Introduction, Draft 3 Scholarship of Integration and the future of Medical education and research

 (A) 

(A)ssessed Need for the chapter in the context of medical education research, practice, publication, or scholarship. Word limit suggested, 400 to 500 words:

Introduction:

For most medical students and teachers medical education begins with their entry to medical school and begins with an introduction to the dead body and the this cadaveric teacher bares it's innards for all budding health professionals to learn the various components of the individual human system even while they attend parallel classes on physiology and biochemistry to further learn how this anatomic structure functions in a living human in all it's fascinating internal molecular and cellular complexity. 

Again in the next year they learn pathology which describes how a body is structurally ravaged by illness at a cellular and molecular level often historically unravelled after death. Finally they are introduced to the whole alive human being in their later clinical years where they learn to apply the knowledge of yester years to a living complex human being with his her complex network of problems rooted either in his her environment or genes. 

However this was not always how medicine was historically learned and this current curricular methodology of putting dry factual content before the student gets to experience learning in the context of the entire human, undermines the very ethos of medical education which is essentially to help health professionals improve patient care outcomes. 

Consequently one main problem statement theme for this chapter is the current "disintegration of Medical education with practice" and the tool that it aims to resolve the problem with is scholarly integration of Medical education and research. 

The other problem that this chapter addresses with the same tool is the current issue of national medical  integration, which has reached a tipping point due to a reigining covid chaos that has fast tracked all diverse interventions with varying methodological backgrounds into battling one single disease. 

Very few people know what is "scholarship of Integration in medical education and research" and how it can be a tool to tackle the current problems in medical education and practice and one important need this chapter will address is to fill in that information gap. 

Very few people realize that Medical education research is a tool to eventually improve patient outcomes as patient is the ultimate beneficiary of Medical education and this chapter will again not only address this vital information gap but become instrumental in driving positive change in this direction. 

Scholarship of integration in Medical education and research : what it is and what it isnt:

Scholarship of integration in medical education and research makes connections within and between disciplines, locating knowledge in a broader context giving meaning to specific discoveries. It aims to distribute the fruits of academic discovery to benefit specific individual members of society aka patients who in turn help academics to multiply the construction of new knowledge translated into practice. (Reference: www.ncbi.nlm.nih.gov/pmc/articles/PMC1891293/#!po=75.3968)

It is vital that academic institutions and medical schools remain relevant in an era when the production of knowledge is increasingly recognized as a social collaborative activity. 

(www.ncbi.nlm.nih.gov/pmc/articles/PMC1891293/ )

In this article we address two important problems and it's subcategories with the tool of scholarly integration namely 

primarily around two broad categories and it's subcategories:

a) Current disintegration of Medical education and practice 

Medical student and faculty engagement in rote memorization through an arcane curriculum that promotes plagiarism and diminishes scholarship 

disconnected from 

Patients who continue to suffer due to lack of student and faculty engagement with them in a broader empathic meaningful manner. 

b) Long overdue National Medical integration of health care delivery through methodologically diverse streams of interventions:

India's traditional and tribal system of Medicine historically neglected due to undue hype created by a dominant Western mode of Medical education that engages our students and teachers as unquestioning slaves.

Although current West has moved on globally, we are unable to get over our colonial past that continues to haunt our education and practice. 

Our proposed tool of scholarly integration, enables shared knowledge through a participatory framework and includes practical methods to guide institutional change along with reporting and evaluating them.  

At the outset one must clarify that scholarship of integration is not the same as scholarship of teaching and learning aka SOTL and borrowing from an excellent recent editorial (Singh T, Gupta P, Can We Consider Scholarship of Teaching Learning Rather than Focusing Only on publications for Recognition of Medical teachers by National Medical Commission? Annals of the National Academy of Medical Sciences (India) 2021; 57(01): 01-02 DOI: 10.1055/s-0041-1728179) , SOTL as identified by Felten13 thrives on  five principles: 

(1) inquiry focused on student learning, 

(2) grounded in context, 

(3) methodologically sound, 

(4) conducted in partnership with students, and (

5) appropriately public. (Felten P. Principles of good practice in SoTL. Teaching and Learning Inquiry 2013;1(1):121–125).

