s part. ASSISTANCE IS REQUIRED.
3. The state lays criminal charges against a HCP
if the authorities have reason to believe that Volker Hitzeroth is Medicolegal Consultant at Medical
the HCP conducted themselves in a criminal Protection Society in London, United Kingdom.
manner. Correspondence: Volker.Hitzeroth@medicalprotection.org
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 32
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Agents. Clinical Therapeutics 2014;36(10):1372-1388e1. 2. Berwaerts J, Liu Y, Gopal S, et al. Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of Schizophrenia. A Randomized
Clinical Trial. JAMA Psychiatry 2015;72(8):830-839. 3. Savitz A, Xu H, Gopal S, et al. Efficacy and Safety of Paliperidone Palmitate 3-Monthly Formulation for Patients with Schizophrenia: A Randomized, Multicenter, Double-Blind,
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2011;5:165-171. 6. Gopal S, Vermeulen A, Nandy P, et al. Practical Guidance for Dosing and Switching from Paliperidone Palmitate 1-Monthly to 3-Monthly Formulation in Schizophrenia. Current Medical Research and Opinion
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JANSSEN PHARMACEUTICA (PTY) LTD, (Reg. No. 1980/011122/07), No 2, Medical Street, Halfway House, Midrand, 1685. www.janssen.com. Medical Info Line: 0860 11 11 17.
CP-213128
FEATURE
THE PSYCHIATRIST’S DILEMMA:
SEXUAL OFFENDING
& PERSONALITY DISORDERS
Sean Kaliski
psychiatric diagnosis. We do know Sean Kaliski
that perpetrators with serious
mental illnesses, such as the
psychoses, intellectual disability
and neurocognitive disorders
constitute a sliver of the total. Do
the rest have a plausible excuse,
such as “it’s my personality and
not really me, and therefore please
just treat me”?
TOTAL SEXUAL OFFENCES RECORDED IN SOUTH
AFRICA 2019/20
CRIME NUMBER
“The Rape of the Sabine Women” by Poisson Rape 42 289
T he ancient Romans were proud of their Sexual assault 7 749
founding myth in which their shortage of
women was remedied by abducting and Attempted sexual offences 2 076
raping the neighbouring Sabine women.
Nowadays we would regard this as a heinous war Contact sexual offences 1 179
crime and would also be horrified to learn that in
ancient (and maybe not such ancient) times rape Total 53 293
was regarded only as a property offence that
could be redeemed by paying compensation Table: africacheck.org | @africacheck - Source: South African Police Service
to the women’s families, or by marrying them.
This is possibly why rape is not mentioned in the SEXUAL OFFENCES OCCUPY AN UNEASY
Ten Commandments. But before we compliment NEXUS BETWEEN MORAL INDIGNATION,
ourselves for our modern enlightened attitudes we THE LAW AND SCIENCE.
must reflect on the meaning of the ongoing #MeToo
campaign. In the 1950s. when the founder of computer science,
Alan Turing, was convicted for a homosexual liaison,
SEXUAL HARASSMENT AND ABUSE not only was he also subjected to denigration of
CONTINUE IN FULL SIGHT AND ARE his morality (and almost lost his prestigious post)
APPARENTLY SOMETIMES ACCEPTED AS but was obliged to undergo psychiatric treatment
JUST BOTHERSOME LADDISH BEHAVIOUR. that included Jungian analysis and injections
of progesterone. He committed suicide. At the
Unsurprisingly, then, the prevalence of sexual time homosexuality was illegal, considered to
offences remains terrifyingly high, as indicated be immoral and was a diagnosable psychiatric
in recent statistical reports (see Table). What the disorder. Since Turing’s unfortunate experience
data do not reveal is how many crimes are not so-called “conversion therapies” have continued
reported (a huge, submerged iceberg), who to thrive, although now they are performed only
are the perpetrators and how many deserve a because of moral and religious outrage and not
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 34
FEATURE
because of science. Political action, not science, Court of Appeal subsequently ruled that he be
removed homosexuality from criminal statutes and referred formally for an assessment under section
persuaded psychiatrists to regard it as a normal 286A of the Criminal Procedure Act to determine
healthy state. whether he is “a danger to the physical and mental
In preparation for ICD-11 there has been a vigorous wellbeing of other persons.. and… the community
but inconclusive debate whether the paraphilias should be protected from him”. The subsequent
should be regarded as orientations and not risk assessment could not produce evidence that
disorders. If the former, then what is there to treat? he represented a high risk of recidivism. Whether
If the latter, what does one treat? Paedophilia he ever received psychotherapy instead remains
straddles these dilemmas nicely, because, unknown. The stalemate between punishment and
although there cannot be any dispute that having treatment remains.
