Dokter Blog: from the desk of Rahajeng Tunjungputri

Medicine et cetera by @ajengmd

The Journal Club, Faculty of Medicine Diponegoro University

Earlier this year, together with the tremendous support and enthusiasm from a group of our medical students, I initiated The Journal Club, where its activities now are maintained by the students themselves.

It is essentially a club where we come together and discuss journal articles. The idea is to learn how to read english journal articles, discuss and share ideas.  The most distinguishing aspect of this club is that all the discussion are conducted in english, and we encourage students to improve their own english level as we go along.

At the moment, this program is an extracurricular activity, although heavily stressing on having immediate impact on the students academic skills.

Before every meeting, the students have the chance to read the journal articles. During the meeting, they will have focus group discussion regarding several questions that I ask them in relation to the journal.

Below are the discussion points from our previous 3 meetings so far with the links to the respective journal articles.

For now, our main goal is to continue to improve and reach out to more students who are interested in improving their academic english skills.

First meeting

Second meeting

Third meeting

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RNT Discussion 2012: Identification of Protozoa

This lecture is a part of the Parasitology 1 course of the Faculty of Medicine Diponegoro University.

Images belong to their respective owners, and used for educational purposes only.
The slides can be viewed by clicking here 

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RNT Lecture 2012 : Schistosomes and other flukes

This lecture is a part of the Parasitology 1 course of the Faculty of Medicine Diponegoro University.

DISCLAIMER: No copyright infringement intended. Images are not mine and all copyrights belong to their respective owners. This pdf file is not for sale and for educational purposes only.

The slides can be viewed and downloaded by clicking here 

 

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RNT lecture 2012 Worms of the large intestine

This lecture is a part of the Parasitology 1 course of the Faculty of Medicine Diponegoro University.
Images belong to their respective owners, and used for educational purposes only.
The slides can be viewed and downloaded by clicking here 

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In focus: “Stop shouting. Start teaching.” – article by Christopher Butler

My news feed today lead me to a very interesting article on Smashing Magazine, “Stop Shouting. Start Teaching.” by Christopher Butler

Interestingly, although the website is about design, marketing, marketing design, or design marketing, this one post started the discussion by talking about teaching and how the “mind is being blown” when it’s a good one.

Some interesting excerpts from the article:

“Imagine you are in a classroom. Let’s say a high school classroom. You’re sitting at your desk, listening to your favorite teacher—the one who inspired you, the one who got you excited about that thing you love for the first time.

You’ve stopped taking notes because your body just can’t quite function normally when your mind is being blown. You don’t feel the pen in your hand, or the surface of the desk under your arms. You’re somewhere in between your body and the blackboard. That’s the magic of learning; it’s transportational.

Now, deep breath.
Back to reality.

Perhaps your learning experiences were not like this, but I hope they were. And if they were, did it ever occur to you in those moments that you were being sold something? That the moment was approaching when you’d be asked to sign on the dotted line or open your wallet? When you’d kick yourself for being fooled into thinking that your teacher was offering something to you for free? When you’d learn to stifle the desire and ability to trust someone?

Of course not. What you received came without strings attached; it was a free gift of knowledge to change you, to shape you, to edify you. Not to compel you to buy something.

After all, your teacher wasn’t a marketer.
Right?
Or, was he?

ATTRACT, INFORM, ENGAGE

So, let’s say you’ve got the quality and positioning stuff worked out. You do something good that nobody else does. Fantastic. That is, assuming people know about you. Taking a Field of Dreams approach—if you build it, they will come—won’t work. If you build it, and they know about it, they will come. But even if they come, you’ve got to make sure they understand what it is that they’re coming for. And then you’ve got to make them want to stick around. This is a three-step process: attracting prospects, properly informing them, engaging with them. That is what marketing should be all about. Attract, inform, engage; not attract, mislead, compel.

If you are well positioned, attraction is much easier. Imagine three hot-dog vendors at a baseball game. Two wander up and down the stands, shouting, “Hot dogs! Get your delicious hot dogs here!” Their success is going to come down to luck—who happens to be closest to the right people. But the third vendor sticks to the low seats. He’s shouting, too, except he’s got different dogs to sell: “Low-fat hot dogs! Eat two for the fat of one!” Now who do you think will have an easier time selling hot dogs? The more specific your audience is, the easier it is to attract them.
If you can attract a specific audience, informing is easy, too. You already know something about them and what they need. If you have a worthy solution to that need, all you have to do is tell them about it. That’s where the teaching comes in: Start generally—Introduction to Your Problem, then Our Solution 101—and be prepared to give them more detail as they need it. Incrementally informing, by the way, will also take care of engagement. Give them some, they’ll want more. Ask any engaged student sitting in Advanced Trigonometry 3 why they are there and you’ll likely hear many similar answers, all having to do with being attracted and informed by someone special back in their beginner days.

