AREA OF INTEREST OF INDONESIAN RESEARCHES IN MEDICAL AND HEALTH PROFESSIONS EDUCATION: FUTURE DIRECTION

Background: Medical education research has been flourished in the past two decades in Indonesia. It is highly important to study results of medical education researches in Indonesia to provide future direction for medical education. Six published literature in medical education from Asian context was used as the basis of this study. Method: We used the narrative review in which quantitative data were interpreted qualitatively. All national and international publication and the unpublished research in medical education from Indonesia between 2000 2013 were collected with multiple methods based on 8 criteria of inclusion/ exclusion. We also grouped the articles into quantitative and qualitative groups based on each method in each study. Results: Total articles interpreted was 151 and grouped into 17 areas of interest and level of evidences from ‘very rarely’ to ‘very frequently’ studied. Studies in the area of understanding problem–based learning (PBL) are still dominating the area of interest including the student-assessment within PBL program. Other areas are still rarely done, especially research in health professions education other than medical doctors. Conclusion: Research in medical education in Indonesia should be more stimulated; in terms of numbers and quality, more importantly to strive for future agent of culture, socio-economic and political changes based on the actual community problems in the universal coverage era toward solid interprofessional team work to accomplish patient safety.


INTRODUCTION
One of the main roles of medical education is to provide valid evidences for stakeholders about decision making in education, education management, proposed changes to the education system, and the changes in medical practice direction.[3][4][5][6] In developed countries, researches in medical education are based on needs and the results are used as the basis for decision making for the direction of medical education.The development of researches in medical education in Asia, Southeast Asia, and Indonesia still faces some obstacles, such as unpublished researches in medical education, less mastery in research methodology, and researches which based on funders, so that may not relevant to community needs.Even though, to be able to affect policy making, research results must be accessible, convincing, and relevant.Meanwhile, studies from abroad cannot be applied directly in Indonesia because of different conditions e.g.different races, genetics, culture, values, and etiquettes. At this point, it is highly important to know what researches in medical and health professions education that have been conducted, including recommendations given by researchers for the development of medical and health professions education in Indonesia.This study aims to do a narrative review and to give recommendations for medical and health professions education in Indonesia.

METHODS
This study is a narrative review of the results of medical and health professions education researches conducted in January 1 st , 2000 until July 31 st , 2013, either of medical, nursery, or midwifery area.Systematic analyses were performed by sorting the studies according to medical education research categorization recommended in Asian context.
In this narrative review study, 8 inclusion criteria were established by all authors: (1) the study was conducted in Indonesia (authors might be a foreigner), (2) the study were published between 2000 to 2013; (3) the publication could be fully accessed; (4) the studies we published in an international medical education journal or medical science journal with an expert of medical and health professions education as one of authors; (5) or published in an accredited domestic journal and reviewed by an expert of medical and health professions education; (6) or studies by undergraduate medical students with a supervisor who has formal background in medical education; (7) or thesis about medical and health professions education with a supervisor who has formal background in medical education; (8) or in the form of dissertation about medical and health professions education with an expert of medical education as a supervisor.Meanwhile, the exclusion criteria in this study was only one, which was invalid and unreliable research design to answer the aims of the study.Data were collected and coded with numbers.Therefore, blind data analyses were performed to know the distribution of researches categorized in aspects of areas of interest according to six international publication that we referred:  1).The following coding process were based on the results in Table 1.All authors performed the coding independently with a briefing prior the coding to uniform the perception on how to code.Collected researches were coded generally, then coded whether they were qualitative or quantitative studies.The research procedure is served as a guidance to elaborate research results data with research plans presented in Figure 1.

