Understanding Clinical Competence: Understanding Student Assessment

The extent, purpose, and model of performance assessment should be guided by our understanding of clinical competence. We have come a long way from believing that competence is generic, fixed, and transferable across contents; to viewing competence as dynamic, incremental, contextual, and non-transferable. However, our pattern of assessment largely remains what it was many years ago. Contemporary educationists view competency assessment as different from traditional format. They place more emphasis on the role of expert subjective judgment, especially for performance and domain-independent competencies. Such assessments have conclusively shown their validity, reliability, and utility. They; however, require trained assessors, trust between the teachers and the taught, and above all, a political and administrative will for implementation.

Delivering Electives the Clerkship Way: Consolidating the Student Doctor Method of Training

Student doctor method of clinical training or clinical clerkship provides students with exposure to the entire longitudinal illness of the patient. The students participate in patient care as a part of treating team and can refine their clinical, communication and procedural skills. It provides them with an opportunity to work with the faculty and experience the future workplace. Although the graduate medical education regulations (GMER) provide for student doctor method of training, the time provided is too little and opportunistic. Electives have also been recently added to the new curriculum for the first time. We propose a model to deliver the electives using the clerkship method, so as to consolidate what students learn from the ongoing clerkship. This model is feasible, practical and can be introduced in the current GMER for Indian medical undergraduates without any major disruptions.

The Concept of Self-Directed Learning: Implications for Practice in the Undergraduate Curriculum

Self-directed learning (SDL) is a modality where learners are expected to take responsibility for their own learning, diagnose gaps in their learning, frame their own goals and resources for learning, implement appropriate learning strategies and evaluate learning outcomes. Flexibility and creativity in designing assignments for students to work individually or collaboratively are the keys to promoting SDL. The recent competency-based curriculum document from the National Medical Commission does not elaborate the concept or implementation of SDL, leaving it open to individual interpretation. We, herein, discuss the concept of SDL, address common misconceptions surrounding SDL, and elucidate strategies by which SDL skills can be inculcated in medical students using pre-existing opportunities in the curriculum. Flipped classrooms, reciprocal teaching, technology-enhanced methods, problem-based learning, and group projects are excellent ways of promoting SDL. SDL requires efforts and policies both at the teachers’ level and at the institutional level; and is an important input to achieve the goal of being a lifelong learner by the Indian medical graduate.

Indian Academy of Pediatrics (IAP) Task Force Recommendations for Incorporating Nurturing Care for Early Childhood Development (NC-ECD) in Medical Education in India

Background: The World Health Organization (WHO) recommends promotion of nurturing care for early childhood development (NCECD) by focusing on five essential components viz., good health, adequate nutrition, promotion of early childhood learning, responsive caregiving, and safety and security. Indian medical graduates and pediatricians are the keys to successful delivery and propagation of NC-ECD in the community. Their training therefore needs to include skills and knowledge needed to promote and practice ECD. Objective: To evaluate the existing undergraduate (UG) and postgraduate (PG) curricula of pediatrics for components related to early childhood development, assess gaps in the training essential to practice and promote ECD, and suggest recommendations to incorporate NC-ECD in the UG and PG curricula. Process: Indian Academy of Pediatrics created a task force to review the UG/PG medical curricula, consisting of experts from pediatrics and medical education. The task force deliberated on 20 March, 2021 and identified the gaps in current curricula and provided suggestions to strengthen it. The recommendations of the task force are presented here. Recommendations: Taskforce identified that the UG/PG medical curricula are lacking training for propagating early childhood learning, responsive caregiving, caregiver support, and ensuring safety and security of children. The taskforce provided a list of competencies related to ECD that need to be included in both UG and PG curriculum. NC-ECD should also be included in topics for integrated teaching. Postgraduates also need to be exposed to hands-on-training at anganwadis, creches, and in domestic setting.

