Preparatory graduate professional training in general practice by using the 'experiential learning' framework

Preparatory graduate professional training in general practice by using the 'experiential... Background: General practitioners (GPs) in Indonesia are medical doctors without formal graduate professional training. Only recently, graduate general practice (GP) is being introduced to Indonesia. Therefore, it is important to provide a framework to prepare a residency training in general practice part of which is to equip GP graduate doc- tors to deliver person-centered, comprehensive care in general practice. Experiential learning theory is often used to design workplace-based learning in medical education. The aim of this study was to evaluate a graduate professional training program in general practice based on the ‘experiential learning’ framework. Methods: This was a pre-posttest study. The participants were 159 GPs who have been practicing for a minimum of 5 years, without formal graduate professional training, from two urban cities of Indonesia (Yogyakarta and Jakarta). A 40-week curriculum called the ‘weekly clinical updates on primary care medicine’ ( WCU) was designed, where GPs met with clinical consultants weekly in a class. The participant’s knowledge was assessed with pre-posttests involving 100 written clinical cases in line with each topic in the curriculum. Learning continued with a series of group discus- sions to gain reflection to reinforce learning. Results: Participants’ knowledge regarding clinical problems in general practice was moderately increased (p < 0.05) after the training from a mean score of 50.64–72.77 (Yogyakarta’s doctors) and 39.37–51.81 (Jakarta’s doctors). Partici- pants were able to reflect on the principles of general practice patient-care. Participants reported satisfaction during the course, and expressed a desire for a formal residency training. Conclusions: A graduate educational framework for GP based on the ‘experiential learning’ framework in this study could be used to prepare a graduate GP training; it is effective at increasing the comprehension of general practition- ers towards better primary care practice. Keywords: General practice/family medicine education and training, Experiential learning, Person-centered care *Correspondence: mora.claramita@ugm.ac.id Department of Medical Education, Faculty of Medicine, Universitas Gadjah Mada (UGM), Radiopoetro Building 6th floor, Jalan Farmako Sekip Utara, Yogyakarta 55281, Indonesia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 2 of 13 on evidences, more ‘experimenting’ through trials, or Background more ‘accommodating’ by frequently repeating another ‘Family medicine’ is well established in some countries, ‘experience’ [7, 8]. including in the United States and European countries as Experiential learning methods have been adopted as a medical specialty which focuses on ‘holistic approach— learning strategies in medical education for basic and people-based—comprehensive care’. In commonwealth postgraduate medical education [9–16]. Most surgical countries, the term ‘family medicine’ is also known as specialists’ learning styles found were primarily ‘experi- ‘general practice’ [1]. The World Federation of Medical menting’ (between theorist and pragmatist), while fam- Education (WFME) introduced three standards of basic ily medicine or GP residents were found to have a more medical education (BME), postgraduate medical educa- ‘assimilating’ learning style (between reflector and theo - tion (PGME) (which includes family medicine speciali- rist), whereas anesthesia residents were found to be zation), and continuing medical education (CME) [2]. more ‘accommodating’ (between pragmatist and activ- However, some countries still allow general practitioners ist) [9–12]. There is clearly a need of general practice/ (GPs) to work doctors working in a primary care settings family medicine graduate programs to participate in the without formal graduate professional training in family development of better quality health care. General prac- medicine or general practice [1, 3, 4]. tice demands a highly flexible curriculum with a mix of In the era of universal coverage, a paradigm shifting in person and online courses to provide easier access to from disease-oriented care to a more person-centered continue learning from community-based clinical set- and goal-oriented care is needed. This shift includes the tings [12]. changing of perspectives from fee-for-service to pub- Much of literatures about ‘experiential learning’ design lic policy reformation, creating a national health insur- discuss integrated clinical workplace-based learning at ance system, making sure all people have equal access community-based educational settings using reflective to health care) [5]. Those reforms will need leadership journals and collaborative learning as the main strategy including policies and regulations regarding health care to elicit socio-behavioral abilities such as communica- services aimed at a more people-centered care. Pri- tion skills, leadership and family-care centeredness at mary health care should be optimized and prioritized, primary care settings [13–16]. Two of these publications while family and community empowerment should be specifically explained instructional design with lesson encouraged; ancillary workers (e.g. nurses and pharma- plans based on the four stages of experiential learning by cists) should work hand in hand with physicians in pri- Kolb and colleagues, but were intended for undergradu- mary care settings [6]. Therefore, educational strategies ate medical education students [15, 16]. should facilitate this movement towards strengthening This study aimed to evaluate the use of the four learn - primary health care. However, specialty training in gen- ing cycles in the experiential learning approach to eral practice is still unfamiliar in some countries, includ- develop and test a more systematic graduate professional ing Indonesia. Based on international recommendations, training for general practitioners. This study is essential preparation must be made to provide a graduate educa- to provide a general practice prototype training frame- tional framework for general practice education [1]. work for doctors who have no formal graduate training Experiential learning theory has been introduced and in primary care following their undergraduate medical used for learning at clinical workplaces in medical educa- education, but have been working for several years at pri- tion worldwide. It was first introduced by Kolb in 1984 mary care settings. and recognizes the importance of ‘reflection’ in the learn - ing process and the need for ‘social context’ to deepen the Methods meaning of learning [7, 8]. The four stages of the learn - This is a pre-posttest study followed by a qualitative ing cycle described in Kolb’s theory starts from ‘concrete exploration to evaluate the training approach, using experience’ (preferable from real patient-care experi- experiential learning cycles, to increase the general prac- ences); this should be followed by ‘reflective observation’ titioners’ knowledge in the area of family medicine and and then ‘abstract conceptualization’; all of these meth- primary care. None of the GPs in this study had any for- ods apply the process of learning by seeking for informa- mal graduate professional training in general practice; tion until gaining a complete understanding. Ultimately, as graduate training in general practice did not exist in the cycle is followed by ‘active experimentation’, to prac- Indonesia at the time of this study. tice and validate the comprehension of the learners. Dif- We developed a 40-week syllabus and lesson plans for ferent ‘learning styles’ have been identified from which a weekly graduate GP educational program, based on learning actions or steps are accentuated after an ‘experi- the four learning cycles of ‘experiential learning’ the- ence’. The learning tendency may be ‘reflective’ or based ory (‘concrete experiencing’, ‘reviewing and studying’, on observational methods, more ‘critical thinking’ based Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 3 of 13 ‘abstract conceptualizing’ and ‘active experimenting’) Instrument [7, 8]. Table  1 describes the syllabus of the graduate Instruments in this study included: a curriculum and family medicine CME program given over 40-weeks lesson plans of graduate general practice CME program namely the ‘Weekly Clinical Updates on Primary Care presented in Tables  1 and 2, completed using various Medicine’, which were assisted by clinical consultants methods of instruction. Pre and posttests of clinical cases from different specialties and general practice team were written based on Graber’s and Wilbur’s specialty staff-members, all from the Faculty of Medicine, Uni - board-review book of family medicine and an examina- versitas Gadjah Mada (UGM), Yogyakarta, Indonesia. tion guide book with typical items used to assess fam- All GP staff members held academic degrees in medi - ily medicine residents in the US [21]. The items in the cine (masters, doctorate, and professorship). They had board-review book represent family medicine princi- been practicing as generalists for more than a decade at ples, continuity of care across ages, genders and stages the UGM clinic, but had no formal degree in graduate of illnesses, written by 40 family medicine specialists as professional training as a GP (due to the lack of general contributors, presented in vignettes/cases followed by practice specialty training in Indonesia). several multiple choices. The items in the book have been The curriculum of the program was constructed endorsed as part of preparation for the examination for based on textbooks of family medicine/general prac- family medicine residency in the US. tice [17, 18] and was reviewed by a technical assistant The items in the chapters of the Family Medicine Spe - (TA) from the World Organization of Family Doctors cialist Book review were written and constructed based in 2013 [19]. The curriculum was revised based on on the five levels of prevention of primary care principles the comments received from the TA. The main com - [21, 22]. Vignettes