The Hospital Episode - The Community Follow-Up Project
Mohd Sidik MBBS, MMED (Family Medicine)
Azhar Md Zain MD, MPM
Mohd Yunus Abdullah MD, MPH
Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia
Community Follow-up Project involves a scheme by which clinical students
follow the progress of patients after discharge from hospital. The
Community Follow-up Project begins with the student choosing a hospital
in-ward patient during their first clinical ward based attachment
and follows this patient's progress after discharge from the hospital.
The students do a series of home visits and also accompany their patients
for some of their follow-ups to the hospital or government clinics;
to their general practitioners and even to the palliative care or
social welfare centres. The students assess the physical, psychological
and social impact of the illness on the patient, family and community.
This project supplements students' knowledge of the natural history
of disease and emphasizes the importance of communication and the
use of community resources. By commitment to the patient for a duration
of time, the students are able to take an active role in patients'
care, understand in depth the problems faced by patients and in assessing
a patient's progress, students find themselves in the role of a teacher
and advisor to their patient as well.
outline the main components of this project, describe its outcome and
consider areas that invite further developments.
community-follow-up, clinical students, home visits.
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.
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.
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)
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.
Community Follow-up Project
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.
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.
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,
· effectiveness of communication between primary care and secondary
· and the extent of sharing of the patients' medical care.
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
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.
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
of the Community Follow-up Project
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.
Evaluation of Course Community Follow - up(CFU) Project 2002/2003
a scale from 1 to 5 (least useful to most useful), please grade the
activity during the CFU Project which you found most useful in your
training as a doctor:
Discussion of your cases with your supervisors
(Small Group Sessions)
Visiting patient on your own (Home Visits)
Following-up your patients for an extended duration
Establishing contact with family members
Establishing contact with medical and health personnel
Small Group teaching
of Illness on the Patient
What other things were you able to learn during the CFU project
(3 most common things)
The importance of comprehensive/ holistic care in patient management
2. Awareness on the community care available in Malaysia
3. Awareness on which patients' needs are met and unmet by the medical
and health care
How were you able to help your patients during the CFU Project:
(3 most common things)
Feeling more confident in offering advice to patients based on knowledge
gained on community care
2. Able to establish a closer relationship with patients by spending
more time with them, getting to know their families as well as conducting
home - visits.
3. Able to assist patients through certain problems during convalescence
Another study also found that students reported significant learning from:
· witnessing the impact of illness on the patient over a longer
· 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)
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)
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.
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)
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)
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.
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.
improve the project, we plan to evaluate longer-term outcomes such as:
do the observed changes in students' attitudes following this project
extend into future medical practice?
what happens to the patients after completion of the project?
questions require systematic and longitudinal investigation in order to
expand the evidence base for community-focused medical education.
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.
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.
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.
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