Experiences of being co-assistant: a pilot study

Background:  Co-assistant program is an important part in medical education in Indonesia. However, the evaluation for the effectiveness of this program is needed to produce the professional medical doctors. This study aimed to explore the experience of being co-assistance in medical education in Indonesia.    Methods:  This study used the descriptive qualitative approach by involving 12 medical doctors who had the experience of being co-assistant. The data in this study were analyzed by content analysis model using four cognitive processes: comprehending, synthesizing, theorizing, and re-contextualizing.   Results:  The findings emerged from the data consisted of having good learning experiences, seniority matter, and inappropriate examination.   Conclusions:  Considering the information from the students in this program was value, therefore, it is suggested that medical educators need to reconsider and evaluate the process of co-assistance program.

section_content: In the world of medical education, a clerkship program is one of the programs to train medical students in the practice of medicine in the final year study. This program takes a place in both classroom setting and teaching hospitals, including in the operating room, intensive care unit, emergency department, and other departments that allow learning by viewing and doing. 1 In Indonesia, this clerkship program has been called as "Co-assistant" program or usually shortened to "Co-Asst". This program is a mandatory for medical students after they are graduated from Bachelor degree. This program is also called as a rotation program, which medical students are rotating to all departments in hospitals instead of focusing on one department only. 

However, it is a great opportunity for them to learn and practice the knowledge in medical education in all clinical practice areas. On the other hand, this program is a mandatory to be completed in order to get a title as "medical doctor". 2 To be a medical doctor in Indonesia, actually, is spending a lot of time, which is approximately 6 years, divided to: 1) Three and a half year for general education in the 1 st semester, and integrated medical education in the 2 nd -7 th semester, 2) One and a half year for clinical experience or clerkship program in the 8 th -10 th semester, and 4) one year for Internship program. 2 It is expected that through this program, it can produce a medical doctor with great knowledge, skill and attitude.
section_name: INTRODUCTION

section_content: This study used descriptive qualitative design involving semi-structured interview and online interview for data collection. Participants were recruited through purposive sampling, which consisted of 12 participants with inclusion criteria, including: a) A medical doctor, b) Having experience of being co-assistant. This study was conducted in Mohammad Hoesin Hospital, Palembang, South Sumatera Indonesia. 

Data analysis in this study followed Morse and Fields content analysis model using four cognitive processes: comprehending, synthesizing, theorizing, and recontextualizing. 4 First, the researchers individually and manually check and open-code the transcripts to sort data and uncover meanings, by making notations in the text of reoccurring words, phrases, sentences, and paragraphs. 5 uring the synthesis stage, data are manually sifted into patterns to extract various ideas, which are analyzed, interpreted to discover phenomena arising, and then findings compared. During theorizing, sub-categories are collapsed into broader ones, categories identified through note taking, data relationships are examined, and compared to validate the categories. In the final stage, recontextualization, emergent theory is formed. 5
section_name: METHODS

section_name: RESULTS

section_content: During the co-assistance program, most of students were expected to learn and gain more knowledge and practice about medical science because learning is tied to context to learner joining a practice. In this study, the researchers found that participants were able to practice their knowledge and providing care with many patients along with various diseases. Therefore, the participants in this program got more knowledge than they got during in the classroom setting, like one participant described:

"…I am able to have practice knowledge because having many patients with diversity (Informant 6)" "…Having more medical experiences than a textbook (Informant 1)"

On the other side, in this program, the students not only learnt about the disease and the treatment, they also learnt about the doctor-patient relationship, particularly communication. The doctor-patient relationship is the central to delivery of high quality medical care and has been shown to affect patient satisfaction and a variety of other biological, psychological, and social outcomes. 6 eside, the power of communication is strongly benefit for patients to decrease their stress that might lead to other diseases. A good doctor today is demanded to have a good emotional communication with patients. One participant described:
section_name: Having good learning experience

section_content: Mostly, participants in this study explained the experiences, which did not focus on the medical science itself, but rather to the personal changes, attitude, and interpersonal relationship. During the program, most of students were busy with full of deadlines, and they needed to manage their time maximally for graduation. In this program, the students worked with their groups, and it is normally that sometimes a group will have multiperspectives and lead to misunderstanding, and it might end with fighting and stop being friend. It was a challenge or a problem for every student because some students showed good and bad characters. Like the participants described:

"…I learn how to be a good friend (Informant 2)" "…Knowing the world, knowing every character of people, both positive and negative (Informant 3)"

In hospital, students also did not work only by themselves. They worked with many health professions, such as Resident, Nurse, Pharmacist, Dietician, etc. Physician sometimes plays a dominant role in hospital. It might be due to lack of inter-professional collaboration among health professions, which might or might not be good for other professions. However, it is good if every profession can respect each other and work as their role and competency. In this study found that students were learning not to be dominant in every condition as participant described: ". . I learn how to respect each other, from Co-Asst, resident, patients, even cleaning services (Informant 8)" "…Learning how to not to be dominant, understanding every condition in the hospitals (informant 7)"