I know it’s abstract, but if there is one single characteristic of good teachers that could stand to make everything we do—as well as how we market it—better, it’s caring. Good teachers care. They care about the material. They care about how they teach it. They care about their students. If we care too—about what we do, how we do it, and who we do it for—then we’ll be OK.
Resisting the Dark Side
That’s the setup, anyway. But caring is hard. Caring requires a commitment to resisting the very things that currently seem to drive the culture of marketing—things like haste, deception, and even your own ego.”

 

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Neglected people, unseen diseases

This article was published in The Jakarta Post 15 May 2011

 

- Rahajeng Tunjungputri, Contributor, Nijmegen

Most of us cannot imagine that there are hidden diseases that affect billions of the world’s population that have been neglected for so many years. Nevertheless, as hard as this may be to believe, this is indeed the case with neglected tropical diseases (NTDs)…

click here to read full article on The Jakarta Post

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Teachers can bully students too: are you part of the problem?

Teaching is what most doctors do during the period of their training or throughout their career as they encounter medical students or even patients. In fact, the origin of the word doctor, came from the word docere, which means “to teach”.

With regards to a post by Wids about teaching, I was prompt to think about other things that may happen in teaching. Regardless of the teaching and learning environment, in whatever context and level of education, bullying can happen; and the worse part is that the teacher can be the bully. Bullying by teacher happen at the lowest level of primary school education up to the university level.

I have no expertise in discussing the matter. However, I’d still like to point out some important resources about bullying by teachers.

WebMD gives an overview about teachers who bully in http://www.webmd.com/parenting/features/teachers-who-bully while another document by Allan McEvoy provides a more comprehensive information at the site ‘Stop Bullying Now’.

According to McEvoy,

bullying by teachers (or other staff, including coaches,

who have supervisory control over students) is defined as

a pattern of conduct, rooted in a power differential,

that threatens, harms, humiliates, induces fear, or

causes students substantial emotional distress.

Regarding the nature of bullying, the author stated the following:

it is an abuse of power that tends to be chronic

and often is expressed in a public manner.

It is a form of humiliation that generates attention

while it degrades a student in front of others.

In effect, the bullying can be a public degradation ceremony

in which the victim’s capabilities are debased

and his or her identity is ridiculed.

This explanation implies that regardless of the chosen method of bullying or intimidation, the effect on the students is what shows that certain behaviour of a teacher as an act of bullying.

Bullying is not a part of proper teaching. 

Let me repeat this: bullying is not a part of proper teaching.

A set of references about bullying in medicine is provided by Wikipedia here. An anonymous site even regularly posts about academic bullying.

Professional attention bring light to the matter. The British Medical Association (BMA) has a complete guidance for medical students on harassment, intimidation and bullying which aims to provide help when students face bullying by peers or teachers. The British Medical Journal (BMJ) published an article by Tim Field entitled “Those who can, do; those who can’t bully”.

Teaching and learning, as any other aspect of culture, can vary between different settings and countries. Most of the time, in a culture where hierarchy is rigidly maintained, students have to accept bullying without ever having the chance to fight it, or even to consider that they shouldn’t accept such treatment by their teacher. Most will never even realize that they are victims of bullying which may lead them to think that intimidation and humiliation is an acceptable form of teaching and academic life. Well, they are not:  bullying is not a part of proper teaching.

The act of bullying can be continuously practiced freely in academics, and so many are unaware that they themselves are part of the problem. In university, even, there are situations that keep alive the vicious cycle of bullying: when there is no knowledge by the staff and students about bullying; when there is no stance against bullying; when acts of bullying are culturally accepted as normal; when acts of bullying are considered as a part of a teacher’s personality and habit instead of abusive behavior towards students; when acts of bullying are considered as part of educating and teaching professionally; when as a teacher you see fellow teacher who bully students but do nothing to stop it; when the students themselves, not being able to fight back anyway, refuse to see intimidation and verbal abuse as form of bullying by teacher.

Perhaps the first step to prevent bullying by teachers is to be willing to admit that there are teachers who bully their students. Perhaps the first step is to understand that students should not accept the unacceptable behaviour of their teachers towards them: students have to be aware that as long as they respect teachers, they also deserve respect from their teachers.

When this is a matter involving power differential, as stated by McEvoy, then students generally will not have the power, authority nor capacity to fight back on their own. The BMA in United Kingdom for example, has acknowledged the issue of bullying in medical teaching, and has a list of counselors and help line that students can contact to seek help when they experience bullying.

