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BLOCK CBP

SEMESTER I
1.
2.
3.
4.

Stadium Generale and Humaniora


Medical Communication
The Cell as Biochemical Machinery
Growth and Development Prenatal and
Postnatal

SEMESTER II
1.
2.
3.
4.
5.
6.

Medical Professionalism
Community-Based Practice
Health System-Based Practice
Evidence-Based Medical Practice
Special Topic
Elective Study 1

SEMESTER III
1. The Hematologic System and Disorders
and Clinical Oncology
2. Immune System and Disorders

SEMESTER IV
1. The Musculoskeletal System and
Connective tissue Disorders
2. Neuroscience and Neurological Disorders
3. Behavior Change and Disorders
4. The Visual System and Disorders

SEMESTER V
1. The Alimentary and Hepatobiliary System
and Disorders
2. The Endocrine System, Metabolism, and
Disorders
3. Clinical Nutrition and Disorders
4. Special Topic
5. Elective Study 2

SEMESTER VI
1.
2.
3.
4.

The Respiratory System and Disorders


The Cardiovascular System and Disorders
The Urinary System and Disorders
The Reproductive System and Disorders

SEMESTER VII
1. Medical Emergency
2. Special Topic: Travel Medicine
3. Elective Study 3

Tahun lalu dilakukan perdebatan di Stasiun TV


Swasta Nasional dalam acara Indonesia Lawyers
Club (ILC) yang membahas UU Pembatasan
Penggunaan Tembakau antara kelompok yang anti
dan yang pro
Hampir semua kelompok anti UU mengemukakan
alasan sbb: Ah, tidak benar merokok ada
kaitannya dengan kanker paru-paru. Buktinya,
saya dan teman-teman saya adalah perokok berat,
dan sudah merokok selama 30 tahun, toh sampai
saat ini tetap sehat-sehat saja.
Pertanyaan: sebagai calon dokter apa
komentar Sdr. dengan mengacu pada prinsip-

APPROCHES OF
CBP

Prevention (not
curative)
Community
(not individual)

Determinants
Genetic

Physical
Social, cultural
Biological, economical

Environment
Behavior
Health Services

Susceptible

(at risk)

Presymtomatic
stage

Clinical
stage

Stage
of
disability

Tertiary prev.

Secondary prev. Disability

Primary prevention
Early detection
limitation
Health promotion & prompt
Rehabilitation
Specific protection treatment

TATA TERTIB
1.

Selama kuliah

HP dimatikan (bukan
silent)
2. Dalam pleno pagi bila
terlambat > 10 menit
(jam di
dinding ruang kuliah)
mahasiswa tidak

BLOCK CBP

RULE/REGULATIONS

(Community-based Medical Practice)


1. HP harus dimatikan selama kuliah dan SGD
2. Study Guide dan semua references agar selalu
dibawa saat kuliah, SGD, individual learning
3. Kehadiran dan keaktifan saat SGD dinilai
(5% dari nilai ujian) INGAT ABSEN
4. Kehadiran saat kuliah dan feedback dihitung
(bila lebih dari 25% tidak ikut) tidak bisa ujian

5. Pada saat plenary mahasiswa presentasi


6. Wakil mahasiswa yang presentasi harus dipilih
pada saat SGD dan bukan di ruang kuliah
7. Wakil mahasiswa yang presentasi harus bergilir
(tidak boleh sama pada setiap hari)
8. Sesaat sebelum plenary dimulai, wakil
masing-masing kelompok yang akan presentasi
langsung duduk didepan
9. Narasumber akan memberi feedback
pada presentasi mahasiswa

REFERENCES & MANUAL


Study Guide & Annexes
Reference 1-6
Manual
Please refer to each day
session/module

CURRICULUM STUDY GUIDE


17 MODULES
DAY 1, 2, 3: MODULE-1
LEARNING MATERIALS:
Reference 1 and 2 ,movie, video
clip, websites (it is advice to download materials
from the websites before the lecture)

