Cathepsin-K inhibition enhances anti-cancerous activity within oral squamous cell carcinoma cells: Uncloaking the potency of new K21 formulation.

BACKGROUND: The ability of cancer cells to be invasive and metastasize depend on several factors, of which the action of protease activity takes center stage in disease progression. PURPOSE/OBJECTIVE: To analyze function of new K21 molecule in the invasive process of oral squamous cell carcinoma (OSCC) cell line. MATERIALS & METHODS: The Fusobacterium (ATCC 23726) streaks were made, and pellets were resuspended in Cal27 (ATCC CRL-2095) OSCC cell line spheroid cell microplate. Cells were seeded and Lysotracker staining performed for CathepsinK red channel. Cell and morphology were evaluated using Transmission Electron microscopy. Thiobarbituric acid assay was performed. OSCC was analyzed for Mic60. Raman spectra were collected from the cancer cell line. L929 dermal fibroblast cells were used for Scratch Assay. ELISA muti arrays were used for cytokines and matrix molecules. Internalization ability of fibroblast cells were also analyzed. Structure of K21 as a surfactant molecule with best docked poses were presented. RESULTS: Decrease in lysosomal staining was observed after 15 and 30 min of 0.1% treatment. Tumor clusters were associated with cell membrane destruction in K21 primed cells. There was functional silencing of Mic60 via K21, especially with 1% concentration with reduced cell migration and invasiveness. Raman intensity differences were seen at 700 cm-1, 1200 cm-1 and 1600 cm-1 regions. EVs were detected within presence of fibroblast cells amongst K21 groups. Wound area and wound closure showed the progress of wound healing. CONCLUSION: Over expression of CatK can be reduced by a newly developed targeted K21 based drug delivery system leading to reduced migration and adhesion of oral squamous cell carcinoma cells. The K21 drug formulation can have great potential for cancer therapies due to targeting and cytotoxicity effects.

Digital teaching: Developing a structured digital teaching competency framework for medical teachers.

AIM: To explore the core competencies needed on part of the medical and dental teachers to carry out effective digital teaching for their students. METHODS: It was a qualitative study which employed phenomenological approach. The data were collected from 12 teachers who were purposively selected for semi-structured interviews. They were all expert digital teachers. The data were transcribed verbatim, coded and analyzed thematically. Textural and structural description of the themes helped to develop a new competency framework. RESULTS: The data yielded 47 selective codes with 15 sub-themes and five themes. The emergent themes included general digital competencies, specific digital teaching competencies, mastery of the subject matter, mastery of pedagogical strategies and proficiency in using innovative digital technologies for teaching. The themes 1, 2 and 5 relate to digital competencies only whereas the themes 3 and 4 are generic competencies which apply to both digital and non-digital teaching. These generic competencies form the basis of all kinds of teaching, hence equally important for digital teaching. CONCLUSION: Medical teachers should possess diverse digital competencies. The competency framework that emerged in the current research encompasses the essential attributes that should be included in any future training program aiming at the digital capacity building of the teachers. This will keep them primed for effective digital teaching. Given its crucial importance, the digital teaching competency should be considered as a cross-cutting competency that applies to almost all of the famous eight roles of medical teacher.

Effect of prostaglandin treatment on the estrus behaviour, follicular and luteal morphometry and serum hormone profile in sub-estrus buffaloes during non-breeding season.

