Saturday, October 28, 2023

Ongoing project: Plant and animal models of distributed meta cognition and parallels with distributed medical meta cognitive systems such as UDHC

"What we understand by mind, or cognition, is the result of a very complex interaction between the elements that constitute the living body, where these continuously adjust their relations through time and in an ongoing exchange with the environment (Bateson 1972; Maturana and Varela 1980)."


Plant models :

"Plants also sense and perceive fluctuations in their environments, registering several kinds of environmental cues and multiple interactions among these simultaneously (Trevawas 200320042005; Karban 2015). These are not merely phenomena of sensation and perception, of signaling and communication, but that they could constitute part of extended plant cognition (EPC)."


TIFR CUBE conversational learning transcripts :

[10/27, 10:40 PM] Rakesh Biswas: Can we use this 👇


as a model system for plant meta cognition

[10/28, 4:38 AM] Nagarjun Thota: Mirabilis Jalapa expressing Codominance or incomplete dominance.. differing from mendel’s theory.. does environment affect expression of genes!!? I was very fond of this plant in younger ages.. especially due to its grenade shaped seeds😁.. one observation made was it’s seeds get thinner as days go on.. my opinion this plant can be a potential subject for plant cognition and gene expression studies.. any cubist interested to pitch in..collaborate for gene expression studies??

[10/28, 4:41 AM] Nagarjun Thota: Long back picture took on 28.04.2019 at chattisgarh by Dr Nagarjun.. currently I’m not holding any seeds of it.. need to search like we did for Cardamine

[10/28, 4:45 AM] Nagarjun Thota: Also did you remember we discussing about red and non red varieties among various plants.. anyone up to collaborate.. can observe for uniparental inheritance and environmental effects..


[10/28, 4:47 AM] Nagarjun Thota: Further can explore on non-nuclear gene expressions..

[10/28, 7:11 AM] Himanshu Joshi Cube Nimhans: Good to know about the expression of co dominance or incomplete dominance ( I guess the colour of flowers), which makes this plant an exception to mendel theory.. 
Why does this happen? Does    mirabilis Jalapa inheritance through non nuclear genes? 
If yes then *Inheritence without nuclear genes* sounds interesting! 
But how exactly does it happen in this plant. 
How can you introduce *plant cognition* in this regard? 
@⁨Nagarjun Thota⁩

[10/28, 8:07 AM] Prof Farhan : This plant is common in Mumbai, in fact even I used to cross pollinate manually and then collect their seeds to study expression of flower colour. It's amazing to work with this plant. Flowers come in different colors.

[10/28, 8:43 AM] Prof Arunan TIFR CUBE : Let's *get hold of seeds of this plant* and simultaneously understand *what you mean by Plant Cognition*.😇 @⁨Nagarjun Thota⁩

[10/28, 4:43 PM] Urmi : This is amazing. This whitefly, a herbivorous insect acquires a plant gene by HGT to neutralise plant’s defence to itself. 

[10/28, 6:59 PM] Rakesh Biswas: Earlier discussion around this in this group last year archived here👇


The metapsych meta cognition connection between plant and animal intelligence?

Animal model :

Snail :

[10/26, 10:13 PM] CUBE chatshala : Today we are discussed the feeding behavior of a snail.  

Previous discussions archived here :




[10/27, 7:56 AM] Rakesh Biswas: This will become an animal model for our ongoing medical metapsych metacognition project. 

Original article here👇


Human :

Other than routine medical cognition tools of  system 1 eyeballing pattern recognition, we use routine tools of system 2 asynchronous intelligence aka primordial AI aka academic learning to solve real patient problems.

Developing the Medical metacognition problem statement at the beginning of the introduction to all our ongoing projects is because, it's at the core of all our projects using both system 1 and 2 cognitive processing:

System 2 thinking began as an asynchronous academic tool to make communication and thinking slower to suit our individual workflows. 

However this essence of academics also makes our three dimensional existential reality two dimensional as that helps to somehow better analyze our three dimensional existence manifest in daily random events and even manipulate the randomness toward apparently improved outcome events.