Learning Outcomes:
a) Describe several determinants (models)
of diseases and death occurring in the
population
b) Explain the applications of
understanding diseases and death
determinants (models)
c) Identify the strengths and weaknesses of
diseases models
d) Draw figure of the natural history of a
certain disease

e) Explain the applications of the natural


history of a disease for prevention
f) Explain the severity of diseases in a
population and its implication to
prevention
g) Describe the level of disease prevention
based on determinants and natural
history
h) Explain the Ice Berg Phenomenom and
its implication in diseases prevention

LEARNING SCHEDULE
(time table)
STUDY GUIDE PAGE 7 (CLASS B)

08.00-09.00: Introductory
lecture
09.00-11.00: Independent
learning
Reference 1 & 2
Learning tasks page 18-21

11.00-13.00: SGD
14.00-15.00: Student presentation &
feedback

LEARNING SCHEDULE
(time table)
STUDY GUIDE PAGE 11 (CLASS A)

09.00-10.00: Introductory
lecture
10.00-12.00: Independent
learning
Reference 1 & 2
Learning task-1 & 2 page 18-21

13.00-15.00: SGD
15.00-16.00: Student presentation &
feedback

APPROCHES OF
CBP

Prevention (not
curative)
Community
(not individual)

Some of the people need health care


some of the time
BUT
All of the people need public health all
of the time."

C. Everett Koop, MD
former U.S. Surgeon General

MODULE-1
Determinants of morbidity
and mortality in a
population
Natural history of the

disease
Diseases prevention

DAY 1
Determinants of
morbidity and
mortality in a
population

Several models/concept used to


analyzed determinants of
morbidity and mortality in a
population
The Epidemiologic Triad/ Triangle
(Teori Segi Tiga) page 26 33

Wheel Model (Teori Roda) page 3539


Web Model (Teori Sarang Laba-laba)
page 33

Model Blum
Model Mosley

Model Segitiga (The Epidemiologic Triad/


Triangle)

HOST (intrinsic)
(age, sex, genotype, behaviour, nutritional
status)

AGENT
(biologic, physic, mechanical,
chemical, nutrient)

ENVIRONMENT
(Physical, Biological, Social)

AGENT
Biological, chemical, physical
Mechanical, Nutrient

HUMAN HOST
Age, race, sex, habit
Genetic, personality
Defense mechanism

ENVIRONMENT
Biological, chemical, physical
Mechanical, nutrient, social, psychologic
Triad epidemiologik

Homeostatic Balance
A

Agent becomes more pathogenic

The proportion of susceptibles


in population decreases

E
H
A

Environmental changes that


favor the agent

At equilibrium
Steady rate

A
E
Environmental changes that
favor the host

Model Roda (Wheel


Model)

Biological
Environment

HOST
Genetic

Physical Environment

EXTERNAL (extrinsic)

INTERNAL
(intrinsic)
Social
politic,
economic
culture

Contoh
Kasus Kematian
Ibu
WEB MODEL
(SARANG
LABA-LABA)

Modifikasi dari: FA Moeloek, 2010

BLUM MODEL
Genetic

Behavio
r

Morbidity and
mortality in
a population

Health
services

Environmental factors
(biological, physical, social, economical,
politic)

CONCEPT (THEORY, MODEL)


INTRODUCED BY
DR. MOSLEY WHICH EXPLAINED
DETERMINANTS OF MORBIDITY AND
MORTALITY OF CHILDREN AGE
UNDER 5 YEARS IN A POPULATION

Socioeconomic determinants

Maternal
factors

Environmental
Contamination

Nutrient
deficiency

Healthy

Personal
Illness
control

Injury

Sick
Prevention
Treatment
Growth
faltering

Mortality

SOCIAL DETERMINANTS OF HEALTH

WHO- CSDH conceptual framework

UNDERSTANDING
CAUSALITY

Four types of Causal relationships


1.Necessary and Sufficient
2.Necessary but not Sufficient
3.Sufficient but not Necessary
4.Neither Sufficient nor Necessary
Necessary = without that factor disease never develops
Sufficient = in the presence of that factor disease always
develops

1. Necessary and Sufficient


Direct:
Factor A
Indirect:
Factor A

Disease

Step1

rarely happens

Step2

Disease

2. Necessary but not Sufficient


Factor A
+
Factor B
+
Factor C

Disease

Multiple factors required: initiator & promoter


(cancer, TB)

