Practical Training in Family Medicine in the Dalmatian Hinterland: First-Hand Experience of Four Physicians
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Teaching family medicine in rural and urban areas Acta Medica Academica 2012;41(1):93-99 DOI: 10.5644/ama2006-124.43 Practical training in family medicine in the Dalmatian hinterland: first-hand experience of four physicians Minka Jerčić, Zorka Čizmić, Miona Vujević, Tina Puljiz Department of Family Medicine Four physicians working in private family medicine offices in Dalma- School of Medicine in Split, Family tian Hinterland described their first hand experience of teaching sixth- Medicine Offices in Muć, Šestanovac year medical students. They supervised students during the 2010/2011 Imotski and Runovići, Split, Croatia academic year, in an area that is economically undeveloped, rural, and where a number of people live in extended families. Although hesitant at first, the patients came to like the interaction with students, and Corresponding author: later even yearned to provide students with as much information as Minka Jerčić possible. They also liked the letters that students had to write to them Ambulanta Muć about their illness, because they could take them home and look for 21203 Muć Donji bb information without needing to see the doctor. The students showed Croatia diverse attitudes to different types of work in family medicine offices, [email protected] mostly depending on their plans for future career. In general, they ei- Tel.: + 385 21 652 348 ther complained or hesitated to perform duties that they did not fully Fax: + 385 21 652 128 master during earlier education, especially working with children. They needed several days to adapt to direct contact with the patients, Received: 30 January 2012 and were more relaxed and cooperative when working in pairs than Accepted: 23 February 2012 alone. The physicians themselves felt that they profited both from the novelty in the everyday routine and from the exchange of their experi- ences with the students. They liked their young colleagues and admit- Copyright © 2012 by ted they could not objectively review their own work, knowledge and Academy of Sciences and Arts skills. of Bosnia and Herzegovina. E-mail for permission to publish: Key words: Rural family medicine, Student practice, Mentoring in [email protected] family medicine, Patient communication. Introduction in family medicine offices in the city of Split, Split surroundings, and some of Adriatic is- We were given the opportunity to partici- pate in practical training of sixth year medi- lands for each student. The goal of the prac- cal students, during their family medicine tice is to apply students’ knowledge, skills course of the integrated undergraduate and and attitudes acquired in the previous phas- graduate medical program at the School of es of the study in a concrete clinical setting, Medicine in Split, in 2011 (1). The course is with the duties of the family medicine phy- positioned at the end of the study program; sician. This was the first such experience for it encompasses11 hours of lectures, 42 hours the three of us, while one had some previous of seminars, and 147 hours of practical work experience. Family medicine practice in the 93 Acta Medica Academica 2012;41:93-99 Dalmatian Hinterland is somewhat specific their health problems, but also talk about when compared to the family practice in other life issues and comment on various cities, coastal villages or islands. Dalmatian events, be it economical issues, politics or Hinterland is a part of south Croatia that is sports. In the Hinterland family physicians relatively large but sparsely populated. The share important events with their patients, population differs both economically and raise children together and share everyday educationally from the rest of the country. lives. They are “ours” and we are “theirs”, day It is still very rural and physicians care for or night, in the office, or on the streets (3). both the pediatric and the adult patients. And so it is common when one of us goes The changes affect the Hinterland at a slower to the shop to be asked: “Zorka, please, can pace compared to the more developed parts I ask you about my disease”. However, the of the country. People also express their students were confused by this practice, and life philosophy in a different way, includ- many asked: “Don’t they call you Mrs. Doc- ing their medical problems. Families in this tor?!” At the beginning of their practice with area traditionally care for grandparents, and us, when a patient would leave the office, grandparents care for grandchildren and students would often comment: “What a homes while parents work. It is mostly men character this man is!” It was then necessary have the jobs and they usually work far away to explain to all of the students that although from their homes and villages. In such a set- we know most of our patients outside the ting women take care of the field work, of the practice, it is we ourselves who have to be house, children and grandparents. This all professional and not endanger the deepest results in a different relationship between the intimacy of our patients. doctors and patients and their families (3). We also noticed a certain discomfort and Here we summarize our experiences and uncertainty in the communication between observations of working as supervisors of the students and small children. It was medical students. necessary to insist that students examine a child, as the students were too often looking What did the students gain from the for ways and excuses of not do so. Some did family medicine practice in a rural accept the challenge and examined children, but with great apprehension and insecurity. area? We believe the reason behind this is that they Encountering family practice at the Dal- did not expect to take care of small children, matian Hinterland was a completely new as children are usually covered by primary experience for our students. The physician- pediatric offices in larger cities. Perhaps they patient communication is closer and less for- were also reluctant to work with children be- mal. Even when we, as practitioners, came to cause they were a bit afraid of their skills and this area first, we were advised by our older knowledge. They complained that it was dif- and wiser colleagues: “If you address them ficult to get sensible answers from children, as You, they will answer as We.” Similarly, an that their answers were unreliable, and that anecdote was passed on to all of us about an it was often difficult to establish the desired old man, who, a few days before he died, said cooperation during the check-up. This made to his physician: “Thank you for your care, us think that family physicians and primary but I have eaten my bread, my child!” care pediatricians should provide a more co- Intimacy and closeness between the ordinated pediatrics teaching. physicians and the patients are common, All of the students were also given the because the patients do not talk only about opportunity to tour the area with their su- 94 Minka Jerčić et al.: Training in family medicine in a rural area pervisors in order to gain insight into the so- ing assignments and to show students some cio-economic conditions of patients. Surpris- useful skills for the future, we had to change ingly, they did not show a great passion for our routine practice to some extent (Table field work – something that is expected from 1). We went more thoroughly through pa- physicians whose job is to provide health care tients’ physical exams and history taking for for all. We do not know the reasons for this the sake of our students, although we were reluctance; perhaps it is related to the current very familiar with the medical histories of system of education, where formal knowl- our patients. We insisted on proper and full edge predominates over practical and field physical examination each visit, even if we work. This problem definitely requires atten- had seen the patient just a few days before tion and different educational approach. the students arrived. The Drug Register was Since the distance from the nearest hos- always there on the table to help students, pital is about 30 km or more, we are more although they often realized that it could likely to perform minor surgeries and pro- not always help them as some of the pa- cedures (suturing minor wounds, removing tients would come and ask for “small white foreign bodies from the eye, placing a urinary pills”. We also had the Therapeutic Manual catheter) than our colleagues in city offices. to look up the generic names of drugs, the The possibility to refresh their skills made group they belong to, their main character- some students happy, while others again istics, and how and when to use them. We retreated in the background. We observed discussed all the other materials we had at that this largely depended on the students´ our hands, from the treatment guidelines to interests in their future careers. Those who the leaflets about new medications brought saw themselves as future surgeons enjoyed in by the representatives of different phar- these opportunities, while others needed to maceutical companies. be specifically encouraged and stimulated. Working with students opened the pos- Some had the opportunity to accompany sibility of interactive learning between us a patient with a heart attack to the closest (4), where knowledge and experience of a hospital, and observe how their supervisors supervisor was exchanged with the students’ coped in emergencies. They learned that we, fresh knowledge from the latest textbooks even after years of experience, have our pro- and lectures. Most of this matter related to fessional dilemmas and very often need to changes in the therapeutic approach: we discuss them with colleagues.