Of all the routine system 2 tools, we have been largely enamoured by a few that we have written about  in the past and  continue to use them daily in our community patient follow up and family adoption through online PaJR groups which are the online components of our case based blended learning ecosystem CBBLE and the two have evolved from what has been often described in the past as "user driven healthcare" which has it's own big fat text book here :  https://www.amazon.in/User-Driven-Healthcare-Narrative-Medicine-Collaborative/dp/1609600975
as well as had a journal with the same name since 2011 here: https://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022

More about our tryst with "using medical cognition tools to optimize clinical complexity" in this 2023 guest lecture at AIIMS, Bhopal archived here: https://medicinedepartment.blogspot.com/2023/10/medicine-department-presentations-2023.html?m=1

Ethical clearance obtained for this major project stem here : http://medicinedepartment.blogspot.com/2023/04/?m=0

Clinical professional development CPD organized on the theme of optimizing clinical complexity is 

Completed and published medical cognition projects :

Clinical complexity and PaJR tools 2023:  https://pubmed.ncbi.nlm.nih.gov/37335625/


Five ongoing old projects on the above theme :

1) Creating dynamic user driven ontologies : http://userdrivenhealthcare.blogspot.com/2022/?m=0





5) Collective, user driven conversational contextual peer review of real time open access research submissions and creation of dynamic user driven learning community ontologies UDLCO 



Current journal UDLCO :

Dr Tella Shruthi :



Ongoing projects previously shared in  2021 in the dsir template on request :


We can broadly divide our "medical cognition" into the right and left path. 

The right path projects are reasonably understandable from a modern perspective, while the left path projects are slightly post modern and may not be included in the offical departmental lists although they will still be linked appropriately in case someone visiting this site is curious. 




Healthy Harvard plate in Telugu

 

The copyright belongs to Harvard institution and this translation has been done by our patient advocates purely to help spread the message available in their publicly available (but not globally translated) webpage here :  https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/



Telegu :

మన శరీర బరువు పెరగకుండా మరియు మన పొట్ట పొడవు 80 సెం.మీ కంటే తక్కువగా ఉండేలా మన ఆహారం ఉండాలి. ఏమి తినకూడదు? చక్కెర మరియు పిండితో కూడిన ఆహారం పూర్తిగా నిలిపివేయబడింది. బిస్కెట్లు మరియు బ్రెడ్ పిండితో తయారు చేస్తారు, కాబట్టి బిస్కెట్లు మరియు బ్రెడ్ తినడం మానేయండి. నెలకు 500 గ్రాముల కంటే ఎక్కువ నూనె వినియోగించరాదు. ఏమి తినాలి ఫుడ్ ప్లేట్‌లో 40% వివిధ ఆకుపచ్చ కూరగాయలు మరియు 10% వివిధ రంగుల పండ్లు. మిగిలిన సగంలో బియ్యం, గోధుమలు మొదలైన తెల్లటి గింజలు మరియు దుంపలు (బంగాళదుంపలు) ఉంటాయి.

Mana śarīra baruvu peragakuṇḍā mariyu mana poṭṭa poḍavu 80 seṁ.Mī kaṇṭē takkuvagā uṇḍēlā mana āhāraṁ uṇḍāli. Ēmi tinakūḍadu? Cakkera mariyu piṇḍitō kūḍina āhāraṁ pūrtigā nilipivēyabaḍindi. Biskeṭlu mariyu breḍ piṇḍitō tayāru cēstāru, kābaṭṭi biskeṭlu mariyu breḍ tinaḍaṁ mānēyaṇḍi. Nelaku 500 grāmula kaṇṭē ekkuva nūne viniyōgin̄carādu. Ēmi tināli phuḍ plēṭ‌lō 40% vividha ākupacca kūragāyalu mariyu 10% vividha raṅgula paṇḍlu. Migilina saganlō biyyaṁ, gōdhumalu modalaina tellaṭi gin̄jalu mariyu dumpalu (baṅgāḷadumpalu) uṇṭāyi.