Sub-estrus buffaloes do not exhibit estrus signs despite being cyclic contributing to extended service periods and inter-calving intervals causing significant economic loss. The present study described the effect of synthetic prostaglandin (PGF2α) on estrus behaviour, follicular and luteal morphometry, and serum estradiol (E2) and progesterone (P4) profile in sub-estrus buffaloes during the non-breeding season. The incidence of sub-estrus was 38.4% during the non-breeding season. The sub-estrus buffaloes (n = 33) were divided into two groups, viz., Control (n = 16) and PGF2α treatment (Inj. Cloprostenol 500 µg, i.m., n = 17). Estrus induction response was significantly greater in the treatment (100 vs. 18.75%, p < .001), and a relatively greater proportion of animals conceived in the treatment group (29.41 vs. 6.25%, p = .08). The time elapsed to induction of estrus and insemination following treatment was significantly lower in the treatment group than control. A significant increment in the follicle diameter (9.72 ± 0.45 vs. 13.00 ± 0.45 mm, P < .0001) and serum estradiol (E2) concentration (66.01 ± 11.92 vs. 104.9 ± 13.21 pg/mL, p = .003) observed at the post-treatment period in the PGF2α treatment group. At the same time, CL diameter was reduced significantly at a higher regression rate in the PGF2α treated buffaloes than those of control. Of the responded buffaloes, only 30% showed high-intensity estrus attributed to the expulsion of cervico-vaginal mucus (CVM), uterine tonicity, micturition, and mounting response by a teaser bull. From this study, it can be concluded that the administration of PGF2α could induce estrus in the sub-estrus buffaloes during the non-breeding season. Behavioural changes, along with sonographic observation of POF, regressing CL, and serum E2 and P4 concentration would be useful to determine the right time of insemination in sub-estrus buffaloes during non-breeding season.

Collaboration cognizance: Development of a self-assessment tool to measure intra-professional collaborative practices (IPCP) in postgraduate medical residents at tertiary care hospitals.

BACKGROUND: The ever-evolving healthcare system of today demands physicians who steer their roles as treatment providers, managers and collaborators. Professionals are highly interdependent due to increased complexity of health problems and risk of errors increases with transitions in care. In hospitals, the main workforce is postgraduate residents; therefore, intraprofessional collaboration amongst residents is essential. Several instruments are available to evaluate interprofessional collaboration amongst physicians, nurses and hospital teams but none specifically assessed intra-professional collaborative practices amongst residents working in tertiary care hospitals in multi-disciplinary teams. This study intends to develop and validate an instrument to self-assess intraprofessional collaborative practices in postgraduate residents undergoing residency in multiple specialties at tertiary care hospitals. APPROACH: This study on Instrument Development employed mixed method study design executed in two phases. In phase 1, six domains of intraprofessional collaborative practices were identified from literature and 35 items were developed. Fifteen experts participated in qualitative content validation and provided comments. To establish content validity in phase 2, content validity index (CVI) and content clarity average (CCA) were assessed by seventeen experts. Response process validity was established by cognitive interviewing of 5 postgraduate residents. Pilot testing was done on a sample of 407 residents. Cronbach's alpha was determined, and confirmatory factor analysis established construct validity. RESULTS: During phase 1, items were modified based on qualitative feedback from 15 experts. In round 2, CVI and CCA were determined based on responses of 17 experts. The items having an I-CVI greater than 0.90 were accepted and six items underwent modifications as their I-CVI fell between 0.78 and 0.90. Similarly, four items with a CCA of less than 2.4 were modified to increase clarity. Cognitive interviews of participants on 30 items resulted in the deletion of 1 item and changes in 5 items. The final instrument had 29 items categorized under six constructs. All items had good factor loadings during CFA, so none was deleted. Cronbach's Alpha α was 0.937. CONCLUSION: Intraprofessional collaborative practices in residents is a valid and reliable self-assessment tool comprising 29 items measuring six constructs. It may be used by residents to assess their collaborative practices and incorporated in curricula to help develop collaborative practices and their assessment during training of postgraduate residents.

Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial.

BACKGROUND: History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents. METHODS: Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time. RESULTS: The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group. CONCLUSION: VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Resilience and academic performance: Exploring the link in dental students.

