Medicine CUBE -- Nail growth conversational learning in the CBBLE PaJR group

Medicine CUBE is a positive cross connection toward a broader collaboration. 

Glossary :

CUBE : Collaboratively Understanding Biology Education .More here : https://www.hbcse.tifr.res.in/research-development/collaboratively-understanding-biology-education-cube

Conversational learning : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117104/

CBBLE : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/

PaJR : https://userdrivenhealthcare.blogspot.com/2022/09/current-pajr-workflow-and-how-to-make.html?m=1

[9/18, 7:55 AM] MBBS 2019 Batch: Saw about Collasmart capsules adv. does it help for my knees?

[9/18, 7:56 AM] MBBS 2019 Batch: Question from patient

[9/18, 8:12 AM] Rakesh Biswas: Type collagen extract efficacy in osteoarthritis and share what you learn. 

However the more important question earlier asked (and still unanswered) here is : does she have arthritis at all? 

Does she have any feature of swelling, restriction of movement and deformity in any of the joints?

[9/18, 8:12 AM] MBBS 2019 Batch: No sir, she doesn't have any of those

[9/18, 8:12 AM] MBBS 2015 Batch: Doesn't she eat chicken?

[9/18, 8:13 AM] MBBS 2019 Batch: No sir, vegetarian

[9/18, 8:14 AM] Rakesh Biswas: Is the incidence of any disease higher in vegetarians (provided they don't indulge in hogging simple carbohydrates)?

[9/18, 8:15 AM] MBBS 2015 Batch: Not sure sir..

But if she's non vegetarian,there's no requirement to take anymore supplements,I feel

[9/18, 8:17 AM] Rakesh Biswas: Why put non vegetarians on a pedestal. I guess even vegetarians eating healthy also shouldn't need any supplements

[9/18, 8:18 AM] MBBS 2015 Batch: Yep agree

[9/18, 8:31 AM] MBBS 2015 Batch: @⁨MBBS 2019 Batch⁩ However if she feels she needs some collagen,try recommending her some good vegetarian sources of collagen.

Google and also share here what are good vegetarian sources of collagen

[9/18, 8:36 AM] MBBS 2019 Batch: In food, collagen is naturally found only in animal flesh like meat and fish that contain connective tissue. However, a variety of both animal and plant foods contain materials for collagen production in our own bodies.

https://www.hsph.harvard.edu/nutritionsource/collagen/

[9/18, 8:37 AM] MBBS 2019 Batch: This also says that all the collagen sources are animal based. Plant based sources only provide raw material for collagen synthesis and not collagen itself

[9/18, 8:38 AM] MBBS 2015 Batch: How are we sure that she isn't synthesizing enough collagen though?

[9/18, 8:57 AM] Rakesh Biswas: 👍Good research question

[9/18, 8:57 AM] MBBS 2019 Batch: Hair, skin and nails, sir?

[9/18, 8:58 AM] MBBS 2015 Batch: Share your findings after you examine hair,skin and nails.

And also,which type of collagen is present on hair,skin and nails.And which type is present in cartilage and bone.

(NEET PG que)

[9/18, 9:00 AM] MBBS 2019 Batch: Hair, skin, nails -type 1

Cartilage - type 2 (mixed with other types)

[9/18, 9:14 AM] Rakesh Biswas: @⁨MBBS 2019 Batch⁩ These are the learning conversations that need to be published and a correlation between the student's learning outcomes shown with the patient's health outcomes. That's the gist of the CBBLE PaJR project

[9/18, 9:14 AM] MBBS 2019 Batch: Ok sir

[9/18, 9:16 AM] Rakesh Biswas: Awaiting similar learning conversations in your neurodegenerative PaJR groups

[9/18, 9:17 AM] MBBS 2015 Batch: Which one is that group?

[9/18, 9:18 AM] Rakesh Biswas: Find out. You are there in those too

[9/18, 9:47 AM] MBBS 2019 Batch: Skin change again since 4 to 6 weeks

[9/18, 9:47 AM] MBBS 2019 Batch: Hair fall is normal and never checked nail brittleness

[9/18, 9:47 AM] MBBS 2019 Batch: But growth of nails has become slow

[9/18, 9:48 AM] Rakesh Biswas: How? What was the usual time she had earlier noted for her nail growth and what is the current time?

[9/18, 9:49 AM] MBBS 2019 Batch: Not sure of the correct time sir, but while regularly cutting nails, she noticed that they were not growing kuch

[9/18, 9:49 AM] MBBS 2019 Batch: *much

[9/18, 9:50 AM] MBBS 2015 Batch: Recall bias

[9/18, 9:51 AM] MBBS 2019 Batch: I didn't ask about nail growth sir, i asked about nail brittleness and she mentioned they growth

[9/18, 9:51 AM] Rakesh Biswas: So let's say earlier she needed to cut them in a week or 7 days and after how many days does she need to cut it now?