and cases were written from simple ment was that the content was too clinical and should to more complex health problems followed by multiple accommodate more general principles of family medi- choice questions. Readers were invited to think through cine. In accordance with this advice, we reworked the five levels of natural history of each of the diseases first 3  weeks to emphasize the more basic comprehen - selected from simple to the most complicated ones. sion of family medicine content. Among the total of 30 chapters in the book, the authors of this study selected only ten constructs or clinical top- ics that represent world-wide illnesses followed with a Subjects selection of ten vignettes/cases of each topic (Table  1). Subjects The ten vignettes/cases selected consisted of two items The subjects in this study consisted of convenience of each of the five levels of prevention. For example, for samples of 61 GPs from Yogyakarta region (central Java the topic of ‘cardiovascular’, there are two items for pri- Island) and 98 GPs from Jakarta, Indonesia; who were mary prevention of cardiovascular diseases (one item specifically assigned by their local district health care for health promotion and one item for specific protec - authorities to do the 40-week graduate course in gen- tion), four items of secondary preventions (two items of eral practice in 2016–2017. Women predominated our early detection and two items of prompt treatment), and samples (81.97% of Yogya’s and 82.65% of Jakarta’s). finally four items of tertiary prevention (two items of The proportion of females in the cohort represents the complication-detection and two items of rehabilitation current mix of Indonesian medical students who are or palliative care). In total there were 100 multiple choice mostly female [20]. Additionally, It is likely that male questions pertaining to the ten vignettes/cases. All mate- doctors will continue to seek graduate professional rials were translated into Bahasa Indonesia and adapted training of medical specialties which are hospital- to the Indonesian context and reviewed by specialist con- based, after several years working at Puskesmas. Con- sultants and GP staff members from UGM. sequently, mid-career doctors at Puskesmas are mostly The same 100 items applied for the pre and posttests female [20]. for both study settings. We avoided items which involved All of the participants are government employees and advanced clinical laboratory tests or advance pharmaco- working at urban sites. The other consideration was the logical drugs that could not be done in a Puskesmas. The active working period of the participants; they should not scores from all participants were tallied by a secretary be a new employee nor approaching their retirement. The afterwards and sent to the statistician directly, to do the working experiences as general practice of the partici- analysis. pants were varied from 8 to 30 years and their ages were The lesson plans as described in Table  2 were designed between 32 and 55 years old. An informed consent form based on an experiential learning design of the four learn- was completed by all participants before the clinical cases ing cycles from Kolb [7, 8]. We provided a ‘holistic medi- pretest was distributed. cal record’ template comprising the bio-psychosocial Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 4 of 13 Table 1 The 40-week curriculum of “Weekly Clinical Updates on Primary Care Medicine” for general practice in this study Week Content Construct of Curriculum in this study Sources: textbooks of general practice [17, 18] reviewed by: a Technical Assistant from World Organization of Family Medicine [19] 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 Foundations of family medicine on experiential learning cycles), the formation of small group learning community and introducing guidelines for critical appraisals 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 Eec ff tive 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 set- Mental health tings 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 Eec ff tive 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 Eec ff tive treatment on ‘burn’ Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 5 of 13 Table 1 (continued) Week Content Construct of Curriculum in this study Sources: textbooks of general practice [17, 18] reviewed by: a Technical Assistant from World Organization of Family Medicine [19] 0 Pre test Construct of assessment Source: family practice specialty examination board review [21] Early detection on blindness risks (cataract, glaucoma, diabetes retin- Sensory organs (EYE) opathies) 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 Sensory organs (skin care) settings and selection of topical treatment for dermatitis 41 Post-test Construct of assessment Source: family practice specialty examination board review [21] background of patients and their family to be one of the Procedures instruments for the participants in this study [18, 19]. The pretest was administered before the first learning This specific medical record format was used to capture session. The pretest was followed by a technical meeting the ‘active experimentation’ of patient-care of the par- session where the large group of participants was divided ticipants based on principles of family medicine, dur- into small groups, each consisting of ten physicians, ing the first stage of the experiential learning cycle. We who worked together for each of the assignments. We also provided guidelines for critical appraisals to help the also provided a rigorous explanation of the curriculum participants to review several published papers. We pro- (Table  1), the lesson plans (Table  2) and other learning moted the evidence-based practice during the ‘reviewing tools [23–25]. We prepared the participants to learn with and studying’ stage of the experiential learning cycle [23]. the following strategies: (1) by experiential learning cycle Teachers in this program who are clinical consultants basis, (2) to work together in a collaborative small team and team members of GP staff were also trained on the group, (3) to regularly appraise literatures, (4) to do series use of ‘one-minute preceptorship’ to provide constructive of individual reflections, (5) to do group discussions, and feedback [24, 25]. Ultimately, ‘abstract conceptualization’ (6) to be open to any feedback from the peers and clinical and ‘planning active experimentation for future patients’; consultants. The key message was ‘continuous learning’. the last two stages of the experiential learning cycle were After each technical meeting session, the first learn - guided by a written reflection and a series of group dis - ing session was implemented. One of the participants cussions with the participants after each topic was pre- presented an actual patient-care case, using a ‘holistic sented [25]. and comprehensive medical record’ format which was Group discussions were conducted 5 times with partic- designed specifically for family medicine doctors that ipants from Yogyakarta and 10 times with Jakarta’s GPs. includes bio-psycho-social-cultural aspects, continuity of The main guiding questions were, “Tell us a story about care and comprehensive care [18, 19]. The main idea was a patient that you most remember,” (the identity of the used to start the learning process with an ‘actual experi- patients remained confidential) and “How do you reflect ence’ of the experiential learning cycle [7, 8]. Afterwards, on the patient-centered clinical care?” We adapted the another two participants within the same small group of generic rules of the Balint group discussions: (1) no inter- learning presented a critical appraisal of a journal article ruption from the start until the end of a story that is told (clinical and family medicine articles), which were closely by a doctor, (2) no judgment based on doctors’ ability, (3) related to the case presented in advance. The aim of this no suggestions or comments from other participants— critical appraisal session was to facilitate the participants only questions for clarification, (4) if there is any reflec - receptiveness to evidence-based practices and included tion it will come from the presenter of the story by her/ in the ‘reviewing and studying’ of the experiential learn- him selves or other doctors who listen to the story, while ing cycle [7, 8]. Each of the participants who presented (5) the identity of all persons remained confidential, (6) cases and critical appraisals wrote at least five questions nobody had access to a paper, or pen, or mobile phone, or to be presented to the class and clinical consultants who a laptop, and (7) the recording is based on an informed- attended the session. The feedback session was con - consent process, e.g. for this study’s purposes [26, 27]. ducted by the clinical consultants and GP staff members. Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 6 of 13 Table 2 The lesson plan (instructional design) of each session/week/topic in the “Weekly Clinical Updates on Primary Care Medicine” for general practice in this study based on experiential learning cycles [7, 8] Time Content Persons in charge Experiential learning cycle Aim Learning tools The first 30 min Presentation of a case based on Primary care physician (1) ‘Concrete experience’ (what To start the learning cycle A medical record based on fam- the topic of the day (an actual was usually done in practice) according to Kolb and col- ily medicine principles patient care) leagues The second 30 min Presentation of a critical Primary care physician (2) from ‘Reviewing and studying’ (what To move to the second stage Critical appraisals tools and appraisals on a publication the same small group learn- should be done based on of learning cycle in the expe- checklist available on the of family medicine journals ing as physician (1) evidences) riential learning internet (introduced in a work- related to the topic of the shop of critical appraisals) case-report The third 30 min Presentation of a critical Primary care physician (3) from ‘Reviewing and studying’ (what To move to the second stage Critical appraisals tools and appraisals on a publication the same small group learn- should be done based on of learning cycle in the expe- checklist available on the of clinical medicine journals ing as physician (1) evidences) riential learning internet (introduced in a work- related to the topic of the shop of critical appraisals) case-report The fourth 30 min Feedback and discussion Clinical teacher who were ‘Abstract conceptualization’ To move to the third stage of Teacher training on ‘construc- invited based on the topic of learning cycle in the experi- tive feedback and one-minute the case-report ential learning preceptor-ship’ The last 30 min Feedback and discussion Family medicine teacher from ‘Abstract conceptualization’ To move to the third stage of family medicine team learning cycle in the experi- ential learning Days after Observation-based learning Family medicine teacher from ‘Active experimenting’ To move to the last stage of The one-minute preceptorship Family medicine team learning cycle in the experi- ential learning Days after–before another Writing a reflection form All primary care physicians ‘Active experimenting’ (what To move to the third stage of Reflection form based on Gibbs’ week as participants in the WCU should be done better next learning cycle in the experi- course time/plan) ential learning Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 7 of 13 The clinical consultants addressed each of the questions (p < 0.05). As noted the samples were predominantly posed by participants, teaching general rules and apply- women, and when we analyzed the data the Yogyakarta’s ing the ‘one-minute preceptor’ method in this feedback female doctors were found to have higher scores than session [24, 25]. Sometimes the consultant needed to Jakarta’s female doctors in pre, posttests and Delta scores describe an illustration with a slide or two, but this media (p < 0.05). However, there were no significant differences was not considered ‘lecturing’ time. Questions from par- between females and males in each of the two cities, ticipants guided the discussion/explanations. The GP for pre-test and posttest and the Delta scores (p > 0.05), staff members acted as moderators in this session and except the posttest of Jakarta’s’ female and male doctors continued to provide feedback appropriate to the subject (p < 0.05) (Table 3). of family medicine/general practice. The feedback session The GPs commented about the course in this study was intended to facilitate ‘abstract conceptualization’ suggesting a more longitudinal—a yearlong course, inte- within the experiential learning cycle. grated graduate course where the GPs staff-members and Considering the limited time available to GPs, we specialists sit in the same row to provide feedback for the scheduled 2.5–3  h/week to do each session. Sessions participants. Also, it was suggested that it should be the were held on Saturdays at the Faculty of Medicine UGM, participants who lead the discussions through the ques- when the patient-care schedules were minimum. The tions and not the specialist. Some GPs’ opinions are as UGM staff members from the GP team then visited each follows: group of participants to be a facilitator of the ‘active “Critical appraisals are difficult, but it opened new experimentation’ stage of the experiential learning meth- information which I would never imagine, medical ods. Finally, each participant wrote a reflection and pre - evidences change very fast over the time.” pared for another topic for the next week’s session. With these goals, the learning process would be on-going for “I already work as a GP for more than 30 years and the entire week. At the end of the 40  weeks of sessions, I am about to retire. But this course is what we actu- a post test was administered and series of group discus- ally need and I would like to study further into a for- sions were conducted. mal vocational training of family medicine.” Analysis “We need the clinical part of patient care training The authors did a paired sample and independent sample more in this course.” t test for the analysis of the clinical cases’ items [28] and also a qualitative open coding for the results of each of “The specialists should provide ‘referral back’ letter the focus group discussions in each topic/lesson [28]. The to us. They rarely do that. We need to learn from our participants’ comments on the course-construct were referred cases and we will be with the patients when- analyzed until saturation of data was gained [28]. We cat- ever they are.” egorized each of lessons learned based on each topic of the course. The results of 15 group discussion sessions are pre - sented in Table  4. Across all topics provided in the course, there were some topics which were not addressed Results by the participants in this study, e.g. ‘sensory organs top- The t test paired sample proved to be significant, com - ics’ and ‘child health’. This phenomenon may be due to paring the results from before and after the 40-weeks limited time for the group discussions in this study, or it of ‘weekly clinical update’ sessions using experiential may be that GPs in this study were not used to dealing learning design intervention (p < 0.050) as presented in with those specific problems due to lack of equipment for Table 3. Yogyakarta’s doctors increased their mean scores sensory organs’ diagnosis and treatment at the primary from 50.64 (pretest) to 72.77 (posttest) and Jakarta’s care settings, or specialists and midwives may have taken doctors increased from 39.37 (pretest) to 51.81 (post- care of the problem adequately (e.g. for the child health). test). The progress of learning was indicated by the Delta scores of Yogyakarta’s doctors (22.13) and Jakarta’s doc- tors (12. 44). The approach of training in this study using Discussion four cycles of experiential learning was demonstrated to To the best of our knowledge, this is the first study which significantly increase the level of knowledge of the doc - reports the use of experiential learning theory framework tors at both cities (Table 3). for postgraduate medical education. It was designed spe- Overall, using t test independent samples, Yogyakarta’s cifically for preparing professional training in general doctors were found to have higher scores than the Jakar- practice and to stimulate more student-centered learn- ta’s doctors in pre and posttests and also Delta scores ing. Other studies using experiential learning theory Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 8 of 13 Table 3 The results of pre-posttest of the participants in this study 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 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) (A) 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 Y (F)vs J (F) Y (M) vs J (M) Y (F) vs Y (M) J (F) vs J (M) (A) J (male) 0.018 0.000 0.000 0.004 0.860 0.115 Y Yogyakarta, J Jakarta, A overall, F female, M male Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 9 of 13 Table 4 Results of qualitative open-coding analysis in this study Categories Quotations 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 “Thank you for giving me an opportunity to reflect on elderly patient – care with individual illnesses 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” Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 10 of 13 Table 4 (continued) Categories Quotations 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 imple- ment these recommendations via home visits, psycho-education for the fam- ily, 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 think- ing to a more logical way. I did careful history taking and the patient appar- ently 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 “I think it is the time to optimize the home-institution for elderly people. Usually unfamiliar for the context of this study 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 moti- vated 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…” 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 proce- dures 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 help- ful 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” Sensory organs (eye) No discussion on sensory organs problems Sensory organs (ENT ) Sensory organs (skin) Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 11 of 13 emphasized residents’ learning style but did not touch on were used to listening to lectures or reading local proto- the instructional design of using the four learning cycles cols on certain diseases. There were arguments from the in the experiential learning theory to promote a more clinical consultants whether this stage of ‘journal reading’ independent and lifelong learning [9–12]. The ‘experien - is necessary. However, after several topics, the partici- tial learning’ framework in this study provides significant pants felt the benefits of the ‘journal appraisals’ to under - examples of stimulation to the GPs to have more self- stand other ‘views’ and scientific reasons behind a basic directed learning strategies, driving the GPs into a more patient-care guideline or protocols that they usually use active and reflective learning. It presents the challenges in daily practice. Participants’ five questions posed to the and opportunities of better patient-care services in the clinical consultant at the end of their presentations had universal coverage era and also illustrates a more col- successfully directed the discussions into mutual dialog laborative relationship between the general practice staff instead of only passively absorbing the information. members, clinical consultants and many other stakehold- The third stage of experiential learning, which is ers who supported the innovation of medical education ‘abstract conceptualization’ started with constructive in this study. Therefore, although this study was done in feedback from both clinical consultants and a GP staff an Indonesian context where graduate training for GPs member in meaningful discussions. This stage was chal - does not exist, the ‘experiential learning’ framework in lenging to always refer to GP principles and not to get this study may be adapted to a context where postgradu- overwhelmed with hospital-style patient-care manage- ate program has been implemented for many years. ment. Although clinical simulation