This study aims to assess the correl ation between t he resilience level of dental students (preclinical and clinical years) and its effects on their academic performance. It is a correlational research study that was carried out on second, third, and final-yea r denta l students at Lahore Medical & Dental College, Lahore. Academic resilience was judged by using the academic resilience scale (ARS-30). The correlation between resilience and academic performance was e s tablished by appl ying the bivar iate Pea rso n correlation. The mean age of the stude nt s was 2 1.49±1.39 years. Among 196 dental students from different years, 132 (67.35%) were females and 64(32.65%) were males. A strong p ositive co rrelati on was obser ved bet ween the academic performance and resilience of denta l students, i.e. r=0.774. From the results, it can be concluded that there is a positive correlation between academic resilience and academic performance among dental students.

Curriculum implementation challenges: Development and validation of an integrated curriculum implementation challenges tool.

Objective: To develop an instrument to identify the challenges faced by faculty while implementing an integrated curriculum in an undergraduate dentistry program. Methods: The study was conducted between September 2020 and October 2021 at the University College of Medicine and Dentistry (UCMD), University of Lahore (UOL). A preliminary questionnaire, developed through literature review and faculty interviews was sent to 10 medical education experts for content validation via the Delphi technique. Content Validity Index (CVI) was calculated for individual items (I-CVI) as well as for the composite scale (S-CVI). A panel agreement of more than 75% was considered as the criterion for the inclusion of items in the questionnaire. Cognitive pretesting of five faculty members was conducted and pilot testing was subsequently done with 27 faculty members. The reliability of the tool was determined by Cronbach's alpha. Results: After the Delphi process, the final Integrated Curriculum Implementation Challenges (ICIC) questionnaire had 42 items. S-CVI was 0.87 and the cut-off value for I-CVI was taken as 0.78 as the criterion for item deletion. Cognitive interviews and pretesting revealed good item interpretation. Cronbach's alpha for this tool was 0.87. Conclusion: ICIC is a useful instrument with good reliability and content validity. It can be used to identify the presence and extent of challenges faced by the faculty while implementing an integrated curriculum.

Impact of emotional intelligence in resolving clinical conflicts among postgraduate residents of surgery.

Background & Objective: Emotional intelligence (EI) can become a vital tool for resolving clinical conflicts (CC) in surgery. The postgraduate residents focus on the technical skills and undermine the soft skills required for their better training. Our aim was to determine the EI of postgraduate resident (PGR) years one & two in General and Orthopedic Surgery. The CC in their workplace and how they use their EI to resolve these conflicts. Methods: This mixed-method study was conducted from March 10, 2019 to May 28, 2020 at Departments of General and Orthopedic Surgery, Mayo Hospital, Lahore. The study was conducted in two phases 1 & 2. In Phase-1, one hundred PGR years one & two were administered the Mayor-Salovey-Caruso Emotional Intelligence test (MSCEIT) to measure EI. In phase-2, semi-structured in-depth interviews of 10 PGRs five with high and five with low EI were conducted to determine the CC and use of EI to resolve the CC at the workplace. A thematic analysis was done. Results: Out of 100 PGR, the mean EI score was 46.25±14.8 with a maximum score of 75.4, and a minimum score of 18.16 (p-value =0.775). Ninety-one (91%) have not improving EI, and 09 (09%) have considered developing EI. Five themes in four settings, including emergency, ward, elective operation theatre, and outpatient department (OPD) were determined. The emerged themes for the CC were nepotism, gender biases, burnout, lack of professionalism, and toxic culture. The following were CC management strategies: self-study, deceit, gender affinity, performing attention-attaining work, aggrieved reaction and being disgruntled when alone. Conclusion: None of the PGR was emotionally intelligent in overall grades, as well as a particular aspect of MSCEIT.

Development and validation of an instrument to measure the Micro-Learning Environment of Students (MLEM).

