Browsing by Author "Sumanasekera, R.D.N."

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Evaluation of teaching and learning in family medicine by students: a Sri Lankan experience
(Medknow, 2015) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Gunasekara, R.; Chandrasiri, P.
BACKGROUND: Family Medicine occupies a prominent place in the undergraduate curriculum of the Faculty of Medicine, University of Kelaniya, SriLanka. The one month clinical attachment during the fourth year utilizes a variety of teaching methods. This study evaluates teaching learning methods and learning environment of this attachment. METHODOLOGY: A descriptive cross sectional study was carried out among consenting students over a period of six months on completion of the clinical attachment using a pretested self administered questionnaire. RESULTS: Completed questionnaires were returned by 114(99%) students. 90.2% were satisfied with the teaching methods in general while direct observation and feed back from teachers was the most popular(95.1%) followed by learning from patients(91.2%), debate(87.6%), seminar(87.5%) and small group discussions(71.9%). They were highly satisfied with the opportunity they had to develop communication skills (95.5%) and presentation skills (92.9%). Lesser learning opportunity was experienced for history taking (89.9%), problem solving (78.8%) and clinical examination (59.8%) skills. Student satisfaction regarding space within consultation rooms was 80% while space for history taking and examination (62%) and availability of clinical equipment (53%) were less. 90% thought the programme was well organized and adequate understanding on family medicine concepts and practice organization gained by 94% and 95% of the students respectively. CONCLUSIONS: Overall student satisfaction was high. Students prefer learning methods which actively involve them. It is important to provide adequate infrastructure facilities for student activities to make it a positive learning experience for them.
Patient held medical record: solution to fragmented health care in Sri Lanka.
(Lahore Institute of Public Health (LIPhealth), 2013) Ramanayake, R.P.J.C.; Perera, D.P.; de Silva, A.H.W.; Sumanasekera, R.D.N.
Sri Lanka has an extensive network of health care institutions, but there is no registered population for any particular health care institution. Patients are free to select which doctor to consult and which hospital to get admitted. Also there is no established referral and back referral system in practice. This free movement of patients within and between the primary, secondary and tertiary levels of care by patient's choice has given rise to a situation where each episode of an illness or disease process is managed by different doctors in differing specialties. As in most care settings, the patient's medical or health record is held by the health service or doctor that is providing care to the patient for a specific ailment. This leads to a gap in communication between multiple caregivers leading to poor co-ordination of care. These difficulties faced and lessons learnt suggest the use of a medical record that is kept with the patient. Patient Held Medical Records (PHMR) are formal and structured records that are given to patients to enable the continuity and quality of care which he takes with him when he goes for medical consultations. PHMRs aim to improve communication between patients and the multiple clinicians and health care workers who are involved in patient management. The PHMR we propose comprises of a folder, clinical notes, problem list, flow sheet and other optional items. The PHMR can be used as a tool to empower and educate the patients. It will improve transparency and trust and facilitate continuity of care. Increased work load, cost, restriction of freedom in writing notes, confidentiality and retention of records by patients are the disadvantages which need consideration.
Perceptions regarding obesity amongst obese females attending an urban primary healthcare center
(Sri Lanka Medical Association, 2014) Sumanasekera, R.D.N.; Ramanayake, R.P.J.C.; Pathmeswaran, A.
INTRODUCTION AND OBJECTIVES: Sri Lanka is seeing a rise in the obesity epidemic. Middle class females living in urban areas are one of the affected groups. To explore the beliefs and expectations regarding bodyweight of middle class females attending an urban primary healthcare centre in Sri Lanka. METHODS: Baseline data from an intervention study was used for this analysis. Fifty participants were selected randomly from obese females (BMI between 27.5 -40 kg/iVi2) registered with the University Family Medicine Clinic in Ragama and volunteered to participate in a lifestyle modification programme for weight reduction. Their demographic data.and baseline anthropometric measurements were obtained and a focus group discussion conducted on perceptions regarding obesity. RESULTS: Participants were aged 21 -58 years, majority were married housewives with 2 or more children, Weights ranged from 55-92.9 kg, BMIs 27.6-39.7 kg/m2 and waist circumference 90-112 cm. On average the participants wished to lose 11 kg (ranging from 2-30 kg) over a 6 month period. Focus group discussion revealed that participants accepted the norm of putting on weight after childbirth and as part of aging. Knowledge regarding food values was poor and myths regarding diet and exercise were identified. CONCLUSIONS: Unrealistically high targets for weight loss were common among participants. Putting on weight after childbirth with aging was perceived as the norm. Many mistakenly perceived that they had put on weight in spite of sensible eating and adequate levels of physical activity.
