Development and Evaluation of a Peer Mentoring Programme for Postgraduate Medical Residents in Pakistan: A Pilot Study.

OBJECTIVE: To develop, implement, and evaluate the impact of one-year peer mentoring programme for postgraduate medical residents. STUDY DESIGN: Mixed methods. Place and Duration of the Study: The Aga Khan University, Karachi, from January 2019 to December 2020. METHODOLOGY: A survey was administered to junior residents in Medicine, Paediatrics, Pathology, and Radiology residency programmes to identify their academic needs from January 2019 to December 2020. Final-year residents, who served as peer mentors were provided a one-day mentoring workshop, including details of the identified needs. This was followed by one-year intervention in which mentors-mentees met as per mutual feasibility. A structured survey and focus group discussions were conducted to inquire the effectiveness of mentoring. RESULTS: A total of 33 out of 52 (63%) Year 1 residents completed needs analysis survey. Four essential identified areas were research (63%), memory (59%), reading (55%), and time management (53%). Residents reported excelling in areas of research, memory and reading, however, time management needed improvement. Focus group discussions emphasised mentoring as mandatory, including the wide range of skills. CONCLUSION: Senior residents should be trained as mentors of juniors, and semi-structured formal and informal mentoring can be implemented across all residency programmes. KEY WORDS: Mentoring, Residents, Postgraduate, Medical trainees.

Life satisfaction, resilience and coping mechanisms among medical students during COVID-19.

PURPOSE: Life satisfaction influences well-being. Medical students often experience more stress as compared to their counterparts in other disciplines as they are required to meet the demands of both academic workload and clinical responsibilities. However, during the current pandemic, in addition to academic changes, inability to complete clinical placements, loss of peer interaction and social connectedness and, deployment to areas in times of crisis could exacerbate their stress. This would impact their ability to cope with stress and eventually influence their life satisfaction. Students approach these challenges in various ways, either positively, religiously, or by avoiding. This study aimed to explore the association between resilience, coping mechanisms and life satisfaction in medical students during the pandemic. METHODS: A cross-sectional web-based survey was conducted from undergraduate medical students from year 1 to year 5. Three instruments were used to measure life satisfaction, resilience, and coping, namely The Brief Resilience Scale, The Satisfaction with Life Scale and the COPE inventory. Mean and standard deviation were calculated for all continuous variables. Robust linear regression model was used for analysis. Hierarchical (forward) stepwise model building technique was used for final model. Alpha cut off was kept at 0.05. RESULTS: A total of 351 students (out of 500 students) completed the questionnaires. A moderately negative, slightly linear correlation between life satisfaction and avoidant coping was reported. Life satisfaction showed moderately positive, slightly linear correlation with resilience score. Three variables stayed significant in the final model: Resilience, avoidant coping, and religion coping. CONCLUSION: Life satisfaction can be improved among medical students by focusing on strategies which enhance resilience. Religion is identified as a significant coping strategy among medical students. Students coping mechanism can vary and more research is needed to assess which types of coping strategies could contribute positively to the quality of their personal and professional lives.

Urinary Incontinence: Understanding the Silent Plight of Women.

Urinary incontinence (UI) is defined as the complaint of involuntary loss of urine. UI affects both men and women but is more common in women. It has been identified as a World Health Organization priority. The burden related to UI at local, national, and global levels is huge and its impact in terms of physical, social, mental, and financial aspects makes it a concerning issue. However, there exist several barriers in terms of knowledge and attitude in seeking healthcare among women experiencing UI. This calls upon a multi-disciplinary approach involving professionals from different disciplines and tackling it with collaborative and collective efforts. Key Words: Urinary incontinence, Burden, Multidisciplinary approach, Pakistan, World Health Organization.

The effect of a culturally sensitive mental well-being module on Pakistani nursing students' knowledge and beliefs regarding their own mental health and illness.

