MODUL SEMESTER 6 160216.docx

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CFHC-IPE MATERIAL BOOK

YEAR 3

SEMESTER 5 - 6

Year 3 topic: “WELL-PREPARED FAMILY”

(KELUARGA SIAGA)

Focus of study: Reducing maternal and infant mortality risks and increasing life expectancy

Specific abilities: Community Diagnosis and Program PlanningThe Shares Information and Shared Decision Making Community Empowerment

Community and Family Health Care Program - Interprofessional Education (CFHC-IPE)

Faculty of MedicineUniversitas Gadjah Mada

Yogyakarta2016

C O M M U N I T Y A N D F A M I L Y H E A L T H C A R E W I T H I N T E R P R O F E S S I O N A L E D U C A T I O N

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CURRICULUM CONTRIBUTORS

dr. Mora Claramita, MHPE, Ph.DDepartment of Medical EducationDepartment of Family, Community Medicine and BioethicsFaculty of Medicine UGM

Dra. RA Yayi Suryo Prabandari, M.Si, Ph.DDepartment of Public Health

Faculty of Medicine UGM

Co-contributors

dr. Fitriana Murriya, MPHC - Department of Family, Community Medicine and Bioethicsdr. Hikmawati Nurrakhmanti, MSc – Department of Medical Education

dr. Fitriana - Department of Family, Community Medicine and BioethicsFitrina M Kusumaningrum, SKM., MPH - Department of Health Promotion

Lastdes Cristiany Friday, S.Gz., MPH - Department of Health Nutritiondr. Noviarina MSc – Department of Medical Education

CFHC – IPE YEAR 3 COORDINATORS

Dr.rer.nat. dr. BJ Istiti Kandarina - Department of Public HealthAkhmadi, S.Kp., Ns., M.Kep, S.Kom – Department of Nursing

Dr.Susetyowati, M.Kes – Department of Nutritiondr. Mahar Agusno, Sp.KJ(K)

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PREFACE

CFHC-IPE program is designed to stimulate undergraduate students within faculty of medicine to understand the practice of health professionals (doctors, nurses and dieticians). They are attached in a family as a group and advocate their health issues during their study periods in the faculty. With this program, the students are expected to understand the importance of continuing and comprehensive advocation in a family. When the family faces a health issue, the students may detect the underlying cause and propose a systematic approach to overcome the problem.

This CFHC-IPE is an interprofessional and multiple approach program. It needs some essential skills as visualized in Figure 1. The three groups students from undergraduate medical degree, nursing and health nutrition program study should perform their unique skills with Family and community health approach. To apply those skills, the students should master some supporting curricula: Interprofessional Education (IPE), Evidence Based Medicine (EBM), Professional Behavior (PB), as well as Skills Lab (SL) training.

Figure 1. Matrix of CFHC-IPE program

Year Coordinators

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CONTENTS

ContentsCOVER...........................................................................................................................................................1

CURRICULUM CONTRIBUTORS.....................................................................................................................2

CFHC – IPE YEAR 3 COORDINATORS.............................................................................................................2

PREFACE.......................................................................................................................................................3

CONTENTS....................................................................................................................................................4

BACKGROUND..............................................................................................................................................5

ANNUAL MATRIX CFHC-IPE...........................................................................................................................6

ACTIVITIES....................................................................................................................................................7

Learning Objectives: (semester 5 to 6).....................................................................................................7

General activities......................................................................................................................................8

LESSON PLAN................................................................................................................................................9

RESOURCES.................................................................................................................................................12

REFERENCE.................................................................................................................................................27

BLUE PRINT ASSESSMENT...........................................................................................................................29

Appendix 1. General PPT format................................................................................................................31

Appendix 2. Portfolio Format.....................................................................................................................32

Appendix 3. Portfolio Assessment..............................................................................................................34

Appendix 4. Checklists of Inter-professional collaboration........................................................................36

Appendix 5. Feedback card/form...............................................................................................................37

Appendix 6. Skenario tutorial C1 – C6 berbasis kegiatan di komunitas (kegiatan CFHC-IPE)......................44

Appendix 7. Tutor-guide for Scenario which was based on community settings (CFHC-IPE settings).........52

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BACKGROUND

There is an outgrowing health issues around community problems such as the high prevalence of infectious as well as non communicable diseases such as diabetes and hypertension. Those diseases need a collaborative management from not only the doctors but also the nurses and dieticians.

Faculty of Medicine UGM has three undergraduate health study programs: undergraduate medical degree, nursing program and health nutrition program. With the CFHC-IPE program, we expect that those students could perform and train their interprofessional collaboration in the community.

The aims of CFHC-IPE Semester 5 to 6:1. The students can establish a hypothesis of the family as well as community health

problem (community diagnosis)2. The students can apply the informed and share decision making skills together with the

individual, family or community (informed and shared decision making skills)3. The students can propose a health problem solving for example: education, advocation,

health promotion and prevention (program planning and community empowerment)

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ANNUAL MATRIX CFHC-IPE

Year 4Disaster preparedness (Village Awareness)

- Students identify any possible problem during disaster event- Students propose a disaster simulation and community training

Year 3Well-prepared family

- Example of case study: maternal and child problem- Students assess a more individual problem, plan a simple individual health conseling and evaluation

Year 2Community health awareness

- Example of case study: the danger of smoking habits- Students identify the health risk in the family and community- Students can perform a simple health promotion

YEAR 1Healthy Family - Example of care study: water and sanitation

- Students introduce themselves to their attached community

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ACTIVITIES

Learning Objectives: (semester 5 to 6)

1. Students can learn and perform communication skills in community setting

2. The students can establish a hypothesis of the family as well as community health

problem (community diagnosis):

Students are able to perform an advanced intervention with 5A Phase: Ask-Assesses-

Advice (Semester 5) and Assist dan Arrange Follow up (Semester 6) ASK and

ASSESS are for community diagnosis purposes

3. The students can propose a health problem solving for example: education,

advocation, health promotion and prevention (program planning and community

empowerment):

Students are able to perform an advanced intervention with 5A Phase: Ask-Assesses

Advice (Semester 5) and Assist dan Arrange Follow up (Semester 6) ADVICE –

ASSIST ARRANGE FOLLOW UP are for program planning purposes

4. The students can apply the informed and share decision making skills together with

the individual, family or community (the informed and shared decision making

skills) these skills are for community empowerment purposes

5. Students are able to perform a screening and discussion about non communicable

diseases comprehensively and interprofessionally

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General activities

1. Lecturea. Overview of CFHC in semester 5b. Guideline to think select the major problem within family/personal health Time allocation: 100 minutes

2. Practical workCovers these topic of discussions of approaches in changing behavior:

a. Self - introduction: the introduction of students’ role and function as a volunteer b. Ask-phase: Health problem exploration should be done together with community

members using various types of methods, such as: PRA Method (Participatory Rural Appraisal) Rapid Assessment Procedure Interview Observation Live-In (if possible one or two days)

c. Assess-phase: from the existing problems, to select which will becomes the priority (should be done together with community).

d. Advice-phase: Plan shared activity by involving the community (emphasizing the shares information and shares decision with individual , family or community)

e. Assist-phase: Assist the activity by involving the individual, family or communityf. Arrange follow up / monitoring program

Time allocation: field-work

3. Fieldworka. Screening within communityb. Discussion of changing health behaviour using 5A guidelines

Time allocation: 600 minutes

4. Feedback sessiona. Faculty lecture feedbackb. Fieldwork feedback

Time allocation: 300 minutes

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LESSON PLAN

For detail information in each activity (ASK-ASSESS-ADVICE-ASSIST-ARRANGE FOLLOW UP) please refer to these following tables:

Table 1. Detailed Lesson Plan Semester 5

Block Activities Time Allocation Location

C1Lecture Overview of CFHC in Semester 5 100 minutes On campusPractical work Cases identification guided with

faculty supervisors/facilitators100 minutes On campus

Fieldwork Attachment in Family/Community using 5 A guide: ASK

200 minutes Community

Feedback Presentation with the faculty supervisor (DPF)

100 minutes Puskesmas / Family doctors’ clinics

C2 Fieldwork Attachment in Family/Community using 5 A guide: ASSESS


Feedback Presentation with faculty supervisor (DPF)


C3 Fieldwork Attachment in Family/Community using 5 A guide: ADVICE




Final report and evaluation Presentation and evaluation with fieldwork supervisor (DPL)

100 minutes On campus

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Table 2. Detailed Lesson Plan Semester 6