TS et al's editorial contributes very interesting questions. 

"How such a scholarship can be evaluated? Should it focus on output or outcome?"

The answer to the first would be open access self publication in one's own online learning portfolio such as even an online question paper designed can be shared for evaluation among  peers as here: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1

The above link to our online test for the month of May 2021 is essentially a student user driven, real patient centered, experiential sharing of individual patient data in the form of patient centered questions for solving and helping those individuals.

The competencies tested are the usual (mentioned in the link above) although unlike last month it doesn't test the competencies for familiarity with Empathy, Humanities and ML AI. 

Q10 looks at another topical area and that is "medical education" itself where students are also encouraged to think about their learning process. 

The answer to the second would surely be outcomes but not just on student learning but also in the context of Medical education directed toward it's  ultimate beneficiaries, that is the patients themselves, through a framework that enables driving of patient outcomes through student learning outcomes and a real time clinical audit trail that allows us to join the dots between the two. 

The above would bring us closer to scholarship of integration in Medical education and research which is not just about integrating scholarship of teaching learning with the scholarship of discovery but is all about integration of patient centered societal goals with teaching and learning. 

Please click on the link below to get back to the first layer of the chapter:

https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1

Abstract for book chapter on "Scholarship of Integration and the future of Medical education and research"

Abstract :

Scholarship of integration in medical education and research makes connections within and between disciplines, locating knowledge in a broader context giving meaning to specific discoveries. It aims to distribute the fruits of academic discovery to benefit specific individual members of society aka patients who in turn help academics to multiply the construction of new knowledge translated into practice. (Reference:

www.ncbi.nlm.nih.gov/pmc/articles/PMC1891293/#!po=75.3968)

The fruits of academic discovery by individual academics, students, their teacher learners and end beneficiaries of their education (patients), are stored in open access, online learning portfolios with optimal transparency and accountability toward development of further knowledge based, user driven, impactful learning and research in medical education and practice. 

This chapter contextualizes and describes a working prototype for scholarly integration in medical education and research framework showcasing student user driven, patient centered assessments of learning outcomes driving health care outcomes. This is a postulated effective tool to tackle the problem statement highlighted in the chapter primarily around two broad categories and it's subcategories:

a) Current disintegration of Medical education and practice 

Medical student and faculty engagement in rote memorization through an arcane curriculum that promotes plagiarism and diminishes scholarship 

disconnected from 

Patients who continue to suffer due to lack of student and faculty engagement with them in a broader empathic meaningful manner. 

b) Long overdue National Medical integration of health care delivery through methodologically diverse streams of interventions:

India's traditional and tribal system of Medicine historically neglected due to undue hype created by a dominant Western mode of Medical education that engages our students and teachers as unquestioning slaves.

Although current West has moved on globally, we are unable to get over our colonial past that continues to haunt our education and practice. 

The working prototype described in this chapter tackles the above problem statements head on and describes a participatory action research framework and learning ecosystem that thrives in transparency, accountability and real time evidence based audit of education and practice. 

Please click on the link below to get back to the first layer of the chapter:

https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1

Conversational learning illustration in the context of national medical integration

For more reading on conversational learning and user driven learning please jump to the open access references at the bottom of this piece :

(Box 2) 

Quoted below are thoughts of an engineer that touches on Ayurveda particularly in the context of National Medical Integration where an optimal strategy to making connections between different ways of knowing and doing in healthcare has become urgent :

"Those who have followed medical studies have either

1. Been driven by an intense desire to serve

Or

2. They have wanted to achieve a good standing in *science*

Those in the first category are already talking about *integrative medicine*. They will decide in favor of whatever reduces the pain and suffering of their patients. 

The other group of those who may be into medicine for a greater love of science, will talk logic just from the perspective of their standpoint. They may be naive about economics of pharma and awareness is a challenge there. But they can be convinced to become *skeptical experimentalists* to *disprove* the claims of Ayurveda. In doing so, either they will be venerated or stand corrected. Either way humanity will win. 

For this second group to be enabled we need to translate Ayurveda into modern language. _Vaat, pitt and kaph_ along with the _nadi_ intricacies need to be stated in terms of modern science - as a measurable quantity. This is a place for *engineering* to pitch in. The correlates may have better accuracy and specificity than modern diagnostics. 

