Using the health humanities to impart disability competencies to undergraduate medical students.

BACKGROUND: Disability competencies were included, for the first time, in India's new undergraduate competency-based curriculum as a result of physician-led advocacy in 2019; the regulatory body also recommended the use of the humanities in medicine. OBJECTIVE: To use tools from the health humanities to impart disability competencies and help students appreciate the social and human rights issues associated with disability. METHODS: A module was developed and piloted in the foundation course on the new cohort of students. The tools included storytelling, visual art, poetry, narratives, and Forum Theatre; many facilitators were doctors and patients with disabilities. Learners were introduced to the concept of universal design through a field visit. Quantitative and open-ended feedback was taken from learners after module delivery; reflections were sought after four months. RESULTS: The data revealed that the humanities tools used in the module had the potential to help learners explore struggle and oppression and to expose discriminatory attitudes. Learners were able to think beyond the hegemony of normalcy, and show an understanding of diversity, dignity, autonomy, disableism, social inclusion, equity, and universal design. They admitted to the misconceptions they carried and showed keenness to advocate for change. CONCLUSION: This study piloted a novel disability competencies module using tools from the health humanities and found that learners were able to engage with and show an understanding of the social and human rights issues associated with disability. Conversations by, for, and with people with disabilities must be part of such interventions in developing and delivering disability courses.

Developing Humanistic Competencies Within the Competency-Based Curriculum.

We herein, describe the rationale, content, methodology and evaluation of a health humanities module in the new competency-based curriculum, and share our experience of the same. Providing training in health humanities to the healthcare trainees will definitely go a long way in having a professional and responsive Indian medical graduate, who is able to provide empathetic and holistic healthcare to all sections of the society.

Evaluation of a faculty development workshop aimed at development and implementation of a competency-based curriculum for medical undergraduates.

INTRODUCTION: Faculty development to implement competency-based medical education (CBME) is urgently needed as the Medical Council of India has implemented the competency-based curriculum this year onwards. OBJECTIVES: To evaluate a 2-day faculty development workshop in terms of: (a) increase in knowledge about CBME terminology and concepts, (b) self-reported capacity to develop and implement a competency-based module in their respective disciplines, and (c) satisfaction of the participants. METHODOLOGY: A single arm interventional study using mixed methods was carried out in which faculty members were purposively identified and requested to volunteer for a two-day faculty development workshop on the development and implementation of CBME. The workshop was evaluated (open-ended and Likert scored items) by the participants for self-reported gain in knowledge, gain in their confidence to develop and implement CBME, and level of satisfaction with respect to the components of the workshop. Quantitative data was analyzed by Wilcoxon signed rank test and Kruskal-Wallis test. Qualitative data was analyzed by doing content analysis and emerging themes have been presented. RESULTS: Eleven faculty members attended a capacity building workshop for developing and implementing a competency-based curriculum for medical undergraduates. There was a significant improvement in their self-reported knowledge and attitude regarding the competency-based curriculum. New concepts learned fell into four domains: modification of the existing curriculum toward competency-based curriculum, knowledge of CBME, teaching-learning and assessment methods, and beneficial to the students. The participants were highly satisfied with the workshop in its current form. CONCLUSION: A two-day faculty development workshop can increase the knowledge and understanding of competency-based medical education and can be an important first step in the journey to more specialized training.

Disability-inclusive compassionate care: Disability competencies for an Indian Medical Graduate.

The new curriculum of the Medical Council of India (MCI) lacks disability-related competencies. This further involves the risk of perpetuating the medicalization of diverse human experiences and many medical students may graduate with little to no exposure to the principles of disability-inclusive compassionate care. Taking into consideration the UN Convention, the Rights of Persons with Disabilities, Act 2016, and by involving the three key stakeholders - disability rights activists, doctors with disabilities, and health profession educators - in the focus group discussions, 52 disability competencies were framed under the five roles of an Indian Medical Graduate (IMG) as prescribed by the MCI. Based on feedback from other stakeholders all over India, the competencies were further refined into 27 disability competencies (clinician: 9; leader: 4; communicator: 5; lifelong learner: 5; and professional: 4) which the stakeholders felt should be demonstrated by health professionals while they care for patients with disabilities. The competencies are based on the human rights approach to disability and are also aligned with the competencies defined by accreditation boards in the US and in Canada. The paper describes the approach used in the framing of these competencies, and how parts of these were ultimately included in the new competency-based medical education curriculum in India.

