Critical Appraisal

CLINICAL ATTACHMENT BLOCK 1.6-BASIC MEDICAL PRACTICE KALSYANA RAJENDRAH 12/340730/KU/15372 TUTORIAL GROUP 1 FACULTY OF MEDICINE INTERNATIONAL PROGRAMME UNIVERSITAS GADJAH MADA GENERAL OBSERVATION Introduction This exclusive practical session revolves around students’ attachment to family doctor or general practitioner. Beforehand, a sound understanding and distinguishable comparison between these two specialty is necessary to perform this task efficiently.

Family medicine is a medical specialty that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and all parts of the body. It is based on knowledge of the patient in the context of the family and community, emphasizing disease prevention and health promotion. According to the World Organization of Family Doctors, the aim of family medicine is to provide personal, comprehensive and continuing care for the individual in the context of the family and community. On the other hand, general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education to patients. The good general practitioners will treat patients both as people and as a population. In some healthcare systems general practitioners work in primary care healthcare centers where they play a central role in the healthcare team. Nevertheless, in some models of care general practitioners work as single-handed practitioners. In conjunction with this block, I visited a local puskesmas to understand more about role of a general practitioner and family physician. Physical Access , Convenience and Facilities The clinic I was designated to is Puskesmas Danurejan I. The puskesmas is located in Bausasran, Danurejan in Yogyakarta. After being renovated and improvised since December 2011, Puskesmas Danurejan possesses new physical structure and more sophisticated facilities. Now, the puskesmas has a new building, whereas the ground floor serves as an infectious and non-infectious area. The puskesmas is almost 656 meter squared in size with general consultation rooms, dental consultation rooms, emergency room, pharmacy and laboratory fitted in the ground floor. On the other hand, the first floor serves as the supporting facility . This floor contains the office, hygiene and sanitation department and prayer room. This health center is located in the midst of housing estates, and therefore very accessible to those living within close proximity. The housing area is also densely populated, with numerous shops, public amenities which makes it a rather ideal and conducive stay. The puskesmas is open daily on weekdays and Saturdays from 7.30am to 3.00pm. The puskesmas also has a landline which makes it reachable for any prior information before the peoples’ visit. One distinct setback of the setting is that of, the signboard was unclear and hidden in tree branches. The direction guiding the visitors are vague and not specified. This may be inconvenient for anyone who is about to make their very first visit without prominently knowing the location. Furthermore, there were not enough parking lots near the puskesmas. The Waiting Room The waiting room is spacious, sufficient to fit about 20 patients at an instance with appropriate number of chairs provided. The cleanliness and tidiness of the waiting room is also well maintained . There were garbage bins provided. The ventilation of the room is also well considered as there are presence windows for good air movement. Huge healthcare pamphlets and banners are also seen in the waiting room, aimed educate and enlighten patients. A staff was

observed in the waiting area as she is assigned to take vital signs of the patients and direct them to the physician as their turn comes. As we were walking pass the waiting room, I noticed surreptitious gazes from the patients who were rather clueless of our enthusiastic presence with white coats. I managed to start a conversation with a few patients even before tending to the consultation room for observation. Patient Load and Examination Room The patients who visit this puskesmas are mostly from the community living within close proximity to the center. Apparently, the densely populated housing estate are attracted to the recently renovated health center. The health center receives a generous average of 40 patients daily, most probably due to the satisfactory health care received and affordable charges. The examination room is rather small but sufficient to carry out basic physical examination, equipped with racks, table for physician and an examination bed. During my observation period, the physician received 5 patients. in which 3 of them were regular patients under controlled medications (hypertension and diabetes mellitus patients), with the other 2 having ordinary fever and viral flu. According to the doctor, most of his patients are children with acute illnesses and elderly patients facing chronic diseases. However, any serious medical complication which cannot be diagnosed or treated by the doctor is referred to the possible hospital. SPECIFIC OBSERVATION Physician-Patient Communication Based on my observation, the physician seemed to have mastered all crucial skills in order to provide the best for the patient. Firstly, I would like to discuss about the primary care management of the physician towards the patient. The doctor successfully connects with the patient via good communication and interpersonal skills, and subsequently put the patient at ease to express his complaints and condition. Therefore, the physician is able do deal competently with the problems presented to her. Even though the physician I observed has just completed internship, she has an amazing person centered care towards each of her patient. She understands and relates her patients as individuals and developed the ability to work in partnership. The physician encountered various different cases involving different ranging from a myriad of genders, age group and illness. However, she applies specific problem-solving skills about the context-specific aspects of general practice and successfully dealt with undifferentiated illness and skills. The duration of consultancy was about 10 minutes per patient for chronic diseases like hypertension and diabetes mellitus and the interaction process took about 5 minutes. Shortly after my observation, I managed to have a word with the physician. She explained to me that the key to a good family physician is the comprehensive approach. It is about how one as a physician must be able to co-ordinate care of acute illness, chronic illness, health promotion and disease prevention in the general practice setting. Not to forget, to respect and honor the patients for an impeccable physician-patient communication. Besides she emphasized the importance to keep patients informed about their condition, listen and respect their views about their health and respond to their question. Documentation and Medical Records The medical records are stored very systematically in the center. There is an allocated room with limited accessibility to keep all of the documents safely in order to avoid breach of confidentiality of the documents. Only the administration personnel are permitted to enter. As we were informed, the documents of the medical record has been computerized using a programme called MedCis System. However, the manual means are still practiced in the physicians desk. The information is then transferred by the administration personnel. The medical record on the physicians desk is a piece of white-colored paper with patient identity particulars such as name, age, gender, registration number, and consultation date at the top. The remainder of the page is filled up by writing by the doctor himself, which are anamnesis, medical history, drug allergies, vital sign results, physical examination results, diagnosis, treatment and prescription. By the implementation of the computerized system, loss of data due to natural disaster is prevented. Besides, the patients

