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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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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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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“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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Investing in young Indonesian Researchers

Last week the article I submitted for The Jakarta Post was published on 22 August 2010. The issue was something dear to my life and work: that we need more young Indonesian researchers; and to accomplish that we need to invest in them.

The article was inspired by my experience with a mentor. He has always taken the time and energy to foster new generations of clinician-scientists. I recently realized, that to “produce” excellent scientists in Indonesia, a senior researcher has to be willing to make an investment. The mentor will have to invest his or her time, energy, patience and guidance, for years, in his or her students. There is no instant process of turning an average student into a leading scientist. Everyone must take part in investing in Indonesian young researchers.

http://www.thejakartapost.com/news/2010/08/22/investing-young-indonesian-researchers.html

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Beyond Borders with “doc2doc”

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I enjoy writing, especially when I can interact with readers through my writings. While my writings here are only the ones more or less academically related, I know that my contemplative/narrative writing style is better appreciated at doc2doc.bmj.com.

I had problems before with some objections against my post in my old blog, thus the idea to build this blog, dokterblog.wordpress.com was born out of my desire to focus on academic medicine. But I miss writing critical and contemplative pieces, and “doc2doc” has been the perfect media for me. It’s a privilege to be able to blog there, I must say. And doc2doc has offered me the opportunity to interact with doctors from around the world.

It’s been amazing to get responses, ask questions, explore different answers and build friendship and networks because of my writing. And what astonishes me the most is to see that now my blog is being read by so many people in UK, Europe, US, Africa, and all across the world! My writings have gone beyond borders.

“A traffic report showing some of my doc2doc blog readers and their countries (for my latest post, “Empathy, or tea and sympathy?”)”

So, thank you doc2doc.bmj.com for enabling me to get more response, interaction and most of all, international readers.

For my fellow Indonesian medical bloggers, keep writing, be critical, and be true to yourself.

– Rahajeng, a.k.a. “AjengMD”

*Special thanks for David Isaacson, http://twitter.com/David_I, your an amazing community manager!

Thanks also to Prof. Cuello @CharlieNeck, Colleen Young @sharingstrength, and Zahid Raja @torydoc.

You can find doc2doc on http://twitter.com/doc2doc, and the website at http://doc2doc.bmj.com

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Announcement for Lectures of Prof. Cremers, 2010

Center for Biomedical Research (CEBIOR) Faculty of Medicine Diponegoro University, Semarang Indonesia in collaboration with Department of Human Genetics Radboud University Nijmegen Medical Centre, The Netherlands is announcing a lecture and presentation event by Prof. dr. Frans P.M. Cremers, PhD.
Below is short introduction of Prof. Frans Cremers:
In 1984, he finished his master Biology at the Radboud University Nijmegen (main subject: molecular biology). He performed his PhD study at the Department of Human Genetics, in the Radboud University Nijmegen Medical Centre and received a cum laude PhD in 1991 on the thesis entitled: ‘Positional cloning of a candidate gene for choroideremia’. In 2004 he was appointed full professor Molecular Biology of Inherited Eye Diseases, and in 2009, he was also appointed Adjunct Honorary Professor in Comsats Institute of Information Technology, Islamabad, Pakistan. In 2005 he was appointed Programme Director of the topmaster ‘Molecular Mechanisms of Disease’. From 1992 – 2010, he supervised 12 PhD students and numerous BSc and MSc students. He was awarded the ‘Internationalizations Award 2010 of the Radboud University Nijmegen’ for his continued efforts to facilitate MSc and PhD students to study in the Netherlands,and to foster international collaborations.
Lectures and presentation will be held 21-23 July 2010, from 08.30 a.m. in 3rd floor of Faculty building, Faculty of Medicine Diponegoro University Semarang.
(Please click image for full poster)

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The Tobacco Epidemic: Problems, Conflicts, Solutions

Dear all,

I mentioned before that I was asked to speak about tobacco for a group of medical students few weeks ago. I wrote a more comprehensive review of the tobacco epidemic in Indonesia into my blog in doc2doc, “The Cure of The Tobacco Epidemic”.