Rate of stunting among a sample of postwar resettled families in the Vanni region: a study from the Mullativu District
(Sri Lanka Medical Association, 2013) Ramanayake, R.P.J.C.; Sumanasekera, R.D.N.; de Silva, A.H.W.; Perera, D.P.; Chandrasiri, P.; Gunasekera, R.; Jayasinghe, L.R.
The Department of Family Medicine, University of Kelaniya conducted a health camp in Puthukudiyiruppu in March 2011. Height and weight measurements were carried out and data of 303 participants were analysed. The rate of stunting among children below six years in this population was 62% compared to 19.3% nationally. Thirty four percent of children and adolescents (6-18yrs) were underweight and 21.4% of adults had a BMI less than 18.5kg/m2.
Referral Communications in Sri Lanka; Views of General Practitioners
(SciRJ, 2014) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Athukorala, L.A.C.L.; Fernando, K.A.T.
INTRODUCTION: Referral of patients to specialists and hospitals is an essential and inevitable aspect of primary health care. Maintain good communication is essential during the process in order to provide quality care without delays and unnecessary expenses. In Sri Lanka referral letter from a general practitioner (GP) is not essential to get admitted to a hospital or to consult a specialist and there is no registered population for a particular practitioner. This study was conducted to look at the views of general practitioners on referral communications. METHODOLOGY: This was a descriptive cross sectional study and postal survey was conducted among members of the college of general practitioners of Sri Lanka using a self administered structured questionnaire. RESULTS: Response rate was 28.7%. Only less than 60% wrote a referral letter always when referring a patient to a hospital/ specialist and the main reasons were; Patients insistence on referral without an indication, No feedback from specialists and lack of ownership to non regular patients. Information related to the disease and administrative details were the items of information mainly included in letters while socio psychological items were given lesser importance. Reply rate was very poor irrespective of the referral destination and main items of information expected in a reply letter were; Diagnosis, plan of management and instructions to the GP. DISCUSSION: There should be better communication and coordination between GPs and specialists/hospital doctors. Ways and means should be explored and rectifying measures should be undertaken which will benefit patients, GPs, specialists/hospital doctors and the health care system.
Referral communications: Bridging the gap between primary care doctors and specialists
(Lesley Pocock medi+WORLD International, 2014) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Lakmini, K.M.S.; Ranasinghe, B.L.S.
INTRODUCTION: In the Sri Lankan health system there is no system for registering a patient under any health care provider and there is no established referral and back referral system in practice. Still there is communication between primary care doctors and specialists mostly through conventional letters. This study was conducted to explore views of specialists on the referral process of the country. METHODOLOGY: This was a descriptive cross sectional study. A self-administered questionnaire based on the data gathered in earlier qualitative, explorative research was prepared to gather data. A postal survey was conducted among Specialists Island wide. RESULTS: 1100 specialists were included in the study and the response rate was 20%. Although specialists expect a referral letter from general practitioners they receive one only around 50% of the occasions. They were not happy with the quality of letters and expected a comprehensive referral letter. They were keen to reply but time constraints (50%), lack of secretarial support (36%) and perception that reply will not reach the sender (31%) were obstacles in replying. Continuous medical education, use of structured referral forms and strengthening training programs were suggested to improve communications. CONCLUSIONS AND RECOMMENDATIONS: Specialists have a positive attitude towards their professional relationship with GPs and they should be made aware of this and try to enhance their communication with specialists. There should be rectifiable measures in the systems which facilitate coordination and communication between the two parties and then the referral process will become meaningful and beneficial to all the stakeholders.
Referral letter with an attached structured reply form: Is it a solution for not getting replies
(Mumbai : Medknow, 2013) Ramanayake, R.P.J.C.; Perera, D.P.; de Silva, A.H.W.; Sumanasekera, R.D.N.; Jayasinghe, L.R.; Fernando, K.A.T.; Athukorala, L.A.C.L.
