A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan.

This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

Developing and piloting an online course on osteoporosis using a multidisciplinary multi-institute approach- a cross-sectional qualitative study.

INTRODUCTION: Postgraduate medical trainees (PGs) in developing nations face various educational hurdles due to limited access to quality resources and training facilities. This study aimed to assess the effectiveness of e-learning, particularly Massive Open Online Courses (MOOCs), within postgraduate medical education. It involved the development of a customized online course focused on osteoporosis for PGs and an examination of their perspectives and preferences concerning online learning methods like Virtual Learning Environment (VLE) platforms. METHODS: The study was conducted from January 2018 to December 2020. A multi-institutional, multidisciplinary team was assembled to design an osteoporosis course on the VLE platform. PGs (n = 9) from diverse disciplines and institutions were selected with informed consent. Focus group discussions (FGDs) among these PGs identified their preferences for the online course, which subsequently guided the development of the MOOC. The modular MOOC comprised recorded micro-lectures, flashcards, videos, case challenges, and expert interviews. The educational impact of the VLE was assessed using pre- and post-module tests among the participants, and their perceptions of the PGs and course facilitators were gathered via an online survey. RESULTS: The study identified the involvement of PGs in the course design process as beneficial, as it allowed for content customization and boosted their motivation for peer-to-peer learning. During the FGDs, PGs expressed a strong preference for flexible learning formats, particularly short downloadable presentations, and micro-lectures. They also identified challenges related to technology, institutional support, and internet connectivity. In the subsequently customized MOOC course, 66% of PGs (n = 6) attempted the pre-test, achieving a mean score of 43.8%. Following the VLE module, all PGs (n = 9) successfully passed the end-of-module test, averaging a score of 96%, highlighting its impact on learning. The majority (n = 8, 88.9%) agreed that the course content could be applied in clinical practice, and 66.7% (n = 6) expressed extreme satisfaction with the learning objectives and content. Participants favoured end-of-module assessments and the use of best-choice questions for evaluation. CONCLUSION: This study highlights the importance of virtual learning, particularly MOOCs, in addressing the educational challenges faced by developing nations. It emphasizes the need for tailored online courses that cater to the preferences and requirements of PGs. The findings suggest that MOOCs can foster collaboration, networking, and opportunities for professional development, and interdisciplinary collaboration among faculty members can be a key strength in course development. This research provides valuable insights for educators, institutions, and e-learning developers seeking to enhance their teaching methodologies and establish accessible educational environments in the digital age.

Integrating basic sciences into clerkship rotation utilizing Kern's six-step model of instructional design: lessons learned.

BACKGROUND: It is generally agreed that basic and clinical sciences should be integrated throughout the undergraduate medical education, however, there is still need for continued formal integration of basic sciences into clinical clerkship in many medical schools across the globe. METHODS: Utilizing Kern's Six-Step Model of Instructional Design, we aimed to develop an intervention that would facilitate cognitive integration of basic and clinical sciences. After problem identification and targeted needs assessment through focused group discussion with the students and faculty, objectives were devised with an implementation plan of using flipped class approach to develop a content-focused and learner-centered teaching strategy. This intervention was piloted in the 2-week cardiology clerkship in Year 5. Evaluation of the content, integration, student and faculty experiences were recorded through in-depth interviews, FGDs and a formative MCQ test. RESULTS: Flipped classroom based integrated sessions were successfully developed. The implementation phase was met with challenges that primarily stemmed from the diverse teaching styles among faculty members, hesitance to deviate from conventional practices, variations in clinic timings, and demanding schedules. Noteworthy observations were in terms of ownership of the project, the need for faculty development in modern student-centered teaching pedagogies, opportunities for content improvement, scheduling of sessions, and suggestion of revisiting fundamental concepts in basic sciences through a brief boot camp-style session at the onset of the clerkship. The role of flipped case model and clinical cases in integrating basic sciences into clinical sciences were appreciated by the students. Standardization in teaching practices was identified as the major challenge by the faculty. CONCLUSIONS: A functional, learner-centered framework of cognitive integration of basic sciences in clinical sciences curriculum of cardiology rotation was developed with a potential to be implemented in other clerkship rotations.

The Impact of Short Intensive Care Rotation on Residents' Experience in the COVID-19 Pandemic: A Mixed-Methods Study.