Faculty reverie on learning ecosystem optimization

We consultants, PGs, interns, UGs are all part of a system that needs optimization. 



Looking back to when I was a PG (we didn't have UGs or interns in that program), I realize the only way I learned Medicine was to make a log of what were the patient events on meticulous history and my examination findings. 



Computers or internet were a rarity and most of our learning happened on the patient's file  (analogous to our current PaJR groups) where as PGs our job was to meticulously record everything on the file and I remember getting feedback from my seniors during my causalty postings through my file notes. 


We had continuous casualty and EMD ward postings for a month, where we did all procedures that are done here in ICU and there was no separate department of EMD. 


I still remember feeling nice when seniors appreciated my line drawings of the clinical images that I sketched in my file case reports before I transferred my patients from the casualty and I have forgotten the toxicity that I faced from them although there is a theory that perhaps that toxicity that I encountered myself as a trainee doctor may have gone a long way to subconsciously shape my own current toxicity! 


What I witness now in the PGs is that the task that we thought most important for our post graduate intellectual development, that of learning asynchronously through the paper based ecosystem by working hard to log our own inputs in the paper based files has been relegated to the UGs and interns by the current PGs who are not even realizing what a vital component of their training they are missing! 



As a result we are forced to treat the interns as our PGs because the PGs cannot possibly present anything useful in the rounds if they haven't made any effort to develop their knowledge of patient's particular requirements! 


Off course even if we are forced to treat the UGs and interns that way they are allowed by the curriculum to spend too less time to learn and contribute anything substantial. 


A simple overhaul of medical training into the previous apprenticeship pattern that is currently threatened by a decadent, static, theory driven curriculum all over India can go a long way to solve the problem



Monday, October 2, 2023

Medicine department workflow with evidence based links driven by NMC and NAAC requirement prompts

Medicine department workflow:



Departmental Motto: Transparency and accountability through data capture and  sharing for real time peer review and audit as regular departmental workflow toward furthering the cause of true evidence based medicine at the same time preserving patient confidentiality in social media.

Sharing below under the NMC and NAAC prompts, some cherry picked evidence  from our departmental dashboard that archives links to thousands of student online learning portfolios containing even more number of archived hospital and community case report links here: http://medicinedepartment.blogspot.com/2022/02/?m=0 as well as other archival site links such as here : https://youtube.com/playlist?list=PLvYjjuT_hEEQDtlHSAvFdRpCb5EBszwgR&feature=shared (minus the shorts that couldn't be playlisted) 

The rest of the volume in the above open access and other  encrypted archives are under further thematic data analytic processing as part of our ongoing projects.

We shall be discussing our workflow using the main prompts listed below primarily from the NMC guideline linked above along with secondary mention of the same from NAAC terminology prompts :


1) Departmental Physical infrastructure

2) Departmental Faculty (and learning participants) for actual teaching and research who also undertake necessary student learning activities on a regular and continued basis

3) Departmental Clinical material : Availability of adequate clinical material in terms of number of patients of different specialties

4)Departmental teaching methodology adopted 

5) Departmental Methods and modes of assessment, grading of the students

6) Departmental review of feedback from students

7) Departmental other parameters related to standards of medical education that may be added from time to time by the respective boards






1) Departmental Physical infrastructure (NMC prompt) 

Departmental Infrastructure 
and Learning
Resources (NAAC prompt):
4.1 Physical Facilities (NAAC sub prompt) 



A) Patient housing :

General and Special wards 


(video also presented during an AIIMS Bhuvaneshwar guest lecture by one of our faculty...check link to departmental presentations below )


(Ward rounds)

ICU 





Step down wards 




B) Instrument housing :

Large lab based Patient investigation tools housed in central labs 

Often shared in the case report links archived inside our student online portfolio dashboard here:  http://medicinedepartment.blogspot.com/2022/02/?m=0 


Departmental radiology diagnostic equipment housed in ward:

