Integrating Medical education and practice: Online real patient data stimulating active learning in medical students

General  Medicine online classes for Final MBBS part – II students are being  conducted through two formats.

One is a passive learning format where PPTs or lecture videos done by our faculty are shared through a schoology portal and then MCQs are provided with auto correct generation of content recall testing.

The other format is an attempt at active learning with students on social media, centered around their Elog books (Online learning portfolio) where students are provided a clinical problem to solve and then encouraged to raise questions around the case and search and discuss the answers with Faculty and other senior students.

This week we have begun our online learning session

with the UGs around

the topic of

"Patient data analysis"

with a

Target competency:

to develop an ability/competency to read and comprehend a patient's history, examination findings, investigations and analyze it in a manner to understand the patient's requirements around his/her diagnosis and treatment.

Methodology:

The students competency will be assessed by their ability to form a problem list in order of the patient's priority for which they need to get in touch with the original creator of the online patient's record and then from each problem in the list they would need to analyze the cause of the problem and come to a diagnosis and therapeutic plan for the patient that will be vetted as useful by the entire general medicine online learning ecosystem that includes, interns, Pgs, faculty locally as well as globally including the online patient himself/herself.

Below is the link to all 200 online learning logs made by the current 8th semester students:

https://detailedclinicalanalysis.blogspot.com/2020/05/online-learning-individual-patient-data.html

And here are some special sample logs from a few students who were the early birds in this online active learning session where majority of their cognitive  activity is in pm conversation with the session moderator and is reflected in the comments section of their log book.

https://decodemed.blogspot.com/2020/05/unraveling-skein.html?showComment=1589730592398&m=1#c8217929345349410897

https://shivani2401elogbookmedicine.blogspot.com/2020/05/my-medical-elog-book-may-15-2020.html?m=1

Student log book with the anonymized online patient's comments

https://anushachowdaryshivakoti150.blogspot.com/2020/05/analysis-of-case-of-42yr-old-female.html?m=1

Student log book with queries raised by the student stimulating an active learning conversation with the moderator https://muskaanmenghwani.blogspot.com/2020/05/42-year-old-female-with-multiple-health.html?m=1

This is a student log where an active learning cross consultation was obtained from another department and added to the student's log book comment box that reflects his her active conversational learning

https://rhea9895.blogspot.com/2020/05/case-of-42-year-old-female-with.html?m=1

All the interns and PGs in the department of Medicine have been informed about this exercise and the student E logs have been made available for them to participate in this active online learning activity that will be hopefully reflected in the comments section of the student's E logs following which the students shall receive formative assessment score based on a percentile once we check out the student log with the maximum number of learning points that can serve as the current highest comparator.

Maybe chat bots will soon take over the active learning and assessment part of the overall workflow?

A medicine PG resident's Web log book

Hello all. I am a resident in Medicine and my daily schedule for the week is detailed here: https://docs.google.com/document/d/1lCU31w0ir_MBsJpLTFdyD9Dt1elAq9nDuwu0hfbcZ6k/edit?usp=drivesdk&ouid=106211649452385508461

This E log book is a mandatory requirement to assess our daily attendance in terms of our mental presence and our daily learning achievements in the medicine department where every PG Resident  here shall by 8:00 PM (unless it's an admission day) provide a brief log of what they have done cognitively as well as hands on for that day from 9:00 AM to 6:00 PM.

I have been told that the daily log can be done here under the following headings 

1) Case based learning 

a) Inpatient

b) Outpatient 

c) ICU 

2) Thesis 

a) That day's thesis case data 

b) Questions around cases or even study design etc 

3) Theory knowledge acquisition for end term summative assessment:

Paper I: Basic Medical Sciences 

Paper II: Medicine and allied specialties including pediatrics, dermatology &

 psychiatry

Paper III: Tropical Medicine and Infectious Diseases

Paper IV: Recent Advances in Medicine

4) Procedures done with video evidence (with patient deidentied)

The E log book or web log book is a formative assessment tool aka internal assessment in India and in India the internal assessment as well as performance in the final exams depends on the HOD's regular formative assessment of the candidate's daily performance that builds up over the three years and this internal assessment is never expressed in the form of any number but in the form of a very very vital role the HOD plays in the candidate's learning journey and it's completion at the end of three years. 

For those not logging their daily learning activities here, the impression conveyed would be that they are not having any daily learning activity worth sharing.

So here goes my log of daily activities starting from:

Monday:

Went early for the morning rounds and found that my junior intern had still not arrived and that really made me mad as it meant that now I would have to collect all the patient reports by myself. 😡

My senior PG admitted this young boy with a chronic gluteal abscess yesterday who had developed both lower limb weakness since five days.

Case report:

23M with complaints of weakness of bilateral lower limbs since 5 days along 

with tingling and numbness 

h/o vomitings 5days back 

3-4 episodes non projectile non bilious food particles in content.

when he got up for urination,suddenly he had a fall and got up with the help of father.

gluteal abscess since 5months (operated 5 months back) 

scrotal abscess since 20 days(incision and drainage 10 days back)

PAST HISTORY 

no similar complaints in past 

auto driver

not past history of HTN/DM/ASTHMA

General examination: 

Gluteal region as in the image below:

Pallor absent

Icterus absent

No cyanosis clubbing 

lymphademopathy, Edema

Afebrile

Bp 120/80 mm hg

Pr 80 bpm

spo2 98%

Cvs s1 s2 hear no murmurs

Rs bilateral air entry + normal vesicular breath sounds heard

P/a soft, non tender

Cns 

conscious

speech-normal

cranial nerves intact.