At the same time, it should be possible to interpret modern diagnostics in terms of vaat, pitt, kaph and nadi. That way Ayurveda practitioners will be able to more actively participate in *modern scientific* integrative medicine. 

Modern science has trained us into *reductionists*. We are *gnostic* in our approach to nature. This, again IMHO, is the lacking factor that renders psychology a dark pseudo science - it still adheres to what I will differentially term as magical thinking and heresy. As far as physiological medicine though, such reductionism does work quite successfully now. We need to therefore *remove any apprehension of magic surrounding Ayurveda*.

On such a rational platform, even our second group of *science loving physicians* will contribute. 

There is another group. That's not a group of physicians, engineers, Ayurveda acharyas, or any other devoted workers. That's a group that worships money. This group practices *econopathy* even if it fosters *idiopathy*. 

Unfortunately, this group finds strength in the edifices of capitalism and capitalistic exploitation. Dealing with these people, whether they are in allopathy, Ayush, or any other system - needs a willing leadership in both the political and professional domains."

Response 1 

Nice.. Very  thoughtful.. Don't know about the fourth group of people.. But the second group of people  that he talks about.. The need for engineers  to translate the ideas of VAT pitta kapha.. May be possible in some way.. One example  that comes from the top of my  head.. The nadi  gatis  have been explained  in our shastras as hansa , sarpa...i. e.  The way a swan,  frog or snake walks... That can be easily captured  in a device and correlated by an engineer..

There must be ways by which gati signatures could be captured using some devices and this in turn could be correlated with hansa Sarpa and Manduk Hari where Sarpa gati is equal to vata  prakriti  etc.

Response 2:

It is impossible to translate Ayurveda terminology into Modern Medicine terms. A fact to be noted that CCMB-CSIR-IGIB have done an extensive work on tridosha theory of Ayurveda, and after analysing the constitution of around 100000 people and their gene mapping, they have concluded that there were three patterns of gene sequence under which all the population can be included, which could possibly be the reason behind the vata, pitta, kapha theory. But practically speaking it has nothing to do with the clinical practice.

It's very unfortunate that none among the modern fraternity, including doctors , scientists, researchers know that Ayurveda can never be explained in modern terms, *atleast as of now*. For example, when modern medicine has touched peaks in understanding human physiology and pharmacology, still the medical solutions for Diabetes is a challenge. Either one has to take medication life long, else switch to insulin etc. But we have personally *cured* many patients from Diabetes, and they are having a complete healthy life without any medications (including Ayurveda). This is something unimaginable, and as this didn't come in any peer review journals, people can never know about this. There are many such examples, just unpublished, where Ayurveda offers a permanent cure. 

The inability to explain the potential of Ayurveda in modern Research framework, if is the criteria to blatantly reject Ayurveda, is an an insult to science as such. This is the ground where I feel that integration shouldn't not dilute the actual inherent scientific principles of Ayurveda, rather give a stage to explain the cause effect mechanisms in its own language. May be after that translational researchers, along with biologists, doctors and Ayurveda fraternity can work together to find the link between systems physiology and later the actual integration can happen. 

Just to cite an example, in case of respiratory conditions like asthma, we study the different pathologies happening in bronchus, various allergic responses, bronchospasms etc. But in Ayurveda it's a disease linked to digestive tract (grossly speaking for a better understanding). So is the case with migraine where we address the gastric disturbance. It's a undeniable fact that after trying all the measures of modern medicine, patients finally land into Ayurveda to find a cure. When in hands of a good clinician, they'll be cured of the issue in no time.

So the basic understanding of human body, physiology and host responses vary a lot. First we'll have to understand the missing link, then can join with integration of streams.

Response 3:

Why do we need to translate ayurveda?? We need to define the terms in english and let the doshas be in its original form.let the Ayurveda terms be there or they will just be replaced by non scientific language. Its like trying to simplify phd for a middle class student. We know sanskrit is more scientific than english so whats the need to downgrade it, rather need to firm a bridge and let them upgrade.