BACKGROUND: There are multiple instruments to measure different learning environments but no valid and reliable instrument is present for measuring the micro-learning environment. This study aimed to develop and validate an instrument to measure the micro-learning environment of students. Measuring the micro-learning environment can give insight into the real-life experiences of students and enlighten us about the disparity between taught, delivered, and learned curricula. METHODS: Multi-institutional Mixed methods study design with consecutive qualitative and, quantitative components was used based on information processing theory. Literature review, results of semi-structured interviews, and focus group discussion were combined to develop a questionnaire. Content and response process validity were established followed by pilot testing, reliability calculation, and exploratory and confirmatory factor analysis. RESULTS: A forty-nine-item preliminary draft instrument was reduced to a total of twenty-four items final instrument having five themes regarding teaching practices, learners support, competence in teaching, progressive faculty, and teaching environment. The values of SCVI/Ave and S-CVI/UA were calculated to be 0.92 and 0.62 respectively. Reliability was calculated to be 0.94. Fit indices values were within the normal range. CONCLUSION: The instrument for measuring the micro-learning environment has excellent content, construct, response process validity, and reliability.

Reliability and validity of Urdu PARENTS for assessing non-technical skills of paediatric residents in a teaching hospital in Pakistan.

PURPOSE: The primary objective of our study is twofold. First, we assessed nontechnical skills (NTSs), such as the cognitive, social, and personal skills of postgraduate residents (PGRs), from paediatric caregivers' perspectives in a paediatric emergency department (PED) of a tertiary care hospital. Second, we evaluated the reliability and validity of the 'Parents' Assessment of Residents Enacting Non-Technical Skills' (PARENTS) instrument in its Urdu-translated version, ensuring its applicability and accuracy in the Pakistani context. MATERIALS AND METHODS: This mixed-method study used an instrument translation and validation design. We translated an existing instrument, PARENTS, into Urdu, the national language of Pakistan, and administered it to paediatric caregivers in the PED of a tertiary care hospital. We collected data from 471 paediatric caregivers and coded them for analysis in AMOS and SPSS. RESULTS: The Urdu-translated version of the PARENTS demonstrated reliability and internal validity in our study. The findings from the assessment revealed that paediatric caregivers expressed satisfaction with the knowledge and skill of residents. However, there was comparatively lower satisfaction regarding the residents' display of patience or empathy towards the children under their care. CONCLUSION: The study findings support the validity and reliability of the PARENTS as an effective instrument for assessing the NTS of PGRs from the perspective of paediatric caregivers. With its demonstrated efficacy, medical educators can utilize PARENTS to pinpoint specific areas that require attention regarding the NTS of PGRs, thus facilitating targeted interventions for enhanced patient care outcomes.

Assessment Of Workplace Related Factors Affecting Tolerance Of Ambiguity Among Trainee Doctors.

OBJECTIVE: To assess workplace factorsinfluencing the tolerance of ambiguity among trainee doctors. METHODS: The sequential mixed-method study was conducted from June 2021 to February 2022 at the Fauji Foundation Hospital, Islamabad, Pakistan, and comprised postgraduate trainee doctors of either gender associated with various specialties.Thebaseline toleranceof ambiguity scorewas establishedusingtheToleranceofAmbiguity in Medical Students and Doctors scale. A group of selected trainees was interviewed face-to-face to examine the workplace factors that they regarded as beneficial or detrimental to their tolerance of ambiguity. Quantitative data was analysed using SPSS 24 and thematic analysis was done for qualitative data. RESULTS: Of the 132 subjects, 59 (21.9%) were males and 73 (55.3%) were females. The overall mean age was 20.95±2.186 years. Of the total, 55(41.7%)subjects were in the first year of training, 28(21.2%) in the second year, 26 (19.6%) in the third year, and 23(17.4%) in the fourth year. There were 78(59.1%)trainees who were married compared to 54 (40.9%) who were unmarried. Against the baseline tolerance of ambiguity score of 132, the overall aggregate mean tolerance of ambiguity level was 71.28 ± 5.81 showing a moderate level. There was no significant correlation between the tolerance of ambiguity and the trainees'age, years oftraining and maritalstatus(p>0.05).The qualitative phase comprised interviews with 9(6.8%) subjects.Thematic analysis suggested that the traineesperceivedautonomy,peersupport,supervisorsupport,manageable workload, and professional development opportunities asfacilitat or softolerance of ambiguity,whilebarrierswere identified as poor physical environment, attitude ofseniors and supervisors, management issues and excessive workload.During the coronavirus diseae-2019 pandemic, excessive workload and fear of infection were identified asfactors affecting tolerance of ambiguity. CONCLUSIONS: The medical trainees were found to have a moderate level of tolerance to ambiguity. Autonomy, peer support, supervisor support, manageable workload, and professional development opportunities contributed positively to this aspect.