At the event I brought up the issue of the tobacco epidemic; the problems, conflicts and solutions. This presentation is aimed to highlight the importance of consumer perception, the tobacco and anti-tobacco campaign “wars”, the socio-economic context of the tobacco epidemic in Indonesia and how physicians can contribute in curing this epidemic.

I have uploaded the presentation from that event to Slideshare.

For further reading, please do check the last slide with a list of great reference sites.

Regards,

Rahajeng

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Semester Exam of Genetic Counseling

I had the semester exam this week in my Master Programme of Genetic Counseling FMDU. I really had to focus on these exams, because as you can see, within 6 days I had 19 different exam subjects, and not much time, energy nor interest in anything else other than preparing myself for these exams.

And the menu for those 6 long days were:

  1. Psychiatry – Grief and bad news, Counseling in children with congenital or genetic abnormalities
  2. Psychology – Helping theory, Development of helping relationship, Genetic Counseling
  3. Obgyn – Psychosocial aspect of fetomaternal cases, Prenatal diagnosis
  4. Endocrinology – Genetics of Diabetes Melitus
  5. Neurology – Myotonic dystrophy, Parkinson Disease, Spinal Muscular Atrophy, Ataxia
  6. Mitochondrial medicine
  7. Immunogenetics – Blood group and HLA
  8. Molecular biology – Gonadal development, Molecular basic, Sexual development disorder
  9. Medical ethics – Bioethics, Professional ethics
  10. Pediatric endocrinology – Basic physical measurement, Cytogenetics, Genetic screening, Genetic disorders
  11. Endocrinology – Genetics of thyroid diseases (congenital hypothyroidism, autoimmune disease, malignancy)
  12. Pediatric urology – Congenital adrenal hypertrophy, Androgen insensitivity syndrome
  13. Pediatric neurology – Epilepsy, Myasthenia gravis, Muscular dystrophy
  14. Embryology – Genetics of embryology, teratology
  15. Immunogenetics – Immunodeficiency, Genetics of immune system
  16. Cancer genetics
  17. Biomolecular aspect of thalassemia
  18. Inborn error of metabolism

*Reenactment of my exam preparation by a model (image is not mine)

And the exam week was particularly challenging because I had what looked almost identical to this (WARNING: This is NOT my picture), the cause I presumed was psychological stress which leads to immune dysregulation (due to exam and several other things… such as my passport issues -Not to be discussed here):

*Reenactment of my canker sores (image is not mine)

Note that it was a large and deep ulcer, heavily inflammed and located on the side of the tongue. When I talk the tongue (and ulcer) is hitting my lips and my teeth, when I sleep the tongue dried and sticked to my palate, and OUCH!!! Basically, the ulcer made eating, drinking, speaking, studying, answering my exam, sleeping, and living, in general, very difficult and extremely painful, each and every minute.

I guess we’ll see the result of the exam in the next few weeks, but generally I’m content and satisfied realizing how broad my studies were in the past 6 months. Considering that my main interest is infectious disease, the opportunity of learning genetics and psychology has been a privilege. I explored the subjects I never really thought about learning before (psychology, counseling, embryology) and I even enjoy them!

And what I truly love from the master programme is: you have this whole new world of knowledge and science opening up, and you are free to explore it for yourself!

*

– Rahajeng

https://dokterblog.wordpress.com

PS: And YES, as the exam finishes, my stomatitis is healing.

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I’m now blogging on doc2doc.bmj.com

I have been writing since 2005, so 5 years until now. I started with a variety of topics, and now I mostly blog about medicine. And I think by now I know that my writing can reach more audience, more than just my local peers or medical students. It’s a good time to “go international“.

And I was recently accepted and published as a blogger on a British Medical Journal (BMJ) group website, doc2doc, http://doc2doc.bmj.com/blogslist.html (as AjengMD).

For my first post, click here http://bit.ly/bgU1YL

Doc2doc is an international online community for doctors worldwide. And from the website, “doc2doc is a free of charge service offered by the BMJ Group. The BMJ Group is a trusted global medical publisher that provides a wide range of products and services to improve the decisions doctors make every day. On a day to day basis, doc2doc is run by its community manager, community clinical editor, and the editor of bmj.com, all of whom are based at BMJ Group’s London office.”

