Sunday, August 15, 2021

Page n: Competency driven assessment and testing of the student logbook author

Please be original and refrain from plagiarism. Please share the detailed online links to every quote or reference cited in your logbook. 

Please review the long and short case reports previously logged by our students and shared as samples here earlier. They are also available in the links below:



The above cases were also read out as a synchronous presentation along with answering of questions from online and offline examiners (as a part of a university summative assessment). The questions were directed to assess the presenter's competency in diagnosing and treating the above cases and is video linked there in the above two links for each of the hundreds of cases by hundreds of students. 

Weekly assignment:

1) Please go through the long and short cases, one at a time in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

Please provide your peer review assessment on not only the the student's written case report but also the reading of the cases followed by the question answer session linked above in the video and share your thoughts around each answer by the student along with your qualitative insights into what was good or bad about the answer. 


2: Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data):

Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. 

3)Testing competency in "Evidence based medicine": 
Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

4) Testing competency in patient data capture and representation through ethical case reporting/case presentation with informed consent :

Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case. 


Q 5) Testing scholarship competency in  
logging reflective observations on your concrete experiences of this last month :  

Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 

A few sample write ups on this last assignment around sharing your experience log of the month can be seen in one student's  answer to Q10 in the  May 2021 assignment in the link below:


And another student answer to Q5 in the June and July 2021 assignment in the links below :




Please reflect on and share  your telemedical learning experiences from the  hospital as well as community  patients over the last month particularly while you were E logging their case report while even in the hospital or perhaps when locked down at home.


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Medicine Log book (paper printed version) with sample cases and proper ethical logbook sharing protocol

1st page 


Dedication :

To our patients and students locally as well as globally 

2nd page :

2a)



Foreword:
Log Book is a tool toward daily student reflective logging of their learning experiences and sharing them with peer learners for further feedback driven learning. 

It was recognized by William Osler in his writings and to quote, 

"Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand . . . Begin early to make a three-fold category – clear cases, doubtful cases and
mistakes and learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the
other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases
grouped in this way that you can make any real progress in your postcollegiate education; only in this way you gain
wisdom with experience. (Ref below) 

More than 100 years later, the log book has been considerably tech enhanced in it's ability to derive global inputs in a weblogged format and the weblog has become so popular that it is now fondly known as "blog" for short. 

This book published by the institution and our department  is a guide toward making a good log book write up using selected guidance logs from our past illustrious students to enable newbies in their medicine  learning journey. We hope this will be useful. 

References:

Osler, W. (1904) Aequanimitas with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia, PA: The
Blakiston Company.

Osler, W. (1928) The Student Life and Other Essays. London: Constable
2b)

Student statement :

"This is a paper based  log book (with a corresponding E log version online) to discuss our patients de-identified health data, shared after taking his/her/guardian’s signed informed consent (check out the multilingual informed consent form template in the subsequent pages ahead). Here we discuss our individual patient’s problems through series of inputs from available local and global online community of learners and teachers with an aim to solve these patient’s clinical problems with collective current best evidence based inputs. This log book also reflects my patient-centered learning portfolio, also available as an online learning portfolio and your valuable peer review  inputs will enable me to learn further as to help our patients better. 


3rd page :

Global patient privacy and confidentiality policies 

Global policies are based on global data protection laws and common laws of confidentiality. Most of the write up here is quoted and borrowed from BMJ's stance published here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/patient-confidentiality

• Any report/article that contains personal medical information about an identifiable living individual requires the patient's explicit consent before it can be shared open access publicly. We will need the patient to sign a consent form, which requires the patient to have read the article. The consent form is available in multiple languages and the author must ensure that the form is in a language that the patient understands.

• If consent cannot be obtained because the patient cannot be traced, then publication/logging toward sharing will be possible only if the information can be sufficiently anonymised. Anonymisation means that neither the patient nor anyone else could identify the patient. A consequence of any anonymisation is likely to be the loss of information/evidence. If this happens we will include the following note at the end of the paper: "Detail has been removed from this case description/these case descriptions to ensure anonymity. The authors/loggers are satisfied that the information shared here backs up the case the authors are making." Such anonymisation might, at an extreme, involve making the authors of the article anonymous.