sex with children is wrong and correctly illegal, its
designation as a disorder has created a thriving But what is a personality disorder? DSM 5 persists
treatment industry that would be wiped out if there with providing distinct categories with their lists
was a sudden conversion to the idea that it is not of criteria that can be ticked off like recipe items,
an illness. even though this edition admits that a dimensional
approach, in which composites of normal traits
NEVERTHELESS, SEXUAL BEHAVIOURS somehow coalesce in a gradated fashion into
THAT ARE PROHIBITED BY LAW, SUCH distinct entities, has greater validity. Unfortunately,
AS EXHIBITIONISM, FROTTEURISM ETC, in a dimensional scheme delineating the transition
ARE RELATIVELY EASILY FOLDED INTO from “normal” to pathological it becomes arguably
CLINICAL DIAGNOSTIC CATEGORIES, an insoluble problem. Clinicians are left with either
WHICH OFTEN DOES ENABLE THE using rigid interviewing tools mechanically, such
OFFENDER TO ESCAPE PUNISHMENT BY as the famous SCID, or relying on their intuitive
AGREEING TO TREATMENT. expertise. The latter is a risky approach in forensic
arenas, and the former is no longer scientifically
This does not imply that the diagnosis of personality honest. What is left is the assumption that there is an
disorder can be used successfully for an insanity awful lot of personality disordered people who may,
defence. It cannot. But the courts are prepared or may not sexually assault others because of, or not,
to accept, after convicting a sexual offender that their personalities. Incidentally, this may explain why
delivering him to a treatment programme may be treatment programmes for sexual offenders have, at
preferable to prison (if a first offender). best, reported very modest success.
DOES THAT LEAD TO THE ASSUMPTION This dilemma characteristically becomes messy in
THAT SEXUAL OFFENDERS PRIMARILY civil litigation. In the midst of the red mist of divorce
HAVE PERSONALITY DISORDERS, AND one party may accuse the other of sexually abusing
THAT THEREFORE THEY ARE AMENABLE their children. Mental health experts are assembled
TO PSYCHOTHERAPY? at great expense, who usually pronounce in lengthy
reports that not only are the allegations true but
Cluster B personalities, and especially psychopathy, that the guilty spouse also has a personality
have disturbed sexuality as core issues that disorder, which somehow disqualifies him (yes,
contribute to their diagnostic profile. Logically this usually him) from being a parent. Narcissistic
means that treating their inability to control their personality disorder is a favoured diagnosis. Their
sexual acting out has to take into account their reports seldom provide convincing supporting
personality structures. Although the association evidence. Many have lost custody and access
between severity of psychopathy and risk for to their children because of this collision between
recidivism is robust there remains the question how alleged inappropriate sexual behaviour and the
the diagnosis of a personality disorder should be diagnosis of personality disorder.