using mannequins In the first ‘concrete experience’ stage of experien - were sometimes performed during this learning stage, tial learning cycle during the course, we did not have the GP staff members aimed to direct the discussions much difficulty, since physicians in this study are used to back to the importance of promotion and prevention for reporting any patient-care they did at primary care set- certain age groups and different genders and emphasized tings. However, the form of ‘holistic and comprehensive the undifferentiated cases [17, 18]. Important principles medical record’ formats we used throughout the training of GP were the ‘watchful waiting’, to think and to observe were quite challenging involving not only focusing on the together with the patients, and to offer adequate infor - illness but also being attentive towards patient-centered mation in order to make better clinical decision-making. care. Instead of focusing only on certain diseases, GPs in This program also provided examples of communication this study were also directed towards patient-centered and collaborative practice with different levels of health care, family focus and community oriented clinical think- professionals. ing; concepts which were lacking during their undergrad- The last learning cycle of ‘active experimenting’ was uate medical education [17, 18]. performed in this study and was facilitated by a reflec - Many of the participants wondered whether they tion-form to guide the participants to make a plan for should do a patient-centered care approach for every present and future learning. The discussions also served patient, because they perceived that they won’t have as an effort of trying to listen to physicians’ stories and enough time. The discussion on the limited time for reflecting on future concerns for patient-care. The GPs in patient-care services revealed that it required usually less this study completed their learning cycle with planning than 5  min of patient-care services for each patient at better services in the future. primary care centers in this study, which is not different There were only a few questions left unanswered by the than in the hospital settings in a previous study [29]. The clinical consultants in the course, for example dealing general practice staff members as facilitators in this study with lack of time and facilities at primary care centers. emphasized the discussion on the use of an ‘appointment However, along with the gate keeper system in the uni- system’, which most of general practitioners in this study versal coverage era in the context of this study, there is already did for, but for only the antenatal care and elderly a national accreditation system of the primary care clini- care patients. Therefore, primary care centers in this cal settings in Indonesia which will drive the improved study may have separated the intake process of the quick maintenance and increasing quality of primary care ser- encounter for ‘quick care’ and the others as ‘appointment vices and facilities in the near future [3]. encounters’ to provide better health care services as rec- As the early stage of a period of universal coverage ommended in the literature [1]. changes in the context of this study, health profession- For the second stage of the learning cycle, which is als and patients may not yet receive the support and care ‘reviewing and studying’, it was considered difficult as they deserve, but the progressive approach of education perceived by most of participants in this study due to and incrementally better health care services can help. the English language and unfamiliarity with appraising This kind of discussion may ultimately lead to alterna - medical literature in their daily practice. The participants tive solutions coming from the participants. During this Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 12 of 13 course, the GPs learned to do maximum prevention for re-edited every year so it is almost impossible to memo- the patients, including reducing medication complica- rize the content. tions by using better quality drugs instead of low level quality of drugs for merely ‘cost-saving’ purposes. However, we admit that interprofessional collaborative Conclusion practice was less emphasized in this course and should be This study demonstrated that using the educational better articulated in the future. By improved team work framework based on the ‘experiential learning cycle’ sig- of different health professionals, patient care services may nificantly increased participants’ knowledge in the con - become more effective and efficient [30, 31]. Interprofes- text of graduate general practice. The group discussions sional collaborative practice should also emphasize not revealed participants’ deep reflections and future plans only curative medicine, but most importantly prevention. concerning better patient care services. Any future effort It has been a known fact that in order for primary care of establishing a preparatory graduate course of general to function effectively and efficiently, a multidisciplinary practice may use the framework provided in this study. team of both clinical and non-clinical professionals must Authors’ contributions be formed and fully function interprofessionally [30, 31]. All authors contributed to the concept and design of the study, implementa- tion of this study, and interpretation of the meaning of the study. All authors contributed to the draft of this study until finalized in this paper. All authors Strengths and limitations read and approved the final manuscript. This study used GP samples from Yogyakarta and Author details Jakarta provinces, who consisted of public servant doc- Department of Medical Education, Faculty of Medicine, Universitas Gadjah tors in public primary care clinics. The results should Mada (UGM), Radiopoetro Building 6th floor, Jalan Farmako Sekip Utara, Yog- yakarta 55281, Indonesia. Department of Family and Community Medicine, be interpreted in appropriate contexts. However, the Faculty of Medicine, Universitas Gadjah Mada (UGM), Radiopoetro Building 1st combination of quantitative data analysis and in-depth floor, Jalan Farmako Sekip Utara, Yogyakarta 55281, Indonesia. Department qualitative exploration strengthened the data saturation of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA. and interpretation. This study should be continued to include a formative Acknowledgements and summative part of clinical bed site teaching when a We thank the participants in this study and the Yogyakarta and Jakarta District Health Care offices who supported the participant in this study. We also grate - formal graduate study program is legally established. In fully acknowledge the contribution of Dr. Rossi Sanusi who strongly recom- the preparation of providing a framework of graduate mended the ‘journal reading’ sessions to strengthen this course. Thank you for educational training for general practice in this study, Prattama Utomo who assisted the quantitative data analysis of this study. We highly appreciate Professors Jason Wilbur and Lisa Soldat, from the University we succeeded in shifting the way of thinking of the exist- of Iowa USA, who have been with us, training our GPs directly in a voluntary ing GPs from disease centered into a more patient-cen- basis for many–many years, also to Professor Michael Kidd, Professor Zorayda tered care, appraising more evidence-based practice, Leopando, Professor Job Metsemakers, Dr. Jihane Tawilah, Christine and Dr. Jill Benson who continuously support the development of graduate programs and learning in two-way dialogues with other medical of general practice in Indonesia to strengthen the universal coverage health specialists. The ultimate accomplishment was a sub - care system. stantial contribution of many clinical departments and Competing interests stakeholders within a year-long program of GP graduate The authors declare that they have no competing interests. training. These lessons learned about preparing a gradu - ate professional GP educational framework in this study Availability of data and materials All data could be accessed once the manuscript is accepted for publication expectantly could be used for many other countries. we will create a link to access all materials. We noticed that the Yogyakarta group of doctors dem- onstrated a higher level of learning than the Jakarta group Ethics approval and consent to participate Ethical clearance was provided by Faculty of Medicine Commission of Ethics of GPs. This phenomenon could have happened due to No. KE/FK/0820/EC/2017. several reasons such as better learning environment in Yogyakarta, which is well-known as a ‘student city’ in Consent for publication Consent for publication was provided by all authors in this study. Indonesia, more conducive learning process, and more receptive participants, compared to a metropolitan city Funding of Jakarta. The ‘weekly clinical updates of primary care’ The study was funded by District Health Care Offices at Jakarta and Yogyakarta Special Regions of Indonesia based on the MOU between UGM and the had been conducted in Yogyakarta, every year, in the Governor of Jakarta and Yogyakarta in 2015–2017. 5 years prior to this study, so the Yogyakarta doctors may have been familiar with the learning strategy of this pro- Publisher’s Note gram. But none of participants had access to the informa- Springer Nature remains neutral with regard to jurisdictional claims in pub- tion to be tested in advance. The program was completed lished maps and institutional affiliations. in 40-weeks of sessions and the assessment items were Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 13 of 13 Received: 7 November 2017 Accepted: 21 May 2018 activities for teamwork and leadership among medical students. Procedi- aSocial Behav Sci. 2011;1(18):622–5. 14. D’amore A, Mitchell EK, Robinson CA, Chesters JE. 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Can health care teams improve primary 13. Juriza I, Ruzanna Z, Hs H, Rohaizak M, Zulkifli Z, Ma F, Radniwan M, Razif care practice? JAMA. 2004;291(10):1246–51. M, Heikal M, Anisah N, Nabishah M. Outdoor camps experiential learning Ready to submit your research ? Choose BMC and benefit from: fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Preparatory graduate professional training in general practice by using the 'experiential learning' framework

