|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 2 | Page : 81-86
Patients' Appreciation of Pre-Clinical Student Performance in Primary Healthcare Centres in Indonesia
D Widyandana1, GD Majoor2, AJJA Scherpbier2
1 Department of Medical Education, Skills Laboratory, Faculty of Medicine, Gadjah Mada University, Jogjakarta, Indonesia
2 Institute for Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
|Date of Submission||01-Sep-2011|
|Date of Decision||14-Aug-2012|
|Date of Acceptance||03-Sep-2012|
|Date of Web Publication||14-Nov-2012|
Skills Laboratory, Department of Medical Education, Faculty of Medicine, Gadjah Mada University, Professor Radiopoetro Building, 6th Floor, Farmako Street, North Sekip, Jogjakarta, 55281
Source of Support: None, Conflict of Interest: None
Introduction: In Indonesia, primary healthcare (PHC) centres are among the eligible institutions to provide 'early clinical experiences' (ECE) for pre-clinical medical students. This study explored whether patients of PHC centres would accept third-year pre-clinical students practicing clinical skills with them. Methods: Immediately after being seen by a pre-clinical student - supervised by a general physician - 76 patients of PHC centres participated in a structured, eight-question interview. Interviews were transcribed verbatim and coded to collate and interpret answers to the questions. Results: Most of the patients were satisfied with the clinical performance of their pre-clinical student. Negative comments regarding some students addressed lack of confidence, being nervous, unable to provide satisfactory explanation and education and failure to speak the local language. Some patients suggested more practice for these students in PHC centres. Conclusion: Patients in Indonesian PHC centres generally appreciated health services provided by pre-clinical medical students; no significant objections were recorded. This supports the suitability of these PHC centres to offer ECE for pre-clinical students.
Keywords: Clinical skills, pre-clinical students/bachelor program, primary healthcare centres
|How to cite this article:|
Widyandana D, Majoor G D, Scherpbier A. Patients' Appreciation of Pre-Clinical Student Performance in Primary Healthcare Centres in Indonesia. Educ Health 2012;25:81-6
| Introduction|| |
Medical curricula are usually divided in two phases: a pre-clinical phase or bachelor program of three or four years and a clinical phase (master program) built from clinical rotations commonly spanning two years. During the pre-clinical phase, student learning predominantly takes place on campus, through classroom lectures, small group tutorials, practicals and often also through clinical skills training in a 'skills laboratory'. The junction between the two phases of these medical curricula confronts the students with a transition from theory-oriented learning on campus to meeting patients and health professionals in the context of health services. , Recent studies have shown this transition may result in significant problems for students. Students may feel anxious in their clinical rotations when they first face their patients in the clinical environment. Such anxieties are most likely caused by differences between campus and skills laboratory settings and clinical reality such as physical facilities, technologies, patients, workload and the expectations of teachers and clinical supervisors. ,,,
Inclusion of early clinical experiences (ECE) in the pre-clinical curriculum has been proposed to improve preparation of pre-clinical students for the clinical phase and to reduce transition problems on entering the clinical rotations.  ECE should accelerate the development of tacit knowledge (e.g. illness scripts, clinical pattern recognition) as the basis to clinical expertise.  Moreover, ECE may improve students' familiarity with the roles of patients and health professionals in healthcare centres and will show them differences between procedures as taught, for instance, in the skills laboratory and as performed in clinical practice.  Particularly in developing countries, differences between simulations on campus and reality in PHC centres can be large because of the limited facilities and lack of adequate human resources in these centres. This situation could be different in industrialized countries where primary healthcare (PHC) centres are usually well-equipped. ,
For the implementation of ECE in the pre-clinical curriculum, one of the options for a medical school is to establish cooperation with PHC centres. Several studies have shown that PHC centres can provide adequate opportunities for students to become actively involved in healthcare, including interactions with patients and communities, to practice their clinical skills. ,, However, most of these studies have been conducted in industrialized countries. There are some reports on ECE implemented in developing countries, for example from Nigeria and from Uganda. , Furthermore, two papers have described ECE for pre-clinical students in PHC settings in Indonesia. , Given the size of that country (over 200 million people dispersed over more than 13,000 islands), Indonesia has adopted the World Health Organization's recommendation to focus on PHC as the most effective way to provide adequate healthcare for all people.  Therefore, in Indonesia it seems highly appropriate to involve PHC centres in offering ECE for pre-clinical students.
Obviously, pre-clinical students still have limited medical knowledge and clinical skills. ECE should consider the student's level of competency in order not to jeopardize the safety and optimal treatment of patients. Consequently, during ECE, clinical supervisors should exert close supervision of and provide extensive feedback to the pre-clinical students.  Wherever ECE is conducted, the position and role of the patient should be taken into consideration. , Patients' opinions on their involvement in longitudinal clinical community-based programs integrated in four-year curricula have been assessed. ,, In these studies, in general, patients indicated appreciation of their involvement in the education of medical students. They tended to be satisfied with student performance, did not feel that students disturb regular health services and expressed that students sometimes even improved health services, possibly because they (can) take more time to provide explanations in the consultation. ,, Patients' critical comments included their expectation that students should always be supervised by clinicians, that the latter should explain the educational context and seek patient's permission to involve a student in the consultation and that confidentiality should be respected by students and supervisors alike. These comments derived particularly from situations in which gender differences may easily cause embarrassment and anxiety with patients and students, as in the case of physical examination of sex organs. ,, The studies quoted were performed with students who were quite advanced in their studies, and in the context of industrialized, "western" countries.