Background: Communication between primary care doctors and specialists/hospital doctors is vital for smooth functioning of a health care system. In many instances referral and reply letters are the sole means of communication between general practitioners and hospital doctors/specialists. Despite the obvious benefits to patient care, answers to referral letters are the exception worldwide. In Sri Lanka hand written conventional letters are used to refer patients and replies are scarce. Materials and Methods: This interventional study was designed to assess if attaching a structured reply form with the referral letter would increase the rate of replies/back-referrals. It was conducted at the Family Medicine Clinic of the Faculty of Medicine, University of Kelaniya. A structured referral letter (form) was designed based on guide lines and literature and it was used for referral of patients for a period of six months. Similarly a structured reply form was also designed and both the referral letter and the reply letter were printed on A4 papers side by side and these were used for the next six months for referrals. Both letters had headings and space underneath to write details pertaining to the patient. A register was maintained to document the number of referrals and replies received during both phases. Patents were asked to return the reply letters if specialists/hospital doctors obliged to reply. Results: Total of 90 patients were referred using the structured referral form during 1st phase. 80 letters (with reply form attached) were issued during the next six months. Patients were referred to eight different specialties. Not a single reply during the 1 st phase and there were six 6 (7.5%) replies during the 2 nd phase. Discussion: This was an attempt to improve communication between specialists/hospital doctors and primary care doctors. Even though there was some improvement it was not satisfactory. A multicenter island wide study should be conducted to assess the acceptability of the format to primary care doctors and specialists and its impact on reply rate
Structured Referral Form: is it a solution for problems of referral communication in Sri Lanka
(Sri Lanka Medical Association, 2014) Ramanayake, R.P.J.C.; Sumanasekera, R.D.N.; de Silva, A.H.W.; Perera, D.P.
INTRODUCTION AND OBJECTIVES: Referral letters convey information required for continuity of care when patients are referred to a hospital or a specialist. In Sri Lanka conventional, hand written letters are used for patient referrals and there is no standard format or widely accepted guidelines. This study was conducted to explore the acceptability, advantages and limitations of a structured referral form for General Practitioners. METHODS: A referral form was designed based on literature review and guidelines. Printed referral forms were provided to 20 general practices representing different background. Telephone interviews were conducted at the end of 3 months to obtain their views on the format. Interviews were recorded, transcribed and themes identified. RESULTS: It has improved the comprehensiveness of letters and saved time. Overall quality of letters improved and participants were of the view that it could be used in any instance, language competency was immaterial and retrieval of information would be easier. Inadequate space under a few subheadings was a limitation. There was no increase in reply letters after introducing this letter. Participants were willing to use the format in the future as well. CONCLUSIONS: This is a useful and acceptable tool to improve information transfer and it will also be a reminder and guide for doctors to include all information. It could be a solution to the problems of communication in patient relevant in Sri Lanka.
Structured Referral Form; Is it a solution for problems of referral communication in Sri Lanka
(Center for Enhancing Knowledge (CEK), UK., 2014) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Athukorala, L.A.C.L.; Fernando, K.A.T.
INTRODUCTION: Referral letters convey information required for continuity of care when patients are referred to a hospital or a specialist. In Sri Lankan conventional, hand written letters are used for patient referrals and there is no standard format or a widely accepted guideline for referral communications. A structured referral form was designed to as a guide for the information to be included, as a solution to the problems in producing a good referral letter (time constrains, competence in language) and to prevent key problemsidentified in letters (omission of vital information, poor legibility and unsatisfactory format). This study was conducted to explore the acceptability, advantages and limitations of the structured referral form for GPs. METHODOLOGY: Referral form was designed based on the guidelines and literature reviews. 20 GPs were purposely selected to represent different backgrounds. Printed referral forms were provided to them and requested to use those for patient referrals for a period of 3 months. Telephone Interviews were conducted at the end of the study period to obtain their viewon the format. Themes expressed by participants were identified. RESULTS: It has improved the comprehensiveness of letters and saved time. Overall quality of letters has improved and participants were of the view that it could be used in any instance, competence in language was immaterial and retrieval of information would be easier. Inadequate space under a few subheadings was a limitation. There was no increase in reply letters after introducing this letter. They were willing to use that format in the future as well. Conclusions: This is a useful and acceptable tool to improve information transfer and it will also be a guide for doctors. It could be a solution to the problems of communication in patient referral in Sri Lanka
Student perceptions of an online post graduate course in family medicine in Sri Lanka
(Health Informatics Society of Sri Lanka, 2010) de Silva, R.E.E.; Fernando, J.; Sumanasekera, R.D.N.; Liyanagama, S.D.; de Silva, D.P.