• If the patient is dead, global data protection laws may not apply, but the authors should seek permission from a relative (as a matter of courtesy and medical ethics). If the relatives are not contactable the author/logger needs to balance the worthwhileness of the case, the likelihood of identification, and the likelihood of causing offence if identified, in making a decision on whether we should publish without a relative’s consent. 

• Children- Parents or guardians can consent on their behalf but children aged between 7 and 18 must also sign the consent form in addition to the parent or guardian. For younger children, even if parents consent, authors should consider whether the child, when older, might regret publication of his or her identifiable details.

• Patients who lack capacity - If the patient lacks the mental capacity to make a decision about publication then usually no one can give consent on behalf of the patient. Even if someone has this power, by means, for example of a health and welfare power of attorney, it has to be exercised in the best interests of the patient

Page 4:

Log Book authors need to download the template for the signed informed consent form available in multiple languages here:

 http://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

Page 5:

Sample logbooks of other students with 

Long and short cases involving different anatomical locations and systems 

Page n

Competency driven assessment and testing of the student logbook author (linked below) :

https://medicinedepartment.blogspot.com/2021/08/page-n-competency-driven-assessment-and.html?m=1


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Saturday, August 14, 2021

Medicine paper for Aug 2021 bimonthly blended assessment

14/08/2021 9:00 PM


Answer all questions:                                                      

Max Marks: 100 (5 questions in total and 20 marks for each  answer) 

Submit by:   25/08/2021               

Please be original and refrain from plagiarism. Please note that every logged answer paper should contain the link to this current "assignment/question paper" page and the patient context for each answer. Also share the detailed online links to every quote or reference cited in your answer. 

Questions plan and context:

All questions are around patient centered case reports prepared by our students.

Please review the three recently made long and short case reports by one of our students in the link below :


The above was also read out as a synchronous presentation along with answering of questions from online and offline examiners. The questions were directed to assess the presenter's competency in diagnosing and treating the above cases and is video linked here below : 




Q1) (Testing peer review competency in the active reader of this assignment) :

Please go through the long and short cases in the first link shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

Please provide your peer review assessment on not only the the student's written case report but also the reading of the cases followed by the question answer session linked above in the video and share your thoughts around each answer by the student along with your qualitative insights into what was good or bad about the answer. 


Q2: Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data):

Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. 

Q3) Testing competency in "Evidence based medicine": Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

Q4) Testing competency in patient data capture and representation through ethical case reporting/case presentation with informed consent :

Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case. 


Q 5) Testing scholarship competency in  
logging reflective observations on your concrete experiences of this last month : (10 marks) 

Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 

A sample answer to this last assignment around sharing your experience log of the month can be seen in one student's  answer to Q10 in the  May 2021 assignment in the link below:


And another student answer to Q5 in the June and July 2021 assignment in the links below :




Please reflect on and share  your telemedical learning experiences from the  hospital as well as community  patients over the last month particularly while you were E logging their case report while even in the hospital or perhaps when locked down at home.

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Saturday, August 7, 2021

Workflow for the MD university final case based viva summative assessment

MCI guidelines for Clinical / Practical and Oral Viva examination quoted below verbatim from their website PDF document linked below:

"(i) Clinical examination for the subjects in Clinical Sciences shall be 
conducted to test the knowledge and competence of the candidates 
for undertaking independent work as a specialist/Teacher, for which 
candidates shall examine a minimum one long case and two short 
cases.

(iii) The Oral examination shall be thorough and shall aim at assessing 
the candidate knowledge and competence about the subject, 
investigative procedures, therapeutic technique and other aspects of 
the speciality, which form a part of the examination.
A candidate shall secure not less than 50% marks in each head of 
passing which shall include

(1) Theory, 

(2) Practical 
including clinical 
and viva voce examination."

