We outline the main components of this project, describe its outcome and consider areas that invite further developments.

Key-words: community-follow-up, clinical students, home visits.

Introduction
The view that medical education needs to equip future doctors for a role that incorporates both clinical and social aspects of medicine is not new. Community-focused approaches that build on an understanding of comprehensive aspects of patient care are seen as essential to effective medical practice. ⁽¹⁾ Recent changes in national health surveys have also emphasized the importance of assessment of patients in the community and primary care settings. Current medical education should become more community-oriented if today's medical students are to become effective doctors in the future. ⁽²⁾ Programs have been implemented to enhance medical education by focusing on community settings, where clinical experiences are most relevant to primary care practice. ⁽³⁾

Traditional undergraduate curriculum separated the teaching of medicine in the hospital and in the community. Previously students learned clinical medicine during the short stay of a patient in the hospital and did not see the subsequent progress of the disease. In general practice, some of the natural history of the disease and care of the patient are observed, but only for a short period. The present undergraduate curriculum now emphasizes the importance of complete care of a patient, which includes not only the illness but also the impact of the illness on the patient, family, community and vice versa. ⁽⁴⁾ To complete the picture, the course of the patient's illness after discharge from hospital, and subsequent care should be studied as described in our community follow-up project.

The undergraduate medical program of the University Putra Malaysia has always emphasized the importance of exposing students to the practice of medicine in the community. This is an important exercise in their learning process to become good and caring doctors of our society. ⁽⁵⁾

This paper describes the Community Follow-up Project at University Putra Malaysia. We outline the rationale and key components of the project, describe the outcome and successes encountered, and consider future directions. We hope our experiences may be useful to others developing similar community based learning programs and will help in producing future doctors who are equipped to respond to the health needs of the communities they serve.

The Community Follow-up Project

The Community Follow-up Project is implemented during the Year 4 undergraduate medical program of the Faculty of Medicine and Health Sciences, University Putra Malaysia. This is when students first come for their clinical ward based attachment, which include the Paediatrics and Obstetrics & Gynaecology postings. The project is conducted for a duration of 6 months.

The number of students involved in the project depends on the number of students in Year 4. There are 84 students currently in Year 4. These students were divided into 2 groups of 42 students each. These 2 groups did the module in 2 rotations while doing their Paediatrics and Obstetrics & Gynaecology postings in the wards. Each group is further divided into 4 smaller groups, where each small group consists of 10 to 11 students each. Each small group has 2 community supervisors and 1 clinical supervisor to guide them in their project.

The supervisors of the Community Follow-up Project include lecturers from both clinical and community departments of the Faculty of Medicine & Health Sciences of the University Putra Malaysia.The clinical supervisors are lecturers from the Paediatrics and Obstetrics & Gynaecology departments. Whereas the community supervisors are lecturers from the Department of Community Health. With the guidance from a supervisor, every medical student is required to choose a patient whose subsequent progress is likely to be instructive. Patients are chosen based on the type of illness (interesting to students, chronic in nature), their willingness to cooperate in the project and their place of residence. Students are advised to choose patients who reside within a reasonable distance from the hospital to avoid problems of home visits. Permission to follow the patients' progress is obtained after informed consent from the patient and family. After patients are discharged from hospital, the students visit the patients at home and also follow the patients during their appointments at the hospital or government clinics as well as to their general practitioners. The frequency of follow-up depends mainly on the students and their patients, but students are advised to visit their patients at least once every 2 months. Students are asked to observe and report on :
· progress of the illness and its impact on the patient and family,
· support from community services with emphasis on whether the patients' needs are met,
· rehabilitation,
· effectiveness of communication between primary care and secondary care,
· and the extent of sharing of the patients' medical care.

Examples of patients chosen for this project were terminally ill patients such as those suffering from cancer or Acquired Immune Deficiency Syndrome (AIDS), as well as other chronic diseases like congenital heart diseases, asthma and infertility secondary to endometriosis. Most patients and families had financial problems, as well as other social problems such as lack of support from other family members, employers, friends and also social stigmatization.

While students have to do the home visits on their own, they were advised to conduct these home visits in groups of 3s or 4s. This was for their own safety. Sometimes, the supervisors do accompany their students for one or two home visits. One of the criteria of choosing patients is that the patient's place of residence should be within reasonable traveling distance (preferably in the same state, the state of "Selangor") to avoid problems with traveling and costs involved. As this project does not involve any funding, students have to bear the costs of traveling themselves. During these home visits, students take photographs of their patients, families, homes and surrounding environment. These photographs are included as part of their project write-up.

The teaching on this project consists of small group sessions during which the supervisors can provide support and guidance to the students. At the end of the project, the students present the findings of their patients with emphasis on problem areas to their class and supervisors. Each student's written report is marked as part of the assessment scheme. Twenty-eight hours (including six hours for visiting patients) are time-tabled in the six-month clinical course. An evaluation form on the project is given to each student at the end of the posting / project. These evaluation forms will be analyzed by the supervisors involved in the project and the results will be presented to the students for further clarifications and discussions on improving the project. The final evaluation results will be presented at the department and faculty level after each project has been completed so that improvements can be made to the next coming project.

