Background
Methods
Week | Content | Construct of Curriculum in this study |
---|---|---|
0 | Pre test | Construct of assessment Source: family practice specialty examination board review [21] |
0 | Technical meeting on the method of the course, the lesson plan (based on experiential learning cycles), the formation of small group learning community and introducing guidelines for critical appraisals | Foundations of family medicine |
1 | Promotion and prevention overview (the natural history of illnesses and continuity of care) | |
2 | General practice principles (the power of better communication skills for better health care services) | |
3 | ‘Ready to work’ (understanding social determinant of health and ‘bio-psycho-socio-cultural-spiritual’ background) | |
4 | Prevention of Fe deficiency in young women and pregnancy | Women’s health |
5 | Prevention of hypertension in pregnant mother | |
6 | Clinical management of TORCH infection in pregnancy | |
7 | “Healthy baby—serene mother—happy family” (antenatal care) | |
8 | Smart patient—proper family planning devices | |
9 | HPV vaccination and early detection of cervical cancer | |
10 | Early detection of breast tumor and cancer | |
11 | Effective management of vaginal discharge | |
12 | Healthy kid (under five)—adequate nutrition | Child’s health |
13 | Healthy kid—complete vaccination | |
14 | Clinical management of dehydration in acute diarrhoea in children | |
15 | Clinical management of convulsion in children | |
16 | Clinical management of anxiety and depressions in primary care settings | Mental health |
17 | Comprehensive management of post-traumatic stress disorder | |
18 | Early detection and long-term effective treatment of schizophrenia at primary care settings | |
19 | Understanding epidemiology of mental disorders | |
20 | Evidence-based practice on ‘headache’ | Neurology problems |
21 | Rational therapy on Bell’s Palsy and other peripheral neurology disorders | |
22 | Prevention and prompt treatment of STROKE | |
23 | Comprehensive care for elderly people | Adulthood, elderly and chronic care |
24 | Clinical management of arthritis | |
25 | Clinical management of TB patients and minimize the drugs side effects and resistance | |
26 | Evidence-based practice on asthma and COPD | |
27 | Screening and managing diabetes type II | |
28 | Up-to-date of managing diabetics ulcers | |
29 | Proper nutrition for metabolic syndrome | |
30 | Effective management of hypertension | |
31 | Complementary alternative medicine | |
32 | Evidence-based practice on abdominal pain | Acute care, surgery and infections |
33 | Are you at risks of prostate hyperplasia or cancer? | |
34 | Emergency of heart disorders | |
35 | HIV and voluntary counselling and testing (concern for disadvantage population) | |
36 | ‘5 days’ fever and its differential diagnosis in Indonesian settings | |
37 | Effective treatment on ‘burn’ | |
Early detection on blindness risks (cataract, glaucoma, diabetes retinopathies) | Sensory organs (EYE) | |
38 | Rational therapy on ‘common cold’ | Sensory organs (ENT) |
39 | Early detection on nasopharyngeal cancers | |
40 | Understanding leprosies for diagnosis and treatment at primary care settings and selection of topical treatment for dermatitis | Sensory organs (skin care) |
41 |
Post-test
|
Construct of assessment
Source: family practice specialty examination board review [21] |
Subjects
Subjects
Instrument
Time | Content | Persons in charge | Experiential learning cycle | Aim | Learning tools |
---|---|---|---|---|---|
The first 30 min | Presentation of a case based on the topic of the day (an actual patient care) | Primary care physician (1) | ‘Concrete experience’ (what was usually done in practice) | To start the learning cycle according to Kolb and colleagues | A medical record based on family medicine principles |