Faculty demonstrating ultrasound guided procedures during to medical students here: https://youtu.be/KTTsp6kIkes?feature=shared

Ventilators, Dialysis machines and other smaller pumps in ICU 

https://youtu.be/5IdV6Q8ZfVA?feature=shared (in the background to the ultrasound machine which is housed in ICU) 

Departmental ultrasound usage (diagnostic non procedural) by faculty and students in action : 



2) Departmental Faculty (and learning participants) for actual teaching and research who also undertake necessary student learning activities on a regular and continued basis (NMC prompt): 

(NAAC sub prompt) 2.4 Teacher Profile and 
Quality


Faculty: 

Evidence of faculty teaching and research activities linked here in their online learning portfolio summaries available open access :

Online portfolio of our PG turned faculty:



Video online learning portfolios:





Other departmental senior faculty sample portfolios that are publicly accessible :


PGs : Yearwise online learning portfolios of all PGs accessible here: http://medicinedepartment.blogspot.com/2022/02/?m=0 

PG 

UGs:  Yearwise online learning portfolios of all UGs accessible here: http://medicinedepartment.blogspot.com/2022/02/?m=0 


Evidence of PG learning sessions linked here: 


Evidence of UG learning sessions linked here: 



3) Departmental Clinical material : Availability of adequate clinical material in terms of number of patients of different specialties:

Evidence of 1000s of Clinical material created in UG PG learning portfolios in the  departmental dashboard accessible here: http://medicinedepartment.blogspot.com/2022/02/?m=0 that also depicts the...


Variety of patients to fulfil all round training of students:


Variety of procedures:


Laboratory investigations:


Radiological investigations: 


Other relevant investigations:


Electrophysiology :


Our clinical material and clinical learning ecosystem is also captured and synthesized overall in this specially made clinical video case report here :  
showcasing one of our clinical cases that received an honorarium from an US institute https://tu.edu/programs/medical-health-sciences/faculty/ facilitated by our collaborator there, Prof Chitra Pai. This other than our summary video of our entire clinical workflow here 
https://youtu.be/xvE5b8Xk3vM?feature=shared , shared previously in AIIMS Bhuvaneshwar. 




4) Departmental teaching methodology adopted (and it's assessment, NMC prompt):

1. Curricular
Aspects
1.1 *(U)Curriculum Design and
Development (NAAC prompt)
1.2 Academic Flexibility (NAAC prompt) 
1.3 Curriculum Enrichment (NAAC ")
2. Teaching-
Learning and 
Evaluation (NAAC prompt) 
2.3 Teaching-Learning
Process (NAAC ")

Our teaching methodology leverages currently available blended learning modalities to create a case based blended learning ecosystem CBBLE first published here : https://pubmed.ncbi.nlm.nih.gov/29996517/



Blended learning components:

9:00 AM to 11:00AM Offline inpatient experiential data capture and synchronous face to face discussion  and follow up 

Illustrative videos: 



11:00 AM to 1:00 PM Offline outpatient experiential data capture and synchronous face to face discussion in the demo room 


And subsequent community follow up and family adoption through online PaJR groups which are the online components of our blended learning ecosystem often described in the past as "user driven healthcare" which has it's own big fat text book here :  https://www.amazon.in/User-Driven-Healthcare-Narrative-Medicine-Collaborative/dp/1609600975
as well as had a journal with the same name since 2011 here: https://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022

PaJR publications and ongoing OPD projects to create persistent clinical encounters :



2:00 PM to 4:00 PM offline (and 
beyond that blended 24x7 online) 


Journal clubs: 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. 