In ECE, as envisaged by the Faculty of Medicine of Gadjah Mada University (FoM-UGM) in Indonesia, patients would encounter third-year pre-clinical students. Moreover, the context of a developing country located in South-East Asia may yield divergent outcomes due to differences in culture (e.g. interaction between males and females) as well as financing and organization of the healthcare system (e.g. fee-for-service model, with no gate-keeping role by family doctors). Therefore, the objective of this study was to explore whether patients of PHC centres in Indonesia would accept, welcome or reject their involvement in training of pre-clinical students. To that aim, outpatients of PHC centres were interviewed immediately after being seen by pre-clinical students-under supervision of a general physician. Interviews focused on patient opinion of their student's clinical competence and performance.
| Methods|| |
In 2010, 40 pre-clinical students were randomly selected from FoM-UGM's third-year class of 186 students and assigned to five PHC centres in the vicinity of the Faculty. At the assigned centre, each student met with two outpatients, one male and one female. PHC supervisors applied convenience sampling to select patients from new or revisiting outpatients, based on their suitability to be seen by pre-clinical students.  Prior to the consultation, the supervisor explained to the patient the setting of the consultation and aim of the subsequent interview and asked the patient's oral consent. Supervised by a general physician (GP) from the PHC centre, in each consultation students were instructed to perform anamnesis and (if indicated) physical examination, diagnostic and therapeutic procedures, and patient education with respect to therapy and lifestyle.
Immediately after the consultation, each patient was interviewed by a research assistant in a private room. Interviews were conducted within 20 minutes using a structured guideline with eight questions, and recorded on audiotape and by written notes.  Questions explored patients' opinions of their student's clinical competence and skills performance. Clinical skills performance addressed communication skills (e.g. history-taking, problem exploration), physical examination, diagnostic and therapeutic procedures (if performed) and patient education (e.g. explanation of disease aetiology, preventive measures and treatment). After the interview, patients received a small souvenir (value equalling approximately US $5) from FoM-UGM in reward for their participation. The study received prior ethical clearance from the pertinent FoM-UGM committee.
Interview recordings were transcribed verbatim by research assistants and coded by three individuals: the first author, a senior clinical supervisor, and a research assistant. The first author briefed the other two coders about the protocol, that is, to code elements of answers to each question, to group and count similar elements and to choose characteristic quotations. This procedure was conducted independently by each coder. A meeting of all three coders was held to build consensus on the final collation of the outcomes. 
| Results|| |
Thirty-eight pre-clinical students (17 male, 21 female) participated in this study (2 students could not attend). Consequently, 76 patients (38 females, 38 males) were interviewed after being seen by the 38 participating students. Distribution of patient ages showed 17% of them to be children (usually accompanied by parent(s), 54% adults and 29% elderly (aged over 50 years). Education levels of patients were: 3% with no education; 5% only kindergarten; 30% had completed elementary school; 18% junior high school; 25% senior high school; and 5% had attended university (14% of the patients did not respond to this question). Most patients were in a low socioeconomic stratum (e.g. student, housewife, retired government employee or jobless). Most patients who were approached participated in the study; only two patients refused because they were in a hurry. Interview results are presented in [Table 1], where, for each question, the five most frequently coded themes of answers are shown.
|Table 1: Themes from patient answers to questions about student involvement in healthcare (only five most frequently coded shown)|
Click here to view
Overall, patients were satisfied with the performance of the students. Most patients had a positive impression of their student's clinical skills performance and judged the student as nice, caring and able to provide good health service. Patients stated 12 times that students' performance was similar to that of a doctor (i.e. GP). In contrast, patients commented negatively when their student was unconfident, nervous or unable to provide satisfactory explanations and education.
"…[the pre-clinical student was] polite, [their clinical skills performance was] already good, their service was like [that provided by a] usual doctor,…" (P.II-M.28)
"…student's examination [anamnesis, physical examination] took too long, [the student] seemed uncertain and confused…" (P.IV-F.57)
Patients generally felt students' communication skills were good and considered the students nice, able to explore their health problem completely and able to express themselves understandably. However, some patients regretted that their student had difficulty speaking the local language (i.e. Javanese). With respect to physical examination, patients also had a positive impression of their student's performance and some felt students paid more attention to details than the GP.