Role of diffusion weighted MR imaging in differentiating benign from malignant prostate lesions

Background: The purpose of the study was to determine the diagnostic accuracy of diffusion weighted MR imaging and to propose a cut off ADC value in differentiating benign from malignant prostatic lesions considering histopathology as gold standard.Methods: It is a descriptive type of observational study done on 40 patients with clinical suspicion of prostate carcinoma and elevated PSA level more than 4ng/ml. The patients underwent Multiparametric prostate MRI and ADC values were calculated using ADC maps.Results: Of the 40 cases included in the study histopathology revealed a diagnosis of abscess (1), chronic prostatitis (2), BPH with chronic prostatitis (4), BPH (12), and malignancy (21). The mean and standard deviation (SD) of ADC values for the abscess (0.59), CP (0.83+0.16), BPH with CP (0.94+0.22), BPH (1.14+0.14) and malignancy (0.72+0.15) (x10-3mm2/s) were found in our study. The mean ADC value of malignant lesion was lower (0.727+0.149) as compare to benign lesion (1.034+0.216) and this difference was found to be statistically significant with p<0.001. By using ROC curve, ADC cut off value was calculated as 0.92 x 10-3mm2/s and sensitivity, specificity at this cut off value of ADC were 95.24% and 73.68% respectively. The PPV, NPV, diagnostic accuracy of at this cut off value of ADC were 80%, 93.33%, 85% respectively.Conclusions: Our study shows that DWI with ADC calculation helps in differentiation of Benign from Malignant prostatic lesions with high accuracy and this quantitative analysis should be incorporated in routine MRI evaluation of prostatic lesions

Massive Open Online Courses: Concept and Implications

Massive open online courses (MOOCs) are currently the buzz word in the field of e-learning. By definition, MOOCs are massivecourses considering the number of participants enrolled across the globe per course, are open accessed, and are available online.MOOCs have evolved along the trajectory of correspondence courses, radio- and television-broadcasts, and e-learning. Thoughvarious taxonomies to classify MOCCs exit, two types – Connectivist Massive Open Online Course (cMOOC) and Extended MassiveOpen Online Course (xMOOC) have distinctly emerged. cMOOC promotes creativity and interaction among participants, while xMOOCis used merely for knowledge dispersion. With increased and unrestricted use of internet, and with ease of developing new onlineplatforms, MOOCs are proving to be an evolutionary phenomenon. Many universities and institutes of higher learning are using MOOCsfor knowledge dispersion and skill development. Their role in faculty development, capacity and capability building in medical educationarena is unequivocal. Potential of MOOCs can be well-tapped for conduct of continuing medical education programs, and programs forimproving soft-skills and research skills in medical field for faculty development. This review details the concepts of MOOCs and theirapplication in education field, particularly in medical education, and feasibility of developing MOOCs in India

Ketamine use in Refractory Depression and Neuropathic Pain - A Case Report

Introduction: Depression is a common psychiatric illness inthe elderly. It often co-exists with chronic neuropathic pain inold age group.Case report: We present a case report of an elderly patientwho was successfully treated with subanaesthetic intravenousinfusion for severe depression with suicidal intention andchronic neuropathic pain.Conclusion: Ketamine has been reported to be used indepression with suicidal features as well as refractory pain.Depression is a common psychiatric problem across the agegroups. It occurs due to neurochemical imbalance in the brainnamely dopamine, norepinephrine serotonin.

Approach to Handling a Problem Resident

Many medical postgraduate teaching programs have residents with professional and personal problems that may limit theirperformance. A Problem resident is the one who does not meet the expectations of the training program owing to deficits in knowledge,skill or attitude. Medical administration and faculty of every institution must have a system that is sensitized to handle a difficult learner.Problems need to be addressed before they escalate or result in compromise of patient care. The present review discusses a broadapproach to recognizing a Problem resident and provides suggestions on remedial measures

Flipped Classroom: A Concept for Engaging Medical Students in Learning

Technological advances have created immense pressure on our younger generation to keep themselves abreast with the newerdevelopments in medical sciences. Educators have to evolve innovative pedagogy to help prepare this generation for future challengesas the training periods are getting relatively shorter. Flipped classroom or Inverted classroom is one such innovation that can empower alearner to develop critical thinking skills and master ways to imbibe vast information by engaging students in active learning process.Reading and understanding are carried at home, and the class-time is utilized for higher levels of learning like analyzing, evaluating, andapplication of the basic information. This review article is aimed to guide the educators in applying the concept of flipped classroom intheir teaching learning armamentarium.

Interprofessional Education: An Approach to Improve Healthcare Outcomes

Interprofessional education (IPE) approach allows learners from different health professions viz. – medical, dental, nursing,physiotherapy, psychotherapy, psychology etc., learn from, learn with, and learn about, each other. The scope of learning depends uponthe requirements and curriculum. Interprofessional education can help in creating a workforce that learns to perform collaborativepractice thereby ensuring better health-care outcomes. Medical educators’ and practitioners’ understanding about teaching, learning,and assessment of IPE is rudimentary. Strategies to incorporate IPE in regular curricula need to be debated and barriers associated withits implementation require to be identified. This review highlights the teaching-learning and assessment tools for IPE and discussespotential challenges in its implementation.