MOTOR SYSTEM 

                         Right.         Left

Bulk:               normal.      Normal

Tone: ul.        normal.       Normal

           LL.       hypotonia    hypotonia

Power          rt.          lt

         ul.        5/5.      5/5

         LL.       2/5.      0/5

Reflexes.  

   Superficial reflexes

                       Right.           Left

Corneal.        P                   P

Conjunctival P.                  P

Abdominal.   P.                  P

Plantar          Extensor   Extensor

    Deep tendon reflexes 

                     Right.             Left

Biceps.        2+                  1+

Triceps.       2+                   1+

Supinator.    3+                   2+

Knee             3+                  2+

Ankle.           3+                  2+

jaw jerk.        1+.                1+

ankle clonus present.     absent

Primitive reflex -absent

Involuntary movements - absent 

SENSORY SYSTEM - normal

CEREBELLUM

titubation - absent

Nystagmus- absent

Intensional tremors - absent

Pendular knee jerk - absent 

Coordination test -normal

MENINGIAL SIGNS

Neck stiffness - negative

Kernigns sign - negative

Brudzinkis sign - negative

INVESTIGATIONS

HBS AG: negative

ANTIHCV ANTIBODIES: nonreactive

HIV : non reactive

HEMOGRAM : 

HB        15.5gm/dl

Platelets 2.23 lakhs/cumm

TLC         9600cells/cumm

Lymphocytes 15%         

LFT

TO.BIL.       0.82mg/dl

DI.BIL.          0.21gm/dl

SGOT.            80IU/LIT

SGPT.             10IU/LIT

ALK.PH.            192IU/LIT

TO.PRO.                7.5gm/dl

ALB.                        4gm/dl

A/G RATIO.           1.19

RFT

UREA.                  16mg/dl

CREATININE.      0.6mg/dl

URIC ACID           3.7mg/dl

CALCIUM.            9.4mg/dl

PHOS.                  4.6mg/dl

SODIUM.              136meq/lit

K+.                         3.9meq/lit

CL-.                       102 meq/lit

ESR 45 mm/1st hr

RBS 99 mg/dl


Cranial mri images:

TREATMENT :

INJ.ZOFER 4mg IV.SOS

INJ.PANTOP 40mg IV OD 

BP ,PULSE MONITORING

INJ.AUGMENTIN 1.2g IV BD

OINT.MEGAHEAL FOR LOCAL APPLICATION

SITZ BATH WITH BETADINE TID

FREQUENT CHANGE OF POSITION

I saw the above treatment penned by my senior in upper case and wondered out aloud as to why every patient who gets admitted is prescribed mandatory pantoprazole and this one had vomiting 5 days back!! This comment was frowned upon needless to say. 

        

   In the afternoon my senior presented this patient and we had an extensive discussion as to the etiology that you can see in the recorded video here 

https://youtu.be/ClopCj2KwZc

  

Procedure:

My senior PG medicine asked me to take this patient with severe anemia (web logged by our medical student here:https://classworkdecjan.blogspot.com/2016/12/60f-with-coma-e-coli-sepsis-and-upper.html?m=1) to the pathology department for a bone marrow aspiration and biopsy. Here is a video of that biopsy procedure: https://youtu.be/MeozrO1Nkyk

Theory preparation:

In the afternoon session the same day we also had a few topic discussions that I reviewed again for my theory preparation. Check out the videos here https://m.youtube.com/watch?v=yhXqgGpfIEo&list=PLvOgc9_v4PCKsIrVK4laA3_rUJOMPAYKJ

One such topic (check out the specific video here:https://www.youtube.com/watch?v=YzVI1XZ3nAI&feature=youtu.be)

was about pheochromocytoma where I learned about why in preoperative management of pheochromocytomas, alpha blockers are given prior to beta blockers.

"At low concentrations, adrenaline acts on beta2 receptors causing vasodilatation.

At higher concentration it acts on alpha 1 receptors causing vasoconstriction.

If beta blockers are given first, they act upon beta2 receptors, thus blocking them and an unapposed alpha adrenergic activity can be seen which results in HYPERTENSIVE CRISIS and cardiovascular collapse sir.

To prevent this non selective alpha blockers are given first to reduce the hypertension.

Non selective alpha blockers cause reflex tachycardia. In order to further reduce the blood pressure and to reduce the risk of tachyarrhythmias, beta blockers are added further."

Also, Labetalol(alpha plus beta blocker) has a 1:7 alpha-beta blocking activity and when it is given to a patient with pheochromocytoma, due to more beta blocking action it results in hypertensive crisis again.

So labetalol is also not given.

I read more about it here https://academic.oup.com/jcem/article/92/11/4069/2597882

Thesis project:

At the end of the day one of my batchmates from another unit mentioned that one patient has arrived at the causalty who looks like my thesis case and I am currently working on a thesis on "Etiology ,Management and outcome in patients with hyponatremia" and I have been separately logging all my thesis cases here http://allabouthyponatremia.blogspot.com/?m=1

Here is the detailed MCI guideline based rationale for our daily roster 

https://medicinedepartment.blogspot.com/2020/05/a-daily-pragmatic-learning-roster-as.html?m=1

A medicine intern's Web log book

Hello all. I am an intern in Medicine and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties from my cases, the procedures that I do as well as the theory questions and discussion that I engage in. 