In response with this, some students realize that they need to be discipline and responsible about their roles in the hospital in order to be a good doctor. The co-assistance program opened their eyes about the real world of being doctor. Students learnt how they would be in the future, and learnt how to live. One student expressed:
section_name: "…In Co-Asst program, I learn how to use emotional (empathy or sympathy), I learn how to be patient when dealing with patients (Informant 5)"

section_content: In conclusion that the co-assistance program help students in their learning. Participants in this study learnt about medical treatment, disease, doctor-patient relationship, communication, attitude, career as a doctor, and interprofessional collaboration.
section_name: "…This program open my eyes of the working world (Informant 9)"

section_content: Instead of gaining more knowledge in the program through learning experiences, the students actually had a problem with the seniority matter. Co-Assistant refers to the assistant of doctor, in Indonesian term. Being an assistant of doctor means helping a doctor in treating the patients. In this study, students learnt from the Resident physician. A Resident Physician is a medical school graduate who is participating in a program and training in a specialized area of medicine. Residents, as they are more commonly called, have a dual role in the health care system in that they are simultaneously learners and medical care providers. 7 In this study, it was found that the Residents guided the students in the hospitals, including their jib description in hospital. The Co-Asst can get patients if getting permission from the residents. It means that if the Residents do not guide and give the student the patients, the students will learn nothing in hospitals. Therefore, most of students studied by themselves, unless the students do something or made approach to the Residents. However, sometimes the Residents asked the students to do something, which is not student's role. Some students felt like a "slave". On the other hand, the seniority matter was not only from the residents, but also other health professions, such as nurses. Nurses like to ask the Co-Asst to do nurses job like measuring blood pressure or vital signs. So, the students felt unclear about their roles in this program as participants described:

"…Most of students work by themselves; we need consultant to guide the students (Informant 4)" "…Sometimes, resident asked us to do something that is not our job (Informant 8)" "…Using the human resource of Co-Asst which sometimes is not relevant, we are not slave (Informant 5)" "…Seniority is bad (Informant 6)" "…Getting no respect, feeling like a slave (Informant 10)"
section_name: Seniority matter

section_content: Due to this seniority matter, most of students were feeling not good in staying in hospital because they might get nothing in that hospital. Some students felt good when they practiced in community that has no Residents. So, the students thought that they could be a real doctor in community and interacted with patients in there, as participant described:

"…I better stay in community than in hospital, many residents that we cannot have a patient (Informant 7)" "…We do not responsible for patients, so we get used to be easy going, our mentality is not developed. Stage in community is better because no resident, so we can work as a real doctor (Informant 7)"
section_name: "…We need to have a clear job description (Informant 2)" "…The collaboration between resident, Co-Asst and Nurses need to be improved. Do not make Co-Asst as an assistant of every profession (Informant 3)"

section_content: In this study, most of participants talked about the examination provided by the medical education. Here, the students complained about the way in conducting the examination. The examiners determined whether the students pass or not after finishing the whole stage of the clinical practice, not from every stage. It remains the program did not look the competency of the students in every stage. It might impact to the lack of competency of the students. In addition, students might get a "tough" examiner, which involves personal subjective evaluation in determining whether students pass the examination or not, as participant described:

"…Don't wait until the last phase to determine whether the students pass or not (Informant 2)" "…I suggest having not only one consultant for examination (Informant 2)"
section_name: Inappropriate examination

section_content: The experience of the students in this study told the need of fixing the system in the co-assistance program. The educators need to pay attention with the process of the program, especially with the students themselves. Despite having good learning experiences that students got, students also complained and explained about the situation during the program. The authors in this paper raised some point for considerations: Firstly, the seniority matters, which might lead a good or bad result. However, for this program, it will never lead to good result. Students, in this program, were coassistant, which refers to assistant of doctor. It means they will help a doctor to deal and treat their patients. Otherwise, the doctor needs to tell students what to do. So, students will know their role and responsibility. In this study, students work by themselves with no one guide them, unless if they can make approach with the Residents. If the Resident is good, they will be safe. Otherwise, if the Resident is easy going, the students will get nothing. This situation, without any changes, will continue and cause the lack of competency of student. Therefore, the medical educators should think about this issue. The authors propose the preceptorship program that might be appropriate for this co-assistance program. A preceptorship is a mentoring experience in which a practicing physician or educator volunteers to give personal instruction, training, and supervision to a medical student. Preceptorships offer the preclinical student an opportunity to follow a patient over time, to get to know the particular clinical field and to experience a clinical setting. Students report that preceptorships can be an excellent way of preparing for board examinations and clinical training. 8 condly, the situation that the students prefer to stay in the community reflected the impact of seniority matter. However, it might be misunderstood if in this community the students acted as a real doctor, because they were still students. So, they still need a preceptor to guide them in order to avoid malpractice. 

Thirdly, the examination system conducted in the program is definitely not appropriate to measure the quality of students, in terms of skill and competency. The medical educators need to measure the quality of the students in every stage, not only in the last stage because students were not good in all stages. 

Fourthly, the examiners should not use subjective evaluation to determine whether students pass or not in examination. The objective evaluation based on competency (skill, knowledge, attitude) is required.
section_name: DISCUSSION

section_content: It can be concluded that the experiences of the students in the co-assistance program in this study presented the positive and negative sides of the students' experiences, which consisted of Having good learning experiences, Seniority matters, and inappropriate examination. This paper provided the insight of information about the experience of clerkship program in medical education in Indonesia. However, the result of this study cannot be generalized for all scope of medical education. The further research is needed in order to explain the relationship between the students' competency and the clerkship program, especially per each department, and factors related to seniority matter.
section_name: CONCLUSION

section_name: Funding: No funding sources