Dr Mora Claramita: Lyn Clearihan award winner 2012
Dr Mora Claramita: Lyn Clearihan award winner 2012
Dr Mora Claramita
The Asia Pacific Family Medicine Journal was born out of a need to provide a voice for regional research in the Asia Pacific region. For the third time, the Lyn Clearihan Award for the best research paper published in the journal in the preceding twelve months has been awarded. This year the winner is Dr Mora Claramita, of Indonesia, for her article, Are patient-centered care values as reflected in teaching scenarios really being taught when implemented by teaching faculty? A discourse analysis on an Indonesian medical school’s curriculum.
Dr Claramita works in the Skillslab (Department of Medical Education) Universitas Gadjah Mada (UGM), in Yogyakarta, Indonesia.
PhD at Maastricht University
Dr Mora Claramita has had a big year, as on March 30 2012, she defended her PhD thesis titled Doctor-patient communication in a culturally hierarchical context of Southeast Asia: a partnership approach at Maastricht University, the Netherlands.
The PhD addressed culturally specific communication issues. The main tasks of doctors are to identify the patients’ problems or to diagnose, and find and deliver the appropriate treatment. It has become increasingly clear in the last decades that doctor-patient communication is at the heart of that medical consultation. The patient can contribute to the process of diagnosing and needs to be involved in treatment decisions. Many doctor-patient communication guidelines developed in western contexts favour a partnership communication style. The question was whether this style fits in the Southeast Asian (SEA) context. In her thesis, based on several published papers, Dr Claramita explores the current doctor-patient communication style in SEA, the perceptions of doctors and patients on communication, and studies a more suitable communication guideline for SEA, including the question of implementation.
During the PhD ceremony tough questions were posed about several topics, which Dr Claramita answered convincingly. All opponents also praised her work, which has great relevance not only for Indonesia, SEA but also for the Dutch society, which is also becoming more multicultural. At the end of the ceremony Dr Claramita received her PhD diploma from Prof Cees van der Vleuten, her Maastricht promoter, in the presence of Prof Hardyanto Soebono, her UGM promoter, and Dr Jan van Dalen,
her Maastricht co-promoter. Some senior colleagues from UGM were involved in her study: Prof Hardyanto Soebono, Prof Adi Utarini and Dr Yayi Suryo Prabandari.
UGM can be very proud of this colleague!
Prof Job FM Metsemakers
Chair Department of Family Medicine
From Dr Claramita - A National Proposal for Indonesia
Hi, I am Mora Claramita, a general practitioner from Indonesia. I come from middle of Java Island, Yogyakarta city. I graduated as a medical doctor from Gadjah Mada University, in Indonesia, in 2000. After graduation, I continued to work and study medical education for my master and doctorate degrees in Maastricht University, The Netherlands. My dissertation was about Doctor-patient communication in a hierarchical context of Southeast Asia: a partnership approach1. Cees van der Vleuten, Hardyanto Soebono and Jan van Dalen were my promoters.
A study on medical education
I was interested in studying medical education because I felt that there was probably something amiss in educating future doctors, in my local context. Therefore, I wanted to do something better for the next generation of health professionals.
One of results of studying medical education was that I could prove that the problem scenarios presented to medical students reveal the opposite to the learning objectives presented. The students first read the scenario which contains patient-centred principles. However, the teachers drive the tutorial discussion process into more doctor-centred learning objectives. As a result, the curriculum which is oriented towards family medicine might not achieved 2.
Thank you for all readers, coauthors and reviewers who brought this study to the judges of the best paper of the Asia-Pacific Family Medicine Journal, in 2012. Our Family Medicine Team and I, felt a huge appreciation from my colleagues for achievement of The Third Lyn Clearihan Award for this paper.
My studies in the area of doctor-patient communication had been opened my eyes to the reality of health care services in Indonesia. Doctor-patient communication looks very complicated in the setting of this study, not just because of the hierarchical culture of interactions between doctors and patients. Complex clinical settings and referral systems are also present. In Indonesia, which currently has more than 80,000 GPs; a Medical Doctor (MD) with only one year internship, can apply directly for a licence of professional practice as a general practitioner (GP).
However, Indonesia has to be careful of this system because: the medical schools’ curriculum may not achieve its goal of orientation towards family medicine, as proven in my study. Furthermore, it is not clear who the teachers during the internship program are, as there is no specialty in Family Medicine / General Practice, in Indonesia. The internship program takes place mostly in hospitals. When a GP is educated only by specialist doctors, the primary care principles may not be properly comprehended. On top of that, GPs who stay in one community may/ may not gain proper continuing education program in primary care. With the current situation that patients can go directly to any doctor they want, “continuity of care”, “comprehensive-care”, “patient-centred care”, “holistic-care” and any other principles of primary care or family medicine are certainly neglected 3,4.