This study examined the effect of a mental well-being module on undergraduate nursing students' knowledge and beliefs regarding causes and treatment of mental health and illness, and explored the relationship between these variables and depression and anxiety. The one group design incorporated pre-intervention, intervention and post-intervention phases, in a consecutive sample of 246 students in a 4-year BScN programme in Pakistan. A culturally sensitive, interactive mental well-being module of four hours length was delivered to three groups of approximately 40 students per group. Repeated measures ANOVA was performed to assess the difference in the mean knowledge scores. Paired t-tests investigated between-group differences on the factor scores. A total of 112 students screened positive for anxiety and depression symptoms. Repeated measures ANOVA showed a significant difference in the mean knowledge scores regarding mental illness (P < 0.001). Factor analysis resulted in four factors for the aetiology items. Paired t-test showed significant differences (P < 0.001) between psycho-social and environmental factors, supernatural and religious beliefs, and neuro-genetics. For treatment, significant differences (P < 0.001) were found between all factors - Professional and Help from others, Religiosity and Socialization, and Alternative and Medical Treatment. There was a significant and positive change in students' mental health knowledge, beliefs and mental health-seeking behaviour and diminished stigmatized beliefs. Based on the findings, it is highly recommended to incorporate the mental well-being program in the curriculum.

Parent training for Autism Spectrum Disorder.

OBJECTIVE: The main purpose of the present study was to investigate the effectiveness of behaviour therapy training to mothers of autistic children on verbal and non-verbal improvement of their children. METHODS: A total of 33 mothers of autistic children were selected for training based on non-probability purposive sampling procedure. Autism Spectrum Disorder (ASD) Knowledge Scale was used to assess mothers' knowledge about autism and Vineland Adaptive Behaviour Scale was used for assessment of the communication skill in autistic children. RESULTS: This study revealed that behaviour therapy training significantly improved communication skills of children with autism by training mothers. The results of paired t-test revealed that trained mothers developed improved communication skills. CONCLUSIONS: These results showed improvement in communication skills of autistic children whose mothers were trained in behaviour therapy.

Using the cognitive apprenticeship model to identify learning strategies that learners view as effective in ward rounds.

BACKGROUND: Cognitive apprenticeship model (CAM) is an instructional model for situated learning. There is limited data available on application of the CAM in clinical settings. The aim of the study was to identify learning strategies using CAM, which in the opinion of learners are effective in ward rounds. METHODS: Participants were residents and medical students who rotated through internal medicine at Aga Khan University Hospital, Karachi. We sought learners' opinion on a structured questionnaire based on four principal dimensions of cognitive apprenticeship. A previously determined set of 10 defined competencies were compared with CAM's six teaching/learning (T/L) methods (modelling, coaching, scaffolding, articulation, reflection and exploration) as well. Mean and SD were calculated. Mann-Whitney test was used to compare scores. RESULTS: Of 195 participants, there were 100 men (51.3%) and 95 women (48.7%). Perceived learning for six T/L methods, ranged from 3.7 to 3.9 (max=5). Coaching and scaffolding had the highest scores. Statistically significant difference between the student and resident groups was noted. Medical students perceived coaching and scaffolding (4.1 and 4.05) and residents rated coaching, articulation and exploration as most effective (3.9 and 3.8). Majority (82.1%) reported a positive learning environment in wards. CONCLUSIONS: CAM enabled to identify two T/L methods (scaffolding and coaching) that are important for learning in ward round. Limited differences in perceived effectiveness of the T/L methods indicate that variety can be used to sustain interest in learners. Positive learning environment, team diversity and tasks of increasing complexity contribute to learning.

Developing role models in clinical settings: A qualitative study of medical students, residents and clinical teachers.

OBJECTIVE: To explore how positive role modelling attributes can be developed in students, residents and clinical teachers. METHODS: The qualitative study using focus group discussions was held at Aga Khan University, Karachi from March to May 2018, and comprised medical students, residents and clinical teachers. Overall 11 focus group discussions were conducted till data saturation was achieved. Content analysis was used to analyse the data which was transcribed verbatim. RESULTS: Of the 116 subjects, 60(51.7%) were medical students, 35(30.2%) were residents and 21(18%) were clinical teachers. Of the 11 focus group discussions, 4(36.5%) each were held with the students and the residents, while 3(27%) were held with the teachers. Five major themes that emerged from the study included definition of role models, attributes of role models, role modelling as a learnt behaviour, challenges in developing role models, and recommendations for developing positive role models. A number of attributes of positive and negative role models were identified by the participants. All the participants including students, residents and teachers appreciated the importance of role modelling in developing professionalism among health professionals and medical students. Factors hindering development and demonstration of positive role modelling were also identified and possible solutions were suggested. CONCLUSIONS: Clinical teachers needed to be made cognizant of their role as positive role models in developing professionally competent physicians. The medical institutions needed to develop and implement policies that would enhance positive role modelling by the teachers and facilitate learning of positive attributes at all levels.