Block Activities Time Allocation Location

C4Lecture Overview of CFHC in Sem 6 100 minutes On campusPractical work Case identification guided with faculty

supervisors/facilitators100 minutes On campus

Fieldwork Attachment in Family/Community using 5 A guide: ADVICE




C5 Fieldwork Attachment in Family/Community using 5 A guide: ASSIST




C6 Fieldwork Attachment in Family/Community using 5 A guide: ARRANGE FOLLOW UP




Final report and evaluation Presentation and evaluation with fieldwork supervisor (DPL)

100 minutes On campus

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Table 3: Role of students and supervisors during each activities

No Campus Activities Activities during fieldworkRole of faculty supervisors Student’s Task Role of fieldwork supervisor Student’s Tasks

1 Facilitate students reflection process concerning medical learning in primary care setting

Write diary and portfolio on reflection forms provided after field visit for five phase: ASK-ASSESS-ADVICE-ASSIST-ARRANGE FOLLOW UP

Facilitate observation process of GMU students concerning real community health problems based on approval of attendance

Follow approval of attendance schedule, by fulfilling target

2 Facilitate reflection using constructive feedback emphasized the informed and shared decision making skills (ASK-ASSESS-ADVICE-ASSIST-ARRANGE FOLLOW UP)

Discuss reflection in discussion session with faculty supervisor on campus

Allow students to join for example, PHC programs or NGO programs related with health promotion

1. Join and participate activities suggested by field instructor individually or in together with community members

2. Propose a program of educating the patients/ community in which have a high sustainability

3 Discussion, feedback and reflection as scheduled with faculty supervisor on campus

Receive feedback reflectively (understand their positive sides and those that need to be improved)

Facilitate students reflection verbally concerning real community health problems

Receive feedback responsively (understand local community needs)

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RESOURCES

EDUCATION AND COUNSELING

The Shares Information and Shares Decision Making Skills

with a Community – Based ApproachMora Claramita

Yayi Suryo Prabandari

Third year students should have an ability to educate and counsel the patients by applying shares information and shares decision-making skills. One of way is to “DISCUSS” the care-plan with patients. However, many facts prove that student’s communication skills capacity, are limited on cognitive aspects rather than application. Students’ inflexible communication affects their professionalism. Students usually focus on disease’s perspective rather than communicating with the patients. Moreover, so far, skills lab has limitation in providing opportunities for students to engage in real setting directly. Direct exposure to community has been proven in many studies to improve knowledge transfer mechanism into an applicable, flexible and professional competence (Dornan et.al, 2010). Therefore, a community based approach is used to introduce students in learning education and counseling skills by discussing with the patients, involving the patients’ perspectives, sharing information and sharing clinical decision making with patients (individual, family or community).

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Targets:

Students explores individual/ family/ community’s health problems through series of “self introduction, ask and assess” methods in the real learning settings.

For detail skills please refer to UGM doctor-patient communication skills guideline in Tabel 1:

THE GREET AND INVITES rows.

Targets:

Students shared decision with individual/ family/ community about a particular health problem that needs intervention of series of “advices, assist and arrange follow up” methods.

For detail skills please refer to UGM Doctor-Patient Communication Skills Guideline in Tabel 1:

THE DISCUSS row.

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Struktur Deskripsi Isi Ketrampilan Komunikasi

Keterampilan Komunikasi Latar Belakang Budaya Indonesia

Keterampilan Komunikasi yang sebaiknya diperkuat

SAPA

Kepercayaan dan rasa nyaman dari pasien yang didapatkan dari proses sambung rasa dengan dokter, akan mendorong pasien untuk menceritakan keluhannya secara terbuka.

Kemampuan membina sambung rasa dan hubungan interpersonal yang dilandasi perhatian dan keinginan untuk menolong masalah kesehatan pasien - selama proses konsultasi kesehatan berlangsung

1. Menyapa dan menyambut pasien dengan hangat yang menunjukkan perhatian terhadap masalah kesehatannya

2. Menggunakan kata-kata yang memperlihatkan perhatian secara verbal

3. Menunjukkan sikap dan bahasa tubuh alamiah yang memperlihatkan perhatian secara non-verbal

4. Melakukan obervasi dan merespon pernyataan pasien (verbal dan non-verbal) mengenai perasaannya dan harapannya. Hal ini dilakukan sebagai kontrak awal agenda pertemuan hari ini.

5. Melakukan refleksi atas harapan pasien

Pasien di Indonesia baik dari kalangan pendidikan tinggi maupun rendah, secara umum mengharapkan kedudukan yang setara dengan dokter.

Prinsip berikut dianut:

- Kesetaraan- Kepercayaan- Komunikasi dua arah

Kemampuan untuk menyapa dan menyambut pasien seperti anggota keluarga sendiri (dengan memperhatikan hubungan antar keluarga sesuai masing-masing budaya daerah) dengan harapan agar lebih akrab dengan pasien.

Dokter perlu bersikap Semanak (“Friendly” - disesuaikan budaya setempat): “Ibu, Bapak, Mas, Dik, “ (Iragiliati, 2006)

Nama panggilan sesuai yang diinginkan pasien perlu disebutkan sebagai klarifikasi.

AJAK BICARA

Ekplorasi dan observasi yang adekuat oleh dokter terhadap masalah kesehatan pasien dan latar belakangnya akan membantu proses penegakkan diagnosis dan rencana penatalaksanaan (terapi/ edukasi)

Kemampuan memulai dan menstruktur pembicaraan tentang masalah kesehatan pasien

1. Mempersilakah dan memfasilitasi pasien mengutarakan keluhannya sampai selesai (ekplorasi penyakit dari sudut pandang pasien)

2. Menggunakan pertanyaan terbuka di awal

3. Menggunakan pertanyaan tertutup untuk mengklarifikasi sesuatu

4. Menyimpulkan apa yang menjadi permasalahan pasien dan mengecek kembali pengertian/ persepsi sakit dengan pasien

5. Menggunakan pertanyaan tambahan secara efektif

6. Menanyakan adakah masalah lain yang ingin disampaikan

7. Meminta persetujuan lisan/ tertulis akan agenda konsultasi hari ini (sudah tersebut di SAPA, bisa diulangi untuk hal yang spesifik).

Biasakan menggali keluhan pasien dari sudut pandangnya dulu (termasuk mengekplorasi latar belakang pasien, keluarga, lingkungan, dan budaya), kemudian baru dilakukan penggalian keluhan dari sudut pandang medis untuk klarifikasi (e.g. Identitas, keluhan utama, RPS, RPD, RPK, RPSosial, Ax sistem)

Waspadai perbedaan hierarki antara pasien dengan dokter, bahwa dokter biasanya dipandang lebih tahu tentang suatu penyakit daripada pasien.

Eksplorasi yang baik dapat menggali seluruh riwayat penyakit – hanya dengan satu-dua pertanyaan terbuka.

Salah satu contoh ekplorasi keluhan pasien menggunakan pertanyaan terbuka:

”Gimana, Pak (ceritanya)...?”

”Ada keluhan apa, Bu?”

”Apa yang bisa saya bantu?”

”Rasanya bagaimana hari ini, Pak?”

”Datang sendiri atau ada yang mengantar, Bu?”

( masuk ke eksplorasi keluarga)

”Di rumah sehari-hari..?” (masuk ke ekplorasi daily activity)

”Oh, mengapa kira-kira bisa seperti itu, Bu? Apa ada perubahan aktivitas? (tunggu respon), Perubahan pola makan? (tunggu respon),..” (masuk ke ekplorasi RPS,RPD,RPK dari sudut pandang pasien)

Pedoman Komunikasi UGM: SAPA – AJAK BICARA - DISKUSI

Taken from: Claramita M, Susilo AP, Kharismayekti M, Van Dalen J, Van der Vleuten C. Introducing a partnership doctor-patient communication guideline to teachers in a culturally hierarchical context of Indonesia. Educ for Health 2013; 26 (3): 147-55

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Memahami sudut pandang pasien terhadap penyakitnya

1. Menanyakan peristiwa hidup, lingkungan, dan komunitas di mana pasien tinggal yang mungkin mempengaruhi kesehatannya

2. Menanggapi harapan pasien terhadap penyakit dan akibat dari penyakitnya terhadap kehidupannya sehari-hari

Pasien di Indonesia mempunyai sikap yang sangat khas yang membutuhkan fasilitasi dan bukan diabaikan oleh dokter:

a. Keterlibatan keluarga/ masyarakat sekitar pasien amat berperan (Dengan catatan: bila pasien setuju akan keterlibatan mereka dan bila pasien dianggap cukup dewasa memberikan informasi – Bukan anak dibawah 5 tahun dan penderita dengan gangguan bicara/ pendengaran)

b. Pasien di Indonesia secara umum ingin bersikap sesopan dan sehormat mungkin pada dokter. Ini bukan berarti pernyataan ”Ya” berarti setuju.