Transformational learning for health professionals through a Theatre of the Oppressed workshop.

Theatre of the Oppressed (TO) is a powerful participatory tool for communities to examine their struggles against oppression. The healthcare community has problems inherent to complex, unequal power equations, and TO may be a useful means to understand and respond to their struggle. A 3-day workshop on TO was facilitated by the authors in the Himalayan Institute of Medical Sciences (HIMS) in Dehradun, India, in August 2017. The workshop culminated in the 'Forum Theatre', which included five short plays, each depicting a struggle due to real-life oppression faced by one or the other participant. The audience (about 200 invited members of the HIMS community) chose one play depending on the struggle with which they identified most. That play was 'forumed': spectators were invited to replace the struggling person and demonstrate how they would handle the oppression. Over the next week, participants reflected on the workshop through a structured online questionnaire. The feedback (n=16/27 participants; response rate 59.3%) was subjected to descriptive statistics and to qualitative analysis. The highest average Likert score (out of a maximum of 5) was given to the following items: TO engages senses and emotions (4.6±0.50), can help inculcate ethical behaviour (4.4±0.81), identifies conflict (4.4±0.51), and resolves issues of attitude, behaviour, communication, diversity and empathy (4.4±0.73). The Forum Theatre was reported to be a means to "express emotions and opinions and to simultaneously gather the same from others"; "make people push their own limits"; "bring out social problems in public"; "examine the root causes behind lived experience"; "provide context for understanding and for exploring alternatives"; and "convert thoughts to action." In conclusion, TO is an engaging activity that identifies conflict; participants' initial reactions suggest that it may initiate change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Current practice in handling and reporting needle biopsies: A hospital-based survey.

CONTEXT: Core-needle biopsy (CNB) is a minimally invasive screening and diagnostic tool which provides intact tissue fragments for histopathological examination. AIMS: This study was conducted to review the current practices of handling and reporting CNBs performed for core-needle biopsies from four organ systems which are frequently encountered in our institution. These include breast, prostate, soft tissues, and lymph nodes. SETTINGS AND DESIGN: This was a retrospective study conducted at a tertiary care hospital. MATERIALS AND METHODS: CNB reports of breast, prostate, soft tissue, and lymph nodes were accessed and categorized based on the site of biopsy, number, and average length of the cores. The CNB reports were categorized into diagnostic or nondiagnostic. In case of diagnosis of malignancy, reports were recorded as structured or nonstructured reports. STATISTICAL ANALYSIS USED: Fisher's exact test and Chi-square tests were applied to check the significance of the results obtained on comparing the number of cores and size of cores with the outcome of report. RESULTS: Out of 16,300 surgical pathology specimens received, 400 were CNBs comprising breast (n = 211), prostate (n = 108), soft tissue (n = 50), and lymph node (n = 31). Majority of the CNBs had 2-5 cores and the size of the core was ≥0.5 cm, which accounted for most of the reports which were diagnostic. There was a lack of clinical and radiological detail in many of the cases. Out of the malignant cases diagnosed, structured reports were given in 30% of breast, 79.3% of prostate, 41.7% soft tissue, and 60% of lymph node needle biopsies. CONCLUSIONS: The audit helped to identify areas of improvement in CNB services.

Reflective student narratives: honing professionalism and empathy.

The affective domain is not explicitly targeted during medical studies and poor skills in this domain may lead to conflict when dealing with patients. Reflective narratives are said to promote humanitarianism and professional development. We aimed to examine reflective narratives written by medical students in our institution for content relating to ethical and professional Attitude and Behaviour, Communication, respect for Diversity and Disability, and Empathy (the ABCDE paradigm). We were also interested in understanding how far the students enjoyed learning through the writing of narratives and in determining their perceived learning from the exercise. Volunteer medical students were introduced to Gibbs' reflective cycle during a half-day workshop. After giving written informed consent, they submitted anonymous reflective narratives (online), based on an interaction that they witnessed between a patient and a doctor/student. The authors performed directed content analysis of the submissions, using predetermined codes pertaining to ABCDE. At the end of the study, the participants sent in their feedback through a questionnaire on the process and the learning acquired, if any. Twenty-six students volunteered and 15 narratives were submitted. The issues that had been identified were discussed with the students. Feedback was submitted by 12 students, who strongly felt that the writing of narratives enhanced learning about ethics, professionalism, communication, diversity and empathy. We conclude that reflective student narratives are a useful and enjoyable way of teaching students about issues in the affective domain that are not conventionally taught.