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BioMed Central
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Copyright © 2018 by The Author(s)
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: General practitioners (GPs) in Indonesia are medical doctors without formal graduate professional training. Only recently, graduate general practice (GP) is being introduced to Indonesia. Therefore, it is important to provide a framework to prepare a residency training in general practice part of which is to equip GP graduate doc- tors to deliver person-centered, comprehensive care in general practice. Experiential learning theory is often used to design workplace-based learning in medical education. The aim of this study was to evaluate a graduate professional training program in general practice based on the ‘experiential learning’ framework. Methods: This was a pre-posttest study. The participants were 159 GPs who have been practicing for a minimum of 5 years, without formal graduate professional training, from two urban cities of Indonesia (Yogyakarta and Jakarta). A 40-week curriculum called the ‘weekly clinical updates on primary care medicine’ ( WCU) was designed, where GPs met with clinical consultants weekly in a class. The participant’s knowledge was assessed with pre-posttests involving 100 written clinical cases in line with each topic in the curriculum. Learning continued with a series of group discus- sions to gain reflection to reinforce learning. Results: Participants’ knowledge regarding clinical problems in general practice was moderately increased (p < 0.05) after the training from a mean score of 50.64–72.77 (Yogyakarta’s doctors) and 39.37–51.81 (Jakarta’s doctors). Partici- pants were able to reflect on the principles of general practice patient-care. Participants reported satisfaction during the course, and expressed a desire for a formal residency training. Conclusions: A graduate educational framework for GP based on the ‘experiential learning’ framework in this study could be used to prepare a graduate GP training; it is effective at increasing the comprehension of general practition- ers towards better primary care practice. Keywords: General practice/family medicine education and training, Experiential learning, Person-centered care *Correspondence: mora.claramita@ugm.ac.id Department of Medical Education, Faculty of Medicine, Universitas Gadjah Mada (UGM), Radiopoetro Building 6th floor, Jalan Farmako Sekip Utara, Yogyakarta 55281, Indonesia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 2 of 13 on evidences, more ‘experimenting’ through trials, or Background more ‘accommodating’ by frequently repeating another ‘Family medicine’ is well established in some countries, ‘experience’ [7, 8]. including in the United States and European countries as Experiential learning methods have been adopted as a medical specialty which focuses on ‘holistic approach— learning strategies in medical education for basic and people-based—comprehensive care’. In commonwealth postgraduate medical education [9–16]. Most surgical countries, the term ‘family medicine’ is also known as specialists’ learning styles found were primarily ‘experi- ‘general practice’ [1]. The World Federation of Medical menting’ (between theorist and pragmatist), while fam- Education (WFME) introduced three standards of basic ily medicine or GP residents were found to have a more medical education (BME), postgraduate medical educa- ‘assimilating’ learning style (between reflector and theo - tion (PGME) (which includes family medicine speciali- rist), whereas anesthesia residents were found to be zation), and continuing medical education (CME) [2]. more ‘accommodating’ (between pragmatist and activ- However, some countries still allow general practitioners ist) [9–12]. There is clearly a need of general practice/ (GPs) to work doctors working in a primary care settings family medicine graduate programs to participate in the without formal graduate professional training in family development of better quality health care. General prac- medicine or general practice [1, 3, 4]. tice demands a highly flexible curriculum with a mix of In the era of universal coverage, a paradigm shifting in person and online courses to provide easier access to from disease-oriented care to a more person-centered continue learning from community-based clinical set- and goal-oriented care is needed. This shift includes the tings [12]. changing of perspectives from fee-for-service to pub- Much of literatures about ‘experiential learning’ design lic policy reformation, creating a national health insur- discuss integrated clinical workplace-based learning at ance system, making sure all people have equal access community-based educational settings using reflective to health care) [5]. Those reforms will need leadership journals and collaborative learning as the main strategy including policies and regulations regarding health care to elicit socio-behavioral abilities such as communica- services aimed at a more people-centered care. Pri- tion skills, leadership and family-care centeredness at mary health care should be optimized and prioritized, primary care settings [13–16]. Two of these publications while family and community empowerment should be specifically explained instructional design with lesson encouraged; ancillary workers (e.g. nurses and pharma- plans based on the four stages of experiential learning by cists) should work hand in hand with physicians in pri- Kolb and colleagues, but were intended for undergradu- mary care settings [6]. Therefore, educational strategies ate medical education students [15, 16]. should facilitate this movement towards strengthening This study aimed to evaluate the use of the four learn - primary health care. However, specialty training in gen- ing cycles in the experiential learning approach to eral practice is still unfamiliar in some countries, includ- develop and test a more systematic graduate professional ing Indonesia. Based on international recommendations, training for general practitioners. This study is essential preparation must be made to provide a graduate educa- to provide a general practice prototype training frame- tional framework for general practice education [1]. work for doctors who have no formal graduate training Experiential learning theory has been introduced and in primary care following their undergraduate medical used for learning at clinical workplaces in medical educa- education, but have been working for several years at pri- tion worldwide. It was first introduced by Kolb in 1984 mary care settings. and recognizes the importance of ‘reflection’ in the learn - ing process and the need for ‘social context’ to deepen the Methods meaning of learning [7, 8]. The four stages of the learn - This is a pre-posttest study followed by a qualitative ing cycle described in Kolb’s theory starts from ‘concrete exploration to evaluate the training approach, using experience’ (preferable from real patient-care experi- experiential learning cycles, to increase the general prac- ences); this should be followed by ‘reflective observation’ titioners’ knowledge in the area of family medicine and and then ‘abstract conceptualization’; all of these meth- primary care. None of the GPs in this study had any for- ods apply the process of learning by seeking for informa- mal graduate professional training in general practice; tion until gaining a complete understanding. Ultimately, as graduate training in general practice did not exist in the cycle is followed by ‘active experimentation’, to prac- Indonesia at the time of this study. tice and validate the comprehension of the learners. Dif- We developed a 40-week syllabus and lesson plans for ferent ‘learning styles’ have been identified from which a weekly graduate GP educational program, based on learning actions or steps are accentuated after an ‘experi- the four learning cycles of ‘experiential learning’ the- ence’. The learning tendency may be ‘reflective’ or based ory (‘concrete experiencing’, ‘reviewing and studying’, on observational methods, more ‘critical thinking’ based Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 3 of 13 ‘abstract conceptualizing’ and ‘active experimenting’) Instrument [7, 8]. Table  1 describes the syllabus of the graduate Instruments in this study included: a curriculum and family medicine CME program given over 40-weeks lesson plans of graduate general practice CME program namely the ‘Weekly Clinical Updates on Primary Care presented in Tables  1 and 2, completed using various Medicine’, which were assisted by clinical consultants methods of instruction. Pre and posttests of clinical cases from different specialties and general practice team were written based on Graber’s and Wilbur’s specialty staff-members, all from the Faculty of Medicine, Uni - board-review book of family medicine and an examina- versitas Gadjah Mada (UGM), Yogyakarta, Indonesia. tion guide book with typical items used to assess fam- All GP staff members held academic degrees in medi - ily medicine residents in the US [21]. The items in the cine (masters, doctorate, and professorship). They had board-review book represent family medicine princi- been practicing as generalists for more than a decade at ples, continuity of care across ages, genders and stages the UGM clinic, but had no formal degree in graduate of illnesses, written by 40 family medicine specialists as professional training as a GP (due to the lack of general contributors, presented in vignettes/cases followed by practice specialty training in Indonesia). several multiple choices. The items in the book have been The curriculum of the program was constructed endorsed as part of preparation for the examination for based on textbooks of family medicine/general prac- family medicine residency in the US. tice [17, 18] and was reviewed by a technical assistant The items in the chapters of the Family Medicine Spe - (TA) from the World Organization of Family Doctors cialist Book review were written and constructed based in 2013 [19]. The