My daily schedule for the week is detailed  here  https://docs.google.com/document/d/1lCU31w0ir_MBsJpLTFdyD9Dt1elAq9nDuwu0hfbcZ6k/edit?usp=drivesdk&ouid=106211649452385508461

Our professor tells me that I need to log and record everything that I do and learn in the ward under three headings 

1) Cases seen that day 

2) Procedures seen or done that day 

3) Theory topics learned that day 

So here goes starting from:

Monday: 

Got a bit late for the morning rounds and my senior PG was not happy about that as she had to collect some reports on my behalf. 

Just saw this patient admitted yesterday 

Case report:

A 35yr old  woman had presented with complaints of vomitings, 3 episodes 6 days back followed by altered sensorium 

no h/o trauma 

no involuntary movements 

no h/o deviation of mouth 

no h/o fever,cough,chest pain,tremors,orthopnea,pnd

no h/o use of anticoagulants,oral contraceptive pills 

past history:

h/o intermittent headache.

known case of tb 4yrs back ,took ATT for 6 months.

no h/o HTN,DM,CVA,CAD,SIZURES.

surgical history negative.

On general examination I found:

Pallor present 

Icterus negative

No cyanosis clubbing lymphademopathy,Edema.

Mild dehydration and malnutrition present .

Bp 100/60 mmhg

Pr 110 bpm

spo2 96%

temp 102F

RR 20cpm

Grbs 119 gm/dl

Cvs s1 s2 hears no murmurs

Rs bae + nvbs hears

P/a soft ,nontender,bowels sound heard,

On CNS  examination in her HMF higher mental functions she appeared  unconscious and 

        stuporous

speech- no response

MMSE- not elicited

cranial nerves-1st not elicited

2nd not elicited

                                             rt         lf

3rd,4th,6th

                     pupil size.      N         N

                     DLR/CLR.       N.        N

NO pstosis, nystagmus.

5th sensory not elicited

motor not elicited

reflex corneal normal,conjuctival normal

7th motor nasolabial fold normal

no deviation of mouth

sensory not elicited

reflex corenal and conjuctival normal

secretomotor moistness of eye and tongue normal,buccal mucosa normal

8 the nerve:Rinnes and Weber's  not elicited

9and 10 th nerve: uvula centrally placed,gag reflex present 

11 th nerve: trapezieus not elicited, sternocleidomastoid not elicited

12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue

MOTOR SYSTEM 

                         Right.         Left

Bulk:               normal.      Normal

Tone: ul.        decre.   Normal

           LL.       Decre.        Normal

Power      Ul     0/5.             3/5

                 LL.    0/5.            2/5

Reflexes.  

   Superficial reflexes

                       Right.           Left

Corneal.        P                   P

Conjunctival P.                  P

Abdominal.   P.                  P

Plantar           increase.     Withdrawal

    Deep tendon reflexes 

                     Right.             Left

Biceps.          ++                     ++

Triceps.       N.                    -

Supinator.       -.                    -

Knee           -                 -

Ankle.          -                    -

Primitive reflex -absent

Involuntary movements - absent ( chorea,ballismus - negative) but left lower limb continuous / intermittent movements positive

 

SENSORY SYSTEM 

not elicited

Pain present in all four limbs

CEREBELLUM

titubation - absent

Nystagmus- absent

Intensional tremors - absent

Pendular knee jerk - absent 

Coordination test not done

MENINGIAL SIGNS

Neck stiffness - positive

Kernigns sign - negative

Brudzinkis sign - negative

See here for a video of the clinical examination findings. 

INVESTIGATIONS

HBS AG: negative

ANTIHCV ANTIBODIES: nonreactive

HIV : non reactive

HEMOGRAM : 

                28/4      29/4.       1/5.         3/5

HB            5.4         6.3.         7.1.          9.4

Platelets  1.94.   0.31.       1.11.        1.5

TLC                                                    12000

PT.                                         20.            16

INR.                                       1.7.           1.1

APTT.                                                      34

TO.BIL.                 1.03.                        1.48

DI.BIL.                   0.27.                       0.33

SGOT.                    17.                           20

SGPT.                    8.8.                           12

ALK.PH.                68.                            64

TO.PRO.                 7.                              7.1

ALB.                                                        4.1

A/G RATIO.                                         1.37

RFT

UREA.                  17.                           52

CREATININE.       0.89.                      0.8

URIC ACID                                          2.6

CALCIUM.                                          10.5

PHOS.                                                  4.2

SODIUM.                                            146

K+.                                                        3.6

CL-.                                                      100

2 packs of RDP and 1pack of PRBC transfused on 30/4/20

Her cranial MRI images are here below and we had a lot of confusion around it and will appreciate your inputs in the comment box:

I checked the TREATMENT chart and found that my senior had written:

1)Head end elevation

4)INJ.NEOMOL 1 g IV.( if temp is more than 102F)

5)TAB.PCM 650 mg RT TID

6) INJ.ZOFER 4mg IV.SOS

7)TAB.VITAMIN C 500 mg RT OD

8) TAB. B COMPLEX RT OD 

9) TAB.ATORVASTATIN 40 mg RT 

11) SYP.LACTULOSE 10 ml RT TID

12) NEB WITH MUCOMIST 6 TH         HOURLY followed by oral suctioning.