Unfortunately, such help is an unobtainable privilege for most students in other countries. The act of bullying is dismissively considered “normal” and “educative”. The perpetrator keep doing it, and the students are intimidated to accept it.

I will end this by asking some questions I don’t have answers to. To what extent can we apply a universal definition of bullying? Does culture play a prominent role in determining whether a teacher’s actions (and verbal statements) are a form of bullying students? Are certain actions and words by teachers seen as bullying by a certain culture (or country), while being perceived as a normal thing by (students and teachers of) other cultures/countries? To what extent students have the right to be respected by the teachers, and to what extent the teachers acknowledge their obligation to respect students?

But one thing we should know. Bullying is not a part of proper teaching. 

23 June 2011.

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Commentary: Professor Robot, psychiatrists, and overdosing CT-scans

I will add interesting news I stumble upon this week, and write short commentaries and thoughts about them. The original links to the news are available and I make no attempts to summarize these news.

Professor Robot

Kevin Warwick, a professor of cybernetics at the University of Reading, has a silicon chip implanted into his forearm to fire electrical impulses back to the brain and observe whether human could interpret and respond to stimulus sent by computers. The success of this self-experiment may be revolutionary for development of prosthesis. He basically has turned himself into bionic human purely for the sake of research.

If that sounds fascinating, try other examples of self-experimenting scientists in the article: Stubbins Ffirth drank the blackened vomit of yellow-fever patients in his attempts to prove that the disease was not an infectious one, while James Caroll and Jesse Lazear, US army physicians expose themselves to mosquito bites to prove that these vectors are transmitting the disease. Caroll had long-term complications and Lazear died during the course of this experiment.

These scientists have been regarded as either altruist or extremists. While it’s interesting what this may lead to discover, most research in the world of course are based on strict research protocol and recruit volunteers which safety are ensured.

Psychiatrists

This week, G. Harris on The New York Times brought us the story of how psychiatry is a transformed field. Psychiatrists, due to what they say a systemic shift in psychiatry care provision -that is payment by insurance companies-, now are “forced” to “talk less and prescribe more”. They no longer have the time for talk therapy and instead opt to examine and treat patients with high efficiency. This include only asking close ended questions relevant to their chief complaints, and prescribing drugs to allow them to function. The words “quality of life of patients” was not once mentioned in the article.

While this is perhaps the first time there is such exposure on the profession in US, I have sensed it since a few years ago, and this perhaps is already true for other fields of medicine in a country where doctors are paid on an out-of-pocket basis like Indonesia. You can’t afford a 45-minutes appointments when there are no appointments system, and you’re paid exactly the amount of money no matter how much time you spent on a patient. It’s still however, very much different from the practice of medicine in a well-insured country like The Netherlands for example, where it is mandatory to schedule your doctors appointments, and have longer appointments time for new patients and a fixed minimum time for every following appointments.

The article was closed on the note that a physician said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”. But that is not the truth. The truth is that they are already in that position, and they know it, and it’s not just to make a living, it’s to make up the lifestyle that they want.

Click here for the original story

Overdosing CT-Scans

Cabell Huntington Hospital in Huntington, West Virginia are under scrutiny after they were found to perform CT-scan with radiation dose of 10x the necessary dose. This result in serious and dangerous medical side effects for patients as a result of over-radiation. The hospital was not responding adequately to this serious events, while the manufacturer of the CT-scan have filed a report to the FDA that this error was caused by medical technician who had manually increased the radiation to obtain sharper image, which was not necessary to detect pathology on the scans.

I can imagine that this events are not being regularly monitored in many parts of the world, and patient safety are relatively neglected. It’s time that we bring more awareness on this matter.

Click here for the original story

Rahajeng. Nijmegen, 7 March 2011

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We have to go to the books

This writing was previously published on doc2doc.bmj.com

A round table discussion I was in today was amusing. I felt like a child sitting down in Dr. House’s office and hearing everyone works their brain out on an exotic disease. But this is not House. This is real life doctors, discussing real patients.

A young woman was referred from a smaller hospital with encephalitis. Everyone started pitching in on the differential diagnoses. Somehow the resident made a working diagnosis of meningitis, and the consultant was patiently explaining that this woman presented with a classic history of encephalitis, and differentials should be pursued for encephalitis in a young women.

Herpesvirus encephalitis? A course of empiric treatment with cyclovir did not make her better.

She apparently lived in a farm where they have cows and she takes care of them. Clue. Her sister, at the same time, came to her general practitioner with a tonsillitis. Clue. Last year she had been to Suriname.