Intestinal GIST masquerading as an ovarian mass: Diagnosed on FNAC.

The preoperative diagnosis of metastatic intestinal gastrointestinal stromal tumors (GIST) on cytology can be quite difficult at times. The present case characterizes the cytomorphological and immunocytochemical features of GIST, emphasizing the utility of fine-needle aspiration cytology (FNAC) in the evaluation of spindle cell tumors of gastrointestinal tract. An accurate and early diagnosis of GIST affects the treatment, primarily allowing the use of tyrosine kinase inhibitors in unresectable or metastatic cases. Presence of highly cellular fragments of spindle-to-oval cells with variable degree of pleomorphism, atypia, and necrosis supplemented by immunocytochemistry can render a cytological diagnosis of GIST in dilemmatic clinical situations. Our case highlights the diagnostic role of FNAC in the evaluation of a pelvic mass, which was clinicoradiologically misdiagnosed as ovarian carcinoma.

Fine needle aspiration biopsy: An entrustable professional activity in cytopathology postgraduate training.

CONTEXT: In the context of competency-based medical education being advocated worldwide, fine needle aspiration biopsy (FNAB) is considered as an entrustable professional activity (EPA). There is no information regarding how much time and training are required to achieve a "competent level" for performing and documenting FNAB in the Indian context. AIM: To determine the time taken by an average postgraduate pathology trainee to become competent in performing FNAB with respect to history taking, clinical examination, and fine needle aspirate adequacy. SETTINGS AND DESIGN: A descriptive, retrospective, chart-based audit was conducted in the Department of Pathology. MATERIALS AND METHODS: FNAB chart records documented during 3 years of postgraduate training by a cohort of 13 postgraduate (PG) resident trainees admitted in 2010 were included in the study. Adequacy rates and criteria for adequacy were defined for the purpose of the study. STATISTICAL ANALYSIS: Data was entered in MS Excel and analyzed using the Statistical Package for the Social Sciences version 20.0. The adequacy rates are presented as percentages and time taken to achieve adequacy rates as median values. RESULTS: A total of 3272 charts were audited. Median time taken to achieve 85% adequacy rate for history taking, for clinical examination by the first and the second criteria, and for FNAB were 1 month, 1 month and 3.5 months, and 1 month, respectively. CONCLUSIONS: Although the mean time taken to achieve 85% adequacy rates for FNAB was 1 month, there was wide variation in the time durations between the residents to achieve this level.

Multifocal Tuberculosis Verrucosa Cutis: A Manifestation Extraordinary of Reactivation Secondary Tuberculosis.

A BCG (Bacillus Calmette-Guérin)-vaccinated 78-year-old man, a native Indian, reported with numerous asymptomatic, peanut-sized, dirty gray, elevated eruptions of 1 year's duration appearing over apparently normal skin on the upper and lower extremities (Figure 1). The onset of the eruptions had been sudden, but they had progressed slowly. A history of cough and/or expectoration, evening rise of temperature, night sweats, or loss of appetite and weight was denied.

Harnessing the medical humanities for experiential learning.

A month-long workshop on medical humanities was held in the Jorhat Medical College, Assam in September 2015. It employed experiential learning (both online and onsite) using humanities tools, such as the theatre of the oppressed, art, literature, reflective narratives, movies, the history of medicine, graphic medicine, poetry and diversity studies. As a result of the interactions, 28 volunteer participants, comprising students and faculty members, wrote reflective narratives on doctor​-patient relationships, produced a newsletter and a logo for their medical humanities group, and staged cultural performances and forum theatre. The narratives, participants' reflections and feedback received were subjected to qualitative analysis; the workshop was evaluated using Kirkpatrick's model. The participants learned to examine their attitudes and behaviour, communicate with their bodies, and experience respect for diversity. There was an improvement in their understanding of empathy, ethics and professionalism. The workshop achieved level-3 (behaviour) on Kirkpatrick's model, suggesting that such workshops can initiate a change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Clinical audit of ultrasound guided fine needle aspiration in a general cytopathology service.