used in the forensic arena. Should these diagnoses
be used to impose longer sentences (aggravation) or What remains are some stark decisions. Perhaps
to motivate for leniency (diminished responsibility)? a perpetrator’s personality structure is irrelevant
In S v T (1997) (1) (SACR 496 SCA) a 23-year-old first and his (or her) deeds should be the sole focus
offender was convicted of abducting and brutally of attention. We can either wait for science to
raping a 15-year-old girl. A panel of 2 psychiatrists catch up with the law to provide clearer answers
and a psychologist diagnosed him with a mixed or we can continue with our intuitive practices that
personality disorder (without specifying what the potentially deals with perpetrators unfairly, or snubs
mixture was) and therefore concluded that he was victims whose abusers are unnecessarily referred
dangerous. However, a prison psychologist argued for treatment to escape sanction.
that he was a good candidate for psychotherapy
and that in the future there was a distinct possibility References can be provided on request from the
that he would no longer constitute a danger. The author.
Sean Kaliski is a forensic psychiatrist and recently retired
as Head of Forensic Mental Health Service, Western
Cape & Department of Psychiatry and Mental Health,
University of Cape Town, Cape Town, South Africa.
Correspondence: sean.kaliski@uct.ac.za
35 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
DISRUPTS THEIR LIVES
AND FUNCTIONING
BUILD THEM
UP AGAIN WITH
Restoring order to their lives1,2,3
References: 1. De Bruyckere K, Bushe C, Bartel C, Berggren L, Kan C, Dittmann R. Relationships Between Functional Outcomes and Symptomatic Improvement in Atomoxetine-Treated Adult Patients with Attention-Deficit/
Hyperactivity Disorder: Post Hoc Analysis of an Integrated Database. CNS Drugs 2016; 30:541–558. 2. Young JL, Sarkis E, Qiao M, Wietecha L. Once-Daily Treatment With Atomoxetine in Adults With Attention-Deficit/Hyperactivity
Disorder: A 24-Week, Randomized, Double-Blind, Placebo-Controlled Trial. Clin Neuropharm 2011; 34:51–60. 3. Lenzi F, Cortese S, Harris J, Masi G. Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic
review and meta-analysis. Neurosci Biobehav Rev 2018; 84:359–367.
For full prescribing info please refer to package insert approved by the South African Health Products Regulatory Authority (SAHPRA.) S5 INIR 10. Reg. No.: 43/1.2/0809. Each capsule contains atomoxetine hydrochloride equivalent
to atomoxetine 10 mg. S5 INIR 18. Reg. No.: 43/1.2/0810. Each capsule contains atomoxetine hydrochloride equivalent to atomoxetine 18 mg. S5 INIR 25. Reg. No.: 43/1.2/0811. Each capsule contains atomoxetine hydrochloride
equivalent to atomoxetine 25 mg. S5 INIR 40. Reg. No.: 43/1.2/0812. Each capsule contains atomoxetine hydrochloride equivalent to atomoxetine 40 mg. S5 INIR 60. Reg. No.: 43/1.2/0813. Each capsule contains atomoxetine
hydrochloride equivalent to atomoxetine 60 mg. Dr. Reddy’s Laboratories (Pty) Ltd. Reg. No. 2002/014163/07. Tel: +27 11 324 2100 www.drreddys.co.za ZA/09/2019-21/001
SAVE THE DATE
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14:00 – 18:00 Scientific Sessions
19:30 – 20:30 Trade sponsored evening symposia
Saturday 4 September:
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10:00 – 13:00 Hot topics in ADHD
14:00 – 16:00 Workshops
18:00 – 19:00 Ethics panel discussion/debate
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Congress Convenor: Prof Renata Schoeman: renata@renataschoeman.co.za
Congress Organiser: Sonja du Plessis: sonja@londocor.co.za
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Sandoz SA (Pty) Ltd; 2021. 4. Schapperer E, Daumann H, Lamouche S, et al. Bioequivalence of sandoz methylphenidate osmotic-controlled release tablet with Concerta® (Janssen-Cilag). Pharma Res Per. 2015;3(1), e00072:1-8. 5. Katzmann MA, Sternat
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PERSPECTIVE
OF ‘HOW ARE
Y O U S ?’ A N D
‘HELLOS’
Claudia Campbell
‘F ine’. How many times have you uttered patients? Could you see yourself
this small word when asked “How are saying to a patient ‘carrying on,
you?”. More importantly, in the last year, but pretty worn-out’ when they ask
how many times has ‘fine’ been a true how you are? Or, do you feel that it
reflection of how you really are? Not, how you are in is your job and duty to seem ‘fine’
comparison with those ‘who are worse off than me’, to them?