RESULTS AND DISCUSSION
From a total of 306 researches in medical and health professions education that we found from January 1 st , 2000 -July 31 st , 2013, we included 151 studies according to the inclusion criteria and they are presented in Table 2.Those researches were then selected and 17 were excluded because they did not fulfill the reliability and validity conditions that we established.We found a few researches with similar method with previous studies, but the results were not as significant (re-inventing the wheel).Moreover, several studies also did not answer the aims of the study, so based on the exclusion criteria we established, those were excluded from this narrative review.Therefore, the total number of researches we included in this narrative review was 134 researches in medical and health professions education.
We obtained 17 areas of interest that we established during the agreement process and was the expansion of the results of the reference codes 1-6 (Table 2).These 17 areas of interest were sorted from the first to last according to the hierarchy of complexity in medical and health professions education accredited in Indonesia. 13      The coding process based on level of evidences was not easy because authors simultaneously excluded several researches that fell into exclusion criteria.One of the advantages of this narrative review was to give an objective picture of the existing researches as the basis to establish the exclusion criteria.Therefore, if there was a rationally invalid and unreliable study, we did not recommend it.Table 4 shows that for qualitative studies, many studies are in level of evidences 3 and 2, where the studies were descriptive or conceptual.
Studies with an Area of Interest of Contextual Learning were found the most and we found scientific publication as the most common form, compared to other research forms in qualitative studies.Area of Interest of Patient-centered Learning followed after.Table 5 shows that for quantitative studies, one study fell in the highest level of evidence in the form of systematic review and it was an international publication.Other quantitative studies were dominated by master theses, followed by international publications.Experimental RCT studies dominated more, compared to non-RCT ones.Meanwhile, the most frequently studied Area of Interest was Teaching and Learning, including Clinical Learning.Problembased Learning (PBL) followed after.Studies in 'medical' education still dominated this area compared to other 'health professions' education.This showed that medical science development was faster compared to other health science.Therefore, the next recommendation is the effort to encourage studies in other health professions education, especially through interdisciplinary studies.

Area of Interest in Problem-based Learning (PBL)
Southeast Asian context, specifically Indonesian, attempted to understand the philosophy of Problembased Learning (PBL) that entered Indonesia in the early 1980s.Research domination in this area shows the efforts to understand it, including understanding the changed paradigm that teachers are not the center of learning anymore, but they are learning facilitators who make various efforts to prepare students to learn.However, studies in this area from Indonesia were mostly a master thesis and most of their level of evidences was descriptive.This shows that Indonesia is still in the stage of developing PBL.][16] Studies about self-directed learning in PBL were still minimal, so it needs to be developed further. 17dical and health professions education in Indonesia could be said to be in the stage of trying to understand what PBL is and has not been explored the independent learning paradigm towards selfdirected learning emphasized in PBL.The selfdirected learning view gets huge challenges due to the hierarchical culture background, where teachers or older people often get more chances to express their opinions compared to students or younger people. 18hen studies about PBL in Indonesia reach the stage of self-directed learning, the questions about hierarchical culture limiting learning independence are expected to be answered.[20]

Area of Interest in Clinical Teaching and Learning
Many quantitative studies in this narrative review studied the Area of Interest of Teaching and Learning, including in the clinical setting.Quantitatively it was still low, while qualitatively it was still at the stage of studying learning process and learning facilitation.This Area of Interest is strongly related to many other Areas of Interest, such as Learning Assessment, Learning Resources, Curriculum Development to answer the needs of community, etc.2] We still explored the process of small-group learning and interaction with the peers.4] However, studies about curriculum development in clinical teaching or learning process according to competency principles outline, were still minimal. 252][23][24] Studies about advanced clinical education of residency have not been explored much and in itself is a challenge.Particularly, now it has been recommended to use Entrusted Professional Ability (EPA) in achieving and delegating clinical authority in residency education. 26udies about clinical reasoning fell into the rare category of Area of Interest.Therefore, there is still much to do to improve medical and health professions education.The variation of learning process still needs as much attention as expected in exploring basic psychology and learning motivation that support the framework of clinical reasoning ability of a prospective healthcare providers. 27

Area of Interest in Patient-centered Care
It is good that in this study, attention towards patient-centered care were found according to the recommendation based on scientific evidences from abroad.Researches in this area in Indonesia were mostly qualitative and were internationally published in high rank journals.This showed that Indonesia has started to pay attention to soft skills, such as communication and professionalism, which are challenges in medical and health professions education worldwide.Studies in this area are closely related to local context and culture.More studies are still needed in this area to explore local cultural treasures that are expected to help PBL implementation.9] A doctor's or a patient's expectation to be able to communicate with partnership principles is eroded by one-way communication and not a dialogue, which usually dominates medical practice in Indonesia. 28This hierarchical culture is most likely the main challenge in teaching and learning process of medical doctor and other health professions in Southeast Asia in general. 29

Area of Interest in Interprofessional Education
Indonesia's attention towards interprofessional education was shown through many studies with international publication.1][32] The effort to integrate various scientific areas was also seen to care about education in emergency science areas, such as the effort to respond the needs of education in disaster preparedness. 33It is so interesting where in a hierarchical culture like Indonesia, young researchers are interested to develop areas to erode this hierarchical culture.Several researches of doctor-patient communication, nurse-doctor communication, nurse-patient communication, integration of areas, are excellent studies as the agents of change in a hierarchical culture such as Indonesia.Therefore, we are optimistic that PBL will be able to be applied in a hierarchical culture such as Indonesia and will be able to prepare agents of change as transformative leaders. 34

