The past, present and future of medical education in Cambodia.

This paper describes the past, present, and future of medical education in Cambodia. Although doctor training began in 1902, the first medical school was not founded until 1946. Since the colonial era, the curriculum and teaching strategies have been strongly influenced by the French system, dominated by didactic lectures and the apprenticeship model. Three chronic issues have plagued medical education in the country following the Khmer Rouge regime: a shortage of doctors, poor-quality training, and lack of relevance to the current and future population needs. An increasing number of medical schools and yearly student enrollment have addressed the first issue. Today, the fundamental challenges have shifted from quantity to ensuring the quality and relevance of medical education. Competency-based medical education (CBME) has been adopted as a new curricular model to tackle the latter two issues. Active collaboration between government institutions, public universities, and development partners drives this curricular reform at the national and institutional levels. This paper further examines the challenges associated with medical education and proposes recommendations.

Assessment of dual practice among physicians in Cambodia.

BACKGROUND: Dual practice and multiple job holding are widespread among health workers throughout the world. Although dual practice can help the financially strained public sector retain skilled workers, there are also potential negative consequences if it is not regulated. In Cambodia, there is substantial anecdotal evidence of dual practice among physicians but there is very little data on the extent and prevalence of the practice. This study was conducted by the University of Health Sciences (UHS) to gain insight in to the employment practices of UHS alumni. Results from this survey may help to inform policymakers in rational planning for future health system development related to capacity building and regulation of human resources for health. METHODS: Data were collected from a self-administered survey of UHS graduates who graduated between 1999 and 2012. A total of 162 medical graduates were randomly sampled from a total of 1867 medical graduates between 1999 and 2012. Contacted individuals were asked to complete a written structured questionnaire regarding demographic characteristics, current employment and types of employment, compensation, and job satisfaction. The response rate of graduates sampled was 49% (79 completed questionnaires). The low response rate was primarily due to the difficulty in locating individuals. RESULTS: Of 79 respondents, 96% were currently employed at the time of the survey. However, only 63 of the respondents (80%) were working in the healthcare sector. The 16 respondents (20%) not working in healthcare were excluded from further analyses since they are not relevant to dual practice analysis. The vast majority (87%) of respondents are public sector employees (61.9% in public sector only and 25.4% in both public and private sector). 12.7% of respondents only work in the private sector. Almost half (47.6%) of respondents hold more than one job. For income satisfaction, physicians employed in both sectors have higher satisfaction than physicians employed in the public sector only. CONCLUSIONS: As policymakers in Cambodia consider new approaches to regulation of the practice, it is important to know the context of the practice, the benefits to the healthcare system, and the costs. Recognizing the high prevalence of multiple job holding in Cambodia, as evidenced in our survey of UHS medical graduates, contributes to the discussion as important information that can be used toward meaningful reform.

Effect of Patients' Life Stories in Bringing Meaning to Nursing Home Care.

INTRODUCTION: Although there is an increasing need for geriatricians, fewer physicians are entering the field. Family medicine residents find geriatrics, especially nursing home care, unsatisfying. Life stories of older adult patients may help providers cope with the challenges of nursing home care and increase provider satisfaction by offering a way to connect with patients. METHODS: We conducted a qualitative study on life stories' effects on attitudes towards nursing home care. Fourteen patient stories were created. Seven Boston University family medicine residents and one nurse practitioner participated in a semistructured interview both before and at least 2 months after learning about their patients' stories. Data were analyzed using qualitative techniques from grounded theory. RESULTS: Participants found nursing home care challenging, particularly for patients who were nonverbal due to advanced dementia, because they had difficulties forming meaningful relationships or discussing medical decisions with their patients. Life stories increased empathy, deepened relationships with patients, and led participants to feel more satisfied in their role as providers. The stories were considered useful for end-of-life discussions. CONCLUSION: Life stories incorporated into physician practice may help health care providers feel more connected to their patients and ultimately more satisfied in the care of nursing home patients.

Teaching geriatric assessment: use of a hybrid method in a family medicine clerkship.

BACKGROUND AND OBJECTIVES: We addressed a lack of geriatric content in our third-year family medicine clerkship. Adding this content posed a challenge in that students are dispersed to clinical sites across New England. Our goal was to promote student skill in functional assessment of elderly patients. METHODS: We used multiple formats: a workshop, a small-group case discussion, an online video, and an online discussion of a new geriatric case. Students were directed to use five assessment tools on actual patients in the office and on a home visit. RESULTS: A total of 155 students participated in the new curriculum. Students completed a required home visit on an older patient and evaluated geriatric patients in an office setting. They performed the Mini-Mental State Exam (MMSE), Activities of Daily Living Scale (ADL), Instrumental Activities of Daily Living Scale (IADL), Geriatric Depression Scale (GDS), and Get-Up-and-Go tests in patients in both settings. There was significant improvement from before to after the clerkship in identification of the appropriate geriatric assessment tool to use (MMSE 86% to 96%; ADL/IADL 32% to 94%; GDS 71% to 94%, and Get-Up-and-Go 4% to 58%). Students evaluated the curriculum positively. CONCLUSIONS: We were able to successfully increase the correct selection of and document high rates of use of geriatric functional assessment tools in our third-year family medicine clerkship using a mixture of teaching methods.

Chief resident immersion training in the care of older adults: an innovative interspecialty education and leadership intervention.

Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2-day off-site chief resident immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini-lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one-on-one mentoring to develop a project in geriatric care or education. Evaluation included pre- and postprogram tests and self-report surveys and two follow-up surveys or interviews. In 2006 and 2007, scores on a 12-item objective knowledge test increased significantly (P<.001) from before to immediately after CRIT. Self-report knowledge and confidence in teaching geriatrics also increased significantly (P<.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2-day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.