not fine in comparison to those ‘who’ve seen more
tragedy than me’, but ‘fine’ on your own barometer A few weeks ago, at the tail-
of terrible-to-fine? end of the second South
African Covid-19 wave, I had an
THERE ARE AMPLE ADJECTIVES TO appointment with one of my long- Claudia Campbell
DESCRIBE HOW WE ARE ALL DOING AT
THE MOMENT, AND I FEEL THAT ‘FINE’ IS time specialists. The treatment I receive from him
NOT ALWAYS THE MOST TRUTHFUL. takes a while, so every three months I spend a few
hours in his practice. I can see many comings
The last year has not been very ‘fine’. Exhausted, and goings from his procedure room. It’s normal
scared, frustrated, weary, fearful, anxious, and expected to sense apprehension in the eyes
apprehensive – those are some adjectives which are of his patients – they’re there because they are
at times more truthful representations of how I feel. truly not well.At the time of my last appointment,
However, I am fortunate in terms of being able to I saw more than medical apprehension, everyone
keep safe by working remotely, journeying through looked wrung-out. That all too familiar pandemic
this strange pandemic world with a husband I love, wrung-out. However, my specialist stepped out of
having parents and a grandmother who have his consulting room door again and again, calling
thus far avoided this dreaded virus, chatting with for his next patient in his normal upbeat tone. On
friends, albeit online, and having a laugh. Even so, the surface (and beneath the PPE) he seemed
the truth is that very often I’m really not entirely ‘fine’. to be just the same as always: energetic, alert, in
‘Fine’ was my stock-standard reply for a long while, control… ‘fine’.
but I’ve become more forthcoming with my reality.
Now my reply to ‘How are you?’ is oftentimes: How though, could he be okay? I knew that the
‘Exhausted but hanging in there’. As opposed to hospital where his practice is located had been
creating a burdensome conversation, this reply packed with Covid-19 patients in wards just prior
seems to do the opposite. Suddenly the person I’m to my visit. I know that PPE is uncomfortable,
speaking to will look me in the eye answer back ‘me particularly in the middle of summer. I knew that
too’. It’s a totally level playing field between myself colleagues of his had lost their lives. And it is a safe
and all fellow humans I meet. assumption that a busy practice, treating people
I imagine many of you may relate to what I’ve with various comorbidities, would have had to
written here. I wonder which interactions of your weather the news of their own patients dying. None
own came to mind. Were they conversations with of this is ‘fine’. Additionally, this specialist cannot run
friends, with family, with colleagues? What about a virtual practice. Zoom consultations are not an
option, he has to treat patients in person. He has
to pack his anxieties away, step over the threshold
and enter the hospital, every single day. And he
does it for us, for his patients.
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 40
PERSPECTIVE
So, when he entered the procedure room and than ever before. I did have a fleeting feeling of
began preparing the needles, I looked him in uncertainty whether I was overstepping boundaries
the eye. I’ve known the man for many years, and by enquiring about the true state of my psychiatrist’s
what I saw were his usually bright eyes shrouded well-being. However, at the end of our consultation,
with depletion, and so I asked him “how are you he said “Claudia, thank you for caring enough to
really doing?” – I truly meant it. He did not say ‘fine’. ask how I’m doing”. My uncertainty faded.