13) PROPPED UP POSITION

14) RT FEEDS 2ND HOURLY MILK 30ml 

                         1 HOURLY WATER 150ml

15)I/O CHARTING

16)GRBS CHARTING 6TH HOURLY

17)BP ,PULSE ,SPO2 ,RRMONITORING

18) AIR BED

19)DVT STOCKING

20)FREQUENT CHANGE OF POSITION 2NDHOURLY

21) TEMPERATURE CHARTING 6th hourly.

I asked her why were we giving her vitamin C and b complex following which she became angry so I thought maybe it wasn't required and she was angry with my finding fault with her inspite of having come late myself. I also wondered if the air bed and stockings were necessary. Again I wondered what could be the reason for her fever and why weren't we treating it with antibacterials to which she replied why was I thinking of bacteria and I asked if she had noted her WBC counts. They were 21,000 to which she said I was supposed to get the reports on time.  

Procedure:

My senior PG medicine thought she had a right  pleural effusion on examining her clinically and asked me to get an ultrasound guided pleural tap so that we could rule out a parapneumonic effusion as a possible reason for her fever. 

I took her to my radiology senior and she reported it was very mild and she wasn't sure if we could get any significant fluid there although she would try. I watched as she cleaned the posterior intercostal spaces and percussed in the most dull space and then put her USG probe in the tenth space which she thought was dull and showed me a thin rim of anechoic area around the lungs suggestive of pleural fluid.  However once she inserted a sterile syringe needle she couldn't pull out any fluid and we had to abandon the procedure. (click here for the video) 

In the afternoon from 2-4 we presented this case to the entire department. See video here. https://youtu.be/fx4Kygh6Nqc

We had a fruitful discussion on the case where the diagnosis of pure hematoma to explain the intracranial space occupying lesion in her left basal ganglia area was contested and alternate differentials were discussed. 

In the same session we also had a few topic discussions that I reviewed again for my NEET MCQs. Check out the video here https://m.youtube.com/watch?v=yhXqgGpfIEo&list=PLvOgc9_v4PCKsIrVK4laA3_rUJOMPAYKJ

One such topic (check out the specific video here:https://youtu.be/2wBfscoXjGg)

was about multiple myeloma where I learned about why the alkaline phosphatase would be normal in multiple myeloma (inspite of having osteolytic lesions and bone pain and I quote from the article linked below:

"In Multiple myeloma, the myeloma cells activate the osteoclastic activity and suppress the osteoblastic activity through molecular pathways.

Osteoblastic activity is seen by increased alkaline phosphatase and osteocalcin levels.

Osteoclastic activity is seen by increase in collagen degradation product levels.

Since the osteoblastic activity is suppressed by myeloma cells due to a mechanism which is not yet clearly known, serum ALP levels are either normal or decreased."

https://www.sciencedirect.com/science/article/pii/S2212137413000201

The above article was actually shared by a final year PG which I have put as my own E log

  

Here is the detailed MCI guideline based rationale for our daily roster 

https://medicinedepartment.blogspot.com/2020/05/a-daily-pragmatic-learning-roster-as.html?m=1

Web log driven online learning portfolios for Daily Formative assessments

To take you to the point where you may be able to appreciate how and why web log books can be used as a valuable learning tool that can positively impact patient outcomes in this hospital I shall try to begin this journey from our current existing paper based log books. Shared below are some images of its key pages each of which I shall discuss separately again below regarding their importance and how web-logbooks can improve on them.

Figure 1

Figure 1 shows the first important page that you see in your log book and it appears to be all about yourself as a PG. What would you like to write about yourself has been suggested although I am not sure if that actually tells us a lot about what you have already attained in your previous years of graduation in terms of your learning. It just tells us that you have cleared some memory based exams to reach your current position.

Figure 2

Figure 2 shows the next page in your log book which is about evaluation of your clinical work day wise. Now considering that you will be working everyday as a PG 365 days a year, I guess the number of pages are grossly inadequate? 🤔😬


Now there are three more type of slots in your log book meant to assess the kind of presentations you have made in terms of 'Journal review,' seminar and case presentation.

So now that you know the university log book requirements well, we just need to come to the most important part of our session and that is how would expanding this paper based log book workflow into a web based log book (and online learning portfolio) be useful for you or the institution.

Here's an online log book from a PG in RIMs Ranchi, India where you can notice the first page of the bio data although not the other pages like day to day work or case presentations or seminars or journal reviews although you can see a lot of his seminar based publications in the past done in his UG and early PG years


Online learning portfolio on research gate 

Here's an online log book (web based portfolio) from a PG in AIIMS Delhi and again you will notice that it contains much less than what is recommended in the paper based format.


Online learning portfolio in LinkedIn 



Here's another more dynamic and impactful online learning portfolio from another PG in AIIMS Delhi


Online learning portfolio in quora

Here you will notice that he has included a case presentation and even a useful seminar answer to someone's query (which shows that his seminar can actually have a wider impact among global users and readers of his portfolio.

He has off course included a lot of other content, which shall we just say is not a part of his syllabus and that brings us to the important point that Online portfolio based learning is not just bound by the narrow confines of a university syllabus which is again one of the reasons some universities who are way behind in creating academic impact will have little to do with it.