3. Sufficient but not Necessary


Factor A
or
Factor B
or
Factor C

Disease

Leukemia = Exposure to radiation OR benzene

4. Neither sufficient nor necessary


(contributory causes)
Factor A + Factor B
or
Factor C + Factor D
or
Factor E + Factor F

Disease

Most accurately represents causal relationships in most


chronic diseases

END OF DAY 1

Plenary day 1
Please refer to the plenary day 1 slides

MODULE-1
Determinants of morbidity
and mortality in a
population
Natural history of the

disease
Diseases prevention

DAY 2
Natural history of the

disease
Disease prevention

Natural History of Disease


Natural history of disease:
progression of disease in an
individual over time WITHOUT
any intervention.

NATURAL HISTORY OF THE


DISEASE
Page 6-9 reference 2
Four stages
Stage of
risk)
Stage of
disease
Stage of
disease
Stage of

susceptibility (population at
pre symptomatic (asymptomatic)
clinical (symptomatic)
disability

Every disease has difference


natural
history (example: HIV/AIDS, DHF)

PREPATOGENESIS
Agen

PATOGENESIS

Host

Fase klinis
Sembuh
Cacat
Fase penyembuhan

Lingkungan

Fase susceptible

Mati
Kronis

Fase subklinis

Perjalanan Alamiah Penyakit

50

Natural history of disease


TIME
Death
Infection

Clinical disease

Susceptible
host

Recovery
No infection

Incubation
Latentperiod
Exposure

Infectious
Onset

Non-infectious

NATURAL HISTORY (PERJALANAN


PENYAKIT)
Contoh:
hepatitis

Meninggal
Symptomatic
stage

Khronis
Carrier

Asymptomatic
stage

Sembuh
dengan cacat
Sembuh
tanpa cacat

Perjalanan infeksi HIV


1000

Viral Load

Jumlah CD4

Jumlah CD4

200

Infeksi Akut

Infeksi asimtomatik

Window period
Serokonversi

5
Bulan 0 1 2 3 4 Tahun

Simptomatik/AI
DS
5

Prevention can be done when


determinants and natural
history of the disease are
understood
LEVEL OF PREVENTIONS IN
BROAD CONCEPT
Primary prevention
Health promotion
Behavior change education
Policy/regulation
Specific protection
(specific to a certain disease)

Secondary prevention
Early detection and
prompt treatment/action

Tertiary prevention Prolonging


Disability limitationlife/increase
Rehabilitation
quality of life
Medical
Psychological

Social
Economical

Using Blum Model/Concept


Genetic

Physical
Social, cultural
Biological, economical

Environment
Behavior
Health Services

Susceptible

(at risk)

Presymtomatic
stage

Clinical
stage

Stage
of
disability

Tertiary prev.

Secondary prev. Disability

Primary prevention
Early detection
limitation
Health promotion & prompt
Rehabilitation
Specific protection treatment

Natural History of Disease and


Level of Prevention

Riwayat Alamiah Penyakit

58

LIMA TINGKAT PENCEGAHAN


Riwayat Alamiah Setiap Penyakit
Interaksi Agen, Pejamu dan Lingkungan
Faktor RANGSANGAN PENYAKIT

Reaksi pejamu terhadap RANGSANGAN PENYAKIT ->


Patogenesis
awal

Periode Prepatogenesis

Kerusakan
Penyakit
awal jaringan
lanjut
Periode Patogenesis

Konvalesens

Promosi kesehatan
Pendidikan kesehatan

Perlindungan khusus

Gizi yang cukup sesuai dengan


perkembangan
Perumahan, rekreasi dan tempat
kerja

Imunisasi
Kebersihan perorangan

Diagnosis dini dan pengobatan


segera
Penemuan kasus, individu dan masal

Perkembangan kepribadian

Sanitasi lingkungan

Skrining

Konseling perkawinan dan


pendidikan seks

Perlindungan terhadap kecelakaan


akibat kerja

Pemeriksaan khusus

Pengobatan yang cukup untuk


menghentikan proses penyakit dan
mencegah komplikasi

Genetika

Perlindungan terhadap kecelakaan

Tujuan:
Menyembuhkan dan mencegah
penyakit berlanjut

Penyediaan fasilitas untuk


membatasi ketidakmampuan dan
mencegah kematian

Pemeriksaan kesehatan secara


berkala

Penggunaan gizi tertentu


Perlindungan terhadap zat yang
dapat menyebabkan kanker
Menghindarkan zat-zat allergen