Doc2doc.bmj.com does not offer blog hosting. Interested blogging doctors/students have to apply with our own ideas and writings in order to blog there, and new bloggers will be reviewed based on the content of their blog posts. I don’t have my own URL on doc2doc, so my writing are published on doc2doc blog page. I was so excited that when I was accepted, it wasn’t just doc2doc who twittered me, but also BMJ Group.

This is the frontpage of the bloglist.

Another look on the summaries,


And, I’m really excited about this one:

So, maybe it’s time to take the blogging one step higher.

–Rahajeng

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Parasitology Identification 1

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Dear Students,

Due to request of the parasitology tutorial I had with my student groups today, I decided to share this with you. Not the file itself obviously, but as usual, it is now available for your viewing pleasure and your studying on Slideshare.

Today we spent about 1 hour in class for “practice-exam” and discussion about these parasites.

Please study, and good luck for your exams. I wish you nothing but the best!

For the powerpoint slides click here

Regards,

Rahajeng

Some extra pics from today’s session:

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What do you expect from your teachers?

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I’ve always loved writing. It hasn’t always brought me positive result. Sometimes I envy people in other countries where they have a little bit more freedom of speech in medicine. And that you don’t have to be old first to share your experience and opinions.

I found a blog of a medical student:

http://blogs.medscape.com/thedifferential with a post titled as “The Deal” by Lucia Li.

She basically states what the medical students expect from the doctors, and what they are willing to give back to the doctors who teach them. Some points there, from a student perspective they ask the followings from the doctors who teach them:

“Don’t ignore us — no-one likes to be ignored. We’re here to learn, we want to learn. show some interest in our education and we’ll likely love you forever.

Remember who we’re going to be — doctors. That means, however many years down the line, we’re going to be your house-officers, your registrars. It’s in your interest to teach us and contribute to our elevation from ignorance/ incompetency.

Remember who we currently are — students. We want to learn. About lots of different things.

Challenge us — ask us questions to get us thinking. It helps us to identify the important things to learn. It also may spark a lasting interest in that specialty…

But, hey, this is a two-way bargain. What can we, the students, offer in return?

And then they offer the teachers what they can do in return

What should we, the students, do?

Mind our manners — We will appreciate the fact that you have given time out of your busy schedule for us.

We’ll make use of your efforts — If I’m going to be taught by someone who I know will ask me questions and challenge me, I will certainly try to do some reading beforehand so I understand more of what you’re teaching. In short, it is only right that we reciprocate the interest you have taken in our education with an interest in improving our own.

Give feedback — if you have taught me well, I will make try to show my appreciation by thanking you when I leave clinic or telling the course organisers. But, the best feedback we can give you…

Be excellent doctors — being taught well by a good doctor has two benefits. The first being the imparting of medical wisdom. The second being the setting of a role model; a good doctor, explaining things as they go along, engaging with me as well as their work, always inspires me to do that same. Learn more, try harder.”


And here, I’d like to make my own personal points. I am still a student, and as a doctor I know I will continue being a student for a very long time (for my residency, for my research). On the other hand, I also teach, which I only started very recently, which gives me great pleasure and a fresh perspective on students and teaching.

From what I experience, I know that still being a student can help me learn how to be a good teacher. I observe my own teachers, learn what is for me an exciting and great learning experience. I love it when my teachers stimulate me to think and answer questions in the class instead of just bombarding me with information because it helped me form my pattern of thinking in a logical way. I love it when they can capture my interest and award me with extra information. I love it when I realize that after a class I gain new knowledge and insight. I love it when the teachers engage personally with us and interested in what we have learned so far. I love it when the teachers give feedback about our assignments and our efforts in working on those assignments. I love it when the ultimate goal is to help us understand the subjects. I love it when they have time to teach us even though they are very busy, and focused on us during the class. I love it when they are interested and enthusiastic about what they teach, because it makes us understand the importance of learning them. I love it when they appreciate me and my efforts. I love it when they inspire!