Post-graduate educational environment of two parallel programs in Pediatric Medicine.

Objective: To compare the trainees' perception of the Educational Environment (EE) of the two parallel post-graduate training programs (MD & FCPS) in Pediatric Medicine. Methods: This quantitative cross-sectional study was carried out by Department of Medical Education UOL and Department of Pediatric Medicine KEMU from February to December 2021. Data about the perception of EE was collected from the Pediatric Medicine trainees by purposive sampling using the 40 items PHEEM inventory. The inventory has three perception domains: role autonomy, teaching, and social support. In addition, to mean scores, the inventory also gives interpretation according to the score ranges. The FCPS and MD trainees of both genders and all years of training across the institutions of Punjab were approached using Google Forms. SPSS (v 23.0) was used for descriptive and analytic statistics. Results: A total of 327 trainees' responses were included-188 (57.5%) FCPS and 139 (42.5%) MD trainees. The mean overall score was 92±19.7 for FCSP and 93.88±21.5 for MD trainees (p-value 0.41). The interpretation of the overall score was "more positive than negative but room for improvement" in 67.3%. For the subscales of role autonomy, teaching, and social support, the perception was positive by 71%, 80%, and 45% of trainees, respectively. Except for three individual items, the mean scores of the subscales and the individual items were not statistically different between the two groups. Conclusion: The Pediatric Medicine trainees' perception of the educational environment in the FCPS and MD groups was comparable overall and in all three domains. Individual item analysis showed almost similar areas for improvement in both programs.

Impact of Language Barriers in Doctor - Patient Relationship: A Qualitative Study.

Objective: To explore the problems faced by recent medical graduates in communication with their patients due to language barriers and the influence of these language barriers on the doctor-patient relationship. Methods: A basic qualitative study was conducted at Allama Iqbal Memorial Teaching Hospital Sialkot, Services Hospital Lahore and Mayo Hospital Lahore over eight months after receiving approval from the Ethical Review Board of the University of Lahore. Twelve recent medical graduates from different departments were selected via a purposive sampling technique. Data was collected through semi-structured interviews conducted over the phone with prior appointments. Manual qualitative thematic analysis was done by transcribing the interview and then codes, subthemes, and themes were generated. Results: Six themes and thirteen subthemes were identified depicting the influence of language barriers on the doctor-patient relationship, namely: frustration (due to repetition, feeling of inadequacy & disappointment), lack of rapport (difficulty in communication, effective counseling & failure in establishment of comfort level), trust Issues (predilection towards the native speaker & difficulty in getting consent) patient dissatisfaction, compliance issues (difficulty in comprehending medication & nature of disease), and threat to patient safety (misdiagnosis & consequent treatment plan & misinterpretation of treatment). Conclusion: This study establishes the detrimental effects of language barriers on the relationship between physician and patient which can help medical educationists and policymakers in devising a curriculum in such a way that it can minimize the impact of language barriers on the doctor-patient relationship.

ChatGPT - Reshaping medical education and clinical management.

Artificial Intelligence is no more the talk of the fiction read in novels or seen in movies. It has been making inroads slowly and gradually in medical education and clinical management of patients apart from all other walks of life. Recently, chatbots particularly ChatGPT, were developed and trained, using a huge amount of textual data from the internet. This has made a significant impact on our approach in medical science. Though there are benefits of this new technology, a lot of caution is required for its use.