“They will have cats in the farm!”

Clue.

How was the timeline of antibiotics prescription and culture when she was still at the smaller hospital? Are the culture results reliable, or are they taken after antibiotics was started? Now the doctors know they have to go back and contact the doctors at the previous hospital and get the story down to the details.

A professor remarked, “We have to go to the books for the rarer cause of encephalitis”.

Another younger consultant commented, “So many clues, but we can’t put them together and figure this out yet.”

The discussion did not reach any satisfying conclusion. For sure everyone has to go to the books to find the possible cause of her encephalitis; digs the travel history again; studied the MRI and lab results.

This is the first time I heard a professor genuinely suggested everyone, including himself, to “go to the books” to find a likely explanation. In a lot of places, they just  silently think. Then orders the resident to do this test and that. Then after more results they knowingly present their answers. This time, it feels like we are trying to figure this out together.

And I’m one fascinated young doctor with a new understanding about how to learn; and knowing that I will definitely go to the books and look up for more things tonight.

- Ajeng. 20 February 2011-

http://dokterblog.wordpress.com

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Writing for “LÓreal For Women in Science”: The genetic counsellor as a bridge between technology and patients

This writing has recently been published on LÓreal For Women in Science website:

The genetic counsellor: a bridge between technology and patients

A genetic counsellor is a health care professional who is trained to provide genetic counselling services. Individuals and families who seek out a genetic counsellor may then receive information regarding the occurrence, risk of recurrence, and possible management of a genetic condition. Genetic counselling is a process that involves collecting and interpreting genetic, medical and psychosocial history information, which most of the time needs to come from relatives and extended family. This material, along with an understanding… (continue reading on For Women in Science website)

 

Join the  LÓreal For Women in Science facebook page: http://www.facebook.com/forwomeninscience

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Starting fresh in Nijmegen

I have recently started my life in Nijmegen. This is not my first stay, but indeed will be my longest. The reason: research and study. The subject: something for my master education. I hope I will learn a lot during my stay here, not just because this is Nijmegen, but also because I hope I have the time and opportunity to learn, read and write more rigorously compared to if I’m in Semarang.

I finally have the time to sit down and write a bit here because it’s Saturday night and  I stayed home. I went out earlier today, but the weather is almost always bad, and it’s especially terrible today, with -9 degrees celcius of (because of the wind chill), 25 km/hr of wind and constant snowfall.

Sinterklaas is coming to town, along with Zwarte Piet, since it’s 5 December tomorrow. When I was small the story of Zwarte Piet from my mother was that he comes to get the naughty children to be put inside his sack. But now I know that he’s the one carrying around Sinterklaas’ gifts for the children.

The shoes are put in front of the fireplace so Sinterklaas can put the gifts there.

Image from google.com

Warm regards from -9 degrees in Nijmegen,

Rahajeng

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..now officially writing for Agora, the “L’Oréal-UNESCO For Women in Science” community

Dear all,

I’m just sharing this very exciting news: I have been asked to be an official writer for Agora, the “L’Oréal-UNESCO For Women in Science” community!

This website, or rather this international community, describes itself as “the platform dedicated to exchange and sharing among members of the ‘For Women in Science’ community. Agora is a meeting place for its members – award laureates, fellowship winners, academics, students and researchers – where they can talk about current advances in scientific research, the place and the role of women in science, their education, national and international careers, and the global development of the L’Oréal-UNESCO For Women in Science program.”

Few months ago I had the honor to be interviewed by Agora/ The L’Oreal Foundation about women in science. And just few days ago, my article, “Facing the challenge of climate change in health issues” is published in Agora.

And as I mentioned before, more than having the chance to submit an article, I had the honor of being asked to be the official contributor for the website. I’m quite convinced that I’m the only Indonesian writing for the site. And it’s indeed a great honor to be asked to join Agora although I’m not a L’Oréal-UNESCO Award Laureate, that is the women awarded fellowships (research grant) by the program.

Below is a preview of the website homepage,

And this is the published article, as appeared on the website,

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My article, “Facing the challenge of climate change in health issues” has been published in Agora, L’Oréal-UNESCO For Women in Science website

My article, “Facing the challenge of climate change in health issues” has been published in Agora, L’Oréal-UNESCO For Women in Science website.

Below is a short excerpt of the article,

“During my training as a medical student with overnight shifts in the wards of a government hospital, new patients admitted with severe leptospirosis or dengue fever means that there may be another long night without sleep. Infectious diseases wards are often overcrowded and a new patient can be admitted only when a patient is discharged. As medical students with clinical responsibilities at the hospital, we rarely have the chance to think beyond the hospital walls: about why the diseases these patients come in with had happened in the first place.

