JOURNAL OF TROPICAL PEDIATRICS, VOL. 60, NO. 2, 2014
Research Letter
Teaching Primary Care in Pediatric Outpatient Department in Developing Countries: A Feasibility Study by Subhashchandra R. Daga, Eric DSouza, Dipali Ambike, and Sameer Mhatre Department of Paediatrics, MIMER Medical College, Talegaon Dabhade-4110516, India Correspondence: Subhashchandra Daga, Department of Pediatrics, MIMER Medical College, Talegaon, Dabhade-410507, India. Tel: þ91 02114 308 416, Fax: +91 02114 223 916; E-mail .
Key words: undergraduate teaching, pediatric teaching, OPD teaching, primary care.
Introduction Most of the clinical teaching in pediatrics takes place on inpatients. The outpatient department (OPD) is considered to be an appropriate forum for teaching preventive medicine [1].The importance of teaching primary care pediatrics in a country like India cannot be overemphasized. OPD teaching is hindered owing to insufficient space [2], more so with the everincreasing number of students per rotation term per batch, and because of time constraints. There is insufficient time to teach in OPD because the teacher is invariably faced with the conflict of limited time available for simultaneous clinical care and service provision along with medical student education. Often, a child is brought to a hospital only when ill. Therefore, such an opportunity should be used to examine the primary care needs of a child and also to teach primary care in a compact manner. Such training is expected to bring about a major change in the understanding and approach of an undergraduate student toward a pediatric patient. We
Acknowledgements S.R.D.: Conceptualization, Developing the strategy, Implementation, Writing the manuscript. E.D.: Developing the strategy, Implementation. D.A.: Developing the strategy, Implementation. S.M.: Developing the strategy, Implementation. All the authors read and approved the final draft.
created a framework for a new untested strategy for OPD teaching that may prove effective. Material and Methods Medical students (M.B.B.S. course) in their final undergraduate year, eighth semester, were chosen for OPD teaching. This report covers 49 students, two batches consisting of 25 and 24 students. For this activity, four 30 min sessions on consecutive days after the regular ward teaching were scheduled. The components of OPD teaching were introduction to the subject; growth monitoring by both weightfor-age and weight-for-height parameters; taking immunization history as per the National Immunization Programme; detection of danger signs for hospital care as per the Integrated Management of Newborn and Child Illness criteria; and clinical assessment and management of three common illnesses, namely, fever and cough, cold and fever and diarrhea as per our hospital protocol. This was followed by communication with parents about the child’s illness and treatment plan. During the spare time in rotational term, 15 min recap sessions were undertaken to ensure that each student was able to perform precise growth monitoring. The case management protocols were discussed at least two times. A test was offered toward the end of the clinical rotation. It had two components: (i) demonstration of growth monitoring on a patient and (ii) oral questions, conducted at two separate assessment stations. The same questionnaire was administered to each
ß The Author [2013]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected] doi:10.1093/tropej/fmt088 Advance Access published on 10 November 2013
174
Downloaded from http://tropej.oxfordjournals.org/ at North Dakota State University on May 23, 2015
Summary We studied the feasibility of teaching primary care to undergraduate medical students in an outpatient department (OPD) using a specially developed teaching package. Teaching was conducted in four 30 min sessions during a 4 week rotation term, and a test was offered at the end. We concluded, on the basis of grades achieved in the test, that it is feasible to impart primary care knowledge through OPD teaching using structured teaching goals for teachers.