The second 30 min | Presentation of a critical appraisals on a publication of family medicine journals related to the topic of the case-report | Primary care physician (2) from the same small group learning as physician (1) | ‘Reviewing and studying’ (what should be done based on evidences) | To move to the second stage of learning cycle in the experiential learning | Critical appraisals tools and checklist available on the internet (introduced in a workshop of critical appraisals) |
The third 30 min | Presentation of a critical appraisals on a publication of clinical medicine journals related to the topic of the case-report | Primary care physician (3) from the same small group learning as physician (1) | ‘Reviewing and studying’ (what should be done based on evidences) | To move to the second stage of learning cycle in the experiential learning | Critical appraisals tools and checklist available on the internet (introduced in a workshop of critical appraisals) |
The fourth 30 min | Feedback and discussion | Clinical teacher who were invited based on the topic of the case-report | ‘Abstract conceptualization’ | To move to the third stage of learning cycle in the experiential learning | Teacher training on ‘constructive feedback and one-minute preceptor-ship’ |
The last 30 min | Feedback and discussion | Family medicine teacher from family medicine team | ‘Abstract conceptualization’ | To move to the third stage of learning cycle in the experiential learning | |
Days after | Observation-based learning | Family medicine teacher from Family medicine team | ‘Active experimenting’ | To move to the last stage of learning cycle in the experiential learning | The one-minute preceptorship |
Days after–before another week | Writing a reflection form | All primary care physicians as participants in the WCU course | ‘Active experimenting’ (what should be done better next time/plan) | To move to the third stage of learning cycle in the experiential learning | Reflection form based on Gibbs’ |
Procedures
Analysis
Results
Regions | Doctors | Pre-test scores | Post-test scores | Mean ∆ post–pre scores (95% CI) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
N | Lowest | Highest | Mean (95% CI) | Median | SD | Lowest | Highest | Mean (95% CI) | Median | SD | ||
Y (overall) | 61 | 28 | 64 | 50.64 (48.25–53.03) | 52 | 9.54 | 52 | 86 | 72.77 (70.71–74.83) | 72 | 8.21 | 22.13 (19.36–24.90) |
Y (female) | 50 (81.97%) | 28 | 64 | 49.96 (47.31–52.61) | 51 | 9.56 | 52 | 86 | 72.20 (69.88–74.52) | 72 | 8.36 | 22.24 (19.09–25.39) |
Y (male) | 11 (18.03%) | 35 | 64 | 53.73 (48.25–59.21) | 55 | 9.27 | 61 | 83 | 75.36 (71.05–79.67) | 80 | 7.30 | 21.64 (15.84–27.44) |
J (overall) | 98 | 10 | 58 | 39.37 (37.73–41.01) | 40.5 | 8.27 | 38 | 65 | 51.81 (50.50–53.12) | 53 | 6.63 | 12.44 (10.49–14.39) |
J (female) | 81 (82.65%) | 10 | 58 | 39,64 (37,87–41,41) | 42 | 8.12 | 39 | 65 | 53.00 (51.70–54.30) | 53 | 5.95 | 13.36 (11.41–15.31) |
J (male) | 17 (17.35%) | 10 | 50 | 38.06 (33.76–42.36) | 40 | 9.05 | 38 | 61 | 46.12 (42.84–49.40) | 47 | 6.90 | 8.06 (2.08–14.04) |
Regions | p value (paired t test/independent t test) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Pre vs post | Pre-test | Post-test | ||||||||||
Y (A) vs J (A) | Y (F) vs J (F) | Y (M) vs J (M) | Y (F) vs Y (M) | J (F) vs J (M) | Y (A) vs J (A) | Y (F) vs J (F) | Y (M) vs J (M) | Y (F) vs Y (M) | J (F) vs J (M) | |||
Y (overall) | 0.000 | 0.000 | 0.000 | 0.000 | 0.244 | 0.512 | 0.000 | 0.000 | 0.000 | 0.223 | 0.001 | |
Y (female) | 0.000 | |||||||||||
Y (male) | 0.000 | |||||||||||
J (overall) | 0.000 |
∆ Post-test–pre-test
| ||||||||||
J (female) | 0.000 |
Y (A) vs J (A)
|
Y (F)vs J (F)
|
Y (M) vs J (M)
|
Y (F) vs Y (M)
|
J (F) vs J (M)
| ||||||
J (male) | 0.018 | 0.000 | 0.000 | 0.004 | 0.860 | 0.115 |
“Critical appraisals are difficult, but it opened new information which I would never imagine, medical evidences change very fast over the time.”