Objectives: To assess the impact and utility of an intensive care unit (ICU) rotation during the coronavirus disease 2019 (COVID-19) pandemic and the need for mandatory ICU rotations in training for all clinical specialties. Methods: A mixed methods study was conducted from January to September 2021 at the Aga Khan University Hospital, including resident doctors who rotated through COVID ICU between May and September 2020. An online survey was undertaken, followed by two focused group discussions (FGDs). Results: Fifty-nine complete responses out of a total of 86 were analyzed. Around 42.3% (n = 25) of doctors belonged to medicine/allied specialties and 57.6% (n = 34) had previous ICU experience. Both groups, with and without prior ICU experience, found the rotation equally challenging (82.3% (n = 28) versus 84% (n = 21), P = .776) and gained similar practical skills (35.3% (n = 12) versus 16% (n = 4), P = .072), however, those with experience gained significantly more knowledge (58.5% (n = 20) versus 32% (n = 8), P = .047). On opinion regarding mandatory ICU rotation, the majority agreed to have a mandatory rotation (82% (n = 28) versus 72% (n = 18), P = .421)) with an optimal duration of 1 to 2 months. The FGDs found that all residents encouraged the idea of mandatory training in ICU which must be tailored to their training specialty and suggested extending the duration beyond 1 week to ensure learning. Conclusions: COVID ICU rotation was a good avenue for learning and the idea of mandatory ICU training was supported. Mandating ICU rotation might theoretically enhance response to emergencies. More research is needed to understand for feasible incorporation of ICU training in the curriculum.

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.

Exploring the 'January effect' at a university hospital in Pakistan: a retrospective cohort study investigating the impact of trainee turnover on patient care quality outcomes.

OBJECTIVE: There are reports of a potential rise in a teaching hospital's morbidity and mortality rates during the trainee turnover period, i.e., with the induction of new residents and house staffs, and the changeover of clinical teams. The published literature displays mixed reports on this topic with lack of reproducible observations. The current study was conducted to explore existence of any such phenomenon (January effect) in Pakistan. METHODS: This retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan. Five-year (2013-2018) record of all the patients in all age groups related to these outcomes was retrieved and recorded in specifically designed questionnaire. Different outcome measures were used as indicators of patient care and change in these outcomes at the time of new induction was related to possible January effect. RESULTS: During the five-year study period, more than 1100 new trainees were inducted into the post graduate medical education program (average of 237 per year) with more than 22,000 inpatient admissions (average of 45,469 per year). Some patterns were observed in frequencies of surgical site infections, medication errors, sentinel events, patient complaints, and adverse drug reactions. However, these were not consistently reproducible and could not be directly attributed to the trainee turnover. All other indicators did not show any pattern and were considered inconclusive. No effect of overlap was observed. CONCLUSIONS: Inconsistency in the patient care quality indicators do not favor existence of January effect in our study. Further research is recommended to establish our results.

Assessing the validity of admission test into the internship programme at a private university in Pakistan.

OBJECTIVE: To report the development and validity assessment of a comprehensive model of assessment method comprising written test and multiple mini interviews for selection in a medical internship programme. METHODS: The psychometric validation study was conducted at the Aga Khan University, Karachi, and comprised anonymised scores of written admission test, multiple mini interviews and exit written exams for all the interns who completed their internships in 2018 and 2019. Correlation between admission and exit tests, and predictions were assessed. Data was analysed using SPSS 20. RESULTS: There were 160 interns; 80(50%) each in 2018 and 2019. Mean scores were 68.8±4.40% for written tests and 76.7±4.66% for multiple mini interviews. The mean score for exit examination was 68.1±6.84%. The Cronbach's alpha of scores on the written admission test was 0.82 and 0.88 for the two years, respectively, while for the multiple mini interviews, the corresponding values were 0.81 and 0.94. The written admission and exit tests were moderately correlated (0.44) while the correlations of multiple mini interviews scores with written admissions and exit tests were -0.28 and 0.04, respectively. CONCLUSIONS: The selection process should comprise multiple measures of assessment to ensure the selection of the best candidates.

In a digitally connected world through Likes, Hashtags and Followers - Advancing surgical research through a social media: A narrative review.

In this era of modern information technology, the world is now digitally connected through various platforms on social media, which has changed the way medical professionals work, communicate and learn. The use of social media in surgery is expanding, and it is now becoming an essential tool for surgical training, research and networking. Articles, journal clubs and surgical conferences are within reach of everyone regardless of geographical location worldwide. Electronic publications have now resoundingly replaced printed editions of journals. Collaborative research through social media platforms helps collect diverse data, enhancing the research's global generalisability. The current narrative review was planned to discuss the importance of social media in advancing surgical research and the use of different social media applications in the context of promoting and disseminating surgical research alongside its evolving ethical challenges.

Low performance of internal medicine senior residents in in-service examinations.