Development and validation of an instrument for assessment of professional behaviour during laboratory sessions.

OBJECTIVE: To develop an instrument to assess professional behaviour among medical students, and to determine its validity, reliability, feasibility and acceptability. METHODS: This cross-sectional study was conducted at Bahria University Medical and Dental College, Karachi, from July to September 2017, and comprised of medical students in years 1 and 2 of their academic programme. The instrument was developed for the Physiology laboratory sessions using nominal group technique and was tested for validity, reliability, feasibility and acceptability by two assessors through validity and reliability statistics. Data was analysed using SPSS 23. RESULTS: Of the 250 students enrolled, 232(92.8%) had their assessment completed. Applicability of the scale was indicated by exploratory factor analysis. Two factors were isolated which explained 57.65% of the variation. The first factor, comprising of 7 sub-factors, was labelled as 'practical performance', and the second factor, consisting of 5 sub-factors, as 'personal interactions'. A final 12-item instrument was retained. Cronbach's alpha was determined to be high at 0.863. Intra class correlation was 0.863 for both years 1 and 2 combined. CONCLUSIONS: It was possible to develop an instrument for professional behaviour assessment in Physiology laboratory skills session which could indicate valid, reliable, feasible and acceptable results.

Insight into COVID-19 Responses and Initiatives from Pakistan.

The coronavirus pandemic is a rapidly evolving outbreak that has tremendously distressed people worldwide. The paper aims to present some key rapid responses and initiatives to COVID-19 undertaken in Pakistan. The information has been gathered by reviewing material and documents pertinent to COVID-19 in the context of Pakistan. The incidences of COVID-19 cases are gradually increasing; however, the case fatality rate is relatively lower in Pakistan as compared to developed countries. The government has taken massive actions, in terms of lockdowns, quarantine homes, testing facilities, closure of schools, and mass gatherings at places, to combat COVID-19. However, the measures seem to be insufficient due to the fear and stigma attached to it and the low socio-economic conditions. The government has launched initiatives, like Ehsaas cash dissemination programme, for the underprivileged families to address their basic needs; and philanthropic organisations are also coming forward to support these families. The spread of the pandemic is gradually increasing in Pakistan and we recommend strategies like increasing public awareness campaigns, improving screening capacity, and contact tracing to augment the efficiency of the current responses and initiatives. Key Words: COVID-19, Pakistan, Responses, Initiatives.

Mental Health Challenges and Psycho-social Interventions amid COVID-19 Pandemic: A Call to Action for Pakistan.

The increase in death and spread-related coronavirus (COVID-19) has shifted the world focus to the containment of the disease by emphasising measures to prevent spread in the general population. Such a complex, threatening, and unprecedented situation has left the psycho-social wellbeing needs of general public unaddressed. This paper aims to review the current COVID-19 scenario and its effects on the psycho-social wellbeing of people; and an attempt to shed some light on the aforementioned questions. Furthermore, the review will propose some recommendations for overcoming the mental illness issues, during and after the COVID-19 outbreak. We extracted information from reliable published international and national literature and reviewed anecdotes from media content from January to June 2020. The mental health implications of this outbreak will be long-lasting; however, by prioritising, investing diligently, and taking a collective approach, this challenge can be dealt with in a promising manner. Key Words: Mental health, Psycho-social interventions, COVID-19, Pakistan.

Reliability and Validity of WATCH: Warwick Assessment InsTrument for Clinical TeacHing.