Outcome of the Community Follow-up Project

The course and its early introduction in the undergraduate medical curriculum have an important effect on the attitudes of the students. Changes in students' attitudes are attributed to home visits, comprehensive patient care and following patients' progress for extended durations. The students are able to observe their patients in their own living environment and with their families. They are also able to assist their patients through numerous problems of convalescence and rehabilitation. They become aware of their patients' needs which are met and unmet by the health and medical care. These findings are expressed by the students in their evaluation of the project at the end of their posting.
(Appendix 1)

Another study also found that students reported significant learning from:
· witnessing the impact of illness on the patient over a longer period,
· having a closer relationship with their patients,
· witnessing the visible impact of social environment factors on the illness of their patients,
· the importance of dealing with people rather than illnesses,
· and the use of the whole team of care, which not only includes the hospital but also the community. ⁽⁴⁾

Students continue to follow-up their patients for an extended duration, even after completing the Community Follow-up Project. This is because the Community Follow-up Project is followed by the District Health Attachment in our medical curriculum, where students are also taught about intervention strategies in comprehensive care. The duration of the students' relationship with their patients has also been shown to have an important effect on the attitudes of the students.⁽⁴⁾

The teaching sessions during this project are done in small groups of students under the facilitation of their clinical and community supervisors. The teaching sessions are based on discussion among students on their patients by sharing their knowledge and experiences about their patients with their colleagues. At the end of the project, the students present their patients' histories and progress to their classmates and supervisors. Medical schools are now increasingly incorporating small group teachings in their curriculum. ⁽⁶⁾ Studies have shown that active learning during small group discussions and role reversal involved in case presentations are valuable ways of learning as the students tend to play an active role. ^(7,8)

The Community Follow-up Project offers a scheme where undergraduate medical students are able to observe the actual way the Malaysian medical and health system is functioning and how this affects the patient's care. Therefore, it helps the students to formulate more realistic expectations of care and also understand the importance of comprehensive care in managing a patient's illness. Another study on community-based learning for medical students in Australia found that their students developed more realistic expectations about patient illness and care by having closer relationships with their patients during the program. ⁽¹⁾

There were some concerns that showing the muddles of real life and problems in the health care system, this may confuse the students, and may even cause loss of clinical confidence. However, the information and experience gained by the students has been shown to increase clinical skills and knowledge of broader aspects of illness. It also improves the students' understanding of the roles played by members of a medical and health care team, including the decision-making and resources which can be utilized in community care.

Future of the Community Follow-up Project
To date, our main emphasis in the Community Follow-up Project has been on establishing appropriate educational strategies and functioning. To achieve this, we take into account the comments from the students' evaluation of the project. The Community Follow-up Project was found to be helpful and beneficial, especially on the aspects of community care, communication skills and comprehensive care. However, for the project to run well, the students require guidance and support from their supervisors throughout the course. The most important aspects of the scheme are the feeling of personal responsibility for the patients and the potential for playing an active role in their care.

To improve the project, we plan to evaluate longer-term outcomes such as:

(1) do the observed changes in students' attitudes following this project extend into future medical practice?
(2) what happens to the patients after completion of the project?

These questions require systematic and longitudinal investigation in order to expand the evidence base for community-focused medical education.

We have recently embarked on the development of a website for the Community Follow-up Project. The aim of this website is to communicate with the students via on-line discussions, as well as to post teaching materials on the web. At present, a pilot study is being conducted on the usefulness of this website in the teaching of the Community Follow-up Project.

We hope that the implementation of the Community Follow-up Project in our curriculum will help in producing future doctors who are equipped to respond to the health needs of the communities they serve.

Acknowledgement
We thank all supervisors and staff of Universiti Putra Malaysia who were involved in the project. We also thank Drs Loh Kheng Yin and Azlan Hamzah for their comments.

References
1. Boyle FM, Posner N, Mutch AJ, Farley RM, Dean JH, Nillson AL. The Building Partnerships Program: An Approach to Community-Based Learning for Medical Students in Australia. Med Educ Online. 2002;7:12.

2. Davison H, Capewell S, Macnaughton J, Murray S, Hanton P, McEwen J.
Community-oriented medical education in Glasgow: developing a community
diagnosis exercise. Medical Education. 1999;33(1):55-62.

3. Henry RC. Community Partnerships: Going Beyond Curriculum to Change Health Professions Education. Med Educ Online. 1996;1:4.

4. Howe A. Patient-centred medicine through student-centred teaching: a student perspective on the key impacts of community-based learning in undergraduate medical education. Medical Education. 2001;35(7):666-672.

5. Mohd Yunus A. 1st Report on the District Health Attachment, University Putra Malaysia. 2002 (unpublished).

6. Blue AV, Elam C, Fosson S, Bonaminio G. Faculty Members' Expectations of Student Behaviour in the Small-Group Setting. Med Educ Online. 1998;3:5

7. Freeman TR. The patient-centred case presentation. Family Practice. 1994;11:164-170.

8. Richards T, Peile E. Learning from our patients and each other. BMJ. 2003;326(7389):564-564.

View UPM Map