Masters in Family Medicine in Laos: A Pilot Distance Learning Program Laura Goldman MD Jeff Markuns MD EdM Phoutone Vangkonevilay MD Ketkesone Phrasisombath MD Jessica Miller MPH

LAOS

Background Most Laotians live in rural areas and have disproportionately high adult, child and maternal mortality Post graduate physician training in primary care occurs in urban areas Physicians in rural district hospitals have no post graduate training, and most of the care is delivered by nurses with little training

Goal Develop, implement and evaluate a distance learning Masters in Family Medicine Program for retraining district hospital physicians in primary care

Structure of the Program Trained 4 physicians as Masters in Family Medicine at Thammasat Univ. in Thailand to become our faculty Adapted Family Medicine curriculum from ASEAN-EU University Network Programme including translation Master students cycle through 3 months in provincial hospital and then 3 months at home district hospital

Structure of the Program At provincial hospital trainees rotate through gen medicine, OB/GYN, pediatrics and surgery learn how to run conferences, teach, use PP and search the internet At home district hospital trainees Continue clinical work Work on community projects Complete thesis on research project

Graduates September 2013

Program Evaluation Methods 1. Family Medicine Questionnaire  Trained vs. Untrained Degree Evaluation  Trainee  Supervisor  Colleagues  Patients 3. Semi-structured Interviews  Program Implementers  Trainees 5 districts visited

COMPARISON OF TRAINED AND UNTRAINED PHYSICIANS IN SELF-REPORTED KNOWLEDGE AND CONFIDENCE

*Differences are significant at p<.05. Scale: 1: Novice 2: Advanced Beginner 3:Competent 4:Expert

*Differences are significant at p<.05. Scale: 1: Novice 2: Advanced Beginner 3:Competent 4:Expert

*Differences are significant at p<.05. Scale: 1: Novice 2: Advanced Beginner 3:Competent 4:Expert

*Differences are significant at p<.05. Scale: 1: none/very limited4: very advanced

RESULTS OF 360 DEGREE EVALUATION

TRAINEE'S ASSESSMENT OF PROGRAM Ave 4.0 I would like to see other general doctors from my area take this program I would recommend general doctors from other districts or provinces take this program I would like to see this training program continue Scale: 1: Completely Disagree 2: Somewhat Disagree 3: Somewhat Agree 4: Completely Agree

Qualitative Analysis Improved clinical skills “It seems that she has some changes in her capacity, such as she can assess the patients’ medical situation, can identify (classify) type of patients well (make accurate diagnosis), she usually tries to find the root-cause of illness, not just look at symptoms” – Supervisor #1

Qualitative Analysis Maternal child health “After joining this program I was able to learn and practice many procedures. I gained a lot of knowledge and skills. Now I can do what I was not able to do before, such as treatment and birth delivery.” –Trainee #5 “I gained more knowledge, more confident in myself, more confident to make decisions. For example, in child birth delivery, I dared not do it before”. –Trainee #5

Qualitative Analysis Dissemination of knowledge “I trained the village health workers and birth attendants once a week every week. After training we gave certificates of completion to the participants. We educated women on how to take care of new-born babies. When visiting community health centers, doctors and nurses were coached on how to give health services to people, such as general health check-ups, pregnant women check-ups, diagnosis, vaccination, etc…” ­– Trainee #2

Qualitative Analysis Dissemination of knowledge “I brought what I have learned from the Provincial Hospital to give training to village health workers and nurses at the community level; In the District Hospital, I taught all lessons I learned from the Provincial Hospital, such as vaccination for disease prevention, dengue fever.” –Trainee #2

Qualitative Analysis Computer skills “Previously I didn’t know anything about using a computer. I didn’t even know how to turn it on and off. I didn’t want to turn it on, as I was afraid I would break it; and while I was using a computer I always asked other people for help. Today my computer skills have improved tremendously.” –Trainee #2

Qualitative Analysis Computer skills “She has good computer skills. Before the training, she had no basic computer knowledge, but now she knows (quite skilled) how to search for medical information regarding diseases, medical treatments from different sources available on the internet. “- Supervisor #1

Qualitative Analysis Application of skills “I found that the distance learning program is a very good program for the doctors in local areas, particularly myself who is working as a director of a district hospital. In each of the three-month rotation/training and practice in Luang Prabang, then come back to work at the district, it allowed me the opportunity to improve my knowledge and skills which can be applied to our work in the district hospitals.” - Trainee #4

Qualitative Analysis Trust, respect, career advancement “More people trust me, always call me to help them, especially for serious cases.” –Trainee #5 “I used to do this work before, but after training, it is likely different- my colleagues and people trust me and respect me as a more qualified doctor.” -Trainee #4

Weaknesses Poor supervision Not enough faculty time Poor internet connections One trainee said there was no one to cover at the district hospital during 3 months away

Qualitative Analysis Continuing the program “Now, even though this is an initial stage of the program, I would suggest the program extend further in order to increase our medical doctors’ qualification.” – Luang Prabang faculty #1 “I want the program to extend some more time so that more candidates – about 5 people from this area will have a chance to join.” – Trainee #4

Conclusions Program successfully updated clinical skills including maternity and newborn care Graduates improved working relationships with other doctors, nurses and community health workers Graduates became teachers and disseminated knowledge Trainees were able to manage more patients at the district level before referring to provincial hospital

Conclusions-2 Graduates learned computer skills, including PowerPoint and use of internet The distance learning structure facilitated acquisition of new skills Graduates gained respect from colleagues Graduates and faculty recommend program for expansion Analysis indicates important areas of improvement

Masters in Family Medicine