Area of Interest in Community-Based Education, Primary Health Care, and Local Resources Utilization
Although many international publications in community-based education (CBE) area and primary health care (PHC) area were found in this narrative review, generally the development of medical and health professions education in Indonesia still has not responded community health problems adequately.6][37][38][39][40] Quantitatively, studies about community-based learning are not sufficient.2][3][4][5][6] Indonesia, with 17,000 islands, 13,000 ethnic languages, and 80,000 general practitioners, should put forward education, researches, and community service based on the real needs of community.
Universitas Gadjah Mada is one of the pioneers in community education by starting the program of Kuliah Kerja Nyata (KKN) for higher education students in Indonesia.Currently, Faculty of Medicine, Universitas Gadjah Mada just implemented a community-based education and interprofessional education program for students since their first year in medical school, nursing school, and nutrition school in the form of Community and Family Health Care (CFHC) program, which is a rebirth of a similar program in the 1970s and 1980s, community-oriented medical education (COME). 41Various programs were also developed in several faculties of medicine.Among the pioneers is a program of Faculty of Medicine, Universitas Hasanuddin, Makassar called "First One Thousand Days of Life".Each student gets a family to attend to since his/her first day as a medical student, and the first day at school starts in primary health care and not in class.Collaboration among healthcare providers stands out, so maternal mortality rate in the families was pushed to zero percent for three years since the program had been implemented. 42Collaboration among health education institutions, community, and local government came to a realization to improve public health.However, scientific publications in this area should be written and published.
6][37][38][39][40][41] Currently, WHO emphasizes affordable, easy, and high quality primary health care for all populations in the world.Community-based medical education is the entry point for social sensitivity and the implementation of general medical sciences for community interests.Indonesia in the future will face the triple burdens, i.e. elderly with chronic diseases, children and adolescents with acute and communicable diseases, and the emergence of diseases that should have been overcome, such as helminth infections, polio, diphtheria, and other diseases. 43Health promotion by far is more needed considering that health problems in Indonesia have shifted from acute diseases to chronic diseases due to shifted demographic profile in Indonesia. 44udies about medical and health professions education curriculum that are able to answer real problems in community are needed.Learning process in Indonesia still emphasizes the cognitive process of a prospective doctor and still explore diseases and not their impact to patients' life. 25Therefore, attention towards real health problems needs to be improved through medical and health professions education researches in Indonesia.

Area of Interest in Learning Resources and Information Technology
Studies about learning resources in this narrative review fell into rare category.However, several studies in the form of theses made use of low cost and accessible learning resources. 24,45,46This is the excellence of medical and health professions education researches in Indonesia.Those studies also cited international researches about learning resources. 47,48The power of these studies about learning resources is in the utilization of local learning resources that are close to daily learning environment, which still needs improvement.
However, IT utilization is also worth considering, in accordance with previous studies. 1,5,6Many ways may be applied, including ones that do not rely on internet access, but generally they make use of mobile phones owned by Indonesian community.

Area of Interest in Student Assessment
0][51] This showed that Indonesia attempted to strengthen student assessment area.Studies about student assessment fell in the third place in quantitative Areas of Interest.However, if we look closely, studies about pure assessment, especially the development of validity and reliability of learning evaluation tools, is still low. 51Therefore, the development of researches in this area in Indonesia is still needed.Researches in student assessment in the future should also be developed and directed to advanced clinical education, residency, consultant, and continuing medical education, which are rarely studied in Indonesia.
Uji Kompetensi Dokter Indonesia (UKDI) or Indonesian Doctor Competency Test, which is similar to the standardized American young doctors test USMLE, is expected to be the learning assessment to improve learning process. 52However, further research is needed to study the accuracy of the assessment, the tools, data collection process, and data analysis in student assessment.Research in this area requires more detailed development, especially the validity and the reliability of the tools used.
Furthermore, the development of learning assessment process in clinical education is needed as the basis of medical and health professions education.Eventually, clinical education would involve direct observation and feedback aspects, which are documented through teacher-student communication, where hierarchic culture still stands as a real challenge in Southeast Asia, including Indonesia.The efforts to study and to explore learning evaluation process in clinical education will complete Miller's Pyramid, where the peak is clinical education with direct observation as the assessment with constructive feedback and participative learning process as its backbone.It is so interesting if we take a look at this leadership area.In the philosophical formulation of the basic life of Indonesia, the 4 th Pancasila, we do not encounter an adequate explanation about leadership. 58What was stated in Pancasila was the decision making through a community discussion and community decision making.However, leading individuals with initiatives tend to be hidden under the decision making from a community decision making.This is truly critical from medical education point of view because leaders actually are individuals with advanced vision and initiatives that are useful for the community.Meanwhile in Indonesia, an individual's initiative is likely to be camouflaged by communityoriented culture, where the decision is made by the forum.Although in this case we must prioritize collective competence, it does not mean that going forward together might neglect the initiative from the individuals.After all, a community competence comes from individual's competence.
Frenk et al (2010) clearly said that in the future, medical education would not be directed just to produce experts or professionals anymore, but to produce leaders or agents of change. 33e Founding Father of Indonesian Education, Ki Hadjar Dewantara, left a message clearly in his articles that noble character, intelligence, and learning skill development is very important for each next generation individual for their own future and independence. 60Teachers' role as facilitators in their learning process is to let them lead themselves, so that eventually they will be able to lead other people excellently.
"The 'Among method' is caring towards children's development based on their basic individual characters.""A child should never be forced to do anything, he has his own will and determination and he should be independent based on his own thinking and abilities."Ki Hadjar Dewantara "Wasita" 2 nd Edition, August 1930 59 This is the biggest challenge of medical education today and in the future: to produce individuals who are leaders of change for community at large.