BACKGROUND: The online Diploma course in Family Medicine (DFM) of the Post Graduate Institute of Medicine (PGIM) of the University of Colombo is one of the pioneering online post graduate medical courses in Sri Lanka.OBJECTIVES : To describe student perceptions on the online DFM course.METHODS : The study population comprised of all the students (19) of the first batch of the course. Pre- tested self administered questionnaires were administered to all students. A Likert scale was used to assess the domains of teaching, learning, levels of understanding, and technical problems. The scale ranged from 1= ["poor / not useful/did not understand"] to 5= ["excellent/ very useful/ understood very well"]. A focus group discussion was carried out to strengthen the student perceptions, based on the themes which emerged.RESULTS : Response rate was 98.4%. Levels of understanding the lessons were perceived to be high with an average of 4.8. Students were of the opinion that discussions and assignments helped them to engage in active learning. Online discussions were found to be the most useful form of learning. 88% commented that they are able to link clinical work to their online course work.CONCLUSIONS : This online course has been useful in improving student knowledge and the levels of understanding of individual lessons are satisfactory. The most useful form of learning appeared to be online discussions
Training medical students in general practice : a qualitative study among general practitioner trainers in Sri Lanka
(Medknow, 2015) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Athukorala, L.A.C.L.; Fernando, K.A.T.
INTRODUCTION: Worldwide Family Medicine has gained an important place in the undergraduate medical curriculum over the last few decades and general practices have become training centers for students. Exposure to patients early in the disease process, out patient management of common problems, follow up of chronic diseases and psychosocial aspects of health and disease are educational advantages of community based training but such training could have varying impact on patients, students and trainers. This study explored the views of General Practitioner (GP) trainers on their experience in training students. METHODOLOGY: This qualitative study was conducted among GP trainers of the faculty of medicine, University of Kelaniya, Sri Lanka, to explore their experience on wide range of issues related to their role as GP trainers. The interviews were recorded and transcribed verbatim. Themes expressed were identified. RESULTS: Altruistic reasons, self-satisfaction, self-esteem and opportunity to improve their knowledge were the motivations for their involvement in teaching. Teachers were confident of their clinical and teaching skills. They perceived that patients were willing participants of the process and benefited from it. There was a positive impact on consultation dynamics. Time pressure was the major problem and ideal number of trainees per session was two. They were willing to attend teacher training workshops to update their knowledge. CONCLUSIONS: GP trainers driven by altruistic reasons were willing participants of student training process. The perceived advantages of involvement of teaching for trainers and patients were an encouragement for potential trainers. University should organize training sessions for trainers which will boost their knowledge, confidence and teaching skills which will eventually benefit students.
Training medical students in general practices: Patients' attitudes
(Lesley Pocock medi+WORLD International, 2014) Ramanayake, R.P.J.C.; de Silva, A.H.W.; Perera, D.P.; Sumanasekera, R.D.N.; Athukorala, L.A.C.L.; Fernando, K.A.T.
INTRODUCTION: Training medical students in the setting of family/general practice has increased considerably in the past few decades in Sri Lanka with the introduction of family medicine into the undergraduate curriculum. This study was conducted to explore patients' attitudes towards training students in fee levying general practices. METHODOLOGY: Six general practices, to represent different practices (urban, semi urban, male and female trainers) where students undergo training, were selected for the study. Randomly 50 adult patients were selected from each practice and they responded to a self administered questionnaire following a consultation where medical students had been present. RESULTS: 300 patients (57.2 % females) participated in the study. 44.1% had previously experienced students. 30.3% were able to understand English. Patients agreed to involvement of students; taking histories (95.3%), examination (88.5%), looking at reports (96.6) and presence during consultation (88.3 %). Patients' perceived no change in duration (55%) or quality (56.3%) of the consultation due to the presence of students. The majority (78%) preferred if doctor student interaction took place in their native language. 45.8% expected prior notice regarding student participation and two to three students were the preferred number. 93.6% considered their participation as a social service and only 8.8% expected a payment. CONCLUSION: The vast majority of the patients accepted the presence of students and were willing to participate in this education process without any reservation. Their wishes should be respected. The outcome of this study is an encouragement to educationists and GP teachers.
Views of Specialists and General Practitioners regarding referral process in Sri Lanka
(Sri Lanka Medical Association, 2014) Ramanayake, R.P.J.C.; Sumanasekera, R.D.N.; de Silva, A.H.W.; Perera, D.P.