“I already work as a GP for more than 30 years and I am about to retire. But this course is what we actually need and I would like to study further into a formal vocational training of family medicine.”
“We need the clinical part of patient care training more in this course.”
“The specialists should provide ‘referral back’ letter to us. They rarely do that. We need to learn from our referred cases and we will be with the patients whenever they are.”
Categories | Quotations |
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Foundation of family medicine | |
The comprehension of the importance of evidence-based practice | “Looking for an evidence-based practice is possible for a family physician because the literature are always change throughout the time. The literature of family medicine also strongly suggested that we should keep up to date with the newest evidences. I think it is good if we build a network among us (the GPs), so that we could discuss any evidences” |
The use of complementary alternative medicine |
“I had a patient with cerebral palsy and she lives at home with her mother who already very old. She did not have any access to hospital and then a nearby midwives was asking for my help. So I initiated to do a home visit with my nurse. The patient could not move and having very severe infection of ‘decubitus’ and also on her vagina, the worst wound you may imagine. I then remembered from the weekly clinical update that we may use honey. So I tried. I clear her wounds each day, slowly, and surprisingly it worked out very well. Just a regular honey!”
|
“My patient had a diabetic ulcer and I referred him to the hospital and the surgeon decided to do ‘amputation’. The patient refused. He came back to me and insisted that he only wanted me to care for him. I was puzzled. Then I remember from the Weekly update, the appraisals about honey and the discussion with the faculty surgeon during that appraisal session. I did an informed consent with the patient. And also that he must obey the regular diabetic treatment that he has. So I started to debridement the wound and carefully use regular honey. Surprisingly, after e period, the wound healed, he could walk normally and now he keeps healthier life”
| |
The importance of home-visits and understanding a family | “As a GP, we could also do a home-care and home-visits, so that we understand the family context of an elderly. There is new financial system at the primary care centers, I am sure we could manage it to provide extra incentives for health professionals who do home care and home visits” |
The comprehension on family and individual life cycle in regards to individual illnesses | “Thank you for giving me an opportunity to reflect on elderly patient – care with many complex problems. I knew now the cycle of life and cycle of a family so I understand that it is also difficult for her son (who also has a family and adolescence teenagers) to take care of their parents at home. It is a complexity of life that we, as a family physician should understand better” |
Initiated community group learning | “Starting to care for chronic illnesses like hypertension and diabetes mellitus based on the national insurance program, we formed a community health group meeting; which ultimately self-funded and self-regulated. It is amazing to see that the elderly people initiate to have periodic meetings, recreation…” |
Closer steps to patient centred care |
“I understand that listening, is very important and we may come to different diagnosis and more correct treatment after deeper listening”
|
“Now I know that we should ‘well-prepared’ the patient before they referred to a hospital, so sufficient information is highly important for the patient to understand what specialists may do in hospitals and how they could discuss with them” | |
“As a fresh graduate doctor, twenty years ago, I worked at a remote area. There was an abortion case and I was following a correct procedure and then referred the patient to a hospital. However, I might not able to do an adequate communication with the family (since I did not know the technique until I joined this course) so I was on a ‘trial’ in front of a ‘community court’. No lawyer or advocate stood at my side. The husband was misunderstood and blamed me causing his loss of a child. Fortunately, the community trusted my explanation, and I knew that the husband had a several records of misbehave in that community. However, I should not only thinking and performing correct medical procedures, I must communicate with the patient and their family better”
| |