BACKGROUND: Studies on ultrasonography (USG) guided fine needle aspiration cytology (FNAC) have been conducted in specialized settings such as thyroid, breast, and intra-abdominal aspirates. There is a paucity of literature on the practices of guided FNAC in a general cytopathology service. AIM: The aim was to determine prevailing practices of USG guided FNAC in a general cytopathology service of a teaching hospital. SETTINGS AND DESIGN: Metropolitan hospital, clinical audit. MATERIALS AND METHODS: Audit of 112 USG guided percutaneous FNAC done over 12 months. STATISTICAL ANALYSIS: Data were coded, entered in an excel spreadsheet and analyzed by translating into percentages and proportions. RESULTS: The 112 guided FNACs included constituted 36 thyroid (32.14%), 45 intra-abdominal (40.17%), 11 breast (9.82%), 10 superficial lymph node (8.92%) and 10 soft tissue and miscellaneous (8.92%) lesions. Previous freehand FNAC was documented on the requisition forms in 14 cases. The reports were: Inadequate 33 (29.46%), nondiagnostic descriptive 35 (31.25%) or diagnostic 44 (39.28%). Inadequacy rates of aspirates from thyroid were 11 (30.56%) breast were 2 (18.18%), and intra-abdominal lesions were 13 (28.88%). Majority of the reports were nonstructured: 108 (96.42%) and nonrecommendatory: 101 (90.17%). CONCLUSIONS: Reporting practices varied and did not conform to a uniform structure. The inadequacy rates of breast and thyroid aspirates were comparable to the rates in the literature. Comparable studies were not available for intra-abdominal aspirates.

Is it Askin Tumour? A Question You Must Ask Even in Elderly.

Primitive neuroectodermal tumour of chest wall has been given the name Askin tumour after FB Askin who first reported this distinctive clinicopathologic entity in 1979. Most of the patients are either children or adolescents, however, rarely it may affect older patients. This case report emphasizes on the diagnostic approach to this rare tumour and underlines the importance of keeping it in the differential diagnosis even in elderly patients. Since it is an aggressive tumour, a high index of suspicion is required to make a timely diagnosis.

Clinical audit of repeat fine needle aspiration in a general cytopathology service.

BACKGROUND: The few studies on repeat aspiration focussed on accuracy of diagnosis following repeat. Numbers and documented reasons for repeat remain unaddressed. AIM: To study factors associated with requests for repeat fine needle aspiration cytology (FNAC). SETTINGS AND DESIGN: Metropolitan hospital, clinical audit. MATERIALS AND METHODS: Audit of 5104 FNAC in 10 months. STATISTICAL ANALYSIS USED: Univariate, and multivariate binary logistic regression. RESULTS: Seven hundred and six patients (13.8%) were advised repeat aspirates. Three hundred and twelve of these were actually repeated (44.1%). Carryover of actually repeated aspirates to subsequent months averaged 10.8 (34.2%). Maximum numbers of repeat requests were from thyroid 76/415 (18.3%), followed by lymph node 310/1856 (16.7%), and from breast 86/716 (12.0%). Outcome of actually repeated aspirates were: Diagnostic 181/312 (58.0%), and non-diagnostic 131/312 (41.9%). Reasons for repeat were inadequate aspirates 370/706 (52.4%), non-diagnostic descriptive reports 309/706 (43.7%); in 27/706 (3.8%), no reason was mentioned. CONCLUSIONS: Inadequate aspirates, non-diagnostic descriptive reports, and FNAC/FNAB from thyroid, lymph nodes, and breast contribute to repeats. We suggest steps to reduce the number of repeat aspirates to eliminate extra work.

Near-peer mentoring to complement faculty mentoring of first-year medical students in India.