As PGs when we chose our profession we had a dream of making an impact and reaching out to a wider audience. This impact can only happen if all of us who are part of the medical college hospital based learning ecosystem strive to improve together. In the beginning straddling two different tools could appear daunting rather than a value addition but we must realize that this is not to burden ourselves additionally but to actually lessen our burden. Any day and in any way if you feel burdensome you can feel free to make an anonymous post and share and we shall try to address that issue without being judgemental. The online learning portfolio ecosystem affords us the luxury of both anonymity as well as transparency.

Here's an online portfolio from one PG from our institution who has made it an anonymous portfolio and we are perfectly fine with that as every individual has a right to express him/herself in his/her own manner.

https://virtualmedicocases.blogspot.com/?m=1


The most important thing that differentiates a portfolio from a paper based log book is that the portfolio brings out the personality of the individual and the point here is that one can guage and admire an author's personality just through his/her reflective writings even if one is unable to identify the author.

Another learning portfolio from our PG with case presentations and her thesis plan. This portfolio is not anonymous although there is no bio page yet.

http://keerthiereddy.blogspot.com/?m=1


Another learning portfolio from our PG which is all about her thesis and details about her thesis cases. This can be very useful to obtain learning inputs on your thesis on a case by case basis.

http://allabouthyponatremia.blogspot.com/?m=1

Here are Web logs of different procedural videos from our institution demonstrating the procedural competencies of the individuals who are performing them.

Bone marrow aspiration biopsy procedural competency video

https://youtu.be/MeozrO1Nkyk

Renal biopsy procedural competency video

https://youtu.be/PIwK30lbYi0

re: Final university MD Medicine summative assessment conduct as per available guidelines from different national and state bodies

What/Current status 

The final university MD Medicine summative assessments are the usual exit point and opportunity for residents to ascend to a higher hierarchy in the healthcare ecosystem with many becoming practicing consultants and many going ahead for further fellowships in organ based specialties. 

Why/Problem Statement 

In an ideal learning ecosystem driven by daily formative assessments, the students would never need a summative assessment that is often performed over few hours in a select day at the end of three years to test an individual's competencies gained over the last three years, which really sounds very imperfect when one thinks about it but then this is the real world where in most medical colleges globally, formative assessments are far from perfect and students are either too overworked to reflect and log their daily workflow with learning reflections, conceptualizations and experimentations in their prescribed web log books and maintain a steadily growing online learning portfolio or their teachers are too overworked to review those. For more around the methodology of web log books driving regular acquisition of formative learning competencies that goes into an individual's online learning portfolio please click here 

https://medicinedepartment.blogspot.com/2020/05/web-log-driven-online-learning.html?m=1

How/Proposed exam design 
(as per current Council guidelines) 

Current local university guidelines 

I found this from the NTRUHS website which was our recent previous university:

http://ntruhs.ap.nic.in/examinationss/index.html

"Note

1. For conduct of exams in PG Degree/Diploma courses rules are followed as per Medical Council of India, New Delhi and the recommendations of Board of Studies/E.C Resolutions of Dr. NTR UHS, Vijayawada/Hon’ble Court Orders from time to time."

And nothing yet mentioned in knruhs website which is our current university http://knruhs.telangana.gov.in/syllabus

So we deemed it best to follow the MCI examination guidlines, which is a central governing councils for medical college education in India. 

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.

(ii) Practical examination for the subjects in Basic Medical Sciences 

shall be conducted to test the knowledge and competence of the 

candidates for making valid and relevant observations based on the 

experimental/Laboratory studies and his ability to perform such 

studies as are relevant to his subject.

(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:

https://www.google.co.in/url?sa=t&source=web&rct=j&url=https://www.mciindia.org/documents/rulesAndRegulations/Postgraduate-Medical-Education-Regulations-2000.pdf&ved=2ahUKEwjL3Jzv-ajpAhV1zTgGHb8iDwUQFjABegQIBRAH&usg=AOvVaw0mx0p_znvnAI1cGeGY5wmU

Finally we come to how exactly we wish to conduct the examination here locally so that 

1) There is minimal intrusion in the local patient centered workflow thus not harming patients 

2) There is maximal utilization of this additional learning in the regular workflow thus actually benefiting patients. 

We shall address points 1 and 2 above as we discuss the actual conduct of the exam in an hourly timeline below:

A)  Clinical examination competency testing of the students. 

1 Long case and two short cases 

(100 + 50x2=200 marks)

General Medicine requires skills and competency to capture clinical data from a given patient in the form of the patient's past and present life events in the form of a history timeline followed by further data collection from the body in the form of general survey points as well as different organ system review in the form of local examination in the patient's body and this is followed by gathering all the data into a pattern that suggests the reason for the patient's symptoms and signs in terms of a physically localizable pathology as well as etiology, which is further followed by formulating a therapeutic plan based on the diagnostic model created from the patient data acquired by the student. 

The competency to do this well in both OPD (outpatient department) and IPD (inpatient department) encounters with a patient is what will be tested by a team of internal and external examiners for each candidate. 

To do this we shall provide each candidate with two short cases from the OPD of 50 points each and one long case from IPD each of 100 points (they are named short or long cases as the time needed is different to achieve closure in either type of case) and the examiners will have the choice of examining the candidates right there in the OPD or IPD or take all of them to a central location in a separate spacious demo room where the candidate can be allowed to also share the clinical data captured over a PPT projection for the convenience of focusing on the candidate's presentations with minimum hassles. 