Medical teachers may be unaware of this situation because faculties of medicine usually are in the big cities of Indonesia where all specialties are available. “Refer to specialist” is a common sentences in the scenarios presented to the third year medical
students. What happens to people 30 kilometres outside big cities where specialists are rare? What happens to people in rural areas if a GP cannot manage the clinical case because of inadequate training?
I would like to propose a national initiative towards accessible high quality primary health care with family doctors as the backbone for every citizen of Indonesia and for other countries in which family medicine is not yet established:
- Provide easy access for every citizen to high quality primary health care with family doctors as the backbone.
- Provide an adequate professional remuneration system for all doctors from all specializations, so that doctors do not expect their patients to be sick and come to them – for earning money.
- Provide an adequate health insurance program for all citizens, not only paying for ill patients but also paying for keeping them healthy by regular check-ups.
- Adequate training for general practitioners as a postgraduate specialization, equal to other specialization training in the country. Adequate clinical ability obtained from adequate length of graduate education is the goal.
- Keeping the doctors well-trained by allocating budget for better recruitment, training and continuing education programs for health professionals.
When I graduated as an MD, I was able to diagnose a patient’s problem for example, hypertension, but was not able to provide an adequate care-plan. Then I met Mark Graber, from Carver College of Medicine IOWA, a professor in Emergency and Family Medicine. I joined some bed-side teaching with him and I learnt so much about delivering the best primary care to my patients. Together with Mark, we created a postgraduate certification program for a three months’ period, for doctors in Yogyakarta. About 10 doctors participated and they felt more confident and more knowledge and skills gained during the course. Unfortunately most of them resigned in the last month because they said that without recognition at the end of the program, their patients will not know that they had done additional training.
To create a postgraduate program for family medicine in Indonesia is like the “chicken and egg” problem. We want to produce “the egg” but the authority said that we have “no chicken” so we cannot produce. “Chickens” who would like to help from outside the country will not be accepted. In a situation like this, what I can do is to help medical students to learn more about primary health care and its importance. Together with my colleagues from Gadjah Mada University, Maastricht University and IOWA Carver College of Medicine, I continue to do early exposure in primary health care settings through a collaborative joint research program. For this program I also collaborate with 27 Primary Health Care Centres (Puskesmas) in Yogyakarta and 11 NGOs (including SHEEP-Indonesia, LESSAN and KEBAYA) who are committed towards better primary health care services. I am happy to continue to inspire young doctors who are impatient to change towards better learning and better health care services.
Primary Health Care should be now more than ever as stated by the WHO 5.
Mora Claramita, MD, MHPE, PhD
Acknowledgment: Thank you to Professor Job Metsemakers who keeps inspiring me. Thank you for Retno Sutomo, Mei-Neni, Shinta Prawitasari, Ova Emilia, Gandes Retno Rahayu, I Dewa Putu Pramantara, Bambang Udji Djoko Rianto, Abu Tholib,
Mansyur Romi, Soenarto Sastrowijoto, Mahar Agusno, Abdul Ghofir, Astuti, Istiti Kadarina, Armis, Sunartini Hapsara, Wasilahrohmah, Bambang Djarwoto, Fitriana Murriya, Tyagita Swasti, Henny Wulandari, Wahyudi Istiono and Adi Heru Sutomo and all friends and colleagues from other specialities who work together for the development of Family Medicine in Indonesia.
- Claramita M. 2012. Doctor-patient communication in Southeast Asia: A partnership approach. A doctoral dissertation submitted to Maastricht University The Netherlands. Yogyakarta: Tiara Wacana
- Claramita M, Sutomo AD, Graber MA, Schrepbier A. Are patient-centered care values as reflected in teaching scenarios really being taught when implemented by teaching faculty? A discourse analysis on an Indonesian medical school’s curriculum. Asia Pacific Family Medicine 2011, 10:4 doi:10.1186/1447-056X-10-4
- Gan, L.G., Wonodirekso, S., Azwar, A. 2004. A Primer on Family Medicine Practice. Singapore: Singapore International Foundation
- Graber MA and Wilbur JK. 2009. Specialty Board Review: Family Practice Examination and Board Review. NY: McGrawHills
- World Health Organization. 2012. Primary Health Care: Now More Than Ever. Geneva: WHO Report.