We observed an unprecedented and consistent low performance of senior residents as compared with juniors in monthly examinations. This compelled us to evaluate systematically and compare the scores of senior residents with their junior colleagues. This retrospective observational study was conducted in April 2020 among internal medicine residents. Residents in first and second year of their training were labelled as junior residents. Residents in third or fourth year of their training were labelled as senior residents. Comparison of mean scores of each resident level was done separately both for monthly formative multiple-choice questions tests, and summative yearly end of term examinations. We discussed the possible reasons as well. There were 67 residents in year 2018 and 69 in 2019. There is no significant difference between scores of monthly examinations of years 2018 and 2019 among residents of each level. Rather, in March and December 2018, junior residents perform better than senior residents with p values of 0.01 and 0.04, respectively. In February and September 2019, senior residents performed better than junior residents with p value of 0.02. Similarly, there is no significant difference in scores of residents of each level in end-of-term examinations of years 2018 and 2019 with p values 0.18 and 0.25, respectively. Performance of senior residents in our residency programme in in-service examinations is relatively low as compared with their junior colleagues. There is a need to evaluate reasons for this relatively low performance of senior residents.

Impact of a global pandemic on surgical education and training- review, response, and reflection.

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

Simulation based team training in surgery - a review.

The healthcare environment in surgery is complex, dynamic and often ambiguous. Besides subject knowledge and technical skills, other competencies, such as team work, communication skills and situation awareness, are required to ensure better patient-related outcome. Teams that demonstrate poor non-technical skills make more technical errors, often resulting in patient morbidity or mortality. Different hospital-based locations, such as operating rooms, intensive care units, emergency rooms and surgical wards, are the areas where poor team dynamics prevail. Simulation-based team training is a strategy to provide inter-professional training and experiential learning opportunities for surgeons, anaesthetists and allied health professionals. It helps them to effectively respond in complex situations in complex surgical environment. Simulation-based team training has 3 components; didactics, simulation itself, and debriefing. Literature has shown that simulation-based team training in surgery improves identification of team-based behaviours, improves team performance and overall patient safety.

Stress and coping among surgery residents in a developing country.

OBJECTIVE: Stress during residency training in surgical disciplines not only hampers professional development but can also compromise patient care and personal health. The purpose of this study was to measure the stress level among the surgical residents, identify factors within the learning and work environment that cause stress, and identify different strategies that the residents use habitually to cope with these stresses. METHODOLOGY: This mix method study was conducted in the department of Surgery at Aga Khan University, Pakistan. Residents' stress level was measured using Perceived Stress Scale (PSS); focus group discussions (FGDs) with faculty and residents explored stressors during residency training, while Brief COPE Inventory identified the residents' preferred coping strategy. RESULTS: A total of 68 (83%) surgery residents completed the survey of which 19% had high stress scores while only one resident had perception of low stress. Females had significantly higher stress scores (25.7±3.0; p=0.008) as compared to male counterparts. Planning (87.8%) and Self-distraction (65%) were the most commonly used adaptive and maladaptive strategies respectively. The reliability of the PSS and BCI measured by Cronbach's alpha was 0.73 and 0.82 respectively. Work-life imbalance, workload and contradicting programme and hospital policies were identified in FGDs as major stressors during residency. CONCLUSIONS: Although surgical residency programmes are very stressful, coping strategies are not formally taught during surgical training. Academia and hospital should join hands in developing interventions to enable residents cope with the situation.

Status of the palliative care education in surgical postgraduate curriculum - implications for Pakistan.

Palliative care has gained considerable attention during last few decades. Increasing demands by the society owing to increased number of elderly and people with chronic illnesses require increased number of health care professionals with competence in providing palliative care. The current review provides a summary of the published literature pertaining to palliative care education in surgical residency programmes internationally and locally. Most surgical residency programmes provide limited, if any, formal education in knowledge and skills related to palliative and end of life care. The situation is alarming in Pakistan where the discipline is in infancy and resources are limited while the demand for palliative care is increasing. Surgery can learn lessons from other disciplines. Development and integration of palliative medicine into most of the existing postgraduate curricula continues to be a challenge for the accreditation bodies and medical educationists. Collaborative measures need to be taken urgently at all levels.

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.

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.

Knowledge gain of the non-vascular surgeons after attending a course on traumatic vascular emergencies.

OBJECTIVE: To measure the effectiveness of the workshop in enhancing the knowledge and skills of the non-vascular surgeons in dealing with traumatic vascular emergencies. METHODOLOGY: It was a Quasi-experimental pre-post design study conducted at Section of Vascular Surgery, Aga Khan University Hospital, Karachi (Pakistan) in February 2019. One-day workshop was conducted to enhance the knowledge and operative skills of the non-vascular surgeons in managing traumatic vascular emergencies. A written test and course evaluation survey were used to evaluate the effectiveness of the course in achieving the desired objectives. RESULTS: Total of 21 participants attended the workshop with mean age of 29 ± 6.06 years. Majority of participants 15 (71%) were surgery residents from different subspecialties. Only 3 (14%) had prior exposure in Vascular Surgery. Mean pretest score was 11.9 ± 4.27 (59.52% ± 21.3) which improved to 16.14 ± 3.69 (81.6% ± 16.6). Gain in knowledge was measured using paired t-test and there was 21% of gain in knowledge of the participants compared between the pretest and posttest score. Overall participants found this workshop to be very useful in refining their skills and learning innovative techniques in managing vascular emergencies. CONCLUSIONS: Carefully designed workshop improves the knowledge of non-vascular surgeons in dealing with common vascular emergencies.