My personal belief- Ayurveda practitioners and other practitioners need to be taught management of emergencies. Diet and lifestyle is best in ayurveda. Alll can learn new investigations and procedures. And research /evidence generation of this  integrative approach while its being practiced. All go together or we will die and still  it wont get integrated

Nadi and dosha identification we all must learn, its interesting as i see my ..., she diagnoses quiet well . Even dream analysis of the patient they have.

So many orientation programs, we can add sanskrit as a language in first year so all can read patanjali yog sutras, sushruta for themselves. Innovate integrative projects eight from first year.

Response 4:

Very well put.

Each point is valid.

To dismiss off a system which has existed for so long may not be appropriate,I guess no one even precisely know since when the system started.

But the problem is in  inadequate understanding and interpretation which has happened after introduction of modern medicine.

So it might be worthwhile to integrate it after appropriately interpreting whatever they are trying to convey by those terminologies which at this point don't sound too good or appealing  to us.

Just as we don't understand their terms,they don't understand or agree with ours.

Watched in one of Rajiv Malhotra's interview of an Ayurveda person this ,we mean the same yet we don't.That needs to be sorted out.

And I have seen  people like Dr BRamamurthi,the pioneer neurosurgeon  have a n Ayurveda research unit working on some projects.I trust the wisdom of these people .

Response 5:

This is what I have been telling all along. Apni jokhon ... te chilen we used to agree on most points except one. ...believed in homeopathy, ayurved or any other form of medicine but Prof ... would always ask for evidence and rightly so

Ami aj o biswas kori in homeopathy and ayurveda. I had gone through some of their texts and it is wonderful. Where we fall behind is we without knowing it deeply tend to remain in prejudice. 

Moving on the best allopathic centres in India have started to open departments of homeopathy and ayurveda in conjunction with allopathy

I believe medicine would be far more advanced if people took up homeopathy and ayurveda and researched it and put up those in public domain

My culmination would be when we can have evidence based medicine why not have evidence based ayurveda and homeopathy

Do you think ayurveda will open up new frontiers in medicine?

Response 6:

It's a sad truth that our country being one of the oldest to introduce and use many kinds of treatments and healing techniques, a greater percentage of people deny due to lack of scientific research evidence. Most of the people who believe in such techniques are considered as spiritual teachers rather than a teacher integrating different fields of study. But I, being a Health Psychologist, very strongly believe that integrated treatment is the best for better prognosis. 

We all study western psychology, Medicine but currently there is increased awareness and research on Indian Psychology that has its root way back in our vedas and upanishads. I am not so aware of Medicine and its research in Indian perspective. But, I Studied about Ayurveda during my masters in Indian Psychology Course which was integrated in the curriculum because of my great professors. Here is something i learned from their 

“The very first invocatory stanza of Ashtanga Hridaya (the main text in Ayurveda, written in 4th century A.D.) describes how emotions lead to both physical and mental diseases”

According to what I have learned so far Ayurveda focuses not just on the physical aspects but also on the Psychosocial aspects of an individual which is most required in the process of healing. I also agree about the difficulty with terminology used in ayurveda, indian psychology and the meanings. We were lucky to have a professor from philosophy who came to help us in understanding vata, pita, athman, brahman and so many other things. To help people understand research in that area knowing the words and their synonyms in medicine would be very helpful.

I am lucky enough to have met and have been meeting lots of “type one” professionals who inspire me because of which even though i am from psychology background which is not considered as science by many due to lack of awareness, I still joined to learn clinical hypnosis (which is neither considered science nor believed or understood my many mental health professionals themselves, again comes the role of creating awareness) to help patients/clients deal better with the problems they have physically and mentally in scientific ways. I am about to get my PGD in Clinical hypnosis and during this process I could help my own self in healing from the ... or ... as my doctors call it. Medicines did help me, but not just medicines is what I would say that controlled my symptoms and distress. 

Many people do complain about the capitalist nature of treatments, but I think it’s reasonable for the pressure professionals have in the process of investing themselves in. Integrated treatment will take time and many visits which is not friendly to those patients who can’t afford it and those who want immediate results due to the collective conditioning that happened over the years. 