OBJECTIVE: To determine the reliability, validity, feasibility, acceptability and perceived educational impact of WATCH: Warwick Assessment insTrument for Clinical teacHing among doctors in Pakistan. STUDY DESIGN: Cross-sectional research study. PLACE AND DURATION OF STUDY: The College of Physicians and Surgeons, Pakistan, from September 2018 to August 2019. METHODOLOGY: Postgraduate trainees were asked to rate the clinical teaching sessions, using WATCH, which consists of 15 items. Percentage was used to calculate gender and participation from different specialties. Inter-item correlations of 15 items with individual mean scores, standard deviations and Cronbach's Alpha were reported, including Friedman test, in order to observe the scores across multiple conditions. The Hotelling's T2 test was used to test whether the answers provided by the study participants to the questionnaire were equal. Construct validity was determined using factor analysis while feasibility, acceptability, and educational impact was evaluated by seeking participants' feedback on five semi-structured questions. RESULTS: More than 80% ranked WATCH from good to excellent.  Oveall 8 items were perceived as excellent, while 7 items received rating of good. Inter-item correlation ranged from 0.61 to 0.81. Cronbach Alpha was reported to be 0.975, with significant difference in mean scores of different items (Friedman's Chi-Square=4285.54; p<0.001). The Hotelling's T2 test (21598.871 with F=185.249, df=14,2654; p<0.001) indicated that the mean values of the responses of different questions in the instrument were statiscally different. Factor analysis indicated one factor accounting for 73.97 of variance. The majority (93%) of the participants found the instrument easy to complete, most participants (91.5%) indicated it as an acceptable method of assessment, and majority (90.8%) perceived that it can improve clinical teaching. CONCLUSION: WATCH demonstrated valid, reliable, feasible, and acceptable results for assessment of teaching of medical doctors and it can be used for providing feedback and rewarding teachers who excel in teaching. Key Words: Clinical teaching, Validity, Reliability, Feasibility, Medical students, Residents, Doctors.

Anxiety, Depression, Stress, and Decision-Making Among Orphans and Non-Orphans in Pakistan.

PURPOSE: Orphanhood is a time which involves many psychological and emotional problems. Lack of self-determination and inability to take decision puts orphans at risk of anxiety. In Pakistan, there is minimal evidence which explores the relationship between anxiety, depression, stress, and decision-making among orphans. The aim of the study is to explore the relationship between anxiety, depression, stress, and decision-making among orphans and non-orphans adolescents. METHODS: The sample size consisted of 150 orphans and 150 non-orphans adolescents (n=300). The data were collected from different orphanages and schools located in the city of Lahore, Pakistan. The instruments used were Depression, Anxiety & Stress Scales (DASS) and the Adolescent Decision Making Questionnaire (ADMQ). Descriptive statistics was used to determine the mean, standard deviations, and range. Pearson product moment was used to determine the correlation. The independent t test was performed to determine gender differences, and simple regression analysis was used to predict the effect of social interaction anxiety. RESULTS: The correlation matrix for decision making, stress, anxiety, depression and DASS indicated that decision making has significant correlation with stress (r= 0.30, **p<0.01), anxiety (r=0.27**, p<0.01) and depression (r= 0.15*, p<0.05). Independent t test revealed significant gender differences between orphan and non-orphans (M=9.45, SD=5.06) (M=8.03, SD=3.61) t(217)=2.48 p=0.01 <0.05. Simple regression analysis indicated that anxiety is a significant predictor of decision making ß = 0.276, F=17.90, p<0.001. CONCLUSION: The study has implications. First, there is a need to raise awareness at governmental and non-governmental institutions towards finding therapeutic programs for orphans. Second, screening for depression and mental and psychological care should be integrated into routine health care provided to orphans. Third, there should be furnishing of life skills training for orphans such as stress management, coping skills, problem-solving, and decision-making skills.

Using Multiple Mini-Interviews for Students' Admissions in Pakistan: A Pilot Study.