RESEARCH LETTER
Ethics The study was approved by the institution’s ethics committee. Results The scores were as follows. First batch (25 students): excellent, 7; good, 10; fair, 6 and poor, 2. Second batch (24 students): excellent, 5; good, 12; fair, 6 and poor, 1. Performance at growth monitoring was generally good. Discussion Most cases attend the OPD for treatment of illnesses such as upper respiratory conditions, diarrhea without dehydration, and fever, or for vaccinations. These patients have few demonstrable signs. Yet, it is very important that students learn the OPD routine. The scope for teaching within the OPD has to be enhanced to include primary care in a compact manner. Clinical material is widely available in the OPD; however, it is of a wider range, whereas uncommon conditions and emergencies are seen more among inpatients [3]. Therefore, the right blend of OPD and inpatient teaching is highly desirable. We tried to adhere to commonly accepted guidelines pertaining to immunization [4], growth monitoring [5] and danger signs [6], and avoided any major deviation from what was taught in community medicine. The ingredients of OPD teaching are not new, but integrating them in a compact manner for OPD teaching may be a new concept. OPD teaching was a new experience for both the teachers and learners at our center, and both seemed to receive the activity well. It is critical to identify the
Journal of Tropical Pediatrics
Vol. 60, No. 2
students for OPD teaching at the right curriculum stage, neither too early nor too late, in the course of their undergraduate training. For example, at our institute the students rotate to pediatrics during the fourth semester for 2 weeks, during the eighth semester for 4 weeks and during the ninth semester for 4 weeks. The fourth semester posting is too early and too short for integrating OPD teaching, and is devoted to teaching history-taking and physical examination. The ninth semester is too close to the final examination and students tend to concentrate more on and prioritize ‘examination-oriented’ learning. We believe that the eighth semester is the right time to undertake OPD teaching. As this rotation is sufficiently long, students are likely to be more receptive. Similarly, OPD teaching should be an add-on to clinical learning in the wards rather than become a full-day activity. In this way, the learners’ interest is adequately sustained during this predominantly passive exercise and also the time devoted for bedside learning is not reduced. The amount of learning is influenced by student ability and is measured by examination performance. We made an attempt to evaluate our teaching activity by offering a test at the end of the clinical rotation with an objective questionnaire with dichotomous answers. The performance of the students was encouraging, particularly in growth assessment. There is a scope for further critical appraisal of the course contents through feedback from students as well as teachers on course contents, duration of teaching, curriculum stage or format of the test to be offered. The efforts to define effective approaches to OPD teaching may continue. However, there is little doubt of the need and feasibility of this activity. References 1. McGee SR, Irby DM. Teaching in the outpatient clinic. J Gen Intern Med 1997;12(S2):S34–40. 2. Bardgett RJM, Dent JA. Teaching and learning in outpatients and beyond: how ambulatory care teaching can contribute to student learning in child health. Arch Dis Child Educ Pract Ed 2011;96:148–52. 3. Duckwall JM, Alul IH, Arnold LM, et al. Educating students in a general medicine ambulatory clinic: a pilot study. Teach Learn Med 1989;1:92–6. 4. Immunization handbook for medical officers. Department of health and family welfare, Government of India, 2008. 5. A joint statement by the World Health Organization, the world food programme, the United Nations system standing committee on nutrition and the United Nations children’s fund Geneva: World Health Organization, 2007. 6. Integrated management of neonatal and childhood illness World Health Organization and Ministry of Health and Family Welfare, Government of India, 2003.
175
Downloaded from http://tropej.oxfordjournals.org/ at North Dakota State University on May 23, 2015
medical student to maintain uniformity for assessment. Each student was asked the following questions: (i) danger signs in a young infant or in a child; (ii) one question on immunization; (iii) demonstration of growth monitoring using both methods; (iv) one question on any one of the following clinical signs: pallor, fever or dehydration; and (v) management of one of the three common ailments, namely, fever and cough, cold and fever, and diarrhea. The same questionnaire was administered to each medical student to maintain uniformity for assessment. Thus, a student was assessed under five headings, carrying a total of six marks. Each correct answer was awarded one mark, except for the answer to the growth monitoring question that carried two marks. The grading was done according to marks scored: excellent, 6; good, 5; fair, 3 and 4; and poor, less than 3. The question on communication skills was not included in assessing the total score because it involved qualitative assessment.