c. Penggunaan obat/jamu tradisional atau pengobatan alternatif menjadi suatu kebiasaan yang sulit dihindarkan baik di kalangan pendidikan tinggi maupun rendah

DISKUSI

Pengambilan keputusan klinik secara bersama-sama oleh pasien dan dokter dengan cara menyamakan persepsi terlebih dahulu diikuti dengan memberikan penjelasan dan mendiskusikan rencana selanjutnya

Kemampuan membagi informasi

(Shares information)

1. Menyamakan persepsi antara pasien dan dokter tentang pengertian penyakit maupun rencana terapi

2. Penghargaan terhadap harapan/ persepsi pasien lebih lanjut (Harapan mengenai penyakit dan akibat penyakit itu thd kehidupan pasien sehari-hari dan masa depannya serta harapan akan proses diskusi dalam agenda pertemuan hari ini)

3. Menginformasikan penjelasan sesuai standar pengetahuan dokter yang tertinggi – dalam bahasa awam

4. Selalu berusaha komunikasi dua arah

Selalu waspada akan sistem hirarki di Indonesia, yang kental. Dokter secara umum dipandang lebih tinggi statusnya daripada pasien. Hal ini membuat pasien tidak nyaman untuk berdiskusi kembali lagi ke kemampuan SAPA dan AJAK BICARA

Kemampuan menyamakan persepsi sebagai salah satu usaha bahwa dokter ingin berada dalam satu level yang sama dengan pasien, (level informasi):

”Apa yang sudah Ibu ketahui tentang penyakit ini?”

(Nada suara – tidak menyalahkan, tidak menguji)

Kemampuan mencapai persetujuan (bersama antara pasien dan dokter)

(Shares decision making)

1. Eksplorasi segala kemungkinan yang cocok/ sesuai untuk keputusan klinik yang diambil

2. Eksplorasi kemungkinan pasien mematuhi rencana terapi

Perkembangan lebih lanjut tentang shares decision termasuk didalamnya adalah kemampuan untuk

- ”Nanting”

Penjelasan yang efektif untuk pasien di Indonesia adalah yang:

1. Mengikutsertakan keluarga/ masyarakat sekitar (Dengan catatan: bila pasien setuju akan keterlibatan mereka dan bila pasien dianggap cukup dewasa untuk mengambil keputusan – Bukan anak-anak dan

Selalu pertimbangkan partisipasi keluarga dalam proses edukasi pasien (bila pasien setuju):

Contoh diskusi antara dokter dan pasien:

“Seandainya Ibu menggunakan obat tradisional, mohon saya diberitahu, saya ingin belajar lebih banyak tentang obat tradisional.. Setelah itu mungkin kita bisa mengamati bersama sejauh mana obat tradisional bermanfaat pada penyakit Ibu.” (Beri kesempatan

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- Menyampaikan Bad-news (misal pengobatan terus menerus untuk penyakit kronis)

- Persuasi Kental dg stigma contoh comunal-test utk HIV lebih berhasil daripada individual test

- Konseling kental dengan hub keluarga dan dukungan sebaya

usia lanjut)

2. Waspada akan sinyal non-verbal dari pasien yang mungkin saja kurang setuju

3. Mendiskusikan penggunaan obat tradisional (Kelebihan dan Kekurangan harus diketahui dan disepakati bersama antara dokter dan pasien)

diskusi).

Catatan:

Pasien yang mengatakan ”nderek” atau ”manut” bisa berarti persetujuan tercapai. Tapi selalu cek non verbal dan verbal pasien, atas pengertian yang diterima pasien kembali ke kemampuan SAPA

Ingat bahwa ”Ya” di konteks Indonesia bukan selalu berarti persetujuan maupun kepatuhan

Kemampuan menyelesaikan pembicaraan

1. Menanyakan masalah yang belum dimengerti pasien dan berikan kesempatan bila pasien ingin menyampaikan sesuatu

2. Menyimpulkan hasil pertemuan hari ini dan rencana ke depan

3. Mengucapkan terima kasih

Tanggap apabila pasien ingin mengutarakan sesuatu (biasanya terlihat secara non-verbal).

Segala informasi tertulis sederhana (Misal panduan untuk penderita DM) akan sangat menjembatani komunikasi verbal yang terbatas antara pasien dan dokter di Indonesia

Mem-verbalkan undangan untuk bertanya akan sangat membantu pasien:

”Ada yang mau ditanyakan lagi, Bu?

”Masih ada yang mau disampaikan, Mas?

”Kalau ada apa-apa segera kontrol/ hub saya?

Menghantarkan pasien untuk keluar ruangan akan memperjelas penghargaan dokter terhadap pasien.

PATIENT EDUCATION

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Nowadays medical education has been focused on factual medical knowledge and medical problem approach based on medical sciences. Almost all processes of study are held in classroom, laboratory, and university network hospitals. Therefore, graduates of medical faculty know little about common community problems and are unprepared to work in regional areas (Magzoub, 2000). Community-based study is a way of showing complexity of health, environment and social problems in the community. Enhancing collaboration between community and university is necessary to find appropriate education models for student’s education and society empowerment (Flicker, 2007).

Recently many medical faculties have been trying to enhance their curriculum to be community oriented by implementing community-based education program (Kristina, 2005). This is being tested by medical faculty of GMU. Using community-based education, at the beginning of education process, students are exposed to community health problems (Magzoub, 2000). This education program will assist them in enhancing their experiences, community services, and community research. According to Davenport (2000), student’s knowledge will be more meaningful when they have to deal with reality. Facing facts will enable them to help certain community based on community’s need.

Feletty (2000) stated that community observation is a way of understanding community problems. Students can utilize their communication skills to recognize such problems. By community involvement, students have many opportunities to work together as a team and apply their knowledge in real community setting, not only in a demonstration or with simulated patient (Hamad, 2000). Recognizing communities problems, students can implement appropriate health approach to the community (Webber, 1990) holistically and multidisciplinary (magzoub, 2000). Moreover, students will also be able to learn local cultures and their impacts to community health perspective when they live and work within certain community (Hamad, 2000). Students who engage themselves in certain community can help them learn more about health. They have lots of models to educate the community. Verbal communication with community involvement, community discussion on certain interesting issues, booklet, videos, all can help them understand more about health (Webber, 1990).

Community-based education has positive impacts not only for students but also for the academic institution and primary health services. Involvement of academic institution in a community setting help strengthening relationship among institutions, particularly medical faculty GMU, in various areas such as government, community institutions, and international organizations (Magzoub, 2000). With multidisciplinary relation, it is expected that community-based education can contribute in the improvement of health system in Indonesia.

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A study by Claramita et al, 2009 shows that some points require observation when students conduct skills training in community setting:

Benefits of conducting medical skills training in community setting are as follow:

1. Experiential learning enhanced awareness and reflection on patients’ background2. Responsiveness of community health problems to gain their trust3. Initiation of two ways exchange information based on patients’ perspective4. Awareness and initiation of community empowerment5. Awareness on the dilemma of using evidence-based medicine and using traditional medicine –

applying negotiation skills6. Awareness of the non-verbal atmosphere of politeness

Obstacles

Student’s obstacles during medical skills training in community setting are as follow:

1. Students tend to over communicate about their experiences in the community, and carried out by their own stories – lack of time to reflect on communication theories.

2. Students’ lack of depth in exploration. They tend to focus on statements or problems that arise initially.

3. Students are incapable to respond others’ emotion4. Students have problems in share thinking skills 5. Some believe that doctor-patient communication skills are genetic and related to personality.

Dilemma

Dilemma between laboratory and community settings felt by students during medical skills training in community setting.

”Is health promotion part of students’ expectation? Community expectation? Or community needs?”

From the study, it is extremely important to provide opportunities for students to engage directly in the community adjacent to where they study or Medical Faculty GMU.

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COUNSELING

Introduction

Beginning in the year 1970 most people agreed that counseling is beneficial and should made more widely available (Tyler, 1969, cit. Hershenson, Power & Waldo, 1996). Not only people in the mental health area use counseling, but also other areas, including general health areas. Doctors, nurses, midwives and other health providers start learning and implementing counseling in the last three decades. As the development of customer oriented climate and patient right, it is important for doctors to enhance their counseling skills, not only their medical skills.

What is counseling?