His reply was not a sugar-coated, fearless-faced, I face a very different set of challenges to the two
reality-stretched version of a medical superhero. medical professionals I have mentioned. Of those
Rather, his reply was an honest, real, human two men, one does not have more challenges than
account of his current reality. It was an expression the other, and I realize my own challenges are not
of the exhausting struggle and balancing act of actually less serious than either of theirs – they are
containing his anxiety and that of his family, with simply different. This global pandemic has proved
the need to carry the fears of his patients, and the to be a great equalizer. Engaging with people
responsibility to practice medicine with care. As a through titles and professions seems secondary
patient, now to recognizing we’re all a bunch of equal
humans muddling through a situation none of us
I SINCERELY APPRECIATED HIS OPENNESS had training for.
BECAUSE IT’S EASIER TO TRUST AN Social distancing and waves of lockdown
HONEST PERSON THAN AN INSINCERE restrictions often limit our ability to support others
ONE – INCLUDING DOCTORS. in ways we would have in the past. It’s tough that
the most effective way to help others is frequently
I know the experience I have related here did not to physically stay away from them – it doesn’t feel
happen with a psychiatrist, but the following day natural. However, there is one thing we can always
something similar unfolded. My next consultation do – always, even virtually. Listen. This requires two
was with my psychiatrist and it was a tele-consult. things. Firstly, when we say ‘how are you?’ we must
His specialization allows him to conduct virtual mean it and intend to listen to the other. Secondly,
consultations. However, it was not a safe assumption when somebody asks ‘how are you?’ and they
that this perceived remote-work-luxury fosters less mean it, I think one needs to give thought to a
stress. I asked him the same thing: “so how are response other than ‘fine’.
you, really?” I know from my own work, that a year
into a pandemic has left people’s mental health in I AM NOT IMPLYING ‘FINE’ MUST ALWAYS
tatters. Rational thinking is not necessarily the order BE REPLACED WITH A RESPONSE OF
of the day, neither is treatment compliance, and DEPLETION AND ANXIETY. SOME DAYS
general reserves of resilience and tolerance are WE HAVE WINS – THEY ARE A LITTLE FEW
sputtering on fumes, if not burnt out completely. My AND FAR BETWEEN AT THE MOMENT, SO
psychiatrist’s answer to ‘how are you, really?’ was I THINK IT’S IMPORTANT TO SHARE THEM.
deeply honest.
Given the state of affairs I have just outlined, it turns When someone tells me about the smallest win
out psychiatrists need to be every other kind of they had in their day it brings a smile to my face I
doctor at the moment too – and that is a tall order wouldn’t have otherwise had. But, when someone
when you’re conducting a tele-consult. It seems says they’re not doing so well, I know that by just
it is a major limitation to effective treatment when listening for a moment there is a reasonable chance
your patient can simply cut the call because it’s that for a couple of minutes their burden might be
uncomfortable. Or they may choose to use the call a little bit lighter.
to discuss every other ailment besides ones related As I wrote this passage, I wondered why the topic
to psychiatry because they have been too scared to feels so important to me. But, I think it’s important
enter a hospital to visit cardiologists, nephrologists, because in contrast to the way insincerity fosters
gastroenterologists, gynaecologists and so the list apathy, sincerity nurtures empathy, which in turn
continues. After all psychiatrists are doctors, so why nourishes resilience. And those are beautiful things.
wouldn’t they be able to treat everything? I realise that my opinion is over-generalised and not
necessarily realistic for every interaction. I guess,
THERE ARE NO PERFECT PRESCRIPTIONS I’ve come to feel that at times offering a polite
FOR TREATING PANDEMIC FATIGUE, OR ‘hello’ is more authentic than an insincere ‘how are
WHATEVER ELSE YOU WANT TO CALL IT. you?’. However, sincere ‘how are you’s?’ can lead
to beautiful, moments of honest humanity. I like
I gathered that psychiatrists face the challenge those.
of treating a much wider, more complex set of
difficulties, with less clinical and supportive options
Claudia Campbell holds a post-graduate degree in psychology and has 10 years experience in the field of corporate
transformation strategy. Claudia works in a voluntary capacity as a psychosocial facilitator, public speaker, and consultant.
