Knowledge and perceptions about Pre-diabetes amongst doctors, medical students, and patients in a tertiary care hospital of Islamabad.

OBJECTIVE: To explore the knowledge and perceptions about pre-diabetes screening and management amongst physicians, final year medical students, and patients. METHODS: The cross-sectional observational study was conducted at Shifa International Hospital, Shifa Foundation Clinic and Shifa College of Medicine, Islamabad, Pakistan, from November 2017 to February 2018. A structured questionnaire was used to assess doctors' and final year medical students' knowledge about screening and management of pre-diabetes. A group of patients were also interviewed about pre-diabetes awareness and their primary resources for health-related information. Data was analysed using SPSS 23. RESULTS: Of the 267 participants, there were 85(32%) doctors, 82(31%) medical students and 100(37%) patients. Only 61(71.8%), 44(51.7%) and 34(39.8%) physicians and 53(64.6%), 30(36.5%) and 26(31.6%) students could accurately identify impaired fasting blood glucose, glycated haemoglobin and impaired glucose tolerance criteria for pre-diabetes, respectively. Regarding risk factors for pre-diabetes screening, ethnicity, cardiovascular diseases and gestational diabetes were identified by 8(9.4%), 6(7.1%) and 9(10.6%) physicians and 10(12.2%), 6(7.3%) and 15(18.3%) students, respectively. There was no statistically significant relation of correct identification of pre-diabetes criteria with specialties, designations and years of experience post-qualification (p>0.5). Only 3(3%) patients were aware of pre-diabetes or borderline diabetes. CONCLUSIONS: Knowledge and perception of doctors, medical students and patients about pre-diabetes was found to be deficient. Efforts are required to reinforce its identification and management at all levels..

Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning.

BACKGROUND: Service-learning (S-L) is an educational approach that integrates community service with academic learning. S-L helps educate youth about their civic role and responsibility in society, and empowers them to tackle societal problems, strengthening communities through civic engagement. The objectives of this study were to demonstrate the effectiveness of S-L in fostering civic responsibility and communication skills in college students and to increase health literacy regarding iron-deficiency anemia (IDA) among both students and community women. METHODS: This interventional exploratory study used a mixed methods approach. Thirteen first-year students from a women's college participated in the project. The authors held small interactive group sessions to teach the students about IDA and communication skills. A questionnaire measured the students' perceived knowledge about civic responsibility, communication skills, and IDA. The students then developed and delivered a health education campaign for sixty five community women and measured changes in the women's health literacy about IDA. A focus group discussion was conducted to collect students' reflections after the S-L experience. The changes in the civic responsibility and communication skills were determined by Wilcoxon rank test, while health literacy in women by a McNemar test. RESULTS: Students showed significant improvement in all three constructs of civic responsibility and in perceptions of their communication skills. Increases in civic responsibility and in acquisition of knowledge emerged as the main themes of the focus group discussion with students. The community women showed substantial improvement in health literacy of IDA. DISCUSSION: In this study, S-L achieves two purposes: (a) Increases students' knowledge of health topics, their sense of civic responsibility and improves their communication skills, and (b) educates women in the community about common and preventable health issues.

Exploring the trustworthiness and reliability of focus groups for obtaining useful feedback for evaluation of academic programs.