The central purpose of counseling is to facilitate wise choice and decisions. However, some professionals also give other definition, ‘counseling can be used to promote adjustment or mental health’. To give more understanding on the definition, counseling is meant by assisting an individual, family or group through the client counselor relationship:

To develop understanding of intrapersonal and interpersonal problems To define goals To make decisions To plan a course of action reflecting the needs, interests and abilities of the individual, family or

group To use informational and community resources, as these procedures are related to personal,

social, emotional, educational and vocational development and adjustment

What is the difference between counseling and psychotherapy?

Psychotherapy implies adherence to a medical model, which views the person seeking help (the patient) as ill and the goal of intervention as curing that illness. Counseling, while it can have therapeutic effects, focuses instead on promoting healthy development by assisting the person seeking help (the client) to learn to cope effectively with problems of living. Thus, the goal of psychotherapy is the elimination of psychopathology (phobia, severe depression or anxiety), whereas the goal of counseling is to empower the client to achieve healthy growth (Hershenson, Power & Waldo, 1996, page 4)

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Counseling process

As written in the skills laboratory manual, a counseling process may summarized as GATHER:

Besides GATHER, two things that facilitate the counseling process should be considered:

Greet, give warm greeting to clientGAsk. Ask clients what happened to themATell. Tell client alternativesTHelp. Help client in choosingHExplain. Explain to the client about the chosen alternativesEReturn. Ask the client to return for follow upR

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CClarifying. Clarify the patient's problem

LListening. Always perform as a good listenerconcentrateKeep eye contactShow interest body languageEncourage client to talkAsk client to explain Re check use paraphrase Leave your opinion Stay calm

EEncouraging. Encourage patients to express their emotions and explain their problems

AAsking for feedback. After you gave your interpretation and alternatives, ask patients for their opinion about your interpretation or alternatives

RRepeating. Encourage patients to apply the alternatives they choose and ask them to return

Relaxing. Maintain a relax situation when conducting a counselingROpening up to client, disclosure your self as counselor and show your honest acceptance of the diversityOLeaning toward client. Always see to the client’ problem and show your “interest and motivated” body language LEye contact. Establish eye contact during the counseling processESmiling and sitting squarelyS

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Counseling principles

The process of counseling should follow principles below:

AcceptanceCounselor should accept clients as they are, and understand the diversity

IndividualExcept for the group counseling, individual counseling should implemented individually and the client should be seen as an unique person.

ConfidentialityThe confidentiality of client’ problem should be kept

The client is the decision makerCounselor should let the clients to make their own decision

Emotion controlWhatever the reaction or behavior of clients, counselor should stay calm

Avoid judgmentAlthough client has “un manner” behavior, counselor should stay in the neutral way and avoid judging the client

Communication skills that should be mastered in counseling process

Relating Maintain a good and relax relationship between counselor and counselee

Observing During the counseling process, counselor should observe the clients’ body language or non-verbal language

Listening As noted previously, counselor should maintain its listening behavior

QuestioningThe way for asking client should perform adequately. It is suggested that counselor should use open question

Attending behavior Acceptance of client is important. Counselors should show their non verbal language that show an acceptance and readiness to help

TalkingUse appropriate language and stay calm, avoid of giving judgment or blaming the client

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Summarizing & paraphrasing Sometimes counselor need to make summary or paraphrase (repeat the client’ talk with your

own language) Interpreting

Counselors also needs to make their own interpretation of the problem or emotion of the clients

Giving interpretationThe interpretation of the main problem and its emotion should be given to the clients.

Researches regarding counseling – a smoking cessation case

Several researches have been conducted for helping the smokers to quit. Some of them use the behavioral treatment, whereas the others use NRT (Nicotine Replacement Therapy) (Tang, Law & Wald, 1994; Fowler, 1994) and combining of behavioral treatment (counseling) and NRT (Gourlay, Forbes, Marriner, Pethica & Mc Neil, 1995).

Considering that stop smoking needs hardly effort, even though innovation strategies have been conducted, some studies involving medications or combining medications and behavioral treatments are still implemented. Fowler (1994) conducted randomized trial using nicotine patch to help the people stop smoking. His study showed that 19.4% out of 842 subjects, who used patches were quit at 12 weeks, compare to 11.8 % out of 844 in the placebo patch group. The number of people who were quit decreased after 12-52 weeks, 10.8 % out of 842 in the patch group and 7.7% out of 844 in the placebo group.

Gourlay and his colleagues (1994) added brief counseling at monthly visits besides giving twelve transdermal nicotine for relapsed smokers. This study indicated that 6.7% (21 out of 315 subjects) had stopped smoking compared with 1.9% (6 out of 314) allocated in placebo. After 26 weeks the percentage of people who had stopped smoking were 6.4% (20 out of 315), whereas in the placebo only 2.6% (8 out of 314).

Brief counseling for helping patients stops smoking – an example

A brief counseling for assisting patients stop smoking has been developed in the USA. The process of brief counseling as below:

23

ASK

Take the tobacco use as ”vital sign” (always ask smoking behavior) Place smoking status in chart Enter smoking status in problem list (if yes)

ASSESS

Assess the willingness of clients to stop smoking Assess the motivation of quitting smoking

ADVISE

Praise patient for trying or planning to stop smoking Link smoking to present symptoms/visit Discuss health, short-term benefits Give clear cessation message Ask all tobacco users “if we give you some help, are you willing to try to stop?”

ASSIST

For those who say YES Ready to stop now:

Provide motivational and self-help Map out plan with patient Set date for stopping

For those who say NO Not ready to stop

Provide motivational literature Ask about barriers to stop Encourage – reconsideration in future; offer ongoing support

ARRANGE FOLLOW UP

Mention that you will follow up at next visit Arrange follow-up date for those ready now as appropriate Telephone/personal contact on quit date

ASK ASSES ADVICE ASSISTARRANGE FOLLOW-

UP

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Final remark

Counseling is one of communication skills. For mastering this counseling skill, students should practice and practice. Use your day life social interaction as a field for practicing. Helping friends’ problem is one example to practice your counseling skill. Enjoy your practice, good luck!

SHARES INFORMATION AND SHARES DECISION SKILLS

The goal of Patient Education and Counseling skills is the SHARES INFORMATION AND SHARES DECISION skills with patients (individual, family or community). We should remind ourselves that doctor-patient communication does not stop after the information is delivered by the doctors. This should be two-way communication as we have learned during the Active Listening skills in Block 1.1. The two-way communication in which involve discussion with the patients should be maintained during the whole consultations until a care-plan was decided and agreed by the doctors and the patients. Most of medical compliance increases when the patients understood the background of a clinical decision making. The shares information and shares decision skills is vital when it comes to chronic diseases such as diabetes mellitus, hypertension, asthma, or tuberculosis that needs extra cooperation from the patients to maintain their health condition. It is the central duty of general practitioners to help the patients preventing their chronic diseases from falling into further “levels of prevention” in the natural history of diseases. This is the fundamental reason why education and counseling skills as well as health promotion skills is necessary for general practitioners to be.

The shares information and shares decision making skills is not only useful for chronic diseases but also for other diseases that require extra prevention and promotion e.g. malaria, dengue fever, typhoid fever, etc. Without adequate exploration on individual or community’s’ NEED and WANT, health professionals may falls into a health promotion program which not fully understandable by the patients. Therefore, an optimal health promotion program may not be reached. Education and counseling skills related to health promotion skills is the central challenge of health promotion system in Indonesia.

More about shares information and shares decision skills was provided in the UGM Doctor-Patient Communication Skills Guideline in Table 2, particularly on the “Discuss” row. To proceed into a partnership discussion with patients, students should master the “Greet and Invites” skills in which already learned during the first and second year of medical education in Faculty of Medicine UGM.

25

The UGM Guideline on communication skills “Greet-Invites and Discuss” was validated during July 2010 and will be registered as a patent - trademark soon. The invention of the UGM guideline was emerged from series of studies conducted in the Skills Lab FM UGM 2006-2010 (Claramita, et al, 2010).

Evaluation:

1. Feedback will be given orally by every field instructor, communication instructor and physical examination instructor in every occasion (field or skills lab)

2. Professionalism assessment will be given by field instructor using approval of attendance

26

REFERENCE

Claramita, M, Susilo AP, van Dalen J, 2010, Workshop on UGM Doctor-Patient Communication Skills Guideline, Faculty of Medicine Gadjah Mada University, February 2010.

Claramita, M, Utarini A, Soebono H, van Dalen J, van der Vleuten C, 2010, Doctor-patient communication in Indonesia: The conflict between ideal and reality, Advances in Health Sciences Education, online-published, September, 2010

Claramita M, Prabadari Y, van Dalen J, van der Vleuten C, Developing and validating doctor-patient communication skills guideline for a hierarchical context, less verbally expressed style of communication and communal society, a poster presented at 7 th APMEC conference Singapore, 2010.