Dimensions of challenges in transformation from traditional to integrated modular curriculum - Experiences from Pakistan.

Objective: The scarcity of successful implementation of integrated modular curriculum in Pakistan created a lack of evidence-based insight into the process of curriculum transformation. We explored the issue by exploring challenges faced by faculty in implementing integrated modular curriculum. Methods: An exploratory qualitative study was conducted in 2019-2020, data collected from November 2019 to August 2020, at undergraduate medical colleges in Lahore and Rawalpindi, with semi-structured online interviews of well experienced 11 faculty members. Two levels of faculty were sampled; one completed a successful implementation in two medical colleges, and another in transition process. Transcribed interviews were analyzed on Atlas.ti software. Results: Challenges were identified in five inter-connected dimensions: integrated modular curriculum (IMC) development, implementation, faculty transformation/change, institutional and regulatory body context. Conclusion: The curricular shift precipitates demoralizing challenges at multiple levels & directions. The identified themes and connections provide the framework for a well-informed curricular shift.

Twelve tips to enhance student engagement in synchronous online teaching and learning.

Synchronous learning is a component of online learning for engaging students in real-time. It is the nearest we can get to a live feeling in the e-environment. These sessions must be designed in a way to keep students continuously involved. This paper aims to provide health professional educators with tips for increasing student engagement in the online synchronous environment. The relevant literature regarding student engagement and synchronous online learning was reviewed and collated with the authors' own experiences, to formulate these tips. Health professional educators can use these tips to enhance student engagement in online synchronous classes.Increased student engagement in online sessions, means better learning. These tips have been tried and tested by the authors as being satisfactory for increasing student interest in synchronous sessions and hence providing an optimal learning experience online.

The Drudgery of a Doctor's Disciple: Exploring the effects of Negative Role Modelling on medical students' professional development.

INTRODUCTION: Role modelling is considered an essential component of teaching in various educational settings and impact students' professional development. Most studies found in the literature have explored the influence of positive role models and limited data is available about the negative role modelling. This study explores the effects of negative role modelling of teachers on the professional development of future doctors. METHODS: A qualitative exploratory study was done in three medical colleges of Lahore, Pakistan. Fifteen, telephonic, semi-structured interviews were done with fifth-year MBBS students. A thematic analysis was done through manual coding of transcribed interviews. RESULTS: A total of 374 codes were generated in the first cycle of coding, that was merged to 42 in the second cycle. These codes led to 4 subthemes that finally emerged as two themes. The first theme was "Students & patients: In the same boat" highlighting the damaging effects of negative role modelling. The second theme was "Taking the bad with the good" focusing on the ambivalent response of students towards the unprofessional behaviours of their role models. CONCLUSION: Negative role modelling exponentially affects the attitude and behaviour of medical students especially in informal settings and have detrimental effects on patient care. Students lose some degree of humanism while unconsciously observing the unethical behaviours, to become a part of hospital culture whereas some students show determination to channelize their resentment to reforms.

Exploring developmental assignments shaping experience-driven acquisition of leadership competencies in young clinicians.