BACKGROUND: At Shifa College of Medicine, evaluation is an integral part of the curriculum. We used focus groups as a tool to obtain in-depth information regarding students' experience with the new integrated, system- based curriculum. The purpose of this study was to explore the usefulness of focus groups in identifying important issues for curriculum improvement and to explore the trustworthiness and representativeness of data obtained through this strategy. METHODS: In 2012, we used focus groups to seek feedback from students regarding their experience with the integrated curriculum. One course of each of the three preclinical years was selected for this purpose. Three parallel focus groups were conducted for each selected course. Each focus group was audio recorded, and the moderator and a volunteer student took additional notes during the session. The audio recordings were transcribed and data obtained from the three sources were analyzed, coded, and categorized independently by three investigators. Both manifest and latent themes were identified, using an inductive approach. Final agreement on themes was reached by comparison of the independently done thematic analysis by the three researchers. Reliability of data was established by comparing responses from the three parallel focus groups of each course. Trustworthiness of inferences was ensured by multiple coding, audit trail and member checking with focus group participants who reviewed the themes for validity. RESULTS: Most of the data on students' perceptions of their courses from each of the parallel groups were in agreement: Similar themes were seen within groups of the same class as well as across the three preclinical years. CONCLUSION: Focus groups can be a useful tool for collecting trustworthy and reliable information through a process that promotes interaction among student participants. They can support quantitative data from students and be used to support curriculum reform.

Enhancing Empathy in Medical Students by Focused Learner Centered Activities.

OBJECTIVES: To determine the change in empathy levels of medical students during their progress in professional years internship, and to examine change in empathy after targeted empathy enhancing activities during the course of medical school. STUDY DESIGN: Longitudinal Study. PLACE AND DURATION OF STUDY: Shifa College of Medicine/ Shifa Tameer-e-Millat University, Islamabad, from January 2015 to December 2019. METHODOLOGY: Student version of Jefferson Scale of Physician Empathy was administered sequentially from 2015 to 2019 which evaluated the change in empathy of medical students in a class of 2019. Targeted empathy-enhancing activities included patient-centered module in year-three and stress management workshops in the final year of medical school. RESULTS: Empathy scores rose from the first year of study (4.27 ±0.38) to the third year (4.52 ±0.70). It fell over the next two years of study (4.25 ±0.62 & 4.21 ±0.40) before rising again during the internship (4.39 ±0.43) with focused empathy-enhancing activities. CONCLUSION: Patient-centered module which focused on activities that help develop empathy may have been a factor in the increase of empathy scores in the third year and internship. Placing recurring formal activities throughout all clinical years may help in enhancing empathy in medical students. KEY WORDS: Medical student empathy, Empathy enhancing targeted activities, JSPE.

Change in action: using positive deviance to improve student clinical performance.

At our medical college many students have lower ratings in their clinical performance once they start their clinical years (third year). This is contrary to their results in other written exams. Some students demonstrate better clinical performance. We used the six-step Positive Deviance (PD) Conceptual Framework to identify and disseminate the strategies employed by the successful students to improve group clinical performance. Fifty 3rd year students (of a 5-year MBBS program) rotating through internal medicine were assessed mid-rotation with mini-CEX and 360° evaluations. Twenty students (40%) who performed well were invited for in depth interviews in order to identify positive deviant behavior in their clinical skills learning practices. The seven students (14%) who reported novel behaviors were asked to develop strategies for dissemination of their learning behavior in their peers. They decided to work in small groups with their peers, using the identified PD behaviors to encourage learning of history taking and examining skills in their peers. Group performance was assessed at the end of rotation, using mini-CEX and 360° evaluation in comparison to a subsequent group of students in the same year that did not work in PD peer learning groups. For the 360° evaluation the EP(2) (generalizability coefficient) was 0.92 and for the mini-CEX the EP(2) was 0.95, taking into account the variances between participants, groups, time and the interactions effects; thus indicating good reliability of both the assessment methods. A statistically significant difference (p < 0.05) was seen for improvement in medical interviewing skills and clinical judgment on the mini-CEX exam and 360 evaluation (p < 0.0001) in the PD group. Positive Deviance approach can help highlight behaviors among medical students, which contribute to success but may go unnoticed. Learning strategies based on the PD framework can improve student's group performance.

Exploring the process of final year objective structured clinical examination for improving the quality of assessment.