Claramita, M. and Widyandana, 2007, Skills Laboratory, Faculty of Medicine Gadjah Mada University, Yogyakarta.

Claramita, M, Kharisma Yekti M, and Prabandari YS, Proposal for Junior Teacher Research Grant 2009: Learning Clinical Skills in the Community Setting, Faculty of Medicine, GMU, Yogykarta

Prihatiningsih TS and Widyandana Proposal for Senior Teacher Research Grant 2009: Transferability of Procedural Skills in the Community Setting, Faculty of Medicine, GMU, Yogykarta

Davenport, BA., 2000, Witnessing and the Medical Gaze: How Medical Students Learn to See at a Free Clinic for the Homeless, Medical Anthropology Quarterly 14(3):310-327.

Feletti, G., Ja’afar, R., Joseph, A., dkk, 2000, Implementation of Community-Based Curricula, Handbook of Community-Based Education: Theory and Practices, hal.11-26, Network Publication, Maastricht.

Flicker, S., Savan, B., McGrath, M., dkk, 2007, ‘If you could change one thing...’ What community-based researchers wish they could have done differently, Community Development Journal Vol 43 No 2; April 2008 pp. 239–253.

Hamad, B., 2000, What is Community-Based Education? Evolution, definition and rationale, Handbook of Community-Based Education: Theory and Practices, hal.11-26, Network Publication, Maastricht.

Kristina, TN., 2005, Generic objective for Community-Based Education in Undergraduate Medical Programmes: the prespective from developing countries, Disertasi S3, Diponegoro University press, Semarang.

Magzoub, M., 2000, Some Principles Involved in Community-Based Education, Handbook of Community-Based Education: Theory and Practices, hal. 27-38, Network Publication, Maastricht.

Patton, MQ., 1990, Qualitative Evaluation and Research Method, 2nd edition, Sage Pub, London.

27

Webber, GC., 1990, Patient Education, A review of the issues, Medical Care 1990;28:1089-1103.

American Medical Association. 1992 How to Help Stop Smoking. USA: National Cancer Institute, Centers for Disease Control and Prevention, American Society of Addiction Medicine

Fowler, G. (1994) Randomised trial of nicotine patches in general practice: results at one year. BMJ COM, 308:1476-1477, dowload 12/26/01

Gourlay, S.G., Forbes, A., Marriner, T., Pethica, D., & McNeil, J.J. (1995) Double blind trial of repeated treatment with transdermal nicotine for relapsed smokers. BMJ COM, 311:363-366, download 12/26/01

Herhshenson, DB., Power, PW., & Waldo, M. 1996 Community Counseling – Contemporary Theory and Practice. Boston: Allyn and Bacon

Tang, J.L, Law, M., & Wald, N. (1994) How effective is nicotine replacement therapy in helping people to stop smoking. BMJ COM, 308: 21-26, download.

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BLUE PRINT ASSESSMENT

The students’ assessment would have several types i.e. checklist from both teachers/supervisors during fieldwork and faculty supervisor (DPL/DPF), feedback, and portfolio.

Formative assessment: Your peers’ feedback (360 degrees feedback from teachers, friends, health workers, community) would contribute on your portfolio i.e. as a formative assessment.

Summative assessment:

1. 40%: The checklist from teachers would contribute 40 percent for the end of your mark. The checklist distributed in your activities such as presentation with your field teachers (DPL) or while discussion session - tutorial with your faculty teacher (DPF).

2. 60%: Your portfolio will have 60 percent contribution for your mark.

The checklist is representative of competencies which should be mastered by the students. Below are the third year competencies for CFHC-IPE:

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Table 4. List of third year competencies of CFHC-IPE:

Year 3Theme: Well prepared Family (Men's, Women's, Children's Health)

Manage ethical dilemmas specific to interprofessional patient/ population centered care situations.Maintain competence in one’s own profession appropriate to scope of practice.Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.Engage in continuous professional and interprofessional development to enhance team performance. Use unique and complementary abilities of all members of the team to optimize patient care. Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. Engage other health professionals—appropriate to the specific care situation—in shared patient-centered problem-solving. Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care. Apply leadership practices that support collaborative practice and team effectiveness. Reflect on individual and team performance for individual, as well as team, performance improvement. Use process improvement strategies to increase the effectiveness of interprofessional teamwork and team-based care. Demonstrate high standards of ethical conduct and quality of care in one’s contributions to team-based care.Applying bio-psycho-socio-cultural communicationBeing able to identify and analyse any health problems in the communityAssess and taking notes on individual as well as family and community health problems during fieldworkEstablish any hypothesis of individual, family and community health problems Suggest any solution for the health problems (such as education, councelling, advocation, or any prevention procedures Understand any related health system analysisUnderstanding professionalism from social constructLeadershipCompromised solution

Note: The list was taken from the Grand Design of CFHC-IPE Learning objectives for the four- year-basic medical education (via several workshops on synchronization curriculum of CFHC-IPE in 2015 with Skills Laboratory, Family Medicine, Public Health and Bioethics longitudinal curriculum).

30

APPENDICES

Appendix 1. General PPT format

Instruction: Each small group of field group should make a Ppt and submitted via game

Time of Ppt submission:

After the end of Semester 5 and 6 (scheduled presentation with the fieldwork supervisor)

Ppt format-Guide set:

a. At minimum font 20

b. Title page contains group members, name of DPF and DPL, Village name, head of the

village name

c. Content : preface/introduction, body, conclusion, problems during fieldwork

d. Equipped with supporting pictures, quotation and video whenever possible

e. Purposes of presentation: all process from the learning objectives for each semesters,

to show what you have done and what you have learned from the field-work activities

and gaining feedback from the fieldwork supervisors

Abilties should be mastered:

All the list of the third-year competencies of CFHC-IPE (Table 4)

Assessors:

This presentation will be assessed by Dosen Pembimbing Lapangan (Family Doctor/ Puskesmas Doctor) based on the list of competencies on Table 4.

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Appendix 2. Portfolio Format

Reflection Form

Instruction: Each students should write according to these question-guides below and submit it via Gamel

Time of portfolio submission:

After each of community-activity (1 activity in 1 block – week 3) and before Feedback Session with the Faculty Supervisor/ DPF

Question-Guide set:

Self-Assessment:

1. Details of what I’ve done:

Describe events, experiences, feelings, difficulties and dilemma towards the events in a

narrative way (unlimited words)

2. The new experiences from the activity:

Describe what you have learnt from the experiences, what are new to you, what are

usual things, what things should be changed to be better? (Unlimited words)

3. The problems I encounter during the activity :

Tell what do you think you should know more about a particular skills/ knowledge/

attitude; in which you feel that you are lack of mastery on it (unlimited words – try to

grouped your problems into a more specific groups for each problem)

Plan of Action:

4. Plan of action for improvement (according to the problems mentioned before):

Tell what your plans of action to master more on the problems that you encounter. Try

to respond to your problems mentioned above.

32

Attached Evidence: (Should be attached)

5. The evidence of what I did for improvement (can be a note taken during expert

discussion/paper read/ article read/ video recording of re-practice):

Prove that you already try to collect information to respond to your plan of actions above. The information should be valid and reliable (e.g. journals, textbooks, interview, etc.), in which you show that you read/ re-do it, by e.g. summarizing, highlighting, note-taking, video-recording. Construct all of the above into a portfolio. Show that you are trying to learn from various evidences and show that you have learn most of the skills and knowledge of this phase of CFHC.

33

Appendix 3. Portfolio Assessment

Portfolio is a continuous assessment method when the students analyze their own study

through guidance and feedback of self-assessment and action plan. In this module, students

have to fulfill their portfolio and collecting them in a binder. Scoring will be done by DPF

concerning students’ performance from the quantity and quality (each range 1-6) and will

contribute 60% of the final mark of particular semester.

Quantity of the portfolio consists of the length of time of study, number of pages and resources. Quality of the portfolio concentrates on students’ written reflection and individual action plan.

Topics of Reflection to be assessed

What will be assessed

Quantity 50% Quality 50%

Rigorous resources and compiled documents by students

Self assessment and reflection25%

Action Plan25%

Objectives 1 Scale 1 to 6 Scale 1 to 6 Scale 1 to 6Objectives 2 Scale 1 to 6 Scale 1 to 6 Scale 1 to 6Dan seterusnya Scale 1 to 6 Scale 1 to 6 Scale 1 to 6

Mean of scale 1 to 6 of 2 observers will be the final score.