curriculum was revised based on on the five levels of prevention of primary care principles the comments received from the TA. The main com - [21, 22]. Vignettes and cases were written from simple ment was that the content was too clinical and should to more complex health problems followed by multiple accommodate more general principles of family medi- choice questions. Readers were invited to think through cine. In accordance with this advice, we reworked the five levels of natural history of each of the diseases first 3  weeks to emphasize the more basic comprehen - selected from simple to the most complicated ones. sion of family medicine content. Among the total of 30 chapters in the book, the authors of this study selected only ten constructs or clinical top- ics that represent world-wide illnesses followed with a Subjects selection of ten vignettes/cases of each topic (Table  1). Subjects The ten vignettes/cases selected consisted of two items The subjects in this study consisted of convenience of each of the five levels of prevention. For example, for samples of 61 GPs from Yogyakarta region (central Java the topic of ‘cardiovascular’, there are two items for pri- Island) and 98 GPs from Jakarta, Indonesia; who were mary prevention of cardiovascular diseases (one item specifically assigned by their local district health care for health promotion and one item for specific protec - authorities to do the 40-week graduate course in gen- tion), four items of secondary preventions (two items of eral practice in 2016–2017. Women predominated our early detection and two items of prompt treatment), and samples (81.97% of Yogya’s and 82.65% of Jakarta’s). finally four items of tertiary prevention (two items of The proportion of females in the cohort represents the complication-detection and two items of rehabilitation current mix of Indonesian medical students who are or palliative care). In total there were 100 multiple choice mostly female [20]. Additionally, It is likely that male questions pertaining to the ten vignettes/cases. All mate- doctors will continue to seek graduate professional rials were translated into Bahasa Indonesia and adapted training of medical specialties which are hospital- to the Indonesian context and reviewed by specialist con- based, after several years working at Puskesmas. Con- sultants and GP staff members from UGM. sequently, mid-career doctors at Puskesmas are mostly The same 100 items applied for the pre and posttests female [20]. for both study settings. We avoided items which involved All of the participants are government employees and advanced clinical laboratory tests or advance pharmaco- working at urban sites. The other consideration was the logical drugs that could not be done in a Puskesmas. The active working period of the participants; they should not scores from all participants were tallied by a secretary be a new employee nor approaching their retirement. The afterwards and sent to the statistician directly, to do the working experiences as general practice of the partici- analysis. pants were varied from 8 to 30 years and their ages were The lesson plans as described in Table  2 were designed between 32 and 55 years old. An informed consent form based on an experiential learning design of the four learn- was completed by all participants before the clinical cases ing cycles from Kolb [7, 8]. We provided a ‘holistic medi- pretest was distributed. cal record’ template comprising the bio-psychosocial Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 4 of 13 Table 1 The 40-week curriculum of “Weekly Clinical Updates on Primary Care Medicine” for general practice in this study Week Content Construct of Curriculum in this study Sources: textbooks of general practice [17, 18] reviewed by: a Technical Assistant from World Organization of Family Medicine [19] 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 Foundations of family medicine on experiential learning cycles), the formation of small group learning community and introducing guidelines for critical appraisals 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 Eec ff tive 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 set- Mental health tings 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 Eec ff tive 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 Eec ff tive treatment on ‘burn’ Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 5 of 13 Table 1 (continued) Week Content Construct of Curriculum in this study Sources: textbooks of general practice [17, 18] reviewed by: a Technical Assistant from World Organization of Family Medicine [19] 0 Pre test Construct of assessment Source: family practice specialty examination board review [21] Early detection on blindness risks (cataract, glaucoma, diabetes retin- Sensory organs (EYE) opathies) 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 Sensory organs (skin care) settings and selection of topical treatment for dermatitis 41 Post-test Construct of assessment Source: family practice specialty examination board review [21] background of patients and their family to be one of the Procedures instruments for the participants in this study [18, 19]. The pretest was administered before the first learning This specific medical record format was used to capture session. The pretest was followed by a technical meeting the ‘active experimentation’ of patient-care of the par- session where the large group of participants was divided ticipants based on principles of family medicine, dur- into small groups, each consisting of ten physicians, ing the first stage of the experiential learning cycle. We who worked together for each of the assignments. We also provided guidelines for critical appraisals to help the also provided a rigorous explanation of the curriculum participants to review several published papers. We pro- (Table  1), the lesson plans (Table  2) and other learning moted the evidence-based practice during the ‘reviewing tools [23–25]. We prepared the participants to learn with and studying’ stage of the experiential learning cycle [23]. the following strategies: (1) by experiential learning cycle Teachers in this program who are clinical consultants basis, (2) to work together in a collaborative small team and team members of GP staff were also trained on the group, (3) to regularly appraise literatures, (4) to do series use of ‘one-minute preceptorship’ to provide constructive of individual reflections, (5) to do group discussions, and feedback [24, 25]. Ultimately, ‘abstract conceptualization’ (6) to be open to any feedback from the peers and clinical and ‘planning active experimentation for future patients’; consultants. The key message was ‘continuous learning’. the last two stages of the experiential learning cycle were After each technical meeting session, the first learn - guided by a written reflection and a series of group dis - ing session was implemented. One of the participants cussions with the participants after each topic was pre- presented an actual patient-care case, using a ‘holistic sented [25]. and comprehensive medical record’ format which was Group discussions were conducted 5 times with partic- designed specifically for family medicine doctors that ipants from Yogyakarta and 10 times with Jakarta’s GPs. includes bio-psycho-social-cultural aspects, continuity of The main guiding questions were, “Tell us a story about care and comprehensive care [18, 19]. The main idea was a patient that you most remember,” (the identity of the used to start the learning process with an ‘actual experi- patients remained confidential) and “How do you reflect ence’ of the experiential learning cycle [7, 8]. Afterwards, on the patient-centered clinical care?” We adapted the another two participants within the same small group of generic rules of the Balint group discussions: (1) no inter- learning presented a critical appraisal of a journal article ruption from the start until the end of a story that is told (clinical and family medicine articles), which were closely by a doctor, (2) no judgment based on doctors’ ability, (3) related to the case presented in advance. The aim of this no suggestions or comments from other participants— critical appraisal session was to facilitate the participants only questions for clarification, (4) if there is any reflec - receptiveness to evidence-based practices and included tion it will come from the presenter of the story by her/ in the ‘reviewing and studying’ of the experiential learn- him selves or other doctors who listen to the story, while ing cycle [7, 8]. Each of the participants who presented (5) the identity of all persons remained confidential, (6) cases and critical appraisals wrote at least five questions nobody had access to a paper, or pen, or mobile phone, or to be presented to the class and clinical consultants who a laptop, and (7) the recording is based on an informed- attended the session. The feedback session was con - consent process, e.g. for this study’s purposes [26, 27]. ducted by the clinical consultants and GP staff members. Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 6 of 13 Table 2 The lesson plan (instructional design) of each session/week/topic in the “Weekly Clinical Updates on Primary Care Medicine” for general practice in this study based on experiential learning cycles [7, 8] Time Content Persons in charge Experiential learning cycle Aim Learning tools The first 30 min Presentation of a case based on Primary care physician (1) ‘Concrete experience’ (what To start the learning cycle A medical record based on fam- the topic of the day (an actual was usually done in practice) according to Kolb and col- ily medicine principles patient care) leagues The second 30 min Presentation of a critical Primary care physician (2) from ‘Reviewing and studying’ (what To move to the second stage Critical appraisals tools and appraisals on a publication the same small group learn- should be done based on of learning cycle in the expe- checklist available on the of family medicine journals ing as physician (1) evidences) riential learning internet (introduced in a work- related to the topic of the shop of critical appraisals) case-report The third 30 min Presentation of a critical Primary care physician (3) from ‘Reviewing and studying’ (what To move to the second stage Critical appraisals tools and appraisals on a publication the same small group learn- should be done based on of learning cycle in the expe- checklist available on the of clinical medicine journals ing as physician (1) evidences) riential learning internet (introduced in a work- related to the topic of the shop of critical appraisals) case-report The fourth 30 min Feedback and discussion Clinical teacher who were ‘Abstract conceptualization’ To move to the third stage of Teacher training on ‘construc- invited based on the topic of learning cycle in the experi- tive feedback and one-minute the case-report ential learning preceptor-ship’ The last 30 min Feedback and discussion Family medicine teacher from ‘Abstract conceptualization’ To move to the third stage of family medicine team learning cycle in the experi- ential learning Days after Observation-based learning Family medicine teacher from ‘Active experimenting’ To move to the last stage of The one-minute preceptorship Family medicine team learning cycle in the experi- ential learning Days after–before another Writing a reflection form All primary care physicians ‘Active experimenting’ (what To move to the third stage of Reflection form based on Gibbs’ week as participants in the WCU should be done better next learning cycle in the experi- course time/plan) ential learning Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 7 of 13 The clinical consultants addressed each of the questions (p < 0.05). As noted the samples were predominantly posed by participants, teaching general rules and apply- women, and when we analyzed the data the Yogyakarta’s ing the ‘one-minute preceptor’ method in this feedback female doctors were found to have higher scores than session [24, 25]. Sometimes the consultant needed to Jakarta’s female doctors in pre, posttests and Delta scores describe an illustration with a slide or two, but this media (p < 0.05). However, there were no significant differences was not considered ‘lecturing’ time. Questions from par- between females and males in each of the two cities, ticipants guided the discussion/explanations. The GP for pre-test and posttest and the Delta scores (p > 0.05), staff members acted as moderators in this session and except the posttest of Jakarta’s’ female and male doctors continued to provide feedback appropriate to the subject (p < 0.05) (Table 3). of family medicine/general practice. The feedback session The GPs commented about the course in this study was intended to facilitate ‘abstract conceptualization’ suggesting a more longitudinal—a yearlong course, inte- within the experiential learning cycle. grated graduate course where the GPs staff-members and Considering the limited time available to GPs, we specialists sit in the same row to provide feedback for the scheduled 2.5–3  h/week to do each session. Sessions participants. Also, it was suggested that it should be the were held on Saturdays at the Faculty of Medicine UGM, participants who lead the discussions through the ques- when the patient-care schedules were minimum. The tions and not the specialist. Some GPs’ opinions are as UGM staff members from the GP team then visited each follows: group of participants to be a facilitator of the ‘active “Critical appraisals are difficult, but it opened new experimentation’ stage of the experiential learning meth- information which I would never imagine, medical ods. Finally, each participant wrote a reflection and pre - evidences change very fast over the time.” pared for another topic for the next week’s session. With these goals, the learning process would be on-going for “I already work as a GP for more than 30 years and the entire week. At the end of the 40  weeks of sessions, I am about to retire. But this course is what we actu- a post test was administered and series of group discus- ally need and I would like to study further into a for- sions were conducted. mal vocational training of family medicine.” Analysis “We need the clinical part of patient care training The authors did a paired sample and independent sample more in this course.” t test for the analysis of the clinical cases’ items [28] and also a qualitative open coding for the results of each of “The specialists should provide ‘referral back’ letter the focus group discussions in each topic/lesson [28]. The to us. They rarely do that. We need to learn from our participants’ comments on the course-construct were referred cases and we will be with the patients when- analyzed until saturation of data was gained [28]. We cat- ever they are.” egorized each of lessons learned based on each topic of the course. The results of 15 group discussion sessions are pre - sented in Table  4. Across all topics provided in the course, there were some topics which were not addressed Results by the participants in this study, e.g. ‘sensory organs top- The t test paired sample proved to be significant, com - ics’ and ‘child health’. This phenomenon may be due to paring the results from before and after the 40-weeks limited time for the group discussions in this study, or it of ‘weekly clinical update’ sessions using experiential may be that GPs in this study were not used to dealing learning design intervention (p < 0.050) as presented in with those specific problems due to lack of equipment for Table 3. Yogyakarta’s doctors increased their mean scores sensory organs’ diagnosis and treatment at the primary from 50.64 (pretest) to 72.77 (posttest) and Jakarta’s care settings, or specialists and midwives may have taken doctors increased from 39.37 (pretest) to 51.81 (post- care of the problem adequately (e.g. for the child health). test). The progress of learning was indicated by the Delta scores of Yogyakarta’s doctors (22.13) and Jakarta’s doc- tors (12. 44). The approach of training in this study using Discussion four cycles of experiential learning was demonstrated to To the best of our knowledge, this is the first study which significantly increase the level of knowledge of the doc - reports the use of experiential learning theory framework tors at both cities (Table 3). for postgraduate medical education. It was designed spe- Overall, using t test independent samples, Yogyakarta’s cifically for preparing professional training in general doctors were found to have higher scores than the Jakar- practice and to stimulate more student-centered learn- ta’s doctors in pre and posttests and also Delta scores ing. Other studies using experiential learning theory Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 8 of 13 Table 3 The results of pre-posttest of the participants in this study 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 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) (A) 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 Y (F)vs J (F) Y (M) vs J (M) Y (F) vs Y (M) J (F) vs J (M) (A) J (male) 0.018 0.000 0.000 0.004 0.860 0.115 Y Yogyakarta, J Jakarta, A overall, F female, M male Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 9 of 13 Table 4 Results of qualitative open-coding analysis in this study Categories Quotations 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 “Thank you for giving me an opportunity to reflect on elderly patient – care with individual illnesses 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” Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 10 of 13 Table 4 (continued) Categories Quotations 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 imple- ment these recommendations via home visits, psycho-education for the fam- ily, 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 think- ing to a more logical way. I did careful history taking and the patient appar- ently 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 “I think it is the time to optimize the home-institution for elderly people. Usually unfamiliar for the context of this study 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 moti- vated 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…” 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 proce- dures 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 help- ful 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” Sensory organs (eye) No discussion on sensory organs problems Sensory organs (ENT ) Sensory organs (skin) Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 11 of 13 emphasized residents’ learning style but did not touch on were used to listening to lectures or reading local proto- the instructional design of using the four learning cycles cols on certain diseases. There were arguments from the in the experiential learning theory to promote a more clinical consultants whether this stage of ‘journal reading’ independent and lifelong learning [9–12]. The ‘experien - is necessary. However, after several topics, the partici- tial learning’ framework in this study provides significant pants felt the benefits of the ‘journal appraisals’ to under - examples of stimulation to the GPs to have more self- stand other ‘views’ and scientific reasons behind a basic directed learning strategies, driving the GPs into a more patient-care guideline or protocols that they usually use active and reflective learning. It presents the challenges in daily practice. Participants’ five questions posed to the and opportunities of better patient-care services in the clinical consultant at the end of their presentations had universal coverage era and also illustrates a more col- successfully directed the discussions into mutual dialog laborative relationship between the general practice staff instead of only passively absorbing the information. members, clinical consultants and many other stakehold- The third stage of experiential learning, which is ers who supported the innovation of medical education ‘abstract conceptualization’ started with constructive in this study. Therefore, although this study was done in feedback from both clinical consultants and a GP staff an Indonesian context where graduate training for GPs member in meaningful discussions. This stage was chal - does not exist, the ‘experiential learning’ framework in lenging to always refer to GP principles and not to get this study may be adapted to a