Due to various health challenges, Claudia’s personal life includes many experiences from the patient’s side of the consultation
room. Correspondence: claudia@redbench.co.za
41 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
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NEWS
PD ESPYA CR T MHEINATTS ROYF
JOE VERIAVA BIOETHICS MEDAL 2020 BURNOUT AND RESILIENCE
AWARDED TO ADJ. PROF. LESLEY ROBERTSON PANEL: MODIFYING MINDSETS
Establishment and Purpose Drs Tejil Morar and Ahmed Badat were invited to
of the Award: partake as guest speakers at a panel on burnout
hosted by the Wits Students’ Surgical Society. They
Professor Joe Veriava has were joined by Professor Shelly Schmollgruber, Dr
made major contributions Shannon Lautenberg, Dr Itumeleng Teffo and fifth
to the advancement of year medical student, Kimon Nicolaides. The aim of
bioethics and human the panel was to provide undergraduate medical
rights in health care. The students with information regarding burnout.
Faculty of Health Science Strategies to better equip oneself in dealing with
has therefore established and preventing burnout, both as students and future
the Joe Veriava Bioethics doctors, were also discussed. Dr Morar has a special
Lesley Robertson Medal to recognize interest in burnout, having conducted research on
the topic and provided information relating to the
academic staff members and postgraduate students symptoms of burnout, stigma and a list of resources
who have contributed substantially in this area.The which students and medical professionals can
purpose of the award is to acknowledge and reward access (including the Healthcare Workers Care
academic staff and postgraduate students who have Network). Dr Badat highlighted the importance of
made a substantial contribution to one or more of scheduled relaxation and the practice of mindfulness
the communities which they are involved with such in preventing burnout. As aspiring psychiatrists, they
as the Faculty-Division, social community, national were encouraged by the invitation to engage with
or international community of their discipline. The another discipline and play a role in the education
award is open to all members of academic staff and of mental health in such a collaborative manner. A
postgraduate students from all ranks. recording of the panel discussion is available on the
Wits Student Surgical Society YouTube page
Criteria:
LOUIS FRANKLIN FREED PRIZE FOR THE BEST
The following activities could be considered as MMED STUDENT IN 2020
contributions to bioethics and human rights in
health care: Awarded to Dr Yumna Minty
• Involvement in projects and/or initiatives for the
upliftment of communities including community-
based research / participatory community service
projects / community-based teaching initiatives,
projects or work.
• Functioning as a change agent within the Faculty
through involvement in key projects, work or
initiatives linked to the broader transformation
vision of the University.
• Participation in committee work, policy making
and organizational development processes
at Faculty, Community and Provincial and/or
National Government level that advances ethical
health care practice and human rights.
• Playing a significant role in promoting the field
of bioethics and human rights in health care
into the wider community through serving as
an acknowledged expert and/or substantially
contribution to the public profile of the University.
43 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
NEWS
PURPLE COUCH: A PSYCHIATRY PODCAST
Podcasts are an exciting new addition to the growing media sphere.
They offer flexibility in terms of access and cover a wide variety of topics.
Educational podcasts serve as a way to offer students information on
demand. I looked to fill my drives with educational psychiatry podcasts
and while they were very enriching,often were not always applicable to
the unique South African context. As someone who is also passionate
about undergraduate medical education in mental health, I realised
that there may be a place for a South African psychiatry podcast, and
hence Purple Couch: A Psychiatry Podcast was created! The podcast
series intends to feature a different psychiatrist covering a topic of their
interest with the aim of providing medical students a basic approach
to the topic, so as to supplement their learning. The title comes from
purple being my favourite colour and I wanted this labour of love to
feel uniquely my own and couch as I intend to carry out the episode
in a very conversational manner, whilst still covering important clinical
Ahmed Badat - 1st year registrar in the department of
aspects related to the topic. I would like to thank Prof Ugasvaree Psychiatry
Subramaney and Dr Indhrin Chetty for the support and ongoing guidance in the development of the podcast. I
would also like to thank Dr Sanushka Moodley who was very encouraging when I proposed the idea to her and
was kind enough to do the first episode with me.The podcast is available on Anchor, Spotify, Pocket Casts and
many other platforms
THE BJVR MEMORIAL LECTURE
The launch and entrenchment of a special
memorial lecture dedicated to the life of
Professor Bernard Janse Van Rensburg (12 April
1960-23 April 2020) took place on the 28th April
2021.