Scale 1: Poor performance E (Fail)Scale 2: Under expectation DScale 3: About expectation CScale 4: Meet expectation BScale 5: Above expectation A/BScale 6: Excellent A

Quantity (Rigorous resources and compiled documents by students)

1. Only providing 1 variation of documentation* of learning process

34

2. Providing 1 variation of documentation* of learning process and 1 variation of resource** (article/journal/text book)3. Providing 1 variation of documentation* of learning process and 2 variations of resources** (article/journal/text book)4. Providing 1 variation of documentation* of learning process and 3 variations of resources** (article/journal/text book)5. Providing 2 variations of documentations* (photos/interviews/observations/artifacts*) of learning process and 3

variations of resources (article/journal/text book)6. Providing 3 variations of documentations* of learning process and 3 variations of resources**

*Documentation variationPhotosResult of ObservationResult of InterviewsArtifacts (forms, guidelines)

**Resources variationArticleTextbookJournal

Quality (Self Assessment and Reflection)

1. Self Assessment and Reflection is limited, only reporting to events2. Self Assessment and Reflection is medium and including self-introspection3. Self Assessment and Reflection is adequate with sufficient reflection of difficulties or dilemmas4. Self Assessment and Reflection is good with presentation of detail critical reflection on certain topics (analysis and

reflect on experiences)5. Self Assessment and Reflection is clear and specific, dynamic (capturing growth and change throughout the program)

with reflection using reliable references.6. Self assessment is clear, specific, dynamic, able to establish correspondence between program activities and life

experiences, reflection using reliable references (transformational learning)

Quality (Action Plan)

1. Not able to formulate a clear and specific action plan regarding their development during the program2. Able to formulate a clear but not specific action plan regarding their development during the program3. Able to formulate a clear and specific action plan regarding their development during the program4. Able to formulate a clear and specific action plan based on a poorly defined purpose and goals, regarding their

development during the program. 5. Able to formulate a clear and specific action plan based on a clearly defined purpose and goals6. Able to formulate a clear and specific action plan based on a clearly defined purpose and goals, not only regarding

their development during the program, but to be later used in real-life situation.

Portfolio assessment = average score ¿3 assessors ¿18

X 100%

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Appendix 4. Checklists of Inter-professional collaborationThis checklist will be used by DPL and DPF (for the 40% of summative assessment) and by Peers for formative assessment

Students name :activities :

No Competencies 0 1 2 3 (max, the student is able to....)

1 Value or ethics for Interprofessional Practice

1. Place the interests of patients and populations at the center of interprofessional health care delivery.

2. Manage ethical dilemmas specific to interprofessional patient/ population centered care situations.

3. Maintain competence in one’s own profession appropriate to scope of practice.

2 Role and responsibilities

1. Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.

2. Engage in continuous professional and interprofessional development to enhance team performance.

3 Interprofessional Communication

1. Menerapkan ketrampilan komunikasi biopsikososial spiritual.2. Use respectful language appropriate for a given difficult situation, crucial

conversation, or interprofessional conflict.

4 Team and teamwork

1. Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care.

2. Demonstrate high standards of ethical conduct and quality of care in one’s contributions to team-based care.

5 Community competency

1. Mengidentifikasi dan menganalisis permasalahan kesehatan dalam komunitas

2. Menilai masalah kesehatan individu, keluarga dan masyarakat di daerah binaan.

3. Menegakkan diagnosis hipothesis pada tingkat individu, keluarga dan masyarakat

4. Memberikan usulan pemecahan masalah(misalnya edukasi, pendampingan management kasus, advokasi dan promosi dan pencegahan)

Yogyakarta,............................................

Sign

observer: ..............

Total = .......... x 10015

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Appendix 5. Feedback card/form

This card will be used by supervisor/ peers for formative assessments:

1. Any activitiesd done by each students willl be assessed by supervisors (Dosen Pembimbing Lapangan (DPL) and Dosen Pembimbing Fakultas (DPF) or their peer students.

2. Whenever the supervisors are unable to give any feedbacks, students are expected to ask feedbacks from their peer students.

3. Students are required to get 3 feedbacks, whatever from the combination of DPL , DPF or from their peer students. Please note your feedbacks in these pages and get their verification from your DPL/DPF.

37

Semester 5C1

No. Assessment

1.

Activities (Semester, year): VerificationFeedback Suggestion

DPL/DPF*Name :

2.

Kegiatan (Semester, Tahun): VerificationFeedback Saran

DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

38

Semester 5C2

No. Assessment

1.


DPL/DPF*Name :

2.


DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

39

Semester 5C3

No. Assessment

1.


DPL/DPF*Name :

2.


DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

40

Semester 6C4

No. Assessment

1.


DPL/DPF*Name :

2.


DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

41

Semester 6C5

No. Assessment

1.


DPL/DPF*Name :

2.


DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

42

Semester 6C6

No. Assessment

1.


DPL/DPF*Name :

2.


DPL/DPF*Name:

3.


DPL/DPF*Name:

4.


DPL/DPF*Name:

5.


DPL/DPF*Name:

43

Appendix 6. Skenario tutorial C1 – C6 berbasis kegiatan di komunitas (kegiatan CFHC-IPE)

TUGAS BELAJAR MAHASISWA:

SKENARIO 5 – KASUS PASIEN yang dijumpai mahasiswa dari Seting Belajar di Komunitas

Kriteria untuk skenario dari seting belajar di Komunitas:

1. Kasus merupakan pengalaman nyata mahasiswa ketika menjumpai pasien di seting belajar

komunitas (ketika CFHC, ketika di Puskesmas, ketika penugasan blok, pasien yang ditemui di

dekat tempat tinggal)

2. Kasus telah dipilih dan disepakati oleh TKT-TKB dengan kata kunci yang telah diumumkan dalam

blok

3. Kasus dapat berbeda untuk masing-masing kelompok mahasiswa, asal kata kuncinya sesuai

dengan arahan dari TKB

4. Setiap kelompok mahasiswa harus sudah mendiskusikan kasus ini, belajar mandiri selama 2 jam

sesuai waktu yang disepakati kelompok (Pertemuan I Mandiri: sebelum minggu ke-2) untuk

mengisi format kasus di bawah ini, sesuai arahan, secara bersama-sama.

5. Mahasiswa menunjuk pemimpin diskusi dan satu sekretaris dalam Pertemuan I Mandiri

6. Setiap kelompok kemudian menyepakati kasusnya dan setelah belajar mandiri, mendiskusikan

kasus ini bersama dengan tutor (Pertemuan II terjadwal dengan Tutor). Jadwal akan dikeluarkan

secretariat TKB.

7. Tutor adalah pemimpin diskusi di Pertemuan II terjadwal

8. Teknik Pengumpulan kasus: Kasus harus sudah dikumpulkan mahasiswa dengan format

(terlampir), maksimal minggu ke-2 blok berjalan ke sekretariat TKB tahuan 3 atau 4. Hal ini

untuk memastikan kesiapan mahasiswa.

9. Keluaran pada saat Pertemuan II dengan Tutor adalah: Rumusan masalah (maksimal 2 hal)

terkait dengan kasus yang dibicarakan.

10. Rumusan masalah ini diketik dan diserahkan pada skeretariat TKB sebagai bahan Diskusi Panel

dengan beberapa pakar di akhir Blok.

11. Selalu ingat tentang level of evidence, bahwa informasi dari pakar adalah level ke-4. Dengan

demikian jangan abaikan proses SELF-STUDY

44

MEDICAL RECORD GUIDE - for any cases brought by students from community settings –

Tutorial Group: Year……………..Group………….Block………………………….

Keywords from the Block coordinators/ TKB: (1) (2) (3)

We met the patient during this learning experience: (Coret yang tidak perlu):

Puskesmas/ CFHC/ or else – please filled in………………………………………

1. WHO IS THE PATIENT?

Write a rich summary of patient’s personal identity, occupation, daily habits, lifestyle, patients’ family, home environment, etc. Write any reason of why this patient is so important to your group?

Example:

We met the patient name: Siti Halimah, 68 year-old lady, during a home visit at CFHC activity year 2. She was the grandmother of the family that we visit regularly. Bu Siti, or we should call her ‘Mbah Siti’ is 68 year-old who lives with her daughter’s family in a small village called: Desa Sukamaju. Mbah Siti helps her daughter takes care of her grandsons, 7 and 1 year-old and during the day she still goes to the rice field. Her husband died of stroke attack 5 years ago. Her daughter and son in law are school teachers nearby the village. Mbah Siti still prepares meals like rice, tempe bacem, sayur lodeh, and other typical traditional Javanese food. They live all together in a small house made from bamboo, Joglo style, ground floor made from partly land and partly cement, almost no window in their house so sunlight is impossible to reach the main hall. When it is rainy season, the house felt like sauna steem room, which was very hot and humid.