Women’s health | “There was a teenager who was unmarried and pregnant without a husband. She was so depressed and so I have to conduct a family meeting. Her parents; respectable couple in the neighborhood, could not accept the condition and forced to do an abortion. I explained the healthy condition of their daughter and future grandson and so I have taken initiative to assist the family, day by day, week by week, up to years later to going through every stage of a family crisis. Now they are happy and the daughter could continue her education via distance learning program. Now I know that what I did was a part of being family doctor and I am very happy for that” |
Child’s health | No discussion on child health problems |
Mental health | “The WHO recommended continuity of care for mentally ill patients and shifted from hospital based into community based care. The recommendation has consequences of strengthening primary care team at primary care settings, empowering the family, educating the family and community, and researches in the area of mental illness. Our community clinic has been trying to implement these recommendations via home visits, psycho-education for the family, the formation of cadre for mental illness, group therapy for the patients and also for the family, all in a program called Health Village Mentally Resilience. We also should work together with all health professionals and hospital, to provide two-way comprehensive care towards patient-centered care. There are so many mental disorders at the community settings” |
Neurology problems |
“I was on duty in a rural area and a patient came back to our clinic. He suddenly could not talk (a young man), has a very weird movement on his extremities. It was not a stroke, but what was it? His father kept talking to me about bad spirit that his neighbor had sent to his family”
“While his father was talking - I had to extremely divide my attention with thinking to a more logical way. I did careful history taking and the patient apparently has consume the metoclopramide. I remember the possibility of allergic and extrapyramidal effects. Fortunately in the clinic we had the antidote that was ‘trihexyphenidil’. I saved the patient and his family was grateful because I won over the bad spirit. Then I explained to the family what happened and he should avoid any metoclopramide” |
Adulthood, elderly and chronic care | |
The idea to optimize the home-institution for elderly people which was unfamiliar for the context of this study | “I think it is the time to optimize the home-institution for elderly people. Usually we perceived that an elderly home is for neglected elderly. We should have a new perception now that an elderly home is for any elderly who need it. And elderly home could be the best place for them to have a social relationship, to talk, chat, and play games, because elderly needs others to share stories” |
“I had a patient with diabetes mellitus type II, chronic. She was often come to my clinic and I already explain anything related to prevention and treatment of diabetes and its complication. She refused any referral to hospitals and she would only visit me. I know her condition got worse and worse and I motivated her to use insulin or to visit hospital. One day she never come again, I know from her neighbor that she died. I should regularly visit her at her home, I regret I never do that…”
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Acute care, surgery and infections | |
Emergency in baby delivery |
“When I was on duty on a remote area of Indonesia, there was an emergency baby delivery that we should be used a vacuum. The baby were twins. It was just me and one very young midwife and no hospital. We did all the procedures correct, but the vacuum was not in good function. The mother was safe, but the twins were died immediately after born. I should have re check all the emergency equipment regularly especially when no other health care settings is around”
|
Emergency in shock syndrome |
“Once there was a patient with a somewhat medium late allergy reaction came back to our clinic, one hour after a molar excision. The dentist already went home, it was after the working hours. I was lucky that the nurses were so helpful in assisting me not to panic and I realize that I have to check the adrenalin and all other emergency drugs and procedures regularly; no place for expires. Thanks God we saved that patient”
|
HIV problems |
“I have a patient, he is a teenager and having the HIV. He came to me in his worst condition with candida all over his body. He seemed like a ‘tree’ than a ‘human’. But I tried to communicate with him as a friend. He used to text me until he trusted me to bring his partner to Puskesmas. The partner was agree to do a counseling prior to an HIV test. I also communicated with them that it is important for their parents to know. For this special patient, holistic and comprehensive care as I learned in this course is certainly needed. I also learned on how to do steps of family intervention in a more effective way”
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Sensory organs (eye) | No discussion on sensory organs problems |
Sensory organs (ENT) | |
Sensory organs (skin) |