MCI examination guidelines PDF linked below:


Now coming to the most important part of the actual workflow for the exam please take a look at the university supplied format here with marks distribution : http://medicinedepartment.blogspot.com/2020/06/lets-first-look-at-pre-covid-status-of.html?m=1 which was meant for a pre pandemic offline audience and even now in this pandemic with a predominant blended online and offline format of the examination, we shall still abide by letter and spirit of the exams as the university intended it earlier. In the above link if you notice in the first columns to the left there are 100 marks allotted for one long and 100 marks allotted for two short cases and 100 marks allotted for the viva with some brief  instructions subject to examiner interpretation. 

To achieve a collective consensus on the interpretation of the traditional university supplied format, we propose that :

1) The candidate begin with the long and short case presentations as currently accessible to them locally in the hospital or even from OPD or telephonic interview (follow up) and they make sure they share their case history (patient events in sequence) and clinical findings images as well as investigations as in the samples below :

Current case :


In traditional case presentations, the case discussion is generally expected to be prepared after a reviewing the literature around similar cases globally :




As well as locally :




If we again review the viva competency assessment 100 marks distribution in the link here: http://medicinedepartment.blogspot.com/2020/06/lets-first-look-at-pre-covid-status-of.html?m=1 we realize that most of them will be covered in the case presentation and the discussion will mostly be centred around the candidate's competency to resolve the diagnostic and therapeutic uncertainties in the case using evidence based literature review as well as prior general knowledge. 

A paragraph here about pedagogy is important as the traditional university document mentions it in the marks distribution : Pedagogy is a natural learning process that can be demonstrated through the candidate's discussion of the case that originates in the pedagogic questions raised. I quote from the article linked below. Pedagogic understanding derived from case based learning, "imparts relevance to medical and related curricula, is shown to tie theory to practice, and induce deeper learning." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736264/

More quoted from:  https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1969-0 around the case based pedagogic approach, "Case-based learning (CBL) is an inquiry-based pedagogical approach that prepares students for clinical practice through authentic cases to develop their clinical decision-making skills.
CBL can foster students’ learning in terms of knowledge acquisition and application, intrinsic motivation [8], patient assessment [11], problem-solving [12], and critical thinking [13, 14]. Moreover, pictorial information in the case materials induces intuition, and objective and quantitative information induces analysis [15]."

The other items in the viva such as thesis and logbook can be represented by the candidate again in an evidence based manner by sharing the links to her thesis such as here :




And log book such as here :








We shall need each candidate to prepare their separate deidentified roll numbered case presentation log, 

three year worklog (E log book mentioning their personal summary of their competencies attained) and thesis log for the examiners to go through. 

Each of these three separate logs will be deidentified and candidates identified only with their roll numbers. 

Informed consent has to be taken from each case being presented, which can be downloaded from here : 

Here is a detailed link :



to the last similar blended online examination conducted this year in the same manner for the PGs passing out this year and below is another link 


to the last similar blended online examination conducted for UGs this year in the same manner although for lesser marks  as it was for UGs but even they had to present one long and two short cases. The difference was that they were interviewed for shorter time as opposed to the PG interview where the mandatory time allotted for each of them is one hour. The difference in long and short cases again lies in the fact that they are time bound into long and short time frames where the entire sequence of patient events (history) is thoroughly discussed in the long case and a quicker decision around the diagnosis is achieved through certain findings alone. 

Hope this explains our current evidence based stance on the conduct of the assessments and further inputs in the form of queries are welcome in the comments section below. 

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Monday, August 2, 2021

Third semester students, hands on learning around critical appraisal of research and evidence based medicine

The following illustration is from our case based blended learning ecosystem, the online component of which happens in social media groups such as whatsapp. 


Here is a previous working prototype linked from our book chapter:  

The section below is a discussion in the group by one of the students with roll number 35 among the 150 in their batch online dashboard linked here : 

[7/29, 2:32 PM] Rishitha Kims 2019: 

_Comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients._


*Patient* - 1102 hospitalized patients older than 40 years. The primary outcome could be assessed in 866 patients.

Given 40 mg of enoxaparin, 20 mg of enoxaparin, or placebo subcutaneously once daily for 6 to 14 days. 