Rehabilitasi
Pembatasan ketidakmampuan

Mencegah penyebaran penyakit


menular

Penyediaan fasilitas untuk pelatihan


hingga fungsi tubuh dapat
dimanfaatkan sebaik-baiknya
Pendidikan pada masyarakat dan
industriawan agar menggunakan
mereka yang telah direhabilitasi
Penempatan secara selektif
Mempekerjakan sepenuh mungkin
Terapi kerja di RS
Penggunaan koloni yang terlindung

Mencegah komplikasi dan akibat


lanjutan
Memperpendek masa ketidakmampuan

Pencegahan primer

Pencegahan sekunder
Tingkat Penerapan Upaya Pencegahan

Pencegahan tertier

ICE-BERG PHENOMENA

SEVERITY OF DISEASES

ICE BERG PHENOMENA


(FENOMENA GUNUNG ES)

TWO CONSEQUENCIES
(DUA KONSKUENSI)
Semakin lebar dasar gunung es:
Semakin sulit penanggulangan penyakit
(control of the disease)
Bila memakai data sekunder, data
(statistik penyakit) akan semakin tidak
akurat
CONTOH: DBD dan RABIES

Epidemiological Iceberg
Only the tip of the iceberg is
easily observable
Dog bite example
3.73 dog bites annually
451,000 medically
treated
334,000 emergency
room visits
13,360 hospitalizations
20 deaths

THE VARIATION OF SYMPTOMATIC


DISEASES SEVERITY
100 CASES

Mild (ringan)

Moderate

Severe
Fatal

The film presentation


showed to you
Contribution (peran) of: scientific
foundations, clinical skill, communication
skill, information management, critical
thinking, professional values and attitudes,
community health
Meneliti kausa suatu penyakit
(AIDS) dan pencegahannya

DIFFERENCES BETWEEN
PUBLIC HEALTH
DOCTOR

CLINICAL
DOCTOR

1. Focus: individual
2. Responsibilities:
all people who come
all people in certain
geographical area, health and to the health facilities.
They usually passive.
sick, those who come and
those who do not come to
health facilities. They must
actively provide diseases
prevention to all people who
are at risk

1. Focus: population
2. Responsibilities:

PUBLIC HEALTH
DOCTOR

CLINICAL
DOCTOR

3. Function: to mobilize all


stakeholders and using
management principles to
plan, implement and
evaluate primary,
secondary, tertiary
preventions

3. Function:
to cure and to
increase the
patients quality
of life

4. Place of works: health


centre, heath department,
community clinics, etc

4. Place of works:
private practices,
hospitals, etc

PUBLIC HEALTH
DOCTOR

CLINICAL DOCTOR

6. Diseases
measurements in the
community:
proportion, prevalence,
incidence, ratio

6. Diseases
measurements for
individual patient: level
of blood pressure, blood
sugar, level of
hemoglobin, etc

5. Diagnostic tools:
5. Diagnostic tools:
epidemiology,
stethoscope, ECG, lab
statistics, demography examinations kits , CT
Scan, etc

PUBLIC HEALTH
DOCTOR

7. Treatment at the
community level
(prevention): public
health program such as
education program,
immunization program,
nutrition program,
family planning
program, etc

CLINICAL
DOCTOR

7. Treatment for
individual patient
(diagnosis and
care):
medical
treatments,
surgery,
radiation,
physiotherapy,
etc

PUBLIC HEALTH
DOCTOR

8. Indicators for
evaluating community
health program: percent
decrease of under
nutrition, percent
increase of contraceptive
use for family planning,
etc

CLINICAL
DOCTOR

8. Indicators for
evaluating the result
of patients
treatments:
decrease of blood
pressure of the
individual patient,
increase of
hemoglobin