While the above may test the candidate's cognitive competencies, to test their procedural competencies, one can in some patients get the candidates to perform certain procedures that will be anyway necessary in those patients that day or evaluate their prior recorded videos clearly showing their skills in one procedure either diagnostic such as ascitic or pleural taps as well as lumbar puncture or even drawing of ABGs and therapeutic such as intubation or central line insertions. 

Other than this a video of the entire examination interview of the candidates discussing their cases during their clinical competency evaluation as well videos of their ability to discuss a topic during the viva examination will be recorded for audit purposes to improve upon the current conduct of the examination. 

For a link to recent internal formative assessment videos depicting a similar clinical case and viva evaluation please click here: 

https://www.youtube.com/watch?v=yhXqgGpfIEo&feature=youtu.be

Viva details: (100 marks) 

As visualized in the above videos other than the case presentation and discussion for 300 marks the viva is carried out by asking the candidate to speak on a chosen topic with a competency assessment goal as directed by the MCI and I quote again from the MCI link, "...The oral or viva aims at assessing the candidate's knowledge and competence about the subject, investigative procedures, therapeutic technique and other aspects of the speciality."

The viva assessments points can be further broken down by testing the candidate's skills in 

1) Broad overview of the topic 30 marks 

2) Searching the evidence base around efficacy of diagnostic and therapeutic interventions 15 marks 

3) Critically appraising the literature especially single RCTs done to establish diagnostic and therapeutic efficacies. 15 marks 

4) Sharing their original work done  during the course of their theses dissertation which will be cross examined by the four member examining Team to obtain an understanding of the candidate's competency in research methodology. 20 marks 

5) Log Book maintained as an online learning portfolio along with their regular reflection on cognitive and procedural competencies gained with some of their procedural videos. 

Some sample E log books along with procedural competency videos can be accessed here in the link below:

https://medicinedepartment.blogspot.com/2020/05/web-log-driven-online-learning.html?m=1

Frequently asked questions FAQs 

1) How will the cases be allotted?

In the morning, the PGY2 student expert conducting the exams will allot one IPD patient and 2 OPD patients each to the ten candidates such that when 5 candidates are examining their 2 OPD cases the the other 5 shall finish their IPD patients, and the IPD patients will largely be exclusively in the AMC, ICU or even wards while the external examiners after inspecting the students taking the cases into their laptops to their satisfaction will lounge in the clinical lecture hall waiting for the presentations to happen which will also be video recorded in toto by one of our PGY1s or interns.

2a) Sir one doubt.. to prepare a ppt it takes time to collect info and type it in a PowerPoint.. so we will be given cases one day before ??

2b) Should the ppt made during the examination sir or should we be ready with the power point beforehand sir?

You don't need to type the text into PPT slides. Just collect images of your clinical findings and imagings that's all. The rest you can present by reading your case notes.

The candidates may or may not collect the clinical data as text but they will definitely collect clinical images or videos as well as EcG, echo, X-ray, USG, CT, mri images and project those during the presentation.

For viva no PPT again except sharing of journal RCT data from a PDF that can be scrolled up and down. 

3) Ok sir so we need our laptops to make a ppt?

Yes but not to make a PPT but to share the clinical, ecg and image data on the clinical lecture hall projector. 

Informed Patient Consent and Authorization

Informed Patient Consent and Authorization form for sharing of deidentified case report

I give my consent and authorization for this information about MY SELF/MY WARD/MY RELATIVE (indicate correct description) relating to my/his/her health to appear in an online E-log case record (case report) that will exist in social media such as whatsapp and facebook. I understanding the following:


1) Health professionals need to communicate about my problem with each other and share my detailed history as well as images of my body in clinical photographs, images of Radiology and other test reports. In the past this was routinely done using paper based files and in the electronic age as it is faster to communicate using electronic devices connected online, this is how my history and images will be shared, as an E log case report (other than the paper based file system that may still continue).


2) My information will be published online by my health-professionals without revealing my identity or any personal information such as identifiable names and numbers like phone numbers, PAN number, UID numbers etc., and Email addresses or house addresses and the professionals in the online forums will make every attempt to ensure my anonymity addressing me solely by my anonymized user-name.


3) I understand, however, that complete anonymity cannot be guaranteed. It is possible that after reading the E log case report, somebody somewhere- perhaps, for example, somebody who looked after me if I was in hospital or a relative-may identify me. The information that will be  visible online will be the existing information that I provide in the form of patient input and new information will be added by many professionals processing my patient inputs in the online forum


4) The information may be published in online forums such as in whatsapp and facebook as well as in associated journals on paper as well as a blog in the internet as an E log case report and will be distributed worldwide


5)Information displayed in the E-log forum is not supposed to replace advice from the primary physician of the patient and my primary physician in charge will continue to look after me and make his own responsible decisions about my treatment.


6) The above information was explained to me in the language I understand.