I only very recently started as assistant lecturer. And when I have discussion with my students, I know that I ask them to do “at least” the followings. I want them to be focused in class. I want them to be prepared before meeting me, because then we can engage more in the discussions. I want them to understand the fundamentals: why we think in certain ways, why certain things are very important, what is the “big picture”, what’s the underlying principle and philosophy of the things we learn, what I want them to learn specifically for the exams and also what they still have to remember for the rest of their lives as doctors. I want them to be able to learn how to think, and what to think about. I want them to start a class with focus and attention because there’s new information I’d like to share with them. I want them to do their assignments and do them well because I also prepare myself to give feedback on their assignments. I want them to read, because I also read and there are items in the reading material that I’d love to discuss with them. I want to share new things with them, because I don’t want them to be bored with the learning session. I want them to share their opinions, their questions and answers. I want them to be interested and to always want to do better.

So, what do you expect from your teachers?

— Rahajeng

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Dokter Muda/ Coass di RS Pendidikan: Aset atau Liabilitas?

Sebuah artikel di koran lokal beberapa hari yang lalu  (Radar Semarang) memuat judul “Dilematika Dokter Coass: Dinilai Repotkan Pasien, Demi Regenerasi Dokter”. Pada intinya artikel tersebut memuat keluhan pasien tentang dokter muda di rumah sakit pendidikan, “saya ogah dijadikan bahan praktik”.

Kemudian muncul pertanyaan setelah keluhan ini; dokter muda/ coass merupakan aset atau justru liabilitas sebuah rumah sakit?

Tentu saja sebagai seorang dokter yang telah menyelesaikan pendidikan, saya menyadari betapa pentingnya kegiatan belajar di fakultas kedokteran. 3,5 tahun di bangku kuliah, dilanjutkan dengan setengah tahun berlatih di laboratorium skill, sebelum akhirnya memulai kegiatan kepaniteraan klinik di rumah sakit selama hampir 2 tahun sebagai dokter muda atau coass. Untuk yang tidak familier dengan pendidikan dokter, kepaniteraan klinik adalah pendidikan profesi, sehingga semua dokter muda yang menjalani kepaniteraan klinik semuanya adalah sarjana lulusan S1. Selain itu, di Fakultas Kedokteran Universitas Diponegoro kami juga masih menjalani pendidikan tambahan selama 2 bulan di RS Daerah dan Puskesmas di wilayah Jawa Tengah sebelum lulus sebagai dokter.

Di rumah sakit pendidikan tidak ada keputusan medis yang dibuat dan dijalankan sendiri oleh dokter muda/coass. Semua tindakan yang dilakukan oleh dokter muda telah sepengetahuan dan pengawasan dokter yang berwenang, dan telah dilakukan atas persetujuan pasien.

Memang dokter muda secara umum hanya “melakukan tugas sederhana”, seperti memeriksa pasien, belajar mengawasi pasien, memasang tensi dan mengukur suhu pasien. Namun selain tugas sederhana tersebut ada banyak kompetensi yang harus dipelajari dokter muda selama kepaniteraan klinik di rumah sakit.

Tentu saja semua dokter pernah merasakan betapa melelahkannya tugas-tugas ini saat pendidikan. Namun menyebut bahwa dokter muda melakukan hanya “tugas sederhana” di atas sepertinya pernyataan yang terlalu menyederhanakan realita. Dokter masa kini paham betul, bahwa saat lulus kita harus memiliki kompetensi yang memadai sebagaimana yang ditetapkan oleh Konsil Kedokteran Indonesia. Diantara “tugas sederhana” yang wajib kita kerjakan siang, malam, dini hari dalam keadaan lelah, mengantuk dan lapar, diantara kegiatan belajar, mempersiapkan ujian, dan mengerjakan tugas-tugas teori, kita memiliki kewajiban untuk mempelajari dan menguasai keterampilan klinis sesuai standar kompetensi dokter umum. Selalu diantara “tugas sederhana” ini dokter muda masih harus belajar untuk memiliki keterampilan klinis misalnya kegiatan bedah minor seperti menjahit luka, memasang infus, menyuntik obat, memasang pembalut luka, melakukan tindakan untuk keadaan-keadaan emergency.