Research Letter
Teaching Primary Care in Pediatric Outpatient Department in Developing Countries: A Feasibility Study by Subhashchandra R. Daga, Eric DSouza, Dipali Ambike, and Sameer Mhatre Department of Paediatrics, MIMER Medical College, Talegaon Dabhade-4110516, India Correspondence: Subhashchandra Daga, Department of Pediatrics, MIMER Medical College, Talegaon, Dabhade-410507, India. Tel: þ91 02114 308 416, Fax: +91 02114 223 916; E-mail .
Key words: undergraduate teaching, pediatric teaching, OPD teaching, primary care.
Introduction Most of the clinical teaching in pediatrics takes place on inpatients. The outpatient department (OPD) is considered to be an appropriate forum for teaching preventive medicine [1].The importance of teaching primary care pediatrics in a country like India cannot be overemphasized. OPD teaching is hindered owing to insufficient space [2], more so with the everincreasing number of students per rotation term per batch, and because of time constraints. There is insufficient time to teach in OPD because the teacher is invariably faced with the conflict of limited time available for simultaneous clinical care and service provision along with medical student education. Often, a child is brought to a hospital only when ill. Therefore, such an opportunity should be used to examine the primary care needs of a child and also to teach primary care in a compact manner. Such training is expected to bring about a major change in the understanding and approach of an undergraduate student toward a pediatric patient. We
Acknowledgements S.R.D.: Conceptualization, Developing the strategy, Implementation, Writing the manuscript. E.D.: Developing the strategy, Implementation. D.A.: Developing the strategy, Implementation. S.M.: Developing the strategy, Implementation. All the authors read and approved the final draft.
created a framework for a new untested strategy for OPD teaching that may prove effective. Material and Methods Medical students (M.B.B.S. course) in their final undergraduate year, eighth semester, were chosen for OPD teaching. This report covers 49 students, two batches consisting of 25 and 24 students. For this activity, four 30 min sessions on consecutive days after the regular ward teaching were scheduled. The components of OPD teaching were introduction to the subject; growth monitoring by both weightfor-age and weight-for-height parameters; taking immunization history as per the National Immunization Programme; detection of danger signs for hospital care as per the Integrated Management of Newborn and Child Illness criteria; and clinical assessment and management of three common illnesses, namely, fever and cough, cold and fever and diarrhea as per our hospital protocol. This was followed by communication with parents about the child’s illness and treatment plan. During the spare time in rotational term, 15 min recap sessions were undertaken to ensure that each student was able to perform precise growth monitoring. The case management protocols were discussed at least two times. A test was offered toward the end of the clinical rotation. It had two components: (i) demonstration of growth monitoring on a patient and (ii) oral questions, conducted at two separate assessment stations. The same questionnaire was administered to each
ß The Author [2013]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected] doi:10.1093/tropej/fmt088 Advance Access published on 10 November 2013
174
Downloaded from http://tropej.oxfordjournals.org/ at North Dakota State University on May 23, 2015
Summary We studied the feasibility of teaching primary care to undergraduate medical students in an outpatient department (OPD) using a specially developed teaching package. Teaching was conducted in four 30 min sessions during a 4 week rotation term, and a test was offered at the end. We concluded, on the basis of grades achieved in the test, that it is feasible to impart primary care knowledge through OPD teaching using structured teaching goals for teachers.