FIVE STARS DOCTOR

(WHO = World Health


Organization
)
Care provider
(clinical dr)
Communicator (clinical & PH
dr)
Manager (PH dr)
Community leader (PH dr)
Decision maker
dr)

(clinical & PH

SOAL-SOAL
PEMANASAN
SEBELUM UJIAN

As shown in the film And The Band Played On


which was presented to you, there were several
sciences involved in investigation the cause of AIDS.
Those sciences are:
A. Social, economic, politic, epidemiology, statistic,
virology, clinical medicine
B. Social, politic, epidemiology, statistic, virology,
clinical medicine, health education
C. Social, epidemiology, statistic, virology,
clinical medicine, health education
D. Clinical medicine, epidemiology, statistic, social, politic
E. Social science, epidemiology, statistic,
virology, clinical medicine

Dalam film dengan judul And The Band Played


On yang telah Sdr. saksikan pada waktu
pertemuan pertama Blok Community-Based
Practice, ada beberapa metode yang dipergunakan
untuk mengungkapan penyebab AIDS, yaitu:
1.
2.
3.
4.

Contact tracing
Cohort
Case-control
Cross-sectional

Bila dilihat dari waktunya, urutan cabang


ilmu yang membantu mengungkapan
penyebab AIDS, yaitu:
A. Paling awal virologi, lalu epidemiologi dan terakhir ilmu klinik
B. Paling awal ilmu klinik, lalu virologi dan terakhir epidemiologi
C. Paling awal ilmu klinik, epidemiologi/statistik/ilmu sosial, lalu
virologi
D. Paling awal virologi, statistik/epidemiologi lalu ilmu klinik
E. Paling awal statistik/epidemiologi, ilmu klinik lalu virologi

Pada Gambar-1 berikut ini adalah kompetensi


(kemampuan) yang harus dikuasai oleh seorang
dokter. Kompetensi untuk memahami statistik
kasus-kasus AIDS dalam film dengan judul
And The Band Played On termasuk:
1. Scientific foundations
2. Information management
3. Professional values
4. Population health

Clinical
skill

Critical
Community thinking

Health
(Pu-blic
Health)

CBP

Information
management Scientific

Communication
skill
Professional,
values,
attitudes

foundations

Salah seorang mahasiswa (inisial X) yang kuliah di


fakultas non-kesehatan mengatakan sebagai berikut:
Ah, tidak benar merokok ada kaitannya dengan
kanker paru-paru. Buktinya, paman saya adalah
perokok berat, dan sudah merokok selama 30 tahun,
toh sampai saat ini dia sehat-sehat saja.
Pertanyaan: berikan komentar Sdr.
terhadap pernyataan mahasiswa X
seperti pada soal di atas (dengan mengacu
pada prinsip-prinsip epidemiologi).

Dalam suatu program interaktif yang


membahas topik wabah HIV/AIDS di sebuah
stasiun radio di Bali, banyak pendengar
dengan berapi-api mengatakan melalui
telepon sebagai berikut:
Lho, kenapa pelacur yang sudah jelas-jelas
dijumpai HIV+ tidak dikarantina. Mereka ..kan
dengan bebas masih menularkan HIV-nya pada
orang lain. Kenapa pada saat terjadi wabah
SARS, yang dicurigai saja sudah langsung
diisolasi?

Anggota DPRD Provinsi Bali tahun lalu mengatakan


sebagai berikut: Kami sudah mengalokasikan
dana APBD yang cukup besar untuk
penanggulangan HIV/AIDS di Bali. Kenapa jumlah
orang yang HIV+/AIDS kok terus bertambah
banyak. Harusnya kan berkurang. Kalau begitu
percuma dana yang kami alokasikan tersebut.
PERTANYAAN: Seandainya Sdr. menjadi petugas
kesehatan, bagaimana Sdr. menjawab pernyataan
anggota DPRD tersebut

Pertanyaan pendengar
dalam program interaktif di
sebuah stasiun radio di Bali
Tempat tidur pasien demam
berdarah yang dirawat di rumah
sakit kok tidak pakai kelambu?
Kalau pasien digigit nyamuk Aedes
kan bisa menularkan penyakitnya
kepada petugas di RS atau kepada
pasien lain?