"…[the student performed] physical examination well, acted like a real doctor…" (P.III-M.41)
Diagnostic and therapeutic procedural skills were rarely performed, because most patients reporting to the PHC centre presented quite simple problems, which did not require procedures like electrocardiography, wound suturing or urethral catheterization. Therefore, only 23 patients had the opportunity to witness a student performing a diagnostic or therapeutic procedure. According to those patients, students' execution of that procedure was good, although six patients reported their student to seem unconfident.
Patients' opinions of their student's health education skills varied. Fifty-five percent of the patients judged the student's performance in this domain as good, clear and complete. In contrast, 45% of the patients indicated not being satisfied with the student's performance because the student's explanation had been incomplete or did not fully meet the patient's needs.
"…there should be more education [to a patient], because I was only told to drink more water and to eat more fruits and vegetables. There should also be education regarding daily activities…" (P.IV-M.55)
In this regard, patients did realize that these pre-clinical students were still in the middle of their studies and consequently still had theoretical weaknesses and lack of clinical experience. Therefore, some recommended students to have more opportunities to practice under close supervision, for instance in PHC centres.
"… he [my student] was good, paid respect,… …[however, he would need] more practice, study more in PHC centres…" (P.I-M.8)
| Discussion|| |
Patients of Indonesian PHC centres responded positively to their interaction with pre-clinical students. In general, patients were satisfied with their student's clinical performance including communication, physical examination, diagnostic and therapeutic skills and health education. This is quite surprising given the very limited clinical experiences of these students, which is largely based on their training in the school's skills laboratory. However, our findings are akin to those from past studies conducted in Europe. ,,
Particularly in developing countries, the presence of students in PHC centres may improve health services, because PHC centres situated there usually have only limited resources. Medical students may expand the centre's human resources and boost functioning by introduction of new techniques.  Introduction of medical students in PHC centres can benefit all stakeholders involved: (1) the PHC centre, which can provide better services with the help of students; (2) the patients who are more extensively attended to; (3) the students who receive an opportunity to practice their clinical skills; and (4) the GP supervisors whose medical knowledge may be updated while educating the students. , Obviously, the contribution of pre-clinical students to the functionary of PHC centres may be less significant than those of more senior students, and pre-clinical students need intense and prolonged supervision. Still, their training in the PHC centres is expected to yield a positive effect on the provision of health services.
Although the majority of the PHC patients belonged to low economic and educational strata, they appreciated contributing to medical education, they accepted their role in the educational process and proved able to recognize weaknesses in student performance. Most negative comments by patients on student performance pertained to confidence and communication skills, rather than physical examination, diagnostic and therapeutic skills. Patients noted when students were unconfident during the encounter. Furthermore, patients proved able to judge the student's level of medical knowledge based on the depth and breadth of the student's exploration of their health complaint, and the comprehensiveness of their explanation on aetiology, prevention and therapy of their disorder. Patients who witnessed students performing physical examination and diagnostic and therapeutic procedures obviously could not give extensive comments on the student's clinical skills performance, because these patients lack the medical knowledge that would allow them to evaluate student performance in that respect. Therefore, clinical supervisors remain fully responsible for providing supervision to safeguard adequate service for the patient, and to provide feedback to the student with respect to his or her clinical performance.
These findings are similar to those of Coleman and Murray who showed that patients were pleased to be involved in medical education, as long as the educational institution assured their privacy (consent and confidentiality), they were not harmed and the educational experience for the students was adequately supervised.  Safety and satisfaction of the patients should be prioritized in this program to ensure its success and continuity. Moreover, the clinical supervisor should be able to convince patients that being involved in this education process is also advantageous to them, because they may be examined more extensively and receive more detailed explanation about their health issues. ,
A limitation of this study is that it only involved pre-clinical students from one medical school who encountered PHC patients. Students from other medical schools with different skills training programmes may elicit different responses from patients. However, previous studies from other medical schools worldwide yielded results comparable to those presented here. ,,,, Therefore, we assume our findings to be applicable in a variety of countries, including developing ones. Another limitation is that the data for this study are only based on opinions of patients, and did not include those of supervisors and pre-clinical students. However, in another study we investigated opinions of students and their supervisors. 
In future studies, an attempt could be made to improve the effectiveness of this ECE program by selecting patients whose complaints require the students to perform clinical skills, which they learned in their previous skills training. Moreover, patients could also be requested to give feedback on the student's clinical performance after encounters. 
Overall, patients in Indonesian PHC centres were receptive to being seen by pre-clinical medical students supervised by a GP from the centre. Although these patients were from low socioeconomic and educational strata, they were able to recognize weaknesses in student clinical performance. Medical schools in developing countries should explore the possibilities of involving PHC centres in offering ECE to pre-clinical students.
| Acknowledgements|| |
The authors acknowledge Dr. Bambang Djarwoto and Ms. Bina Muntafia Dewintari for their help with qualitative data analysis. The authors are grateful to Mrs. Dany Lukita Sari and several student assistants for data collection in PHC centres. The authors express their gratitude to the skills laboratory of FoM-UGM, the PHC centres and their clinical supervisors for cooperating in this study.
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