Online asynchronous : http://medicinedepartment.blogspot.com/2021/08/third-semester-students-hands-on.html?m=0

Offline synchronous : 

https://youtu.be/LXy4FM6NBXA?feature=shared

Seminars: 

Dr Aditya Covid :

https://youtu.be/unW70mGlh1Y?feature=shared

Prof Meltzer Behchets disease : 

https://youtu.be/IX3Mz2Y1teE?feature=shared

Prof Sturmberg :

https://youtu.be/2lBlfz9dNvc?feature=shared

Flipped classroom discussions: 

https://youtu.be/VjF9eGfOaSk?feature=shared

Case discussions: 

https://youtu.be/QhjiomY-S74?feature=shared

Dr Manasa :

https://youtu.be/3VVH7w3rWSM?feature=shared

Group discussions: 

Dr Aditya : 


Dr Nikita:


Didactic clinical methods:


Respiratory movement (and cognitive clinical bias) :


Reflexes:


Joint position sense :


UG Peer to peer learning:


 https://youtu.be/XrY8f8m_3oQ?feature=shared (Respiratory Examination)


Thesis review :

Dr Rashmita : 

Procedural competences:

UG ascitic tap :

Anahita 3rd semester (under PG Dr Sai Charan's supervision)  : https://youtu.be/8WsoVLLHKWY?feature=shared

Hyndavi 9th semester (under PG Dr K Vaishnavi's supervision) 


PG various procedures :

IJV, LP, Pericardiocentesis, Renal biopsy 




5) Departmental Methods and modes of assessment, grading of the students (NMC prompt):
2.5 Evaluation Process and
Reforms
2.6 Student Performance and
Learning Outcomes (NAAC prompt) 

Medicine department 360 degree formative and summative assessment and grading at end of UG/PG other than the traditional university driven summative assessment approaches  : http://medicinedepartment.blogspot.com/2023/09/submitted-internship-competence.html?m=1

This month's single observer and patient driven  blended learning Mini-Clinical Evaluation Exercise (mini-cex) sample:


Quantitative evaluation : 65/100
No extension (pass) 

Qualitative evaluation  : Takes initiative, trainable, Hardworking, sincere

Can focus on asking more questions and sharing and communicating more 


Quantitative evaluation : 50/100
No extension (pass) 

Qualitative evaluation  : Trainable

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 




Quantitative evaluation : 40/100
Extension 20 days 

Qualitative evaluation  : Needs more extension to see if she's trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

4) went on USMLE leave midway 


Extension : 30 days 

5) Did not report at all 

Extension  60 days 

More of this month's single observer mini-CEX linked here: 
Comprehensive assessment in terms of Bloom's taxonomy and the specified rubric questions around the student's written sample from his/her online learning portfolio here: 


**1. Bloom's Taxonomy driven Evaluation:**

- **Level 1 Knowledge (Remembering):** The intern successfully gathers basic patient information such as history, presenting complaints, personal and family history, and examination findings. This demonstrates knowledge application at the remembering level.

- **Level 2 Comprehension (Understanding):** The intern understands the patient's condition by correlating the symptoms, physical findings, and laboratory results. This level of comprehension is evident in the diagnosis section.

- **Level 3 Application (Applying):** The intern applies medical knowledge by ordering relevant investigations like serology, RBS, B.urea, S.Cr, and ECG, and interprets these results to make a diagnosis. They also prescribe medications and treatment, which reflects the application of medical interventions.

- ** Level 4 Analysis (Analyzing):** The report lacks in-depth analysis of the patient's condition. While a diagnosis is provided, there is limited discussion of the underlying pathophysiology or potential differential diagnoses. An in-depth analysis would involve considering various possibilities and critically evaluating them.

**Level 5 Evaluation (Evaluating):** The report does not include an evaluation of the effectiveness of the treatment plan, the potential complications, or the overall management strategy. This is an important aspect that could improve the report's quality.

- **Level 6 Synthesis (Creating):** The intern does not demonstrate synthesis in the report. They do not connect the patient's condition to broader medical concepts or research. Synthesis would involve exploring how this case fits into the larger context of COPD, acute cor pulmonale, and other related conditions.

**2. Rubric Evaluation:**

Rubric formulated here : 

- **General Knowledge Learning Points:** The report provides basic information about the patient's condition, such as symptoms, examination findings, and lab results. However, it lacks insights into the broader implications or epidemiology of COPD or acute cor pulmonale. It also doesn't reference external sources or guidelines for further context.