Cell surface proteins play an important role in probiotic activities of Lactobacillus reuteri

BACKGROUND: Eight Lactobacillus reuteri strains, previously isolated from breast-fed human infant feces, were selected to assess the potential contribution of their surface proteins in probiotic activity. These strains were treated with 5 M LiCl to remove their surface proteins, and their tolerance to simulated stomach-duodenum passage, cell surface characteristics, auto aggregation, adhesion, and inhibition of pathogen adhesion to Caco-2 cells were compared with untreated strains. RESULTS: The survival rates, auto aggregation, and adhesion abilities of the LiCl-treated L. Reuteri strains decreased significantly (p< 0.05) compared to that of the untreated cells. The inhibition ability of selected L. reuteri strains, untreated or LiCl treated, against adherence of Escherichia coli 25922 and Salmonella typh iNCDC113 to Caco-2 was evaluated in vitro with L. reuteri ATCC55730 strain as a positive control. Among the selected eight strains of L.reuteri, LR6 showed maximum inhibition against the E. Coli ATCC25922 and S. typhiNCDC113. After treatment with 5 M LiCl to remove surface protein, the inhibition activities of the lactobacilli against pathogens decreased significantly (p< 0.05). Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) analysis indicated thatLR6 strains had several bands with molecular weight ranging from 10 to 100 KDa, and their characterization and functions need to be confirmed. CONCLUSIONS: The results revealed that the cell surface proteins of L. reuteri play an important role in their survivability, adhesion, and competitive exclusion of pathogen to epithelial cells.

Cultivating Lifelong Learning Skills During Graduate Medical Training.

Lifelong learning is referred to as learning practiced by the individual for the whole life, is flexible, and is accessible at all times. Medical Council of India has included lifelong learning as a competency in its new regulations for graduate medical training. Acquisition of metacognitive skills, self-directed learning, self-monitoring, and reflective attitude are the main attributes of lifelong learning; and all of these can be inculcated in the students by using appropriate instructional methodologies. It is time to deliberate upon the instructional designs to foster the lifelong learning skills and behaviors in medical graduates. In this communication, we aim to debrief the concept of lifelong learning, particularly in context with medical training and detailing the process that can be explicitly used to cultivate the attitude of lifelong learning in medical graduates.

Teaching and Assessing Communication Skills in Medical Undergraduate Training.

Good communication skills are essential for an optimal doctor-patient relationship, and also contribute to improved health outcomes. Although the need for training in communication skills is stated as a requirement in the 1997 Graduate Medical Education Regulations of the Medical Council of India, formal training in these skills has been fragmentary and non-uniform in most Indian curricula. The "Vision 2015" document of the Medical Council of India reaffirms the need to include training in communication skills in the MBBS curriculum. Training in communication skills needs approaches which are different from that of teaching other clinical subjects. It is also a challenge to ensure that students not only imbibe the nuances of communication and interpersonal skills, but adhere to them throughout their careers. This article addresses the possible ways of standardizing teaching and assessment of communication skills and integrating them into the existing curriculum.

Re-entry NEET (National Eligibility-cum-Entrance Test): Opportunity and concerns.

The recent judgment on NEET will go a long way in reducing gross malpractice and corruption in admissions to MBBS and postgraduate medical courses. It is also an opportunity to improve the quality of the tests conducted. Currently, medical schools in India have different policies for admission to government-run and privately-run institutions. There are 200 government medical schools (27 180 seats) and 212 private medical schools (25 535 seats), with a total capacity to admit 52 715 students.1 In 2013, the Medical Council of India (MCI) notified the National Eligibility-cum-Entrance Test (NEET) for admission to MBBS and postgraduate medical courses.2 Through NEET, aspirants could appear for a single examination and apply for admission to any college of their choice across the country, except in the states of Andhra Pradesh, and Jammu and Kashmir. NEET also specified that students would be admitted on the basis of the examination scores alone and no extraneous factors would come into play. NEET has been held only once in 2013, following which it was struck down by the Supreme Court. On 11 April 2016, a Constitution bench of the Supreme Court recalled its controversial 2013 judgment which struck down the common entrance examination for all medical colleges in India. NEET was introduced with the purpose of reducing the mental and financial burden on medical aspirants, who had to appear in a number of entrance examinations across the country—at the allIndia level, state level or private medical school level. Students had the option to appear for 17 different examinations, each set at various levels of difficulty. The process was costly, cumbersome and confusing, with students of varying academic capabilities being admitted to medical schools through a long-drawn admission process. Another important reason was to prevent financial malpractices, such as compulsory donations, profiteering and capitation fees. NEET would emphasize merit as the only criterion for the selection of students for medical admissions. Private medical schools were permitted an approved fee structure that could be higher than public-funded medical schools. Private institutions would definitely be affected by this judgment, and would argue that it violated their right to practise any profession and that their admission procedure was fair, transparent and nonexploitative.