This patient is very important to our group because we met her for the first time when we visit this family. She is a humble and generous lady…bla-bla….and we remember her because we concern about her elderly life as well as her grandchildren early life, considering the impact of this illness….

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2. WHAT IS THE HEALTH PROBLEM?

Write a rich summary of patient’s history of illnesses accompanied by physical examination and supportive examination needed

Example:

The health problem of Mbah Siti was coughing for more than…..days with blood and difficulty in breathing……(write the summary of the history taking, current history, past history and family history)……

This result is supported by physical examination: (write a rigorous physical examination – format below only served as a general guideline. Students may adjust if necessary)

Vital signs:

Head and Neck:

Heart:

Lungs:

Abdomen:

Extremity:

Supportive examination: labs, X-Ray, etc:

Routine Blood exam:

X-Ray:

BTA:

Did you feel the need to check the blood sugar in elderly patients?

46

3. WHAT IS THE POSSIBLE DIAGNOSIS AND TREATMENT OF THIS PATIENT?

Write any possible differential diagnosis and diagnosis:

1.

2.

3.

4.

5.

Write any possible treatment for this patient:

a) Treatment of non-pharmacology:

b) Treatment of pharmacology:

47

4. WHAT ARE POSSIBLE PATIENT’S PROBLEMS – based on patients’ perspectives?

Write a rich summary of what patient might perceive as her problem, regarding the diagnosis and treatment that we proposed and how do you approach that as a health professional?

Patients’ problem may be rather different with doctors’ problem, however, if we start from what the problem is perceived by the patients, we may help the patients better, because we start with thinking as they think. Patients usually think about: FEAR – HOPE – EXPECTATIONS – WORRY – IMPACT OF ILLNESS ON DAILY LIFE (keywords for patients’ perception)

Example:

The exact diagnosis of lung tuberculosis in an elderly patient seems obvious because it is supported by physical findings and laboratory findings. Also the treatment was based on guideline of treating TB patient from……….and …….(references)

However, the patient may be reluctant intaking medication on daily basis because of these possibilities:

1. She may feel comfortable after 1 month medication so she felt that the medication should be stopped

2. She may feel embarrassed and therefore she takes herbal medicine instead of pills3. She does not understand the importance of taking TB-drug package

Any effort from the students to approach patients’ perspective:

Example:

We did regular home visit to mbah Siti’s family and we tried to talk to her, the importance of the medication and it will prevent other family members to get the disease. We try to explain the duration of the TB treatment that will last more than 6 months. We understand that it will be boring, however……..etc…..etc…………..

During taking medication, she also has to continue to take care little grandsons…it had made her guilty because she did not want her family to expose the same illness. It is kind like a dilemma for the patient because…………bla…………….bla………………..bla

48

5. WHAT DO YOU PLAN TO LEARN FOR CARING THIS PATIENT?

During taking care of this patient, what kind of problem that you found, what are learning objectives that you think it is important and how do you seek information to overcome your problems?

Our problems with this particular patient-care are: (LEARNING OBJECTIVES)

1. Obtaining blood sample for BTA test which was very difficult because of bla…..bla….bla2. Health provider as well as other patients’ family safety, due to infectious disease like TB3. Educating patient on the importance of not stopping medication for more than 6 months4. What about MDR TB?5. How many is TB in Indonesia? (Epidemiology?)6. How much is it related to Diabetic Mellitus problem?

SELF STUDY:

Results of this SELF STUDY should be ready when there is a schedule to discuss with a tutor/ attached

1. We checked the references on obtaining gold standard diagnosis for TB2. We checked the references on patient and provider safety due to TB3. We had checked the method for educating chronic illnesses and patient-empowerment

for a specific disease like TB4. We had checked the references on MDR TB5. We had checked the references on TB Patients with Diabetic

Results of SELF STUDY are attached

49

6. IF YOU MEET ANOTHER PATIENT JUST LIKE HIM/HER, WHAT WOULD YOU DO DIFFERENTLY NEXT TIME?

Please discuss this questions with your friends and write a list of what would you do better next time. Please consider general issues like:

Epidemiology of this case world-wide, in Indonesian context, and in Yogyakarta Patient and provider safety Inter-professional or team work Clinical practice guidelines or consensus Medical ethics and law (Undang-Undang. Peraturan Daerah, Regulasi dll) Patient education and counseling Other issues

Example:

We think that people like Mbah Siti who suffers from both TB and DM type II are a lot in Indonesia. During home visit with Mbah Siti, we did not get adequate chance to talk with her because during the day she mostly work in the rice field and we do not have much time in the evening to visit. However, next time we will try to talk to her in a convenient time for her so she could undertand comprehensively about treatment of TB.

It is also important to check and educate other family members at the same house, due to…..bla-bla-bla………….

As one of MDGs’ target in Indonesia, TB is uneasy to eradicate because of bla-bla bla…………….as a health professional we may do better next time in………..bla………….bla………….bla.

Other references that we would like to know are:

TB guidelines, TB consensus, etc……………

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7. IF THERE ARE EXPERTS OF THIS PROBLEM, WHAT WOULD YOU LIKE TO LEARN FROM THEM?

Discuss with your friends on what do you want to learn from the experts in order to comprehend this particular patient-care better (maximum 2 problem formulation). Remember that experts’ opinion are listed as number 4th as level of evidences, so please not to neglect any self study.

Example:

What we would like to learn from the experts regarding this case are:

1. The MDR TB are still very high in Indonesia, how we deal with that and where is exactly the problem lied? Is it on the treatment formula? Is it with the patients’ adherence? Or else?

2. How to put into practice the DOTS program in reality?

Note: You must submit these two problems to TKB Secretariat once this discussion is finished.

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Appendix 7. Tutor-guide for Scenario which was based on community settings (CFHC-IPE settings)

Panduan untuk Tutor Skenario dari seting belajar di Komunitas:

1. Tutor memfasilitasi mahasiswa dalam 1 sesi tutorial saja

2. Mahasiswa sudah membawa kasusnya dalam format yang kami sediakan dan sudah

melakukan Sesi SELF STUDY sebelum tutorial.

3. PANDUAN PERTANYAAN TUTOR dalam diskusi tutorial dengan masalah dari seting

belajar komunitas (terlampir)

4. Hal yang kritikal adalah perlunya upaya belajar sepanjang hayat oleh mahasiswa dengan

cara:

a. TAHAP BELAJAR: Memahami bahwa proses belajar mengenai penetapan

diagnosis banding, diagnosis, maupun terapi pada tahap pendidikan ini adalah

tahap belajar. Dengan demikian semua hasil diskusi mahasiswa tidak harus selalu

benar. Tugas tutor adalah membantu mengarahkan pola pikir/ penalaran klinik

mahasiswa agar mahasiswa selalu berusaha belajar dari keterbatasannya

b. KETERBATASAN DIRI: Penekanan pada ‘uncertainty’ dan keterbatasan diri sangat

penting, meskipun seorang dokter telah merasa bahwa diagnosis yang akan

ditegakkannya sudah dapat dipastikan. Kewaspadaan pada keterbatasan diri dan

berbagai kemungkinan-kemungkinan lain, menjadi bekal dari seorang dokter

untuk selalu meningkatkan diri, belajar sepanjang hayat, berinisiatif melakukan

up-date ilmu, bertanya pada kelompoknya, seniornya, dan selalu mengikuti

perkembangan ilmu kedokteran.

c. RELASI DOKTER-PASIEN: Penekanan pada relasi/ hubungan dokter pasien sangat

penting agar mahasiswa memahami bahwa dalam pengelolaan masalah

kesehatan, hanya dengan menegakkan diagnosis dan memberikan terapi begitu

saja tidak cukup bagi keluaran kesehatan.

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d. ETIKA PROFESI: Pembahasan mengenai hal dilematis antara kenyataan yang

dihadapi mahasiswa ketika belajar di seting komunitas yang sangat mungkin

tidak se-ideal teori-teori medis yang dipelajari di kampus, perlu ditekankan

dengan prinsip-prinsip: Menghormati sejawat sesama dokter, semangat

memperbaiki diri, semangat sebagai pemimpin perubahan ke arah yang lebih

baik (seandainya mahasiswa nanti bekerja di seting layanan kesehatan yang tidak

ideal, ia akan selalu berupaya memperbaiki diri dan bukan menyalahkan orang

lain, menyalahkan sistem kesehatan, standar prosedur, atau apapun), dan tetap

mendasarkan perilaku profesinya pada bukti ilmiah terkini, keselamatan pasien

dan petugas kesehatan, etika, hukum dan perilaku professional serta komunikasi

yang efektif.

