Table 3 Description of discourse-analysis findings of three scenarios and its learning objectives from three academic years of an Indonesian medical school's curriculum

Taken from a scenario in year 1- Block 1.3 Digestive system

Year theme: Human Body System

Title: Sunken Eyes

Sentence 1: A male baby, 11 month was brought to primary health care with diarrhea and vomiting for two days.

Sentence 2: His mother usually giver him formula milk in a bottle.

Sentence 3: He was irritable, eager to drink and had sunken eyes.

Sentence 4: The midwives in the PHC assessed him to some degree of dehydration and gave him oral rehydration solution.

Sentence 5: Please think a lot about the mechanism of the problem above.

1. Anatomy and physiology or small and large group intestine

2. The role of digestive enzymes

3. Biochemical digestive and absorption process of dietary food

4. Microstructure of digestive enzymes producing cell

5. Physiology of digestion and absorption of carbohydrate, lipid, protein, minerals and water)

6. Biomedical importance of carbohydrate

7. Biomedical importance of protein

8. Biomedical importance of lipid

9. Pharmacokinetic and pharmaco-dynamic

10. Basic of virology

11. Normal fluid consumption

12. Influence of drug route administration and drug onset and duration

General agreement on Tuesday April 13^th 2010:

None of the learning objectives in this scenario addressing the patient's background, patient's problem or patient's family and environmental condition. It is clear that there is a gap of patient-centered care between scenario and learning objectives. The theme of year 1 should be expanded to more than "a human body system" and more to address the family as a unit of care.

Agreement on the Comprehensive Care value:

In sentence 2 in the scenario, there is a wide opportunity to explore the background of the patient and his mother. Possible questions were: Why the mothers prefer to give him formula milk? What was she doing every day, did she take-care of her baby by her selves or there is somebody else help her? Did she have to work full time a week? What about her husband, the grandpa and grandma and the supportive neighborhood that was characterized this society in raising a baby?

However, no learning objective seemed to support this direction of patient-centered care. The coders understand that for the first year students, basic medical sciences such as anatomy, biochemistry and physiology were fundamentals. However, a curriculum that oriented towards family medicine should also address the family as a unit of care, since early basic medical curriculum.

Agreement on the Continuous Care value:

Sentence 3 and sentence 5 was rather contradictory. Sentence 3 may stimulate students to think of the natural history of such illness and may facilitate thinking of how to provide preventive care so that such a case would never happened again to the baby. However, before students could think a bit about preventive care and the natural history of disease of an acute illness such as diarrhea, sentence 5 directly drove students to learn basic sciences of anatomy, physiology and biochemistry, which is of course important for first year students, but may drive the tutorial discussion away from a patient-centered care.

Taken from a scenario in year 2- Block 2.3 Infancy and childhood

Year theme: Human Body System

Title: Sunken eye girl

Sentence 1: A two years old female child was brought to an outpatient clinic because of diarrhea.

Sentence 2: She had watery diarrhea for 15 days and passed stool about 7 times a day.

Sentence 3: There was neither mucus nor blood in the stool.

Sentence 4: Her mother had tried to give her oral rehydration solution. She was eager to drink but vomit afterwards.

Sentence 5: On physical examination she looked restless and irritable.

Sentence 6: Her eyes were sunken and abdominal skin pitch went back slowly.

Sentence 7: She was very think and her body weight was 8 kilograms.

Sentence 8: The doctor found diaper rash.

Sentence 9: Her eyes were sunken and abdominal skin pitch went back slowly.

Sentence 10: She was hospitalized in order to manage her dehydration.

Sentence 11: A further assessment into child's case found that she had been hospitalized several times because of diarrhea and respiratory tract infection.

1. Explain the definition of diarrhea

2. Explain the etiology of diarrhea

3. Recall of water and mineral absorption in the gut

4. Explain the pathophysiology of viral and bacterial diarrhea

5. Explain the degree of dehydration

6. Explain the management of diarrhea based on guideline of WHO

7. Explain the complication of severe dehydration including electrolyte imbalance, acid-base imbalance and hypovolemic shock

8. Describe the cause of toxin induce food borne illness

9. Define lactose intolerance

10. Explain the composition of oral rehydration solution

11. Explain the management of persistent diarrhea

12. Explain hypernatremie

13. Explain about vomiting

14. Explain about constipation

15. Explain about abdominal distension

16. Explain jaundice

General agreement on Tuesday July 13^th 2010:

It is good that similar case was repeated again in the second year to show the spiral based education. This case may stimulate students' prior knowledge and adjust more knowledge in the same area.