Name  & Signature of Consent   Giver

Signature of Guardian/ Relative,

Name & Designation of Consent Taker      

(Anonymized Identifier)

Address :

Mobile No:                  







*సమాచార సమ్మతి మరియు అధికార పత్రం*


 విస్తరించిన విషయములు నాకు అర్ధమినివి:
నేను నా గురించి/ నా వార్డ్/ నా   బంధువు యొక్క  ఆరోగ్య పరిస్థితుల గురించి ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేసి సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో పోస్ట్ చేయుటకు అనుమతి ఇస్తున్నాను. ఈ క్రింది విస్తరించిన విషయములు నాకు అర్ధమినివి:

1. 1. నా ఆరోగ్య పరిస్థితులను, నా వ్యాధులకు సంబంధించిన టెస్ట్ రిపోర్ట్స్, రేడియాలజీ రిపోర్ట్స్ ఈతర డాక్టర్స్ తో చర్చించుటకొరకు ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేయపడుతున్నది. ఇంతకు ముందు ఈ విధమైన సమాచారాము కాగితపు రూపంలో జరుగుతుండేది. ఈ ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ ఎలెక్ట్రానిక్ పరికరాలతో సునాయాసంగా సులభంగా త్వరగా పంపవచ్చు.

2. నా పేరు, ఫోన్ నంబర్, పాన్, ఉఇడ్ నంబర్స్, ఈమేల్ అడ్రెస్ లను వెలువరించకుండా, నేను  సమాచారం డాక్టర్స్ ఈ లాగ్ కేస్ రిపోర్ట్ లో ప్రచురిస్తారు. ఈ ప్రచురించిన ఈ లాగ్ కేస్ రిపోర్ట్కు తెలియని పెరు పెడతారు.


3. నా పూర్తి వివరాలు ఎవరు చూడకుండా, చదవకుండా దాచటం సాధ్యం కాకపోవచు. ఉదాహరణకు, నాకు సంబంధించిన విషయాలను నేను ఆసుపత్రి లో ఉన్నపుడు నా స్నేహితులు కానీ , బంధుమిత్రులు కానీ చూసి చదివే అవకాశం ఉంది. ఈ లాగ్ కేస్ రిపోర్ట్ లో ఉండే సమాచారం ద్వారా ఈతర డాక్టర్లు నా ఆరోగ్యముకు సంబంధించి ఆన్లైన్ లో చర్చించవచ్చు.


4. ఈ లాగ్ కేస్ రిపోర్ట్ ద్వారా సేకరించిన సమాచారం ఆన్లైన్ ఫోరమ్ లో, జర్నల్ క్లబ్ లో, జర్నల్స, సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో నా పేరు, వివరములు  వెలువరించకుండా ప్రచురించవచ్చు.


5. ఈ లాగ్ ఫోరమ్ లోని ఎటువంటి సలహా సమాచారము వచ్చిన, నా ప్రస్తుత ప్రాథమిక వైధ్యుడు యొక్క సలహాలతో మాత్రమే మార్చబడును.నా చికిస్తకు సమబంధించిన పూర్తి    బాద్యత నా ప్రాథమిక వైధ్యుడిది.


6. ఈ పయ ప్రక్రియ అంతయు నాకు అర్ధం ఇయే భాషలోనూ వివరించబడినది.


సమ్మతి యొక్క పేరు మరియు సంతకం:

సంరక్షకుడు/ బంధువుల సంతకం:

దాత పేరు మరియు హోదా:

సమ్మతించు వాడి పేరు మరియు హోదా:

సమ్మతి ఐడి:

అడ్రెస్ :

సెల్ నంబర్ :


*রোগীর সম্মতি পত্র*

আমি সম্পূর্ণ খোলা মনে এই মর্মে সম্মতি জ্ঞাপন করছি যে আমি নিজে/আমার পরিচিত/আমার আত্মীয় (সঠিক যায়গায় টিক চিহ্ন দিন) রোগ সংক্রান্ত তথ্য একটি অনলাইন ই-লগ কেস রেকর্ডে (কেস রিপোর্ট) প্রদর্শিত হবে  যেটা হোয়াটসঅ্যাপ (whatsapp) এবং ফেইসবুক (facebook)- এই ধরনের সোশ্যাল মিডিয়াতেও অবস্থিত থাকতে পারে এবং এতে আমার কোন আপত্তি নেই।  আমি নিম্নবর্ণিত তথ্যগুলি বুঝেছি যেগুলি হলঃ

১) আমার স্বাস্থ্য সমস্যা সম্পর্কিত রোগের ইতিহাস, আমার শরীরের ক্লিনিক্যাল ও রেডিওলজিক্যাল ছবি (যেমন- এক্সরে, সিটি স্ক্যান, এম আর আই) সহ অন্যান্য পরীক্ষার রিপোর্টগুলো স্বাস্থ্যসেবা প্রদানকারীগন নিজেদের মাঝে শেয়ার করতে পারেন। পূর্বে এটি নিয়মিতভাবে কাগজে-কলমে করা হতো এবং এটি ছাড়াও, প্রযুক্তির উৎকর্ষ সাধনের সাথে সাথে, এই যোগাযোগ কে আরও দ্রুত করতে বিভিন্ন ইলেকট্রনিক ডিভাইস বা প্ল্যাটফর্ম ব্যবহার করে রোগের তথ্য শেয়ার করা হবে, যেমনঃ অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে।

২) আমার স্বাস্থ্যসেবা প্রদানকারিগন আমার রোগের তথ্য কোন রকম ব্যাক্তিগত তথ্য (যেমনঃ নাম, নম্বর, ফোন নম্বর, প্যান নম্বর, UID নম্বর, ইমেইল এড্রেস, বাড়ির ঠিকানা ইত্যাদি) ছাড়াই অনলাইনে প্রকাশ করবেন।