PURPOSE: The first year is stressful for new medical students who have to cope with curricular challenges, relocation issues, and separation from family. Mentoring reduces stress and facilitates adaptation. A program for faculty mentoring of first-semester students was initiated by the Medical Education Unit in 2009 at University College of Medical Sciences, Delhi. Feedback after the first year revealed that mentees were reluctant to meet their mentors, some of whom were senior faculty. In the following year, student mentors (near-peers) were recruited to see if that would improve the rate and quality of contact between mentees and mentors. METHODS: Volunteer faculty (n=52), near-peers (n=57), and new entrants (n=148) admitted in 2010 participated in the ratio of 1:1:3. The program aims were explained through an open house meeting, for reinforcement, and another meeting was conducted 5 months later. At year-end, a feedback questionnaire was administered (response rate: faculty, 28 [54%]; mentees, 74 [50%]). RESULTS: Many respondent faculty (27, 96%) and mentees (65, 88%) believed that near-peer mentoring was useful. Compared to the preceding year, the proportion of meetings between faculty mentors and mentees increased from 4.0±5.2 to 7.4±8.8; mentees who reported benefit increased from 23/78 (33%) to 34/74 (46%). Benefits resulted from mentors' and near-peers' demonstration of concern/support/interaction/counseling (35, 47.3% mentees); 23 mentees (82%) wanted to become near-peers themselves. CONCLUSION: Near-peer mentoring supplements faculty mentoring of first-year medical students by increasing system effectiveness.

Implementation of the bethesda system for reporting thyroid cytopathology: interobserver concordance and reclassification of previously inconclusive aspirates.

Standardized diagnostic terminology was introduced by the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) in an effort to bring uniformity to the reporting of thyroid cytopathology, provide more defined categories to enable clinical management, and minimize the number of inconclusive cases. Previous studies indicate that the BSRTC is a reliable and valid reporting system for thyroid cytology. This study was conducted to compare the concordance between observers with varying cytopathology experience when using the BSRTC, and to assess the impact on the number of inconclusive reports. A retrospective study was conducted in two parts. In the first part 415 thyroid aspirates were reviewed independently by three observers with different experience levels. The aspirates were reclassified according to BSRTC and agreement scores were calculated using kappa statistics. In the second part 39 inconclusive aspirates signed out previously, were recategorized according to BSRTC. Agreement level between the three observers using the BSRTC was strong (Fleiss' kappa score = 0.6561). Inconclusive cases could be categorized further with BSRTC; there was significant reduction in the number of inconclusive diagnoses (P < 0.001). Strong interobserver agreement with BSRTC indicates the ease with which the new system can be applied in regular reporting. Significant reduction in the number of inconclusive diagnoses results in better communication with the clinician and improved risk assessment for thyroid aspirates.

Immunocytochemical detection of mycobacterial antigen in extrapulmonary tuberculosis.

The aim of the study is to determine whether immunostaining for mycobacterial antigen can contribute to the cytological diagnosis of extrapulmonary tuberculosis (EPTB). The study was carried out on aspirated material of lymph nodes, and other accessible sites, from 65 patients with clinical diagnosis of tuberculosis (TB). Twenty patients, diagnosed by fine-needle aspiration, with non-tuberculous granulomas served as controls. The diagnosis of TB was based on the demonstration of acid-fast bacilli (AFB), culture positivity for Mycobacterium tuberculosis (M. tuberculosis), or response to treatment with standard anti-tubercular therapy. Immunostaining was done using polyclonal antibody to mycobacteria. AFB positivity by Ziehl Neelsen (ZN) staining was 21%, 65.38%, and 68% respectively in Pattern 1 (granulomas alone), in Pattern 2 (granulomas with necrosis), and in Pattern 3 (necrosis alone). Overall AFB positivity was 56.92%. Twenty-eight of 65 cases were negative for AFB on direct smear. Culture was positive in 46% (13/28). Sensitivity and specificity of immunostaining were 96.92% (63/65) and 95%, respectively. Immunoreactivity was seen in 26 (92.8%) of 28 cases which were negative by ZN staining. Except in the case of leprosy, in which cross reactivity was seen, there was no immunoreactivity in the control group. Immunocytochemistry (ICC) had high sensitivity (96.2%) and specificity (95%) in the diagnosis of EPTB. ICC may be a useful adjunct to evaluation of cytomorphology and ZN staining.

Theatre of the Oppressed in medical humanities education: the road less travelled.

Internationally, there is an increasing awareness of the need to include humanities in the medical curriculum. The Medical Humanities Group at the University College of Medical Sciences, Delhi, organised a series of events to explore this area. This paper describes our experience with Augusto Boal's "Theatre of the Oppressed" (TO). Twenty-six participants attended a 2-day workshop culminating in a "forum theatre", in which the spectators are transformed from passive observers to active participants or spect-actors. The participants' responses to our workshop indicate that TO provides a multitude of experiences and addresses a wide range of learning domains. TO challenges the senses and offers a promising and enjoyable option for learning medical humanities.