OBJECTIVE: To explore the process of final year Objective Structured Clinical Examination (OSCE) for improving the quality of assessment. METHODS: The analytical cross-sectional study was conducted with purposive sampling on one-year Medicine Objective Structured Clinical Examination (OSCE) scores of Final Year batch of 2009 at the Shifa College of Medicine, Islamabad. The scores from December 2008 to December 2009 of 77 Final Year students were analysed. The process of examination and the interpretation of the scores was evaluated using the Standards for Educational and Psychological Testing as the conceptual framework for validity testing which identifies five sources of test validity evidence. Internal consistency reliability of the examination was determined by Cronbach's alpha. Comparison and Correlation between students' end-of-clerkship (EOC) and end-of-year (EOY) examination scores were analysed by paired sample t-test and Pearson's Correlation Coefficient respectively. RESULTS: There was no significant positive correlation between the scores of end-of-clerkship and end-of-year Medicine Objective Structured Clinical Examination. Overall, the students' performance in the former segment was better. Evaluation of exam stations showed that mean scores significantly decreased in almost all end-of-year stations. Reliability decreased from 0.53 in the former to 0.48 in the latter assessment. Validity evidence showed that content validity was established by blueprinting of the objective exam. Response process evidence revealed that checklists, response key and rating scale were discussed with the faculty observing the stations. However, lack of other important sources of validity like standard setting for pass/fail criteria and poor reliability are serious threats to the validity of such exam scores. CONCLUSIONS: Multiple sources of validity evidence are needed to make defensible assumptions from performance scores. Consideration of all sources and threats to validity evidence is important to improve the quality of assessment.

Efficacy of levonorgestrel intrauterine system (LNG-IUS) for abnormal uterine bleeding and contraception.

OBJECTIVE: To find out clinical response, side effects and patients' acceptability of levonorgestrel-releasing intrauterine system (LNG-IUS). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Gynaecology Department of Shifa International Hospital, Islamabad, from June 2005 to May 2008. METHODOLOGY: Adult women were enrolled in the study. In group-A, 57 married women were enrolled presented with abnormal uterine bleeding while in group-B, 16 married women attended for contraception. All women in group-A had thyroid stimulating hormone, pelvic ultrasound and outpatient endometrial biopsy. Detailed counselling was done before insertion. Outcome variables were improvement in bleeding pattern, safety profile, spontaneous expulsion rate and continuation at the end of one year. RESULTS: In group-A (abnormal bleeding) menstrual cycle became normal in 40.4% women in the first 3 months. At the end of one year, 50.9% women experienced normal cycle, 8.8% were oligomenorrhic and 12.3% were amenorrhic. In group-B (contraceptive group) all women started with normal cycles. At the end of 3 months 42% complained of vaginal spotting which reduced to 10% at the end of one year. Menstrual pattern at the end of one year showed normal cycles in 52%, oligomenorrhea in 19% and amenorrhea in 10% women. Vaginal spotting was experienced by 42% women at 3 months as main complaint which reduced to 10% at the end of one year, however, 7% women requested for removal of device at one year. CONCLUSION: LNG-IUS is an effective and acceptable treatment for abnormal uterine bleeding as well as for contraception. Vaginal spotting was the most frequent side effect experienced by both groups.

The structure and function of a new clinical skills and medical informatics laboratory (SCIL) in a developing country--a two year institutional experience.

OBJECTIVE: To combine clinical skills and medical informatics learning by offering a combined 'SCIL' rotation to third year medical students and to determine its long-term impact. METHODS: A combined clinical skills and medical informatics laboratory (SCIL) was set up at our institution with international collaboration. Nine months to one year after formal third year SCIL rotations were conducted, a questionnaire rated on (1-5) Likert Scale was administered to the inaugural class undergoing this rotation. RESULTS: The rotation was rated positively in terms of both acquisition of clinical skills as well as medical informatics skills. (overall rotation rating: 3.32 +/- 0.53) CONCLUSION: Our results have shown the positive long-term impact on undergraduate medical students of a combined clinical skills and medical informatics rotation.

Differences in Empathy Levels of Medical Students Based on Gender, Year of Medical School and Career Choice.

