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Medical Education in Indonesia INDONESIA is an archipelago of more than 3000 islands stretching between Asia and Australia over a distance greater than from New York to Los Angeles. It lies across the Equator; the lowlands are hot and humid, but the mountains are cool and pleasant. Indonesia's population of 130 million makes it the world's fifth largest nation; it is expected to reach 240 million by 2000. More than 75 million people live on Java, where the capital, Jakarta, has more than six million. Half of the people live in villages, and more than 200 dialects are spoken. The cultures range from stone age to modern sophisticated industrial society. All major religions are represented. Oil is the main source of income, but other resources include lumber, rubber, palm oil, spices and various minerals. Rice is the predominant food crop. Indonesia was a Dutch colony for almost 300 years. It became independent in 1945 after the Japanese occupation ended. A political upheaval in 1965 led to the present republic in which the military still plays a major part. Students start primary school at age 6 and complete high school after 12 years, when they may take university entrance examinations. Each university gives its own. The largest ones are in Jakarta where most health care professional training is located. Medical students, a large number of whom are women, are admitted directly after secondary school. The government dictates maximum class size, in the range of 125 to 200, but schools can take fewer. The 14 government and 10 private schools all follow the same 6-year curriculum prescribed by the government. It resembles the Dutch pattern with early science courses followed by clerkships. Because of a shortage of spaces in teaching hospitals, students in private schools may have to wait 2 to 4 years to complete requirements. Because of burdensome government examination policies, applied only to private schools, students in them may actually take up to 10 years to graduate. The private schools are periodically reviewed by a government-appointed Consortium of Medical Scientists that makes recommendations for accreditation to the Ministries. None has ever been fully accredited, which prevents any from being listed by the World Health Organization and hampers access to overseas residency training. Dental schools mostly have female students, and some private ones are fully approved. Accreditation would permit universities to award degrees after the student passes the school examinations. Actually the Consortium administers duplicate examinations each year after the student has passed the university ones. After Year 6, if all written examinations by both groups have been passed, the student is eligible to take a government practical oral examination, which uses patients. It

is given, in Jakarta for instance, only once each year at the government-run University of Indonesia to a maximum of 60 candidates at the rate of one subject per week. This scheduling makes it impossible for all graduating students of even a single school to complete the examination in a year. As a result, students must go to one of four other places in the country where the examination is given twice a year with two subjects per week, but only to 10 candidates at a time. Some students become discouraged with the delays and elect other careers, often business. The M.D. degree is awarded only after the government oral examination is passed. The graduate is then eligible to practice as a physician. Each is required immediately to spend 3 years in "rural practice" at a location prescribed by the government. He can begin his private practice simultaneously during the period of rural service. On completion, he may practice where he wishes and is not required to continue to hold a part-time government job, as are dentists. Some students meet the "rural" requirement by military service, often in a hospital. In the past, a few have been permitted to serve as junior faculty members in a government school. Residency training in specialties is under the control of individual specialty societies and cannot begin until after the "rural" requirement. The schools have no responsibility for graduate or continuing education. The faculties are listed in catalogues as both full- and part-time. In fact, all have private practices off campus. Most basic science courses are taught by M.D.s. The government appoints many faculty members and some administrators, even to private schools. Teaching hospitals are administratively separate from universities, and staff usually do not have clinical faculty appointments. Teaching is largely by lecture in all years. Student laboratories are poorly equipped and animal experiments few. Religious and other customs greatly restrict autopsies, so that pathology is taught largely from microscopic collections, with students seeing only forensic or legal necropsies. N o electron micrographs are available. Libraries in schools and hospitals consist of a few textbooks, mostly in English, with almost no journal runs. Little effort is made to encourage self-study. Student work space, such as laboratories or charting rooms in hospitals, is very scarce. Much time is spent in traveling between teaching exercises and living quarters in the community. Little undergraduate time is allocated to family medicine, behavior, or psychiatry. Most clinical teaching is urban hospital-based with little ambulatory experience, especially in rural areas, as preparation for the required government service or later practice. Available government estimates are that 50 persons of each 1000 will be ill at any time but only 20% of those in villages will come to a health center. At present, 40% of 121

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government rural health centers have no permanent doctor. The problems faced in planning include a high fertility rate, high infant death rate, and an expected increase in industrial illnesses. The most common illnesses are anemia and other nutritional deficiencies, respiratory and gastrointestinal infections, malaria, and dermatologic and venereal diseases, which are grouped together. Tuberculosis and cancer are not listed separately in hospital statistics. Schistosomiasis apparently is not a problem despite widespread rice paddies. Traffic accidents are an increasing problem, as reflected in the large number of neurologic beds occupied by persons with head injuries. Stomatology has a high outpatient load, indicating a lack

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• Annals of Internal Medicine • Volume 90 • Number

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of available dental care. A 1978 Ministry of Health document recognizes the manpower needs, especially of nurses, to staff health centers. The Rockefeller Foundation is supporting an interesting experiment in the medical school at Yogyakarta to improve teaching of community health; it includes reliance on mothers as the point of access to primary care. Few other innovations in education or patient care are being tried. (GEORGE T. H A R RELL, M.D.; Timonium, Maryland; and Vice President for Medical Sciences Emeritus, The Milton S. Hershey Medical Center, The Pennsylvania State University) © 1 9 7 9 American College of Physicians

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Medical education in Indonesia.

ABROAD Medical Education in Indonesia INDONESIA is an archipelago of more than 3000 islands stretching between Asia and Australia over a distance gre...
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