*Intervention* - 
~40 mg of enoxaparin : 291 / 866
~20 mg of enoxaparin : 287 / 866

*Comparator* - 
~placebo : 288 / 866

*Results* - 
1. The incidence of venous thromboembolism was significantly lower in the group that received _40 mg_ of _enoxaparin_ [16 of 291 patients]  than in the group that received _placebo_ [43 of 288 patients]

2. There was no significant difference in the incidence of venous thromboembolism between the group that received _20 mg_ of _enoxaparin_ (43 of 287 patients] and the placebo group 

3. The incidence of adverse effects did not differ significantly between the placebo group and either enoxaparin group.

4. By day 110,
-50 patients had died in the placebo group (13.9 percent)
-51 had died in the 20-mg group (14.7 percent)
-and 41 had died in the 40-mg group (11.4 percent); 
the differences were not significant.




[7/29, 3:27 PM] Rishitha Kims 2019: PICO-
"Patient, Intervention, Comparator, Outcomes and :

P stands for the number of patients in the human experiment that participated 

I stands for number of people in the intervention group. 

C stands for number of people in the "comparator" group ideally those who received placebo 

O stands for outcome in each group of people.


[7/29, 4:21 PM] Rakesh Biswas: Thanks Rishitha. 

Very well done 👏👏

So what are your learnings from this data?

Although this is not in patients of DVT but still it was a very useful study because critically ill patients (especially as the recent covid patients that we saw) may develop thrombus formation in small vessels as a part of the septic inflammatory response. 

Thanks for sharing this study in such a nice manner. Very useful. Do let me know your take home message and I shall let you know mine



[7/29, 4:48 PM] Rishitha Kims 2019: Thank you sir. 

So, 
We can hereby conclude that prophylactic treatment with 40 mg of enoxaparin subcutaneously per day safely, effectively reduces the risk of venous thromboembolism in patients with acute medical illness. 

Since the case study does not involve the condition of DVT, the subject needs to be studied further. 
Hence, the following link would provide the relatable content. 



[7/29, 4:59 PM] Rakesh Biswas: Alright now look at point 4

What happened after 110 days inspite of treatment or no treatment (placebo)?

Everyone of these groups an equal number of people died? So did the treatment really matter?



[7/29, 5:30 PM] Rishitha Kims 2019: Sir, when the test statistic is not big enough to reject the hypothesis of no treatment effect, investigators often report no statistically significant difference. 
The ability to detect a treatment effect with a given level of confidence depends on the size of the treatment effect, the variability within the population, and the *size of the samples* used in the study. Just as bigger samples make it more likely that you will be able to detect an effect, smaller sample sizes make it harder. 
The distinction between positively demonstrating that a treatment had no effect and failing to demonstrate that it did have an effect is subtle but very important, especially in the light of the small numbers of subjects included in most clinical studies.
I have compiled this information from :

A good maximum sample size is usually around 10% of the population, as long as this does not exceed 1000. 
So in our research, the sample size is around 30% which can yield appropriate results and marginally equal in all the treatments.


[7/29, 5:39 PM] Rakesh Biswas: Yes so assuming that the study you shared around anticoagulants in critical illness, had the right sample size, do you feel that it will be useful to anticoagulate all patients of critical illness in our ICUs as an equal number died in all groups regardless of their anticoagulation?


[7/29, 6:58 PM] Rishitha Kims 2019: No sir. Many factors are taken into consideration to assess whether the treatment is efficient or not. 
Sample size gets to be of major importance in clinical study.



[7/29, 7:01 PM] Rakesh Biswas: Try to talk about the critical illness anticoagulant study that you shared. 

What factors do you think suggests that anticoagulation could be useful in all critical illness patients ?
[7/29, 7:09 PM] Rakesh Biswas: Is there something wrong with the sample size of the study you shared in PICO format?



[7/29, 7:09 PM] Rishitha Kims 2019: No sir. The sample size is appropriate.



[7/29, 7:12 PM] Rishitha Kims 2019: Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation. 
But,
I think we cant only rely on sample size to assess whether the treatment would be effective without having appropriate information about relationship between the dose of anticoagulant therapy and the incidence of thrombotic complications.