INTRODUCTION AND OBJECTIVES: Sri Lanka has an impressive healthcare system, despite the lack of a system for registering patients under healthcare providers and no established referral and back referral system. In referring patients in Sri Lanka, communication between General Practitioners (GPs) and specialists take place mostly via letters. METHODS: A descriptive cross sectional study using self-administered questionnaires explored views of specialists and GPs on the referral process. RESULTS: Island wide, 20% of 1100 specialists representing 28 specialties invited to participate responded According to specialists, referral letters were few in number and poor in quality. Specialists expected comprehensive referrals describing the problem, patient and administrative details. Few replied to referrals and reasons stated were; time constrains, lack of secretarial support, perceptions such as the letter will not reach the GP, no benefit to GP or patient. Response rate from general practitioners was 28.7%. Less than-60% always wrote a referral letter. Reasons for not writing referral letters were; lack of ownership to non-regular patients, no feedback from specialists and patients insistence on referral without an indication. GPs stated that reply rate was poor irrespective of referral destination and main items of information expected following a referral were a reply letter with diagnosis, plan of management and instructions to the GP. CONCLUSIONS: Both groups agree that there should be better communication and coordination between GPs and specialists/hospital doctors. Ways to improve communication should be explored and rectifying measures should be undertaken.
Views of specialists on referral communications - a qualitative study from Sri Lanka
(mediWORLD International, 2014) Ramanayake, R.P.J.C.; Perera, D.P.; de Silva, A.H.W.; Sumanasekera, R.D.N.; Jayasinghe, L.R.; Fernando, K.A.T.; Athukorala, L.A.C.L.
INTRODUCTION: The referral letter is the interface between the primary and secondary/tertiary levels of care. It facilitates the referral process and is beneficial for optimizing patient care. In Sri Lanka a referral letter is not essential to consult a Specialist. In this scenario, the quality as well as the number of referral letters encountered in practice needed to be explored. OBJECTIVES: To describe Specialists’ views on the quality of referral letters received, perceived advantages of referral letters and to identify other modes of communication between General Practitioners and Specialists. METHODS: Conducted in 2013, this study consisted of in-depth interviews using a semi-structured format, with 21 purposively selected Specialists representing a range of specialties. They included clinicians and university academics from both the government and the private sector. Analysis was by generating a thematic framework based on the recurrent themes and issues which was then applied to the textual data. RESULTS: Most patients consulted Specialists without a referral letter and also the few letters received were of poor clarity, lacking important information and scribbled in illegible hand. Main themes identified as advantages of referral letters were: impart important information about the patient, clear description of the initial condition and treatment given, reduced consultation time, prevents delays in diagnosis and reduced healthcare costs by reducing polypharmacy and repetition of investigations. Some of the other modes of communication suggested by Specialists were via telephone, SMS, fax and email. CONCLUSIONS: The general belief amongst Specialists is that referral letters are an important part of the patient care system. This has not been adequately utilized by the primary care providers in Sri Lanka, despite the numerous advantages described. Also consideration needs to be given to newer modes of emerging information communication technology.
Why are specialists reluctant to reply to referral letters-exploring the views of specialists in Sri Lanka
(Lahore Institute of Public Health(liphealth), 2014) Ramanayake, R.P.J.C.; Perera, D.P.; de Silva, A.H.W.; Sumanasekera, R.D.N.; Fernando, K.A.T.; Jayasinghe, L.R.; Athukorala, L.A.C.L.
BACKGROUND: The referral letter from General Practitioner and the reply from the Specialist is the interface between the primary and secondary/tertiary levels of care. It facilitates the referral process and is beneficial for optimizing patient care. In Sri Lanka there is no established referral/back referral system. Not receiving a response to their referrals is a common grievance made by most primary care doctors. In this scenario, the views of Specialists were explored on the importance of reply letters and measures to improve communication. METHOD: Conducted in 2013, this study consisted of in-depth interviews using a semi-structured format, with 21 purposively selected Specialists representing a range of specialties. They included clinicians and university academics from both the government and the private sector. Specialists rarely contacting a GP, such as anesthesiologists and microbiologists, were not invited to participate. Analysis was by generating a thematic framework based on the recurrent themes and issues which was then applied to the textual data. RESULTS: Most Specialists identify that it is important to reply to referrals. These reply letters provide the Primary care doctors with a further management plan, enhance continuity of care and is a source of education to the General Practitioner. Despite the above benefits, the practice of writing a reply is dependent on the following factors: time constraints, lack of clerical assistance, known General Practitioner, patient’s condition and the quality of the referral letter. As methods of improving communication between primary and secondary care it was suggested that referrals be made mandatory to be seen by a Specialist, improving informal communication between Specialists and GPs via regional clinical meetings and introducing a structured referral letter with an attached reply form. CONCLUSIONS: Specialists acknowledge the importance of reply letters in the referral process. Further steps need to be taken to improve the reply rates. This includes changes that need to occur in the referring General Practitioners, Specialists and the practicing institutions creating an environment that is conducive to the referral process.