[9/18, 9:52 AM] Rakesh Biswas: She was more correct

[9/18, 9:52 AM] MBBS 2019 Batch: I'll ask sir

[9/18, 9:54 AM] MBBS 2019 Batch: 2 weeks or a little long

[9/18, 9:54 AM] Rakesh Biswas: And previously? 1 week?

[9/18, 9:55 AM] MBBS 2019 Batch: Yes sir

[9/18, 9:55 AM] Rakesh Biswas: Since when has she noticed this?

[9/18, 9:57 AM] MBBS 2019 Batch: Around 2 months

[9/18, 10:00 AM] MBBS 2015 Batch: 

@⁨Rakesh Biswas⁩ Is slow growing nails a serious sign?

We can do one thing to confirm if they are growing really slow.

@⁨MBBS 2019 Batch⁩ Can u ask your patient to trim nails today and share pics on day 7 and day 14 from now?

Let's compare it with our nails and also @⁨ might help us sharing picture of her patient's(another 47F) nails,today,at day 7 and at day 14

[9/18, 10:05 AM] Rakesh Biswas: Also review the literature to see if someone else has already done this experiment

[9/18, 10:05 AM] MBBS 2015 Batch: Sure sir

[9/18, 10:30 AM] MBBS 2019 Batch: Will do sir, but is it a serious concern? I think we're deviating from the question on whether she needs collagen supplements?

[9/18, 10:34 AM] MBBS 2015 Batch: She's doesn't need any collagen supplements because she doesn't have arthritis.

It is not a serious concern.However,we don't even know if her nails are really growing slow.If we confirm that her nails are growing too slow(as compared to others),we evaluate it further.

[9/18, 10:35 AM] MBBS 2015 Batch: Nail brittleness and slow growth of nails is commonly seen in water soluble vitamins,zinc deficiency.She is already on mvt supplements as you mentioned earlier.

[9/18, 10:37 AM] Rakesh Biswas: This factual statement needs to be supported by some literature

[9/18, 10:38 AM] Rakesh Biswas: We don't yet know if she has or doesn't have arthritis till we have the clinical examination findings and images

[9/18, 10:39 AM] Rakesh Biswas: Seriousness of concern is very subjective and is a variable of how the individual patient perceives seriousness and that is again perhaps dependent on his her worldview? @⁨Psychologist⁩

[9/18, 10:40 AM] Rakesh Biswas: We still need to evaluate her ourselves if there is no clinical video evidence

[9/18, 10:43 AM] Psychologist: Yes Sir, from her perspective it can be understood that she has been going through pretty tough period since march. She agrees to the fact that her physical symptoms have a direct correlation with her life situation

[9/18, 10:44 AM] Psychologist: It might be a definite possibility that as her life situation improves, her physical symptoms too would subside

[9/18, 3:17 PM] Rakesh Biswas: Check out the CUBE STEM discussion on nail growth here : https://metastudio.org/t/s4e78-cube-chatshaala-analysis-of-nail-data/11940 

Will also archive ours as "Medicine CUBE conversational learning session on "nail growth."

Two cases for the Monday clinico diagnostic meet

Presenter : Dr Sai Charan PGY2 Medicine 

Discussant : Dr Aditya Samitinjay SR Medicine 

Case 1:

OBG request referral : We have a long distance current inpatient, 33F with chronic pelvic pain since last three years. She had a tubal ligation five years ago. 

Would it be possible to review her for a diagnostic Laparoscopy for endometriosis or PID? 

More details of the patient in her deidentified case report here 👇

https://113riyagupta.blogspot.com/2022/09/case-of-29-years-old-female-with.html?m=1

Case 2:

Dermatology and Pathology  request referral :

We have a 51M inpatient of left foot drop due to left peroneal mononeuropathy and a perforating plantar ulcer who has been biopsied in the earlobes as well as planter skin. 

More details about the patient here :

https://113riyagupta.blogspot.com/2022/09/case-of-51-years-old-man-with-loss-of.html?m=1

Will be looking forward to the presentation also from the dermatologists and pathologists tomorrow. 

Image source : Laparoscopy Wikipedia 

Medicine department current stance on LORs

Introduction :

LORs are frequently necessary for residency applications globally and it's important for the LOR seeker and LOR giver to do justice to this process. 

The problem statement below in  

Conversational learning transcripts :

[6/3, 9:09 AM] LOR Seeker: Hi sir 

Good morning

[6/3, 9:10 AM] LOR Seeker: 

Hope you are doing good 

Myself ... 

I am from 2Kxy batch.

I did my internship under you.

I was with xyz mam, abc sir..PGs 

[6/3, 9:12 AM] LOR Seeker: I gave my step exams and currently working as a research fellow currently at ...US 

I need your support for the residency application. 

I am so sry I am very informal texting you.

I am currently in US,so couldn't meet you in person to request you an LOR.

[6/3, 9:13 AM] LOR Seeker: Could you please send me your email address so that I can send my eras portal request to upload an LOR.

Thank you.