RS Pendidikan harus mendidik mahasiswa kedokteran, sebagaimana sebagai RS mereka tetap harus melayani pasien. Kembali saya ingatkan bahwa para dokter muda telah mendapat pendidikan dan persiapan sebelum memasuki jenjang kepaniteraan klinik maupun selama menjalaninya. Di Indonesia, hal ini dilakukan di beberapa lingkup tertentu RS Pendidikan tersebut sesuai kebijakan RS yang bersangkutan, dalam pengawasan dokter yang berwenang. Harap diingat, hal semacam ini dilakukan oleh semua rumah sakit pendidikan di seluruh dunia termasuk di negara barat. Tidak ada tempat bagi dokter-dokter baru lulus yang hanya merupakan produk lulusan laboratorium dengan alat-alat peraga berupa boneka. Dokter adalah profesi dengan tanggung jawab kemanusiaan yang berat, yang harus dididik dan dilatih untuk dapat bekerja mandiri menghadapi pasien, situasi klinis dan problem kesehatan yang kompleks di masyarakat. Dokter-dokter baru ini yang nantinya akan menjadi petugas kesehatan, dan bahkan sebagian akan memilih untuk menjalani kegiatan pengabdian dan ditempatkan oleh Departemen Kesehatan di daerah terpencil dan sangat terpencil di seluruh pelosok Indonesia. Meningkatnya derajat kesehatan bangsa Indonesia dan tingginya kualitas dokter tidak bisa lepas dari peran RS Pendidikan dalam mempersiapkan dokter-dokter baru.

Untuk menjawab pertanyaan di atas, maka kehadiran coass di RS Pendidikan sebagai aset dan bukannya liabilitas membutuhkan kerja sama dan usaha keras dari semua pihak, baik RS Pendidikan, fakultas kedokteran, para coass sendiri dalam hubungannya dengan penyediaan layanan terhadap pasien.

Kegiatan supervisi yang selanjutnya harus ditingkatkan agar dokter muda dapat tetap menimba keterampilan dan pengalaman agar siap terjun di masyarakat, sementara pasien tetap mendapat penanganan yang optimal dari sebuah rumah sakit. Tentu saja hal ini harus dibarengi etika dan persiapan keterampilan yang matang dari dokter muda yang melayani pasien di rumah sakit.

Dr.Rahajeng Tunjung

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Choosing Medical Specialty (and more on Internal medicine, infectious disease, and academic medicine)

By: Dr. Rahajeng

I recently stumbled on a very interesting publication of Lange, The Ultimate Guide to Choosing Medical Specialty by Brian Freeman.

For many, the decision of taking up a specialty is easy, for others it’s much more complicated. The best thing is of course to be able to choose based on your interest and the kind of life you want for yourself. I realized very early on that a certain medical specialty is not just about the kind of work that you have to do, but also about the commitment you have to make to a certain lifestyle. I was lucky to have had a real life experience about the field I am going to take up, as well as to have several mentors to introduce me to it.

What is sometimes not immediately anticipated for us Indonesian young medical doctors is that choosing a medical specialty is a decision of the family (and family sometimes means the whole extended family). This means you can’t really make your own decision. There’s mum, dad, grandparents (if they’re around), and maybe others that will have a say about the decision, and for some unlucky ones, the decision is not even yours anymore. For some, they never had a say in what they like, it’s always about what they have to take.

For example, a friend of mine had been pursuing his interest in surgery for a long time during medical school. Dad is a pediatrician, and mom is an ophthalmologist. He did express his interest of surgery to his parents, but dad took over the decision-making and told him that ob-gyn was the best choice for him. He agreed to it despite the fact that he had another choice. He thought that it was what’s best for the family.

For another guy, ob-gyn is a no-question choice, as many in the family (grandpa, uncles) was ob-gyn specialist and they already establish their own private hospital and clinics. Neither a bright nor dedicated student, by circumstances that many call luck, he is to take over the family business.

My own experience is by situation a more liberated one despite the family medical legacy. Grandpa from dad’s side was an orthopedic surgery professor, uncle is also an orthopedic surgeon and his son is now an orthopedic surgery resident. My father was briefly in surgical residency but he resigned and decided that being a company’s medical manager and acupuncture was more enjoyable. He worked for 25 years in a national oil mining company as medical manager and have started and now runs the first dermatology/ aesthetic acupuncture clinic in the city. Uncle from mom’s side is a psychiatrist. I had ob-gyn and pediatrics in mind for a short period. I was finally exposed to the wonders of internal medicine and infectious disease and eventually choosing infectious disease for myself two years ago, preferably in academic setting.