RESEARCH LETTER
Ethics The study was approved by the institution’s ethics committee. Results The scores were as follows. First batch (25 students): excellent, 7; good, 10; fair, 6 and poor, 2. Second batch (24 students): excellent, 5; good, 12; fair, 6 and poor, 1. Performance at growth monitoring was generally good. Discussion Most cases attend the OPD for treatment of illnesses such as upper respiratory conditions, diarrhea without dehydration, and fever, or for vaccinations. These patients have few demonstrable signs. Yet, it is very important that students learn the OPD routine. The scope for teaching within the OPD has to be enhanced to include primary care in a compact manner. Clinical material is widely available in the OPD; however, it is of a wider range, whereas uncommon conditions and emergencies are seen more among inpatients [3]. Therefore, the right blend of OPD and inpatient teaching is highly desirable. We tried to adhere to commonly accepted guidelines pertaining to immunization [4], growth monitoring [5] and danger signs [6], and avoided any major deviation from what was taught in community medicine. The ingredients of OPD teaching are not new, but integrating them in a compact manner for OPD teaching may be a new concept. OPD teaching was a new experience for both the teachers and learners at our center, and both seemed to receive the activity well. It is critical to identify the
Journal of Tropical Pediatrics
Vol. 60, No. 2
students for OPD teaching at the right curriculum stage, neither too early nor too late, in the course of their undergraduate training. For example, at our institute the students rotate to pediatrics during the fourth semester for 2 weeks, during the eighth semester for 4 weeks and during the ninth semester for 4 weeks. The fourth semester posting is too early and too short for integrating OPD teaching, and is devoted to teaching history-taking and physical examination. The ninth semester is too close to the final examination and students tend to concentrate more on and prioritize ‘examination-oriented’ learning. We believe that the eighth semester is the right time to undertake OPD teaching. As this rotation is sufficiently long, students are likely to be more receptive. Similarly, OPD teaching should be an add-on to clinical learning in the wards rather than become a full-day activity. In this way, the learners’ interest is adequately sustained during this predominantly passive exercise and also the time devoted for bedside learning is not reduced. The amount of learning is influenced by student ability and is measured by examination performance. We made an attempt to evaluate our teaching activity by offering a test at the end of the clinical rotation with an objective questionnaire with dichotomous answers. The performance of the students was encouraging, particularly in growth assessment. There is a scope for further critical appraisal of the course contents through feedback from students as well as teachers on course contents, duration of teaching, curriculum stage or format of the test to be offered. The efforts to define effective approaches to OPD teaching may continue. However, there is little doubt of the need and feasibility of this activity. References 1. McGee SR, Irby DM. Teaching in the outpatient clinic. J Gen Intern Med 1997;12(S2):S34–40. 2. Bardgett RJM, Dent JA. Teaching and learning in outpatients and beyond: how ambulatory care teaching can contribute to student learning in child health. Arch Dis Child Educ Pract Ed 2011;96:148–52. 3. Duckwall JM, Alul IH, Arnold LM, et al. Educating students in a general medicine ambulatory clinic: a pilot study. Teach Learn Med 1989;1:92–6. 4. Immunization handbook for medical officers. Department of health and family welfare, Government of India, 2008. 5. A joint statement by the World Health Organization, the world food programme, the United Nations system standing committee on nutrition and the United Nations children’s fund Geneva: World Health Organization, 2007. 6. Integrated management of neonatal and childhood illness World Health Organization and Ministry of Health and Family Welfare, Government of India, 2003.
175
Downloaded from http://tropej.oxfordjournals.org/ at North Dakota State University on May 23, 2015
medical student to maintain uniformity for assessment. Each student was asked the following questions: (i) danger signs in a young infant or in a child; (ii) one question on immunization; (iii) demonstration of growth monitoring using both methods; (iv) one question on any one of the following clinical signs: pallor, fever or dehydration; and (v) management of one of the three common ailments, namely, fever and cough, cold and fever, and diarrhea. The same questionnaire was administered to each medical student to maintain uniformity for assessment. Thus, a student was assessed under five headings, carrying a total of six marks. Each correct answer was awarded one mark, except for the answer to the growth monitoring question that carried two marks. The grading was done according to marks scored: excellent, 6; good, 5; fair, 3 and 4; and poor, less than 3. The question on communication skills was not included in assessing the total score because it involved qualitative assessment.