Hope you consider my request. 

Sincerely, 

[6/3, 9:14 AM] Medicine Department: 

Can you share some links to your work to let me assess you for the LOR?

[6/3, 9:17 AM] LOR Seeker: Sir,I will send few cases which I worked on and presented.

The mortality and morbidity meets which I attended.

Amma Nana ashram visits.

But in that year,we didn't create an online portal for our patients which was started 2 years later...

[6/3, 9:19 AM] Medicine Department : Currently we are providing LORs only to our students who are working with us in our current projects here 👇

http://medicinedepartment.blogspot.com/2022/06/linking-students-to-our-departmental.html?m=0

[6/3, 9:27 AM] LOR Seeker: Ok sir 

Thank you ...

I will try uploading my cases if I can.

[6/3, 9:31 AM] Medicine Department : 

No we may have a better project role for you. 

Can you share the deficiencies in the current case reports posted by the current batches listed here 👇

https://medicinedepartment.blogspot.com/2022/02/?m=0

We can add you to our current 2017 case discussion group for the same

[6/3, 9:33 AM] LOR Seeker: Yes sir

Sure will do

[6/3, 9:42 AM] LOR Seeker: It was so good and helpful.

I could have asked you and joined the group long back..

I have my deadline to upload my LOR in 10 days.

Still,I will do my best and be in touch base with my juniors and provide my input.

[6/3, 9:43 AM] Medicine Department : Better get that LOR from the college Principal office as per protocol

[9/3, 9:45 AM] LOR Seeker: Most of the program's are asking from the chair of Internal Medicine sir.

I have submitted my MSPE from principal sir.

I worked under you during my internship.So,thought I would take from you

[6/3, 9:47 AM] Medicine Department : 

Should have thought about it earlier. We don't do 10 days.  10 months is the least we can do although most of our LOR students are 5 years

[6/3, 9:49 AM] LOR Seeker: Yes sir .I even regret that.

I didn't knew that,my friends last year have taken like that.

So I am not sure of the process.

I am really sorry for that.

Thank you for adding me to the group.

[6/3, 9:51 AM] Medicine Department : 

Many of your friends didn't get our LOR as they couldn't live up to these requirements we set for them

Previous stance on LORs from Medicine department :

http://medicinedepartment.blogspot.com/2021/07/evidence-based-letter-of-recommendation.html?m=1

Probable solution 

In conversational learning transcripts :

[6/5, 8:11 AM] LOR Seeker: Sir 

U will definitely remember me.

We saw bud-charie syndrome(icu 1st bed)young female 

PSVT

Acute necrotising fascitis

In mortality meet we presented Pulmonary embolism and hypokalemia cases 

Old male with back pain-later turned out to be spinal Mets (we referred him to cancer centre)

Dengue 

Sydenham chorea 

Malaria

HIV-i have been to lab to check stool for cyclospora,isospora,.(ART was given)

Stroke cases.

Hyponatremia.

I even worked for ashram cases.

[6/5, 8:15 AM] Medicine department : Alright write up all your experiences with our unit in your blog and that will be good evidence for us to provide the LOR.

[6/5, 8:32 AM] Medicine department

: In your write talk more in detail about the patients you saw and the problems they had and the way our unit tackled their problems

[6/5, 8:35 AM] LOR Seeker: Ok sir 

Sure will do that 👍

Thank you so much.

[6/12, 7:03 AM] LOR Seeker: Sir ,this was my experience with the patients.

I wrote it .

[6/12, 7:05 AM] LOR Seeker: Should I post it like a blog how my juniors are doing the case presentations?

[6/12, 7:07 AM] Medicine department

: Yes. That would be considered an open access publication submitted for post publication peer review 👍

[6/12, 7:56 AM] Medicine department

: Also we would need yours and everyone of the past and current batch students permission for this "LOR driven reflective learning" project and will be subjecting your current reflective-narrative publication to a global post publication peer review (as in with the other 1000 students in our dashboard) in which case would you like to remove the identifiers in your write up and also realistically point out the shortcomings in your internship instead of just painting a pretty picture as you have done currently as that would immediately be labeled skewed if not totally unrealistic

[6/12, 8:06 AM] Medicine department

: Let me share another interns write up to give you a better idea

[6/12, 8:09 AM] Medicine department

: Yours is a generalized incident narrative while this one here https://chandanavishwanatham19.blogspot.com/2022/05/a-day-in-life-of-medicine-pg.html?m=1 is a particular incident narrative by one of our current interns/residents (I guess you know that in US their interns are PGY1s)

[6/12, 10:11 AM] LOR Seeker: http://yyyy1234567.blogspot.com/2022/09/transitioning-from-text-book-approach_11.html

[6/12, 10:13 AM] LOR Seeker: I have changed the URL also sir

[6/12, 9:04 PM] Rakesh Biswas: Thanks. I shall get this peer reviewed and let's see if we can have a suitable LOR for you, going by your self testimony in this blogged write up.