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PANDUAN PERTANYAAN UNTUK TUTOR pada sesi belajar dengan kasus dari komunitas (CFHC-IPE):

(1) WHO IS THE PATIENT?

Write a rich summary of patient’s personal identity, occupation, daily habits, lifestyle, patients’ family, home environment, etc. Write any reason of why this patient is so important to your group?

(2) WHAT IS THE HEALTH PROBLEM?

Write a rich summary of patient’s history of illnesses accompanied by physical examination and supportive examination needed

(3) WHAT IS THE POSSIBLE DIAGNOSIS AND TREATMENT OF THIS PATIENT?

Write differential diagnosis, diagnosis, treatment of pharmacological and non pharmacological

(4) WHAT ARE POSSIBLE PATIENT’S PROBLEMS (based on patients’ perception)?

Write a rich summary of what patient might perceive as her problem, regarding the diagnosis and treatment that we proposed and how do you approach that as a health professional?Patients’ problem may be rather different with doctors’ problem, however, if we start from what the problem is perceived by the patients, we may help the patients better, because we start with thinking as they think. Patients usually think about: FEAR – HOPE – EXPECTATIONS – WORRY – IMPACT OF ILLNESS ON DAILY LIFE (keywords for patients’ perception)

(5) WHAT DO YOU PLAN TO LEARN FOR CARING THIS PATIENT?

During taking care of this patient, what kind of problem that you found, what are learning objectives that you think it is important and how do you seek information to overcome your problems?

Learning objectives are: SELF STUDIES are: (results of self study should be reported her, during this tutorial session)

(6) IF YOU MEET ANOTHER PATIENT JUST LIKE HIM/HER, WHAT WOULD YOU DO DIFFERENTLY NEXT TIME?

Please discuss this questions with your friends and write a list of what would you do better next time. Please consider general issues like:

Epidemiology of this case world-wide, in Indonesian context, and in Yogyakarta Patient and provider safety Inter-professional or team work Clinical practice guidelines or consensus Medical ethics and law (Undang-Undang. Peraturan Daerah, Regulasi dll) Patient education and counseling or other issues

(7) IF THERE ARE EXPERTS OF THIS PROBLEM, WHAT WOULD YOU LIKE TO LEARN FROM THEM?

Discuss with your friends on what do you want to learn from the experts in order to comprehend this particular patient-care better. Remember that experts’ opinion are listed as number 4 th as level of evidences, so please not to neglect any self study.

Write maximum 2 problem formulation

Students must submit these two problems to TKB Secretariat once this discussion is finished

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15 FEBRUARI – 17 JUNI 2016

NO KEGIATAN WAKTU KETERANGANMINGGU BLOK HARI & TANGGAL JAM1 Overvew CFHC-IPE Th. 3 II C.4 Selasa, 16 Februari 15.00-16.00 R. Kuliah 3, 4 dan 52 PERSIAPAN:

1. Pertemuan dengan DPF dan persiapan kelompok turun ke keluarga dampingan

2. Pembahasan Informed and Shared Decision Making (Panduan Informed and Decision Making dan pemberdayaan masyarakat)

3. Pembahasan Tabel 4 dan Appendix 4 penilaian IPE

II C.4Kamis - Jumat

25, dan 26 Februari

15.00-17.00 Praktikum

3 PENUGASAN LAPANGAN IEksplorasi dari intervensi lanjutan yang telah dilakukan Intervensi program penanggulangan PTM (Panduan umpan balik 5A Fase ASSESS & ADVICE)

III C.4 Sabtu, 27 Februari 07.00-11.50 Lapangan

4 Presentasi laporan dengan DPL III C.4 Sabtu, 27 Februari 12.30-14.00 Praktikum5 Mahasiswa mengisi portfolio untuk fase terkait (upload

GAMEL) sebagai bahan sesi Umpan Balik dg DPF (Gunakan appendix 2: Format Portfolio – upload beserta bukti-bukti belajar)

IV C.4 Senin – Jumat (sebelum melakukan umpan balik)

6 Mahasiswa dari kelompok tutorial yang sama merumuskan scenario berbasis komunitas yang akan di gunakan untuk tutorial di Blok C.5 Key Word : Ederly (degenerative : DM, Hypertensi, gout, Demensia, PPDK, Asma, Osteoporosis, Osteo Atritis, Mata, Ngompol) Gunakan apendix 6 dan format MR scenario komunitas

Pertemuan mandiri

Submit skenario berbasis komunitas ke sekretariat TKB C5 maksimal tanggal…X

7 UMPAN BALIKUmpan balik Informed and Shared Decision Making dan pemberdayaan masyarakat (Panduan umpan balik 5A Fase ASSESS & ADVICE, Tabel 4 dan Appendix 4 penilaian IPE)

IV C.4 Jadwal menyusul Praktikum

55

NO KEGIATAN WAKTU KETERANGANMINGGU BLOK HARI & TANGGAL JAM8 PENUGASAN LAPANGAN II

Eksplorasi dari intervensi lanjutan yang telah dilakukan Intervensi program penanggulangan PTM (Panduan 5A Fase ASSIST & ARRANGE FOLLOW UP)

III C.5 Sabtu, 9 April 07.00-11.50 Lapangan

9 Presentasi laporan dengan DPL III C.5 Sabtu, 9 April 12.30-14.00 Praktikum10 Mahasiswa mengisi portfolio untuk fase terkait (upload

GAMEL) sebagai bahan sesi Umpan Balik dg DPF (Gunakan appendix 2: Format Portfolio – upload beserta bukti-bukti belajar)

IV C.5 Senin – Jumat (sebelum melakukan umpan balik)

11 Mahasiswa dari kelompok tutorial yang sama merumuskan skenario berbasis komunitas yang akan di gunakan untuk tutorial di Blok C.6 (sesuai kata kunci oleh TKB C6: Life style – dalam konfirmasi)

C.5 Pertemuan mandiri

Submit skenario berbasis komunitas ke sekretariat TKB

C6 maksimal tanggal…X

12 UMPAN BALIKUmpan balik Informed and Shared Decision Making, pemberdayaan masyarakat (Panduan 5A Fase ASSIST & ARRANGE FOLLOW UP, Tabel 4 dan Appendix 4 penilaian IPE))

IV C.5 Jadwal menyusul 3 Jam Praktikum

13 PERSIAPAN PENGABDIAN MASYARAKAT di akhir semester

C.5

Usulan TOR pengabdian masyarakat oleh mahasiswa (aturan menyusul)

56

NO KEGIATAN WAKTU KETERANGANMINGGU BLOK HARI & TANGGAL JAM13 PENUGASAN LAPANGAN III

Eksplorasi dari intervensi lanjutan yang telah dilakukan Intervensi program penanggulangan PTM (Panduan 5A Fase ASSIST & ARRANGE FOLLOW UP)

II C.6 Sabtu, 14 Mei 07.00-11.50 Lapangan

14 Presentasi laporan dengan DPL II C.6 Sabtu, 14 Mei 12.30-14.00 Praktikum15 Mahasiswa mengisi portfolio untuk fase terkait (upload

GAMEL) sebagai bahan sesi Umpan Balik dg DPF III C.6 Senin – Jumat (sebelum melakukan umpan balik)

16 UMPAN BALIKUmpan balik Informed and Shared Decision Making (Panduan umpan balik 5A Fase ASSIST & ARRANGE FOLLOW UP, Tabel 4 dan Appendix 4 penilaian IPE)

III C.6 Jadwal menyusul 3 jam Praktikum

PENGABDIAN MASYARAKATKegiatan bakti sosial, promosi kesehatan massa

C.6

Pemenang TOR Grant Pengabdian Masyarakat akan

melaksanakan kegiatan ini

Pemenang grant mendapatkan sertifikat dan grant pengabdian

masyarakat

17 Penilaian oleh DPLPresentasi hasil laporan kegiatan dan evaluasi (DPL) Format ppt di Appendix 1 dan penilaian IPE Tabel 4 dan Appendix 4)

IV C.6 Jadwal menyusul 3jam Penilaian terjadwal

18 Mahasiswa memperbaiki portfolio untuk seluruh fase ADVICE, ASSIST, ARRANGE FOLLOW UP (upload GAMEL) sebagai bahan penilaian portfolio oleh DPF

C.6 Mandiri

19 Penilaian oleh DPFPenilaian Portfolio Laporan Aktivitas Belajar Mahasiswa Semester VI (Oleh DPF) Panduan penilaian portfolio Appendix 3

IV C.6 Penilaian terjadwal

Mbak Berlin, mohon yang blok kuning dijadwalkan dan TIDAK Hari Sabtu

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