OBJECTIVE: To measure mean empathy scores of Pakistani medical students and to explore any association of empathy scores with gender, medical school year and future career choice. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Shifa College of Medicine, Shifa Tameer-e-Millat University, during the academic year 2015-2016. METHODOLOGY: The student version of Jefferson Scale of Physician Empathy (JSPE) was distributed to the students electronically via the student portal. Response that were completed in full were included in the study. Descriptive statistics was used to analyse student demographic data. The student score on the JSPE was reported as the mean (out of 7) of each item. Independent samples t-test was employed to check the significant differences between genders. Empathy score with advancing year of study was investigated using ANOVA. ANOVA with post-hoc Tukey's test was used to study the relationship between career choice and empathy score. RESULTS: The response rate was 70.94%. The mean score was 4.51 ±0.69. Females obtained greater, but statistically insignificant (p=0.08) empathy score (4.58) as compared to the male students (4.45). No statistically significant difference was seen between scores on the survey across the five academic years (F=0.88, p=0.47). Students who selected medicine and allied as career choice showed a significantly higher empathy score than those who opted for surgery. The internal consistency reliability (Cronbach's alpha) was 0.78. CONCLUSION: There were low levels of empathy in Pakistani medical students. Students with interest in medicine and allied showed higher empathy scores compared to surgical or technical specialties. No association of empathy scores with gender and medical school year was observed.

Preliminary experience with a new medicine morning report format incorporating multimedia and up-to-date.

To determine the impact of multimedia and up-to-date on internal medicine resident learning in morning report (MR), we converted our traditional medicine morning report to 'Up-to-date' programme incorporated and multimedia supported format which includes computer, multimedia projector and up-to-date CD ROM. A questionnaire was administered three months after the change and rated on a Likert scale. Preliminary experience demonstrated of a favourable overall resident and faculty perception and acceptance of the change.

Frequency and antimicrobial susceptibility of aerobic bacterial vaginal isolates.

OBJECTIVE: To determine the frequency and antimicrobial susceptibility of aerobic bacterial isolates from high vaginal swab cultures. DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, from January 2003 to February 2004. PATIENTS AND METHODS: The subjects included 136 symptomatic women attending Obstetrics and Gynecology Out-Patient Department. A proforma was filled to document the demographic details, presenting complaint and examination findings. High vaginal swabs were taken for gram staining, culture and antimicrobial sensitivity testing using standard microbiologic techniques. RESULTS: Normal flora was isolated in 30% of the cases, followed by Candida spp. (21.3%), Enterococcus spp. (14.7%), E.coli (10.2%), Beta hemolytic Streptococcus spp. (7.3%), Staphylococcus spp. (4.4%), Enterobacter spp. (4.4%), while Streptococcus pyogenes, Staphylococcus epidermidis and Klebsiella spp. were isolated 1.5% each. Enterococcus, Staphylococcus and Streptococcus were mostly sensitive to penicillin and amoxicillin while E.coli and Klebsiella were sensitive to (piperacillin-Tazobactum, Imipenem and vancomycin. Enterococci species showed significant resistance to aminoglycoside antibiotics (68.8% to 81.3%) resistance to vancomycin was 5%. CONCLUSION: Thirty percent of symptomatic patients had normal flora on culture. Candida spp was the most frequent pathogen isolated. Co-amoxiclav should be used as empiric therapy until culture-sensitivity report is available.

Frequency of hepatitis C in pregnancy and pregnancy outcome.