৩) আমার ব্যাক্তিগত তথ্য কখনই অনলাইনে প্রকাশ করা হবে না কেবল আমার সাংকেতিক নামই সকলে জানবে আমার প্রতিটি পত্রের জন্য।

৪) আমাদের প্রাথমিক উদ্দেশ্য হল কোন ব্যাক্তির ব্যক্তিগত রোগ সম্পর্কে বিভিন্ন তথ্য, বিভিন্ন পারদর্শিগনের সঙ্গে মতবিনিময় করে এক তথ্য ভান্ডার তোলা যাতে সেই ব্যক্তি তার রোগ সম্পর্কে সঠিক ধারনা পায়।

৩) আমি বুঝি যে, সবসময় আমার এই শারীরিক গোপনীয়তা নিশ্চিত করা সম্পূর্নরুপে সম্ভব নয়, কারন উদাহরন স্বরূপ যিনি আমার দেখভাল করছেন বা আমার পরিচিতেরা আমাকে চিনে ফেলতে পারেন।

৫)  আমার রোগের তথ্য কখনই বিকৃত করা হবে না, কিন্তু প্রয়োজনে তার বাক্যের গঠন, ব্যাকরণ ইত্যাদিতে প্রয়োজনীয় পরিবর্তন আনা হতে পারে।

৬) আমার রোগ সম্বন্ধীয় তথ্যগুলি সারা পৃথিবীব্যাপি একটি অনলাইন ই-লগ কেস রেকর্ডের মাধ্যমে প্রচার করে ছড়িয়ে দেয়া  হবে এবং সেটি বিভিন্ন স্বাস্থ্য সংক্রান্ত পত্রিকাগুলিতে প্রকাশ হতে পারে।

৭) এই অনলাইন ই-লগ কেস রেকর্ডে প্রদর্শিত চিকিৎসা সংক্রান্ত তথ্যগুলি কখনই আমার প্রাথমিক চিকিৎসকের উপদেশের বিকল্প হতে পারে না এবং আমার প্রাথমিক চিকিৎসকই  আমার চিকিৎসার জন্য চূড়ান্ত সিদ্ধান্ত নিবেন।
8) উপরে উল্লিখিত তথ্য আমাকে আমার ভাষাতে পরিষ্কার করে বুঝানো হয়েছে। এতে আমার সম্মতি আছে।

সম্মতি প্রদানকারীর নাম ও সাক্ষর

সাক্ষ্যপ্রদানকারীর (অভিভাবক/আত্মীয়) সাক্ষর

সম্মতি/সাক্ষ্য প্রদানকারীর ঠিকানা ও মোবাইল নং

সম্মতি গ্রহণকারীর নাম ও সাক্ষর


Previous version of the forms including Hindi and Bengali

Hindi

http://bmjcaselogvivek.blogspot.com/2017/09/consent-forms.html?m=1

Bengali

https://drive.google.com/file/d/0B9Hr8RrSXSgYbHUtRW14NzZsRDg/Vite

A daily pragmatic learning roster as per MCI summative and formative assessment guidelines

The current MCI summative and formative assessment guidelines can be accessed online here https://www.mciindia.org/CMS/information-desk/for-colleges/pg-curricula-2

Quoting briefly from those below:

Final university MD medicine summative assessment also known as the Post graduate examination shall be in three parts:

1. Thesis

2) Theory that would include four theory papers, as below:

Paper I: Basic Medical Sciences (at the end of first year of training)

Paper II: Medicine and allied specialties including pediatrics, dermatology &
 psychiatry

Paper III: Tropical Medicine and Infectious Diseases

Paper IV: Recent Advances in Medicine

3. Clinical / Practical and Oral/viva voce Examination:

The final clinical examination should include:

 cases pertaining to major systems

 stations for clinical, procedural and communication skills

 Log Book Records and day-to-day observation during the training (Record of formative assessment-logical interpretation)

 Oral/viva voce examination shall be comprehensive enough to test the
 post graduate student’s overall knowledge of the subject

Daily Roster:

1) For evaluation around "cases pertaining to major systems"

The student regularly begins the day evaluating the cases admitted in his her unit and presents it to the professor (also a university examiner) in the grand rounds. In the absence of the professor the next in command is to be presented the cases for analysis and decision making.

2) For evaluation of "clinical, procedural and communication skills," the students will be assessed in their grand round case for these specific competencies using technique of cross examination of their performance along with recorded videos of them performing the procedures.

3) Oral viva voce shall include questions related to the necessary knowledge needed in resolution of diagnostic and therapeutic uncertainty in their regular cared for  individual cases, by formulating evidence based queries in the PICO format, reviewing the literature by searching online and finally critically appraising the accessed literature in the form of regular journal clubs and seminars. All these regular activity shall be documented and shared by the student in his her E logbook aka "online learning portfolio."

4) For regular practice and evaluation of thesis and theory retention skills, the student shall have a regular 2-4 PM session to discuss his her thesis face to face with all the departmental members for their feedback on his her current prowess and a regular online thesis case-data sharing session through his her E log book. The student's theory retention skills will be tested by asking them to prepare a speech on one theory topic for the day so as to not only enable his prowess to tackle the summative theory papers on D day but  also test his pedagogic skills in imparting knowledge.