Agreement on the Comprehensive Care value:

Sentence 2 should facilitate students to think more about the background of this child and her family. Based on the year theme Life Cycle, possible questions are: Into what stages this child had grown up physically and mentally based on natural child growth and development? Why after 15 days the child was brought to a clinic? Why not immediately after she found diarrhea? What is the underlying reason of her parents? Did they face difficulty on social economic or something else? Who take care of the baby every day? What is happening during the last 15 days?

However, such curiosity on patients' bio-psycho-socio-eco-educ-cultural background did not supported by the learning objectives of this scenario. All 16 learning objectives may drive students to think about only medical knowledge rather than deepen their curiosity on patient-centered care issues.

Agreement on the Continuous Care Care value:

The last sentence in the scenario should facilitate students to think about underlying illness. A child who often hospitalized because of diarrhea and respiratory infection may have an underlying disease which is important to explore. The main possible question is: How a doctor that oriented towards family medicine helps to prevent the particular illness from falling into further stage in the natural history of particular illness? Moreover, a doctor that oriented towards family medicine should put attention on child's normal development stages and possible influence of this underlying disease. It is a misfortune that all 16 learning objectives did not support this preventive and promotive care in which vital for primary cares doctors.

Taken from a scenario in year 3- Block 3.3 Abdominal complain

Title: Bloody stool

Sentence 1: A 50 years old female came to her physician for a routine health maintenance examination.

Sentence 2: On physical examination, there were no remarkable findings but a stool sample was positive for occult blood.

Sentence 3: Doctor planned to do further laboratory examination for tumor marker's identification and colonoscopy.

Sentence 4: The patient refused further treatment and workup.

Sentence 5: Ten months later she visited her physician because of constipation, micrositic anemia and 5 kg lost of body weight in the last 3 months.

Sentence 6 On physical examination, there were hepatomegaly slight ascites. Ultrasonography shows multiple mass in the liver.

1. Explain the epidemiology, the natural history, symptom and sign, the diagnosis and management of colorectal cancer

2. Explain the association of the cancer with fiber diet

3. Emphasize the importance of endoscopy in dyspepsia

4. Emphasize the importance of tumor marker examination in colorectal cancer

5. Explain the staging and grading of the colorectal cancer.

General agreement on Tuesday 24 August 2010:

This is a "good" scenario to show the perplexity of guiding students into basic medical sciences or primary care or hospital based level. The case was often found in the hospital and it seemed intended to show how primary care level had failed. It is a good example when the teacher knows to facilitate students to prevent such a terminal illness. However, without careful attention, students may not realize that this is the primary care physician's task and responsibility and so he/she should have an excellent relationship with the patient to gain her trust and cooperation for further clinical decision making.

Agreement on the Comprehensive Care value:

Sentence 1 in the scenario shows that this patient was on routine general check up. It means that she was possibly aware of the importance of general check up and she has adequate health insurance to support, particularly in this context of this study where fee for services usually out of pocket.

Sentence 4 shows that this patient did not want to follow the procedure for further examination. Here comes a big question: Did the patient was well-informed about the possibility of the result of a general check up and the consequences? A middle age women who undergone routine checkup - (every year?) - should be well informed about the consequences of a medical checkup. This is one of the main tasks of a doctor who oriented towards family medicine to shares information; before the illness become advances and before a further clinical decision was made. If situation in the sentence 4 happens, doctors should explore the reasons why this woman refuses for further examination. Good interaction skills between doctors and patients are necessary and should be stated as one of learning objectives. So, students could emphasize on illness perspective and not only focus on the disease perspective as stated on the learning objectives.

Agreement on the Continuous Care Care value:

If situation in the sentence 4 happens, doctors should shares information about the natural history of diseases of particular illnesses as a consequence of the result of the current general check up. The patient should be well-informed and a written informed consent maybe necessary. This process is an important task of a doctor to prevent the patient from falling into further stage of illnesses as expressed in sentences 5 and 6. This process of shares information and shares decision should also be stated as one of learning objectives.

We identified that the task of a doctor who oriented towards family medicine, to provide/assist optimum (if it cannot be maximum) prevention to the patient was not adequately comprehended in this scenario and its learning objectives. Sentence 5 and sentence 6 in the scenario seemed to adequately addressing the issue of prevention, but most likely to be fail by the time students saw the learning objectives.