Back to the book, it also offers looking to MBTI personality types to see if you cut-out to be in certain specialty although for internal medicine, it is very flexible on who it is most suited for (Introverted–Intuitive–Feeling– Judging INFJ, Extroverted–Sensing–Feeling– Judging ESFJ, Introverted–Intuitive–Thinking– Judging INTJ, Extroverted–Intuitive–Thinking– Judging ENTJ). It doesn’t really matter I guess, as long as you have good access to yourself, knowing what you like and what you can be passionate about. I happen to be an ENFJ (sorry, you gotta find out what that is yourself).

I started thinking about these 4 years ago when I was still doing my preclinical years (naturally, without having a book to guide my thinking):

• What do you want to get out of your medical career? (intellectual and spiritual satisfaction)

• For whom do you want to work? (international academic institutions)

• Do you want to be a leader in your specialty? (i’d like that very much, so yes)

• How much time do you want to devote to research, teaching, or administrative work? (research and teaching: a lot of time. Administrative: naaah, not really into it)

And knowing that I’ve explored answers to these questions has definitely made me confident in the choices I make.

I have a vision of what career I want for myself, as well as very personal reasons of why I choose a certain path. But the thing is I always know what I like, not just the science but also the lifestyle. I like international travel, I like discussions, I like challenges of pursuing knowledge of the unknown. I like reading, writing and facing cerebral challenges. And I definitely like giving presentations in front of international audience, preferably about something I know a lot about. Those reasons above are part of the things that shape my choices.

And surprise surprise, my Keirsey profiling ended up being “teacher”.

*

These are selected excerpt from the book “The Ultimate Guide to Choosing Medical Specialty” by Brian Freeman

TO SUBSPECIALIZE OR NOT: THE FELLOWSHIP DECISION

Before considering their practice options, residents in every specialty have to decide whether or not to subspecialize. The additional time spent in fellowship training gives them advanced knowledge and skills—both of which are essential for practicing as an expert in a focused variety of specialty medicine.

Residents who become inspired by a particular organ system or a complex problem within their specialty should seriously consider pursuing a fellowship. The training provides sophisticated knowledge and skills, making you an expert to whom colleagues look for advice and teaching. Knowing one narrow area very well can enhance your career satisfaction and build your professional confidence. With an emphasis on research and scholarly endeavors, fellowships are also great preparation for careers in academic medicine.

Are there any disadvantages to pursuing a fellowship? Just one—the temporary financial sacrifice. You will have to wait several more years before paying off all those big educational debts hanging over your head.

Private Practice: Delivering the Best Patient Care

Most of you will enter private practice after completing residency or fellowship. In the private sector, physicians either work by themselves or with others, providing high-quality medical care to all types of patients. Because they are not tied strictly to the large academic medical centers, private practitioners have the flexibility to set up shop anywhere in the country—urban, suburban, or rural. Depending on the specialty, you may be working in the office-clinic (dermatology, rheumatology, allergy medicine), the hospital (anesthesiology, radiology, pathology), or both (internal medicine, surgery, pediatrics). Some private practitioners also make rounds at other places, like nursing homes (geriatricians, internists), state facilities (psychiatrists), and prisons (internists, family practitioners).

Academic Medicine: Shaping the Future of Your Specialty

Medical students who want to be leaders in their specialty should consider a career in academic medicine. A much smaller percentage of physicians work at university hospitals than in the private sector. Academicians serve as medical school faculty members in their specialty’s department and also provide patient care at their affiliated teaching hospital. With less emphasis on patient volume and turnover, the pace of academic medicine is more relaxed than that of private practice. Although the job market for new faculty physicians is quite strong, the tertiary care medical centers are usually in major metropolitan areas. This limitation means that academic physicians—whether pediatricians or interventional radiologists—have less geographic flexibility than their counterparts in the private

sector.

Whereas private practitioners deliver patient care to the masses, academic physicians in every specialty and subspecialty have a set of three universal—and equally important—responsibilities.