BACKGROUND: Experiential leadership development is well documented in the corporate sector, but those models cannot be applied as is, in the healthcare domain. The current study proposes a framework for the healthcare sector to enable experiential leadership development for young clinicians. The authors identify developmental assignments (DAs) and explore those characteristics [developmental assignment characteristics; DACs] therein that help develop leadership competencies in young clinicians. METHODS: As part of a qualitative exploratory study in Pakistan, the authors conducted 16 semi-structured interviews with senior clinicians in leadership positions with post-graduate residents under their supervision from different medical specialties. The participants were selected through purposive sampling, ensuring a maximum variation sample. Focusing on participants' experiences and perspectives related to experience-driven leadership development, the authors used a multi-level theoretical framework for analysis. RESULTS: The thematic analysis resulted in 19 subthemes with four overarching themes for both objectives. The authors categorized the developmental assignments (DAs) into clinical, academic, and administrative assignments. These assignments can be utilized for leadership development by ensuring that they have the requisite characteristics built into their context and structure. These developmental assignment characteristics (DACs) can range from learner-driven to supervisor-driven. The learner-driven characteristics include autonomy, high levels of responsibilities, unfamiliar assignments, working across boundaries, managing diversity, making a commitment, and creating change. The supervisor-driven characteristics include briefing, debriefing, accountability, and learner-assignment matching. The authors also developed a learner-assignment matching (LAM) framework to guide supervisors in customizing and adjusting the level of each DAC in a DA. CONCLUSION: A modern healthcare educational system can utilize studies like this to enable supervisors to develop required leadership skills in young clinicians along with clinical skills.

Probing in the complexities of the integrated undergraduate medical curriculum: A qualitative exploratory study.

OBJECTIVE: To explore the perceptions of the faculty regarding the level of curriculum integration and their interpretation of the integration ladder in achieving the complex process. Methods: The qualitative exploratory study was conducted at Islamic International Medical College Islamabad, University College of Medicine and Dentistry Lahore and Rehman Medical College Peshawar, from March to August 2018. The participants were the faculty members involved in the designing and implementation of the integrated curriculum in these institutes. The semi-structured interviews were audio-recorded, transcribed and analysed using Braun and Clarke's thematic content analysis. RESULTS: Of the 18 faculty members, 6 (33.3%) belonged to each of the three institutions. Four themes identified were: curriculum planning, an uphill task; dream versus ground reality; moving up and down the ladder; and teamwork in the paradigm shift. There were different perceptions of the level of integration among faculty members within the same institute. The level of integration ranged from 5-9 in different phases of the curriculum. The processes included all the teamwork steered by the departments of medical education. Conclusion: Although Harden's integration ladder is a useful tool, curriculum integration is an inherently inconsistent and complex process that does not follow a simple hierarchical continuum of integration and requires a teamwork. Identifying the patterns of integration in different phases of the curriculum might be more practical than just determining a single level of integration in the whole curriculum.

Entrustment in physician-patient communication: a modified Delphi study using the EPA approach.

BACKGROUND: Competency based curricula across the globe stress on the importance of effective physician patient communication. A variety of courses have been used to train physicians for this purpose. However, few of them link competencies with practice resulting in confusions in implementation and assessment. This issue can be resolved by treating certain specific patient communication related tasks as acts of entrustment or entrustable professional activities (EPAs). In this study, we aimed to define a competency-based framework for assessing patient physician communication using the language of EPAs. METHODS: A modified Delphi study was conducted in three stages. The first stage was an extensive literature review to identify and elaborate communication related tasks which could be treated as EPAs. The second stage was content validation by medical education experts for clarity and representativeness. The third stage was three iterative rounds of modified Delphi with predefined consensus levels. The McNemar test was used to check response stability in the Delphi Rounds. RESULTS: Expert consensus resulted in development of 4 specific EPAs focused on physician-patient communication with their competencies and respective assessment strategies all aiming for level 5 of unsupervised practice. These include Providing information to the patient or their family about diagnosis or prognosis; Breaking Bad news to the patient or their family; Counseling a patient regarding their disease or illness; Resolving conflicts with patients or their families. CONCLUSIONS: The EPAs for Physician-patient communication are a step toward an integrative, all-inclusive competency-based assessment framework for patient-centered care. They are meant to improve the quality of physician patient interaction by standardizing communication as a decision of entrustment. The EPAs can be linked to competency frameworks around the world and provide a useful assessment framework for effective training in patient communication. They can be integrated into any post graduate curriculum and can also serve as a self-assessment tool for postgraduate training programs across the globe to improve their patient communication curricula.