Prof Van Rensburg (BJVR) passed away suddenly
after a brief illness in 2020. The Department of
Psychiatry decided to honour his extraordinary
and unusual service (often over and above his
normal duties which he displayed during his
life as a doctor and psychiatrist). The month
of April was chosen as both the month of his
birth and death. At the Wits School of Clinical
Medicine Faculty Honours celebration for 2020,
Bernard (BJVR) was awarded the distinction
of the “Dean’s award for exceptional service”,
posthumously. He was indeed an exceptional
person who clearly influenced the Faculty in
achieving its strategic goals and made an
impact on the broader community not only
within the discipline of Psychiatry, but also in
Clinical Medicine and beyond.
He was a special person who fought tirelessly for
human rights issues,notably in the mental health
care domain; but with his passing the many
interactions he had with different individuals
indicate other domains, departments and
structures. It is with this in mind that it is hoped to
have an annual lecture, with speakers from far
and wide i.e. not just Psychiatry, and not solely
from the Faculty of Medicine. In the spirit of the
talk his wife Prof Ariane Janse Van Rensburg from
the School of Architecture was the speaker at
the inaugural lecture. Future invited speakers will
be a person of distinction from one of the many
disciplines/domains Bernard was involved in,
who embodies some of the values we knew
Bernard to have and promote
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 44
NEWS
HEALTHCARE WORKERS HEROES’ SUPPORT AFTER DEVASTATING TAFELBERG FIRE
MEMORIAL: PROF DAN LAMLA MKIZE The 20th of April 2021 was a sad day for UCT, inclusive
of UCT Libraries. Members of the Dept of Psychiatry
The department paid its last respects to played a key role in supporting staff and students.
distinguished Prof Dan Lamla Mkize (pictured
below) at a Healthcare Workers Heroes’ Memorial, ONLINE SEMINAR: 24 FEBRUARY 2021
held on 21 January 2021 in his honour.
Topic: Capacity Building in the Alan J. Flisher Centre
for Public Mental Health. Our Past, Present & Future
Speaker: Dora Wynchank
Dora Wynchank, originally from South Africa,
is a psychiatrist living and working in The Hague
conducting pharmacological research, lecturing
widely, and serving on national patient organisations
and the Society of Psychiatrists. Dora did a case
presentation that illustrated many of the practical
difficulties clinicians experience in managing these
complex patients. She referred to, among other
things, new insights that had been gained in recent
studies that explore the personality traits that are
common in ADHD
WELCOME PERSONAL RECOVERY SYMPOSIUM:
24-25 MARCH 2021
Dr Kaveshin Naidu is warmly welcomed as specialist
registrar in the Division of Child and Adolescent A “Personal Recovery” Symposium was hosted by
Psychiatry with effect from 1 February 2021. the Inclusive Practices Africa Research Unit at the
University of Cape Town from 24 - 25 March 2021.
GOODBYE This symposium brought together scholars and
practitioners to explore the relevance of a Personal
We wish Bradley Knight all the best for his future and Recovery orientation to research, management as
career; and thank him for his valuable contribution well as teaching and learning practices for students’
as staff member of UCT and the Outpatients success in higher education in South Africa.
Department at Valkenberg Hospital.