RECOMMENDATIONS
Several significant researches in medical and health professions education were just published after this study had been analyzed and interpreted.A few of them is a study by Rahayu et al. (2015) about quality improvement of medical education through national structured clinical skills assessment. 61This is in accordance with the effort to standardize medical graduates mentioned above.Another study that is not less important is a study by Wistiono et al.
(2015) about the effort to make primary doctors to be equals with specialists, in the context of primary health care improvement in the era of National Health Coverage this decade. 62In line with WHO recommendations about primary care reformation centered in individuals, medical education studies directing to primary care improvement are much needed in the future.A study by Widyahening et al.  (2016) emphasized the importance of evidence-based medical education and how to make a clinical guide in the context where there is minimum scientific researches. 63A study by Sedyowinarso et al. (2014)  and Randita et al. (2016) emphasized the importance of interprofessional education and collaboration to actualize patient and healthcare workers safety. 64,65tudies in medical and health professions education keep arising towards medical and health professions education improvement in Indonesia.Basically, health workers are agents of change, not just to change health education through various scientific researches, but also to change community culture and characters towards prosperous civil society.A good change starts from the exploration of recent, continuous scientific evidences to be applied wisely in local context and to be constantly updated. 66herefore, the challenge of medical education in the future will be about skills mastery to support leadership, i.e. assertive communication, sensitivity to health problems and local culture, always searching for recent evidence-based scientific information sources in initiating improvement of all sectors, prioritizing teamwork, including the inevitable use of electronic technology.

Figure 1 .
Figure 1.The procedure in this narrative review study

Table 2 .
Medical and Health Professionals Education Researches in Indonesia (January 1 st , 2000 -July 31 st , 2013) 4 Master thesis in medical education, in which at least one of the supervisors is an expert in medical education (n = 137) (Inc = included; Exc = excluded)

Table 3 .
Results of coding from qualitative and quantitative studies (January 2000 -July 2013)

Table 4
and 5 presents the overall results of this narrative review.Results in Table4and 5 are not the exact number of all researches we coded.To maintain the results of Areas of Interest coding, the number showing the Areas of Interest was not the same with the total number of the coded researches.

Table 4 .
Narrative review of the qualitative studies (January 2000 -July 2013)

Table 5 .
Narrative review of the quantitative studies (January 2000 -July 2013) 53,54 Areas of interest of studies in medical and health professions education are still oriented towards the understanding of problem-based learning as well as student assessment process.A few areas of interest still require a series of evidence-based scientific explorations, especially ones involving teamwork in order to actualize patient safety in the era of Universal Health Coverage reformation.Health workers should be transformed to be future agents of change towards healthier global economic-socialpolitical, and culture; based on scientific medical and health professions education researches.36.Kristina TN, Majoor GD, van der Vleuten CP.Does CBE come close to what it should be?A case study from the developing world.Evaluating a programme in action against objectives on paper.Educ Health (Abingdon).2005 Jul;18(2):194-208.Widyandana D, Majoor G, Scherpbier A. Transfer of medical students' clinical skills learned in a clinical laboratory to the care of real patients in the clinical setting: the challenges and suggestions of students in a developing country.Educ Health (Abingdon), 2010 Nov;23(3):339.41.Community and Family Health Care Program.Yogyakarta: Fakultas Kedokteran UGM; 2016.