[7/29, 7:16 PM] Rakesh Biswas: So is this conclusion for another issue? 

That of anticoagulants in critically ill Covid patients? Would you like to share any covid study with adequate and appropriate sample size where they have managed to scientifically prove that anticoagulation is effective in critically ill Covid patients? If you are not able to find one such well done study then can we conclude that scientific societies may not always base their guidleines on science but based on other factors such as market forces or convenience?


[7/29, 7:20 PM] Rishitha Kims 2019: Yes sir. I have taken criticall ill COVID patients into consideration. 
I could find a case study which says High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage.

This information has been taken from: 

538 patients included, 
104 patients experienced a total of 122 thrombotic complications. Pulmonary embolism accounted for 52% of the recorded TCs.


[7/29, 7:20 PM] Rakesh Biswas: In response to your last paragraph here, the study that you shared in PICO format above did have appropriate information that you yourself pasted about the dose of anticoagulants and incidence of thrombotic complications?


[7/29, 7:24 PM] Rishitha Kims 2019: Yes sir, the information i displayed about the dose and incidence is appropriate, as stated in the study.

[7/29, 7:44 PM] Rakesh Biswas: In that case if the study was appropriate what would be your take home message from the study? 
Should we anticoagulate all critically ill patients as it significantly reduces the incidence of pulmonary embolism over placebo or should we not anticoagulate because there is no significant difference in the mortality?

[7/29, 7:45 PM] Rakesh Biswas: Please share it in the PICO format that you shared for the non covid study

[7/29, 8:04 PM] Rishitha Kims 2019: Since the risk of thrombotic complications is high in critically ill patients, having Pulmonary embolism to contribute highest, we shall anticoagulate all critically ill patients over placebo irrespective of insignificant difference in the mortality in the above discussed case. 
But it has been that the dose of anticoagulant to be increased progressively based on thrombotic risk factors that include obesity, high oxygen demand, need for mechanical ventilation, and biomarkers of major inflammation or hypercoagulability, despite the lack of evidence supporting this strategy.
Because, despite the use of regular prophylactic anticoagulation, the proportion of hospitalized patients experiencing thrombotic complications ranges from 18% to 37%, say some studies as mentioned in this:

[7/29, 8:05 PM] Rishitha Kims 2019: Sorry sir, but i am unable to compile data to assess this case study in the PICO format.

[7/29, 8:18 PM] Rakesh Biswas: So then is the study worth it?

[7/29, 8:21 PM] Rakesh Biswas: Why do you think those critically ill people are having pulmonary embolism and dying eventually after 110 days regardless of placebo or anticoagulant used? 

Is it possible that it's not the coagulopathy which is killing them but the sepsis cascade which is also producing coagulopathy as a side effect?

[7/29, 9:59 PM] Rishitha Kims 2019: Severe corona virus maintains common features to sepsis.
Most critically ill patients admitted to ICU showed a dysregulated host response characterized by hyperinflammation, alterations in the coagulation, and dysregulation in the immune response that further contribute to MODS (Multi organ dysfunction failure), like occurs in sepsis. 

Due to virus infection and to MODS in some cases, many patient have meet the Third International Consensus Definitions for Sepsis. 
Some common characteristics with sepsis of respiratory origin, such as dense mucus secretions in airways, diffuse alveolar damage, increased pulmonary inflammation, and high levels of systemic proinflammatory cytokines and microthrombosis, probably as consequence of the increase in angiotensin II and angiotensin-converting enzyme 2 interaction and high levels of interleukin (IL)–6 and other proinflammatory cytokines contributing to *COAGULOPATHY.* 

So, thereby we can say that coagulopathy is a side effect for the sepsis cascade because of the viral infection. 
It is clear that hyperinflammation and coagulopathy contribute to disease severity and death in these patients.

[7/29, 10:02 PM] Rakesh Biswas: Good read. 

But the side effect of coagulopathy may not be responsible for the deaths, which are more likely due to the sepsis multi organ failure

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