1. Teaching: Every doctor receives residency training in a teaching hospital. By staying there to practice, academic physicians instruct generation after generation of specialists. Much of this time is spent supervising and teaching fellows, residents, and medical students. Through hours of mentorship, academic physicians can make a meaningful difference in their charges’ professional lives by shaping their formative years of clinical training. These inexperienced young doctors will pepper you with lots of probing questions, keeping you sharp in your specialty. Most faculty members recruited out of residency or fellowship start teaching at the level of Assistant Professor. Promotion and tenure—just like in nonmedical fields—are directly related to your ability to teach and conduct ground-breaking research.

2. Research: Through cutting-edge clinical and basic science research, academic physicians are responsible for advancing their specialty. They generate new knowledge, develop procedures and drugs, and evaluate the efficacy of different types of treatment. For instance, a general surgeon might conduct a study looking at the best time to take out a chest tube, and an internist investigates the outcomes of treating diabetic and renal failure patients with ACE inhibitors. Academic physicians also have to teach their colleagues in private practice about the latest advances in their specialty.

They do so by writing up their findings in medical journals and giving lectures at national conferences. To carry out any research project, academic physicians have to obtain the necessary funding—by submitting grants themselves or by receiving money from their department. In the world of academia, the number of papers published and amount of federal research grants received confers prestige on a university medical center. (In a certain weekly news magazine, the formula used to rank US hospitals and medical schools gives the greatest weight to research awards from the National Institutes of Health.)

3. Patient care: In every specialty, academic physicians provide the latest and most innovative medical care. Tertiary medical centers draw a diverse mix of patients, from the indigent (most teaching hospitals are historically located in underserved city neighborhoods) to the very wealthy (e.g., Saudi princes who fly in for the most advanced treatment). Most patients receive care directly from residents and fellows, who are supervised by their attending physicians, of course. Compared to private practitioners, full-time faculty members generally take less call, devote fewer hours to patient care, and earn less money. All revenue generated from clinical practice goes directly to the medical center instead of counting as personal income. In turn, the hospital pays each faculty physician a fixed salary that is directly proportional to the type and volume of medicine he or she practices. This is why academic pediatricians earn less than an academic cardiothoracic surgeon.

Academic medicine is perfect for doctors inspired by working with some of medicine’s greatest minds the authors of well-known textbooks, the renowned researchers who develop new drugs and vaccines, the innovators who figured out how to surgically separate two newborns sharing the same brain. Because teaching hospitals are part of major referral centers, academic physicians are the ones who manage most of the rare and complicated cases. You will take care of diseases and conditions on a level that few physicians ever surpass. This career path, therefore, gives you the autonomy to become a true leader in your specialty.

The book also features profiles of every specialty. And here I will only put up what is obviously my pick: Internal medicine (and a little bit more about infectious disease).

READY TO EXERCISE YOUR BRAIN?

Internal medicine is perhaps the most cerebral of all specialties. It requires a high level of critical thinking. Many students are drawn to internal medicine for the intellectual stimulation. There are always interesting cases that require a lot of problem solving and interpretation of signs, symptoms, and other pieces of data.

Internists are very intellectually curious doctors. They always like to ask questions of themselves and others during the differential diagnosis process. Fascinated by the science of medicine, internists love exploring details—like the mechanisms of drug therapy or the pathophysiology of disease. To make the best diagnosis, internists tend to read quite a bit. Keeping abreast of the latest advances in general medicine requires a career-long commitment to reading journals such as JAMA or The New England Journal of Medicine.