Side scatter versus CD45 flow cytometric plot can distinguish acute leukaemia subtypes.

Background & objectives: Flow cytometry is an important tool to diagnose acute leukaemia. Attempts are being made to find the minimal number of antibodies for correctly diagnosing acute leukaemia subtypes. The present study was designed to evaluate the analysis of side scatter (SSC) versus CD45 flow dot plot to distinguish acute myeloid leukaemia (AML) from acute lymphoblastic leukaemia (ALL), with minimal immunological markers. Methods: One hundred consecutive cases of acute leukaemia were evaluated for blast cluster on SSC versus CD45 plots. The parameters studied included visual shape, CD45 and side scatter expression, continuity with residual granulocytes/lymphocytes/monocytes and ratio of maximum width to maximum height (w/h). The final diagnosis of ALL and AML and their subtypes was made by morphology, cytochemistry and immunophenotyping. Two sample Wilcoxon rank-sum (Mann Whitney) test and Kruskal-Wallis equality-of-populations rank tests were applied to elucidate the significance of the above ratios of blast cluster for diagnosis of ALL, AML and their subtypes. Receiver operating characteristic (ROC) curves were generated and the optimal cut-offs of the w/h ratio to distinguish between ALL and AML determined. Results: Of the 100 cases, 57 of ALL and 43 cases of AML were diagnosed. The median w/h ratio of blast population was 3.8 for ALL and 1 for AML (P<0.001). ROC had area under curve of 0.9772.The optimal cut-off of the w/h ratio for distinction of ALL from AML was found to be 1.6. Interpretation & conclusions: Our findings suggest that if w/h ratio on SSC versus CD45 plot is less than 1.6, AML may be considered, and if it is more than 1.6, ALL may be diagnosed. Using morphometric analysis of the blast cluster on SSC versus CD45, it was possible to distinguish between ALL and AML, and their subtypes.

Teaching and Assessing Clinical Reasoning Skills.

Clinical reasoning is a core competency expected to be acquired by all clinicians. It is the ability to integrate and apply different types of knowledge, weigh evidence critically and reflect upon the process used to arrive at a diagnosis. Problems with clinical reasoning often occur because of inadequate knowledge, flaws in data gathering and improper approach to information processing. Some of the educational strategies which can be used to encourage acquisition of clinical reasoning skills are: exposure to a wide variety of clinical cases, activation of previous knowledge, development of illness scripts, sharing expert strategies to arrive at a diagnosis, forcing students to prioritize differential diagnoses; and encouraging reflection, metacognition, deliberate practice and availability of formative feedback. Assessment of clinical reasoning abilities should be done throughout the training course in diverse settings. Use of scenario based multiple choice questions, key feature test and script concordance test are some ways of theoretically assessing clinical reasoning ability. In the clinical setting, these skills can be tested in most forms of workplace based assessment. We recommend that clinical reasoning must be taught at all levels of medical training as it improves clinician performance and reduces cognitive errors.

Entrustable Professional Activities: Teaching and Assessing Clinical Competence.

Entrustable Professional Activities are gaining acceptance as tools to demonstrate acquisition of competencies in a competency-based curriculum. The main advantage of Entrustable Professional Activities are that they are observable activities (thus assessable), are related to day-to-day functioning as a health care provider (thus relevant), and are awarded once the learner can be trusted to perform the activity effectively and safely, without supervision, and by integrating across different competency domains. In this article, we describe how Entrustable Professional Activities can serve as a useful learning and assessment tool. We have described the steps in formulation, the pitfalls to avoid, and the possible role of the Medical Council of India and the Indian Academy of Pediatrics in encouraging the use of Entrustable Professional Activities for executing competency-based modules.