BACKGROUND: A significant challenge continuing to face medical educators is the development of an effective method for student admissions into medical school. Conventional interviews have been commonly used for assessment of non-cognitive skills; however, they are subject to different biases and lack of standardization. The present study aims to determine the validity, reliability, feasibility, and acceptability of implementing Multiple Mini-Interviews (MMI) as a selection method for undergraduate medical students. METHODS: MMI consisting of 8 stations was developed and implemented. A variance component analysis was computed to identify different sources of variance and estimate overall reliability. Content validity was established by seeking consensus on non-cognitive attributes desired by stakeholders. Acceptability and feasibility were determined by a post-MMI questionnaire. RESULTS: A total of 381 out of 450 (84.66%) candidates participated in the study. The G coefficient was 0.70. Participants found MMI as an acceptable and feasible method of assessment, with 75% of candidates and 95% of assessors preferring MMI to traditional interviews. CONCLUSION: MMI as an assessment method for students' admissions demonstrated reliable findings. Stakeholders found it feasible and acceptable. Individual institutions can tailor the stations towards selection of the characteristics that are most valued within their local context.

Empathy in clinical practice: a qualitative study of early medical practitioners and educators.

OBJECTIVE: To explore the reasons for decline in empathy among physicians and to identify strategiesfor fostering empathetic clinical practice. METHODS: The qualitative study was conducted at the Aga Khan University Hospital, Karachi, from February to June 2017, and comprised focus group discussions involving separate sessions with medical students, residents and clinical teachers. Content analysis was used to analyse the verbatim transcripts for identification of codes which led to derivation of themes from the data. Consolidated criteria for reporting qualitative research was used to assess the quality of the study. RESULTS: Of the 109 subjects, 57(52.3%) were medical students, 30(27.5%) residents and 22(20.2%)clinical teachers. Of the 9 focus group discussions, 4(44.4%) were held with the students, 3(33.3%) with residents and 2(22.2%) with the teachers. Four themes that generated were delineating empathetic clinical practice, reasons for decline, challenges for promoting empathetic clinical practice, and recommendations for developing and facilitating empathetic clinical practice. All the participants unanimously agreed that there was a decline in empathetic clinical practice. Primary challenges included increased workload and time constraints inhibiting empathetic practice.. CONCLUSIONS: It is essential to teach empathetic clinic practice to students and residents during medical training while continuous professional development should reinforce the significance of empathetic clinical practice among medical practitioners and educators.

Medical Students' Perceptions of Clinical Teachers as Role Model.

INTRODUCTION: Role models facilitate student learning and assists in the development of professional identity. However, social organization and cultural values influence the choice of role models. Considering that the social organization and cultural values in South East Asia are different from other countries, it is important to know whether this affects the characteristics medical students look for in their role models in these societies. METHODS: A 32 item questionnaire was developed and self-administered to undergraduate medical students. Participants rated the characteristics on a three point scale (0 = not important, 1 = mildly important, 2 = very important). One way ANOVA and student's t-test were used to compare the groups. RESULTS: A total of 349 (65.23%) distributed questionnaires were returned. The highest ranked themes were teaching and facilitating learning, patient care and continuing professional development followed by communication and professionalism. Safe environment and guiding personal and professional development was indicated least important. Differences were also observed between scores obtained by males and females. CONCLUSION: Globally there are attributes which are perceived as essential for role models, while others are considered desirable. An understanding of the attributes which are essential and desirable for role models can help medical educators devise strategies which can reinforce those attributes within their institutions.

WATCH: Warwick Assessment insTrument for Clinical teacHing: Development and testing.

OBJECTIVE: Medical education and teaching skills are core competencies included in the generic curriculum for specialty training. To support the development of these skills, there is need for a validated instrument. This study aims to develop and test an instrument to measure the attributes of specialty trainees as effective teachers. METHODS: The study was conducted in two phases. In first phase, the content of the instrument was generated from the literature and tested using the Delphi technique. In second phase, the instrument was field tested for validity and reliability using factor analysis and generalizability study. Feasibility was calculated by the time taken to complete the instrument. Acceptability and educational impact were determined by qualitative analysis of written feedback. Attributes of specialty trainees were assessed by clinical supervisors, peers, and students. RESULTS: The Delphi study produced consensus on 15 statements which formed the basis of the instrument. In field study, a total of 415 instruments were completed. Factor analysis demonstrated a three-factor solution ('learning-teaching milieu', 'teaching skills', and 'learner-orientated'). A generalizability coefficient was 0.92. Mean time to complete the instrument was five minutes. Feedback indicated that it was an acceptable and useful method of assessment. CONCLUSION: This new instrument provides valid, reliable, feasible, and acceptable assessment of clinical teaching.