Changing face of trauma and surgical training in a developing country: A literature review.

Trauma continues to be the major cause of disability and death globally and surgeons are often involved in immediate care. However there has been an exponential decrease in the number of the trained trauma surgeons. The purpose of the current review article is to summarize the published literature pertaining to trauma education in postgraduate surgical training programmes internationally and in a developing country as Pakistan. Several electronic databases like MEDLINE, PubMed, Google scholar and PakMediNet were searched using the keywords 'trauma education' or 'trauma training' AND 'postgraduate medical education', 'surgery residency training', 'surgery residents' and 'surgeons'. The current training in most surgical residency programmes, locally and globally, is suboptimal. Change in trauma management protocols, and decrease in volume of trauma cases results in variable and/ or inadequate exposure and hands-on experience of the surgical trainees in operative and non-operative management of trauma. This warrants collaborative measures for integration of innovative educational interventions at all levels of the surgical educational programmes.

Effect of a two-day extensive continuing medical education course on participants' knowledge of clinical and operative urology.

OBJECTIVE: Continuing Medical Education (CME) is an established method for facilitating the lifelong learning and developing knowledge, skills and attitudes to ensure delivery of a medical care which is up-to-date, evidence based, safe and patient-centered. An extensive 2 day urology course was conducted to meet the needs of learners. The purpose of the current study was to measure the effect of this CME activity on the knowledge of the participants. MATERIAL AND METHODS: This quasi-experimental, single group pre-, and post-test study measured the gain in learning as a result of the two-day extensive CME course conducted by the section of Urology at Department of Surgery, the Aga Khan University, Karachi-Pakistan. Gain in knowledge, defined as the difference between the pre-test and the post-test scores, was taken as a measure of course effectiveness. The test comprised of 40 one-best type carefully constructed multiple choice questions (MCQs). Item analyses were also performed. RESULTS: Forty-five out of a total of 70 participants from within and outside the city completed both pre and post-tests and were included in the study. The mean age of the subjects was 33.3+6.7 years. Of these 45 participants, 68.9% (n=31) of them were trainees at different levels. Mean gain in knowledge was 12.7±6.8% (p<0.01; 95% CI: 4.17-5.79). Mean test scores improved significantly from 37.8±11.3% to 50.3±10.8%. Difference in pre and post scores due to age, gender, practice type or years since start of training was not significant. The reliability of the test using Cronbach's α was 0.634. CONCLUSION: CME sessions when designed and delivered carefully are effective means of increasing the knowledge significantly. Pre- and post-test is a reliable and valid strategy to measure gain in participants' knowledge.

Frequency, severity and risk indicators of retinopathy in patients with diabetes screened by fundus photographs: a study from primary health care.

OBJECTIVE: To determine the frequency, severity and risk indicators of diabetic retinopathy (DR) in patients with diabetes attending a primary care diabetes centre. METHODS: This observational study was conducted at Diabetic Association of Pakistan - a World Health Organization collaborating center in Karachi, from March 2009 to December 2011. Registered patients with diabetes were screened by two field fundus photographs. Retina specialists graded the signs of retinopathy according to diabetic retinopathy disease severity scale. RESULTS: Of total registered diabetic patients (n=11,158), 10,768 (96.5 %) were screened for DR. Overall DR was found in 2661 (24.7%) patients. DR was found in decreasing order of frequency in patients with type 2 (n= 2555, 23.7%) followed by patients with type 1 diabetes (n=101, 0.93% ) and patients with gestational diabetes mellitus (GDM) (n=5, 0.46%). Among patients with DR, signs of non-sight threatening retinopathy was dominant. Females and patients of working age group predominantly had retinopathy. Type 1 patients >16 years and type 2 patients < 5 years of history of diabetes had sign of retinopathy in increased frequency. CONCLUSION: Every forth patient with diabetes in this large cohort had signs of diabetic retinopathy. Females and patients in working age group predominantly had retinopathy. Type 2 patients with short while type 1 patients with long history of diabetes most frequently had DR. Dissemination of the present study findings may help in increasing the awareness of this serious complication of diabetes.