Critical thinking is necessary because internists take a scientific approach to being master diagnosticians. They thrive on making a great diagnosis, analyzing a fascinating big case, and solving complex medical problems. Internists love to sit around and discuss disease. They get excited by putting together a patient’s signs, symptoms, and laboratory findings and trying to come up with a long list of possible differential diagnoses. Unfortunately, sometimes the daily activity in internal medicine is perceived as lots of thinking and talking but little action. In particular, academic inpatient rounds can perpetuate the stereotype of internal medicine as mental masturbation. This is because internists are thorough individuals who make sure not to leave out any possible diagnoses. Students who love to solve problems and mental puzzles find internal medicine a fascinating specialty. Internists are experts at taking patient histories and performing physical examinations. It is with the information derived from the H&P that they make most diagnoses. After talking to the patient, the internist constructs a list of differential diagnoses for each of the patient’s problems. This process allows them to clearly organize in their minds what is going on with the patient and how to address each issue; many patients have multiple medical problems or complaints. To finalize a diagnosis from a list of many, the internist relies on a great deal of critical thinking and deductive reasoning from the data at hand. They take pieces of evidence from the history, physical, laboratory data, and imaging studies to rule in or rule out various disease states. It is kind of like mental detective work. An internist in academics commented that “figuring out how all the pieces to a patients’ clinical puzzle fit together is extremely rewarding.” With a confident diagnosis in hand, the internist then moves on to treating the patient. Across the subspecialties of internal medicine, therapeutic interventions take the form of either pharmacologic agents or procedures. General internists, for instance, keep up with the advances in treating high blood pressure with the newest medications and are experts at figuring out the proper antibiotic for a patient with bacterial meningitis. Although this specialty requires thorough, organized thought, internists are more than just thinkers; they are also proficient in many technical skills essential for the diagnosis and treatment of illness. These skills include a number of inpatient procedures, such as thoracentesis, paracentesis, lumbar puncture, and central line placement, and outpatient procedures like flexible sigmoidoscopy, endometrial biopsy, and intra-articular injections.

WHAT MAKES A GOOD INTERNIST?

Likes physical diagnosis, pharmacology, and physiology.

Is a thorough, cautious problem- solver.

Can interact well with people and maintain long-term relationships.

Likes working with his or her mind.

Is a good, patient listener.

FELLOWSHIPS AND SUBSPECIALTY TRAINING

Internal medicine is comprised of many subspecialties. In 2000, roughly half of

all graduates from internal medicine residency programs sought fellowship training.

Currently there are 10 possible areas of subspecialization. Before jumping into one of these disciplines, take a moment for some honest self-evaluation. It is essential that you give some thought to

your field of interest and the type of personality most suited to it.

For aspiring physicians who prefer direct primary patient care, general internal

medicine is the place to be. Specialists tend to be much more scientifically oriented

and enjoy more complex and difficult cases. They serve as consultants to the general internist, directing medical care for a specific organ system and often teaching the general internist about the patients’ disease process. For certain specialties, like cardiology, gastroenterology, and critical care, more time is spent caring for patients in the hospital environment than in the office setting. No matter whether you choose cardiology or rheumatology, all subspecialists are, at heart, excellent general internists. You will still be required to have high-quality history and physical examination skills, as well as the ability to interpret laboratory and radiographic findings, to produce a comprehensive differential diagnosis. In every subspecialty, all internists take care of very sick adult patients who have many medical problems.

Infectious Disease

If you love studying bacteria, viruses, parasites, and fungi, then the subspecialty of infectious disease is for you. These physicians take the basic science of microbiology and apply it to clinical situations. In their diagnostic workup, they approach the patient’s disease process by taking into consideration recent travel, geographic region, country of origin, and cultural practice. They are experts in the proper collection and analysis of culture specimens, plus a variety of laboratory tests, such as antibiotic sensitivity tests, CD4 counts, and infectious serologies.

Their treatment regimens are largely pharmacologic and draw on the latest developments in antibiotic therapy. Through the use of vaccines, they practice a great deal of preventive medicine. Most patients who require the expertise of these clinicians have diseases that are short-term in nature. Thus, infectious disease specialists typically serve as consultants for other physicians. In the summer of 2002, they were on the front lines of the West Nile virus outbreak in the United States. They consult on patients in the hospital for diagnostic challenges (e.g., fever of unknown origin) and for treatment regimens of specific infectious diseases (e.g., bacterial endocarditis, meningitis, cellulitis, sepsis). Many infectious disease physicians maintain longer relationships with patients suffering from chronic diseases, such as HIV/AIDS and tuberculosis, who require extensive follow up. Some practice travel medicine, serving as consultants to patients preparing for international travel and to those who acquired illnesses while overseas. Other areas of expertise include infection control within health care settings, international public health, and the prevention of antibiotic resistance through education and research. They also are involved in the tracking and epidemiology of certain communicable diseases. As the threat of biological attack becomes a growing concern, the prevention, recognition, and treatment of bioterrorism are now focal points of infectious disease. Fellowships require 2 years of training after residency.

Semarang, 7-6-2009

*

Reference:

Freeman B. The Ultimate Guide to Choosing Medical Specialty. Lange 2007.

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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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