CONGRATULATIONS
1. The department congratulates Pieter Naude
in the Division of Psychopharm & Biological
Psychiatry on his extraordinary achievement in
winning a ‘Wellcome International Intermediate
Fellowship’. The Fellowship will allow Pieter to
extend his research on neuroinflammation, an
area of growing importance in psychiatry.
2. Lameze Abrahams, co-Head of Division of
Psychotherapy, is congratulated on being
awarded a research development grant from
UCT, which is directly relevant to her clinical work.
3. Mwanja Chundu is congratulated on passing her
M Med (Psychiatry) thesis. Her project on the role
of parenting style in relation to suicide and non-
suicidal self-injury in university students makes
a valuable contribution to the mental health of
'emerging adults'
45 * SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021
NEWS
ACADEMIC LUNCHTIME LECTURES
The following academic lectures were hosted: focus on intellectual disability. In general, children
and adults with intellectual disabilities are at greater
Date: 23 February 2021 risk for COVID-19 complications.
Topic: Capacity Building in the Alan J. Flisher Centre Emeritus Prof. Colleen M. Adnams
for Public Mental Health: Our Past, Present & Future
Speakers: Prof Katherine Sorsdahl & Dr Claire Van Date: 15 April 2021
Der Westhuizen
Topic: Prevention of Depression
The Alan J Flisher Centre for Public Mental Health Speaker: Prof Michael Berk
(CPMH) is a collaborative inter-institutional multi- At a lecture co-hosted by the African College
disciplinary centre which is led jointly by the of Neuropsychopharmacology and the World
faculty from the University of Cape Town (UCT) and Psychiatric Association’s Collaborating Centres,
Stellenbosch University (SU), with the overarching Professor Michael Berk (South African-trained
goal of promoting mental health in Africa. before moving to Australia) spoke on “Prevention of
Depression”.
Since 2010, CPMH has been conducting high He is ranked first in psychiatry globally on the
quality research on public mental health, and bibliometric resource "Expertscape", and in both
using evidence for teaching, consultancy and depression and bipolar disorder, he is ranked
advocacy to achieve this goal. Capacity building second globally. He emphasized that there
and mentorship activities have been an integral are many potentially modifiable risk factors for
part of CPMH activities and have included: (i) depression, including changes to diet, exercise,
supervision and training of MPhil and PhD students, and smoking cessation.
and postdoctoral research fellows; (ii) development Many of the risk factors he discussed, and their
of junior researchers and academic staff; and (ii) impact on inflammation, are shared with other
short courses for a range of audiences. non-communicable diseases (NCDs). Prof Berk
expressed the need for a shared framework to
Recently, in response to a gap in the public mental prevent non-communicable diseases.
health postgraduate pipeline, the CPMH team has His view is that mental health is “in the pound
refined plans to offer a postgraduate diploma in seats”. He explained that it is much harder to
Public Mental Health. persuade someone to change behaviour to
prevent a disease that will only show up in 30 years;
The presentation on the day was a reflection on relating to a 20-year-old about feeling better is far
capacity building initiatives at CPMH since its easier. “I believe that mental health might be the
establishment and on future capacity building motivational hook to get younger people engaged
plans to strengthen public mental health in Africa. in preventive interventions”
Date: 2 March 2021
Topic: Intellectual and Developmental Disability: A
Current International Outlook
Speaker: Emeritus Prof. Colleen M. Adnams
Prof Adnams was instrumental in setting up the
clinical academic sub-speciality of Developmental
Paediatrics in South Africa. Colleen served on
the WHO Working Group for the International
Classification of Diseases 11th edition (ICD-11)
classification of Intellectual Disability.
She is President, and Africa and Middle East Region
representative for the International Association
for the Scientific Study of Intellectual and
Developmental Disabilities (IASSIDD).
Prof Adnam’s presentation described current
international research and practices in the field of
intellectual and developmental disabilities, with a
SOUTH AFRICAN PSYCHIATRY ISSUE 27 2021 * 46
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