context where postgradu- overwhelmed with hospital-style patient-care manage- ate program has been implemented for many years. ment. Although clinical simulation using mannequins In the first ‘concrete experience’ stage of experien - were sometimes performed during this learning stage, tial learning cycle during the course, we did not have the GP staff members aimed to direct the discussions much difficulty, since physicians in this study are used to back to the importance of promotion and prevention for reporting any patient-care they did at primary care set- certain age groups and different genders and emphasized tings. However, the form of ‘holistic and comprehensive the undifferentiated cases [17, 18]. Important principles medical record’ formats we used throughout the training of GP were the ‘watchful waiting’, to think and to observe were quite challenging involving not only focusing on the together with the patients, and to offer adequate infor - illness but also being attentive towards patient-centered mation in order to make better clinical decision-making. care. Instead of focusing only on certain diseases, GPs in This program also provided examples of communication this study were also directed towards patient-centered and collaborative practice with different levels of health care, family focus and community oriented clinical think- professionals. ing; concepts which were lacking during their undergrad- The last learning cycle of ‘active experimenting’ was uate medical education [17, 18]. performed in this study and was facilitated by a reflec - Many of the participants wondered whether they tion-form to guide the participants to make a plan for should do a patient-centered care approach for every present and future learning. The discussions also served patient, because they perceived that they won’t have as an effort of trying to listen to physicians’ stories and enough time. The discussion on the limited time for reflecting on future concerns for patient-care. The GPs in patient-care services revealed that it required usually less this study completed their learning cycle with planning than 5  min of patient-care services for each patient at better services in the future. primary care centers in this study, which is not different There were only a few questions left unanswered by the than in the hospital settings in a previous study [29]. The clinical consultants in the course, for example dealing general practice staff members as facilitators in this study with lack of time and facilities at primary care centers. emphasized the discussion on the use of an ‘appointment However, along with the gate keeper system in the uni- system’, which most of general practitioners in this study versal coverage era in the context of this study, there is already did for, but for only the antenatal care and elderly a national accreditation system of the primary care clini- care patients. Therefore, primary care centers in this cal settings in Indonesia which will drive the improved study may have separated the intake process of the quick maintenance and increasing quality of primary care ser- encounter for ‘quick care’ and the others as ‘appointment vices and facilities in the near future [3]. encounters’ to provide better health care services as rec- As the early stage of a period of universal coverage ommended in the literature [1]. changes in the context of this study, health profession- For the second stage of the learning cycle, which is als and patients may not yet receive the support and care ‘reviewing and studying’, it was considered difficult as they deserve, but the progressive approach of education perceived by most of participants in this study due to and incrementally better health care services can help. the English language and unfamiliarity with appraising This kind of discussion may ultimately lead to alterna - medical literature in their daily practice. The participants tive solutions coming from the participants. During this Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 12 of 13 course, the GPs learned to do maximum prevention for re-edited every year so it is almost impossible to memo- the patients, including reducing medication complica- rize the content. tions by using better quality drugs instead of low level quality of drugs for merely ‘cost-saving’ purposes. However, we admit that interprofessional collaborative Conclusion practice was less emphasized in this course and should be This study demonstrated that using the educational better articulated in the future. By improved team work framework based on the ‘experiential learning cycle’ sig- of different health professionals, patient care services may nificantly increased participants’ knowledge in the con - become more effective and efficient [30, 31]. Interprofes- text of graduate general practice. The group discussions sional collaborative practice should also emphasize not revealed participants’ deep reflections and future plans only curative medicine, but most importantly prevention. concerning better patient care services. Any future effort It has been a known fact that in order for primary care of establishing a preparatory graduate course of general to function effectively and efficiently, a multidisciplinary practice may use the framework provided in this study. team of both clinical and non-clinical professionals must Authors’ contributions be formed and fully function interprofessionally [30, 31]. All authors contributed to the concept and design of the study, implementa- tion of this study, and interpretation of the meaning of the study. All authors contributed to the draft of this study until finalized in this paper. All authors Strengths and limitations read and approved the final manuscript. This study used GP samples from Yogyakarta and Author details Jakarta provinces, who consisted of public servant doc- Department of Medical Education, Faculty of Medicine, Universitas Gadjah tors in public primary care clinics. The results should Mada (UGM), Radiopoetro Building 6th floor, Jalan Farmako Sekip Utara, Yog- yakarta 55281, Indonesia. Department of Family and Community Medicine, be interpreted in appropriate contexts. However, the Faculty of Medicine, Universitas Gadjah Mada (UGM), Radiopoetro Building 1st combination of quantitative data analysis and in-depth floor, Jalan Farmako Sekip Utara, Yogyakarta 55281, Indonesia. Department qualitative exploration strengthened the data saturation of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA. and interpretation. This study should be continued to include a formative Acknowledgements and summative part of clinical bed site teaching when a We thank the participants in this study and the Yogyakarta and Jakarta District Health Care offices who supported the participant in this study. We also grate - formal graduate study program is legally established. In fully acknowledge the contribution of Dr. Rossi Sanusi who strongly recom- the preparation of providing a framework of graduate mended the ‘journal reading’ sessions to strengthen this course. Thank you for educational training for general practice in this study, Prattama Utomo who assisted the quantitative data analysis of this study. We highly appreciate Professors Jason Wilbur and Lisa Soldat, from the University we succeeded in shifting the way of thinking of the exist- of Iowa USA, who have been with us, training our GPs directly in a voluntary ing GPs from disease centered into a more patient-cen- basis for many–many years, also to Professor Michael Kidd, Professor Zorayda tered care, appraising more evidence-based practice, Leopando, Professor Job Metsemakers, Dr. Jihane Tawilah, Christine and Dr. Jill Benson who continuously support the development of graduate programs and learning in two-way dialogues with other medical of general practice in Indonesia to strengthen the universal coverage health specialists. The ultimate accomplishment was a sub - care system. stantial contribution of many clinical departments and Competing interests stakeholders within a year-long program of GP graduate The authors declare that they have no competing interests. training. These lessons learned about preparing a gradu - ate professional GP educational framework in this study Availability of data and materials All data could be accessed once the manuscript is accepted for publication expectantly could be used for many other countries. we will create a link to access all materials. We noticed that the Yogyakarta group of doctors dem- onstrated a higher level of learning than the Jakarta group Ethics approval and consent to participate Ethical clearance was provided by Faculty of Medicine Commission of Ethics of GPs. This phenomenon could have happened due to No. KE/FK/0820/EC/2017. several reasons such as better learning environment in Yogyakarta, which is well-known as a ‘student city’ in Consent for publication Consent for publication was provided by all authors in this study. Indonesia, more conducive learning process, and more receptive participants, compared to a metropolitan city Funding of Jakarta. The ‘weekly clinical updates of primary care’ The study was funded by District Health Care Offices at Jakarta and Yogyakarta Special Regions of Indonesia based on the MOU between UGM and the had been conducted in Yogyakarta, every year, in the Governor of Jakarta and Yogyakarta in 2015–2017. 5 years prior to this study, so the Yogyakarta doctors may have been familiar with the learning strategy of this pro- Publisher’s Note gram. But none of participants had access to the informa- Springer Nature remains neutral with regard to jurisdictional claims in pub- tion to be tested in advance. The program was completed lished maps and institutional affiliations. in 40-weeks of sessions and the assessment items were Claramita et al. Asia Pac Fam Med (2018) 17:4 Page 13 of 13 Received: 7 November 2017 Accepted: 21 May 2018 activities for teamwork and leadership among medical students. Procedi- aSocial Behav Sci. 2011;1(18):622–5. 14. D’amore A, Mitchell EK, Robinson CA, Chesters JE. 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Asia Pacific Family MedicineSpringer Journals

Published: May 29, 2018

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