- **Discovery-Driven Learning Questions:** The report mentions the patient's history and symptoms but does not delve into specific questions related to the internal or external medicine aspects of the case. It could benefit from exploring questions like the cause of the acute exacerbation, the role of smoking cessation, or the relationship between COPD and heart failure.

- **Clinical Complexity:** The report briefly touches on the patient's clinical complexity, mentioning comorbidities like diabetes and hypertension. However, a deeper analysis of the biological, psychological, and social aspects of the patient's condition is lacking.

- **Thematic Analysis:** The report does not conduct a thematic analysis of the patient's case or identify overarching themes that could provide insights or guidance for future management.

- **Impact on Patient Outcomes:** The report does not discuss the potential positive or negative impacts of the diagnosis and treatment on the patient's short-term and long-term outcomes.

- **Competence of the Intern:**
  - (i) **Competence in Data Capture:** The intern successfully captures the patient's data, including history, examination findings, and lab results.
  - (ii) **Competence in Asking Questions:** The report lacks in-depth questioning and exploration of the case. It does not effectively sort themes for thematic analysis.
  - (iii) **Competence in Finding Answers:** The intern makes a diagnosis and prescribes treatment but does not engage in in-depth analysis or exploration of new knowledge.
  - (iv) **Competence in Communication:** The report could improve in communicating the case's learning points effectively, particularly in relation to how the findings could influence patient outcomes and future research.

In summary, while the medical report demonstrates competence at the knowledge and comprehension levels of Bloom's taxonomy, it falls short in terms of analysis, synthesis, and evaluation. Additionally, it lacks depth in addressing the rubric's questions related to clinical complexity, thematic analysis, and the impact on patient outcomes. Enhancing critical thinking and providing more comprehensive insights would improve the report's quality." 


More log book assessment and student work audit prompts practiced in the department here : http://medicinedepartment.blogspot.com/2021/09/log-book-audit-as-medical-student.html?m=0

PGs weekly log assessment :


6) Departmental review of feedback from students (NMC prompt) :
2.7 Student satisfaction Survey (NAAC prompt) 


Analysis of anonymized student feedback regarding Medicine department

Summary : This is a single observer review and analysis of student feedback regarding teaching delivery and formative assessment of medicine department received from a batch of students finishing their degree and on their way to finish the final hurdle of the university. The validity of this anonymized feedback appeared high as students had fearlessly opened their heart outs and well addressed our negatives as we had ensured that we were properly blinded to their identity.

The entire feedback in images of their hand written notes can be accessed here: https://medicinedepartment.blogspot.com/2023/10/analysis-of-anonymized-student-feedback.html?m=1
The feedback has been analyzed and problem statements identified as well as solutions planned. 

7) Departmental other parameters related to standards of medical education that may be added from time to time by the respective boards ( NMC prompt):

3. Research, 
Innovations
and Extension
3.1 Promotion of Research and 
Facilities
3.2 Resource Mobilization for 
Research
3.3 Innovation Ecosystem 30 10 NA 10
3.4 Research Publications (NAAC prompt) 

Departmental Publications :

2023 (KNRUHS format) 


Older 2021-17 (NAAC dsir format) 


Departmental Presentations:

2023-22:


Older 2021-17




Ongoing thesis projects:


Ongoing projects: 

https://medicinedepartment.blogspot.com/2023/10/ongoing-medical-cognition-projects-in.html?m=1

Ethical clearances :


Outreach : 

PaJR family adoption pan India :



SO  WHAT?? 


S

trengths 

Cherry picked and shared above 

W


eaknesses

Hint: A system is only as competent and efficient as it's individual components and participants 

On a scale of 1-10 rating would be...


O

pportunities

NAAC prompts: 3.5 Consultancy 
3.6 Extension Activities
3.7 Collaboration 
7. Institutional 
Values and 
Best Practices and 
Social Responsibilities
7.3 Institutional Distinctiveness 

T

hreats