privacy and confidentially is recognised as the system is well secured, in the sense no changes of previous medical history is made possible. The system can only be viewed by physicians for follow-ups and patient himself upon request. Clinical Care Processes The overall process of treatment is very structured indeed. It begins with registration and recording of vital signs. Later, the patients are directed accordingly to the appropriate departments namely psychology, nutrition, general consultation and dental consultation. After receiving their treatment, they were to settle payments before collecting their prescription from the pharmacy. As per clinical care specifically, the physician has performed necessary procedures to diagnose and treat the patient. The physician accomplishes her role as a family physician very successfully. Her anamnesis was very detailed and intricate. She thoroughly skims the past medical history, medication history, and latest prescription before she proceeds further. Concerning chronic diseases of the elderly like hypertension, she initiated by asking the patient how did they feel lately and if there were any relieve or aggravation from their condition. As the temperature, height, weight, blood pressure, respiratory rate and pulse rate has been obtained earlier from the registration personnel, she proceeds with treatment and prescription. The physician prescribes simple generic medicine for the patient which was available in the pharmacy. As for the child, she performed basic physical examination as he complained of body ache. I also observed that treating an elderly person and a child requires different approach altogether. Obviously, they had to be nurtured with care and respect. The physician was seen to have given importance to personal safety by the usage of gloves, masks, and hand sanitizer. This is an undisputedly important step to prevent nosocomial infections in the health center. One setback that I observed was in terms of educating the patients. The physician only provided the patients with very minimal input and education. Payment There are several paying methods made feasible by the puskesmas to facilitate the patients, namely insurance coverage and direct payment. For instance, Jaminan Kesihatan Masyarakat, Jaminan Kesihatan Daerah, Jaminan Kesihatan Social, Jaminan Kesihatan Persendirian and Jaminana Kesihatan AKS. Patients who owns insurance coverage as mentioned need not make any payment, whereas those without pays an amount as low as RP5000.00. However, the medications has to be purchased by the patients at their own expense. For the most part of my observation, the patients receives prescription of their medication to be purchased themselves in the pharmacies, unless generic medicines which are provided in the puskesmas. I could deduce that the charges are very affordable compared to that of private practices. Therefore, quality medical care is made accessible to everyone regardless of their economic background. This is indeed extremely favorable in reaching out to the needs of the people in an actively developing region. Discussion In the context of satisfactory health care, patients gratification is substantial. This explains why health care providers should make extraordinary efforts in providing the best achievable standards of health care. In the context of Indonesia, family medicine is developing slowly, however a clear structure and guideline for patients has not been constructed. On the other hand, due to limited number of specialist available, most specialists carry out private general practice outside their work hours. This may reduce the efficiency of the physicians due to stress and overwork. Moreover, the general practitioners training programme is not welcomed and well supported by the specialist because they are held in direct competitions with the general practitioners. Pertaining the clinical attachment, the physician tried their level best to provide appropriate health care to her patients despite the limited resources. However, there is also abundant room for improvement in terms of educating the patient about prevention of diseases and the effects of medication prescribed. Besides, the physician should have given more enlightenment when concerning lifestyle related

diseases, because at all times, prevention is better than care. On the whole, the entire health care team should work on the regulations concerning controlled medication to avoid abuse and overuse. Another most crucial point in family medicine is the community orientation. Community orientation is about the physical environment of your practice population, the need to understand the interrelationship between health and social care, and the tensions that may exist between individual wants and needs and the needs of the wider community. As a conclusion, holistic approach is about your ability to understand and respect your patients’ values, culture, family beliefs and structure, and understand the ways in which these will affect the experience and management of illness and health. I am very contented to be granted an opportunity for this clinical attachment. This would, in time, help me in my future endeavors as a doctor. Reference Allen, J, Hibble, A, Rughani, A 2012, Being a General Practitioner, Royal College of General Practitioner, viewed 20th June 2013, 012/RCGP-Curriculum-1-Being-a-GP.ashx General Practitioners Committee of the BMA and the Royal College of General Practitioners, 2008, Good Medical Practice for General Practitioners London: RCGP, viewed 20th June 2013 Thistlethwaite, JE, 2002, Making And Sharing Decisions About Management With Patients: the views of House Officers In General Practice And Hospital Medical Education 2002; 36: 49-55 Dr. Adi Utarini, [Universitas Gadjah Mada] 2013, Pre Attachment, Home Visit, and Field Trip Briefing, 13th June 2013 Wijayanti,MA, et al. 2013, Block Book 1.6 Basic Medical Practice, 6th edition, Faculty of Medicine Universitas Gadjah Mada, Yogyakarta
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