OBJECTIVE: To determine the frequency of HCV infections in pregnant women, to find out the risk factors for HCV infection in pregnant women and to compare pregnancy outcome of the sero-positive women with sero-negative women. DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, from June 2001 to May 2002. PATIENTS AND METHODS: Study was conducted on 947 booked pregnant women who were screened for HCV antibodies during antenatal consultation and were admitted for delivery in labour room. At the time of admission in labour ward, medical records of all patients were reviewed for anti HCV antibody testing and the presence of risk factors for HCV infection. Previous vaginal deliveries with episiotomy, previous surgeries, blood transfusions, and D&C for abortion or dysfunctional uterine bleeding were taken as independent variables. The obstetric outcome variables studied were: completed weeks of gestation by mother, birth weight and apgar score of newborns. The risk factors under study and the outcome variables were compared among HCV positive and negative women through a case-control study and measures of association calculated. RESULTS: The proportion of HCV sero-positivity among pregnant woman in our study was 3.27%. Among all the risk factors under study, previous surgery was found to have a significant association with HCV positive status of women (p=0.001). Other variables did not have significant association with HCV positive status in our study. There was no statistical difference in the mean birth weight of newborns (p= 0.94), mean Apgar score of newborns (p= 0.73) and mean gestational period among HCV positive cases and controls (p= 0.47). CONCLUSION: Prevalence of hepatitis C in pregnant women was 3.27%. Past history of surgical procedures was the most important factor for transmission of hepatitis C virus infection. No adverse effect on pregnancy outcome was observed in terms of gestational age, Apgar score and baby weight when compared with the controls.

Knowledge of type 2 diabetic patients about their illness: pilot project.

OBJECTIVE: To evaluate the baseline level of knowledge and awareness of diabetic patients about their disease and it's complications. METHODS: It was a Cross Sectional Survey conducted at Foundation Clinic, Shifa College of Medicine, Islamabad, in April 2004. A structured questionnaire was used. Forty diabetic patients were interviewed to know their knowledge attitude and practices about diabetes. All data was entered into SPSS version 10.0. The data was re-validated and analyzed. RESULTS: Mean age of study participants was 45.35 +/- 13.05 years, 11(27.5%) were male and 29(72.5%) were female. The mean BMI of the study participants was 27.06 +/- 6.29 kg/m2. Majority of the patients 27(67.5%) had type 2 diabetes. The mean fasting blood sugar was 159 +/- 73.89 mg/dl and random blood sugar was 200 +/- 91.2 mg/dl, 50% of the patients were using antidiabetic drugs regularly and only 15% of the patients were regularly monitoring their blood glucose at home using a glucometer. Awareness level of the study participants was low. CONCLUSION: The awareness about the disease in majority of diabetic patients was not adequate in this study. Routine individual teaching and counseling represents an effective educational model.

Isolated pleural fluid lactic dehydrogenase level: a cost effective way of characterizing pleural effusions.

BACKGROUND: Characterization of pleural effusion into an exudate or transudate is usually the first step in diagnostic evaluation. Light's criteria have been universally accepted as gold standard in this regard. We wanted to see the utility of isolated pleural fluid lactic dehydrogenase level (representing one of Light's classical criteria) in characterizing pleural effusion in our setting. We also wanted to compare the accuracy of commonly used conventional criteria with Light's criteria of isolated pleural fluid lactic dehydrogenase. METHODS: Patients who underwent diagnostic thoracentesis for one-year period were studied. Characterization of pleural effusions using biochemical criteria including pleural fluid protein, lactic dehydrogenase level (LDH), red blood cell (RBC) count and white blood cell (WBC) count were identified and compared with predetermined clinical criteria (gold standard). For each biochemical criteria sensitivity, specificity, positive predictive value and negative predictive value were calculated. RESULTS: Sixty-two patients underwent diagnostic thoracentesis. Sixteen were excluded, as they did not fulfill predetermined clinical criteria. Eight patients had transudative effusion vs. 38 exudates. LDH was found to be the most sensitive (97.2%) while WBC > 1000/mm3 was the most specific (100%) of all the criteria looked at. The overall accuracy was highest for Light's criteria of isolated LDH > 200 IU/litre (95.6%) followed by pleural fluid protein, WBC count and RBC count. CONCLUSION: We conclude that isolated pleural fluid LDH, as a representative of classical Light's criteria, is the most accurate criteria for characterizing pleural effusions. Due to its low accuracy isolated pleural fluid protein should not be ordered routinely. This approach may result into potential cost savings in our economically restraint society.