Climate change as a major cause of infectious diseases in Indonesia

In Indonesia, infectious diseases are still the main health problem. Diarrhoeal diseases, dengue haemorrhagic fever, typhoid fever, malaria, tuberculosis and respiratory infections are the most common infectious diseases (World Health Organization, 2010). Most of these are vector-borne and water-borne diseases which have been known to be influenced by climate change. The IPCC (Intergovernmental Panel on Climate Change) has concluded that “climate change is projected to increase threat to human health, particularly in lower income populations, predominantly within tropical/subtropical countries.” Climate change has affected the incidence and pattern of infectious diseases through environmental change, increased flooding, drought, changes in weather patterns and increasing incidence of natural disasters (IPCC, 2001)…” Read the rest of the article in Agora, L’Oréal-UNESCO For Women in Science website


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Visiting Professor Lecture Series with Prof. J. Galama, MD, PhD: CMV Infection in Post-Transplant Patients

This article was previously published in the website of Faculty of Medicine Diponegoro University

Visiting Professor Lecture Series

Prof. J. Galama, MD, PhD: CMV Infection in Post-Transplant Patients

Prof. Jochem M.D. Galama, MD, PhD, a distinguished clinical virologist from the Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, delivered a special guest lecture, “CMV Infection in Post-Transplant Patients”, on Monday, 15 November 2010 in the Faculty of Medicine Diponegoro University (FMDU).

Prof. Jochem M.D. Galama, MD, PhD in FMDU. -image courtesy of aryardiant

Transplant patients are prone to infection, especially because they receive immunosuppressive therapy which consequently alters the normal immune response of the body. Different kinds of solid-organ transplants and human hematologic stem cell therapy pose different risks of infection to patients most likely due to the kinds of immunosuppressive therapy given.  Different viruses, including adenovirus, herpesviruses, parvovirus B19, polyoma virus (BK and JC), respiratory viruses (Influenza, RSV, rhinovirus) may be the etiological agent of post-transplant infection.

Cytomegalovirus, or CMV, is associated with poor outcome in hematologic stem cell transplant patients. CMV, is a Beta-herpes virus, possessing DNA genome of 235 kBp. CMV may be latent in myeloid precursor cells and posses strong immunomodulatory potential. In an immunocompetent host, CMV may cause primary or recurrent infection, with transmission through breastmilk from mother, saliva, urine, blood, sexual contact and transplant organ. The seroprevalence of CMV in the total population in the Netherlands is between 42% and 73%, while in Indonesia it may reach up to 90%. CMV disease is a combined clinical and virological diagnosis; and patients’ risk factors are very important in considering CMV disease.

Determining the CMV serostatus of donors and recipients before transplant procedure is mandatory. And pre-emptive and or prophylactic treatment for CMV is required when CMV disease is considered.

Prof. J. Galama current research focus is the role of enterovirus in type 1 diabetes. The lecture is part of the visiting professor lecture series held by Faculty of Medicine Diponegoro University in cooperation with Radboud University Nijmegen. This program was instituted to bring prominent international scholars and researchers to exchange their knowledge and experience, as well as have intensive discussions with the medical students, residents, fellows, and faculty of FMDU during the academic year. (dr. Rahajeng N. Tunjungputri -contributor)

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“The real world of medicine”

A discussion about teaching and learning medicine was brought up in doc2doc, and this is quoted from Odysseus, in http://doc2doc.bmj.com/blogs/doctorsblog/_expect-teachers

If your students were your soldiers in boot camp and you were the drill sergeant you are responsible for their success or failure as a soldier up to a point and thus responsible for their death or survival. But no matter how hard you ride the recruit, whether or not he or she takes on board all you have told them, is still their own responsibility.

Indeed it is your responsibility as an examiner (teacher) to ensure they jump as high as the bar you set and if they fail, they will not stand the pressure of the real world and must repeat or drop out.

The real world of medicine is life and death and coronial inquests and court cases and even jail if you get it badly wrong, so raising the bar to a high level and exhorting them to jump is essential.

"The real world of medicine is life and death and coronial inquests and court cases and even jail if you get it badly wrong"

I just thought that this is a good piece to start a lecture with.

I’d also like to introduce the professional values for medical students from the General Medical Council UK, http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp . I’d expect all my students to read this during their preclinical years.

-Rahajeng, Semarang 30 October 2010

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Disclaimer

Medicine is a growing field, and information presented here is reflective of the time of posting. Please refer to your physician for direct medical consultation. My views do not reflect those of my employers. --
Regards, Rahajeng

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