Response 7:

 There could be some exceptions in both the groups, even some people who desire to serve, they dont accept integrative medicine. 

We can convince them through the evidence generated through integrative medicine. 

But, finally either of their goal must be patient centered healthcare in which patientcare should have a pivotal role.

 I think, this is the basic aim of most of the doctors, whether its allopathic or ayurvedic.

Their Languages (Ayurveda, Allopathy, etc.) might be different, but the essence or outcome could be the same.

More reading on conversational learning and user driven learning open access links :

Bera, K., Seth, B., & Biswas, R. (2013). Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Annals Of Neurosciences, 20(2).

www.ncbi.nlm.nih.gov/pmc/articles/PMC4117104/

Biswas, R., Sturmberg, J. P., & Martin, C. M. (2011). The User Driven Learning Environment. In R. Biswas, & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 229-241). doi:10.4018/978-1-60960-097-6.ch017

www.researchgate.net/publication/292652611_The_User_Driven_Learning_Environment

Please click on the link below to get back to the first layer of the chapter:

https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1

Part 1 Contextualizing the need for a framework toward scholarly integration of Medical education and research

 To put the current disintegration of Medical education and practice into context, we need to first understand individual patient requirements and societal requirements to gain further insights into medical practice and how it can be integrated with medical education. 

We share below an illustrative example from one of our online expert patients that we have published before here: https://pubmed.ncbi.nlm.nih.gov/19018905/

The layer of Individual patient experience

(Medical practice) : 

Patient’s voice – (in italics)

It all started in the summer of... when I

returned from a long weekend . . . it was

cool and rainy there.

I ate too many gravy coated potato fries,

drove home in damp clothes, and caught

what I thought was the flu.

It didn’t respond to my usual cure of lying on

the sofa and watching four rented videos.

In a few weeks I noticed some black and

blue marks on my arm and panicked when

I didn’t stop bleeding from a small cut.

My days became a struggle to continue life,

as I once knew it and understand why

my body was betraying me.

(Medical Education) A medical students related lecture notes although apparently distant  from the above patient context:

Physiology of Haemostasis

The cessation of bleeding from damaged

blood vessel. After vessel injury, process of

haemostasis takes place in two phases:

Primary:

1. Vessel wall contraction

2. Platelet aggregation & plugging of injured

area

Secondary:

3. Formation of an insoluble fibrin clot

because of activation of clotting system

What are the abnormalities of haemostasis

that may have caused abnormal bleeding

in this patient?

Haemorrhagic diseases can result from

abnormalities of:

Blood vessels

Platelets

Clotting systems

Diseases affecting the smaller blood vessels

& platelets produce the clinical picture of

purpura.

Integrating medical education and practice:

The practice passage above  begins an individual

clinical encounter with an audience (us) and we

notice that the initial queries generated

even by a patient are always something

like: 

Where is the problem? (a physician’s

morphologic diagnosis)

Why is the problem (a physician’s etiologic

diagnosis) 

and this is mostly answered by

pathophysiologic rationale that patients are

not expected to know (and may not

understand even through Internet

searches).

However, this is what physician’s are

expected to know as a result of their

training (and improve on with experience).

The most basic of these is the knowledge

of anatomy that takes time to change

unlike empirical evidence in medicine that

has proven to have a very short shelf life.

A physician by virtue of this basic knowledge

of macro- and microanatomy is able to

quickly grasp other information that keeps

adding to his lifelong day-to-day learning in

medicine.

It can often happen that what the physician had held as rote memorized facts (education) to apply to the current patient at hand (practice) may often fall short when it actually comes to deal with diagnostic and therapeutic uncertainty. 

Let's return to the same patient centered example to check the challenges around integrating therapeutic uncertainty 

Patient voice 2:

"The haematologist suggested prednisone,

the drug of choice. I was wary of the

side effects, but this seemed to be the

best option.

For three weeks I endured the brain fog,

sleepless nights, and anxiety, hoping the

drug would be a quick fix. It wasn’t.

There was only a slight rise in my platelet

count, then a fall. He then suggested IVIg."

Most physicians elect to not treat patients

unless their platelet count is below

50 000 L-1 or bleeding manifestations are

present.

Only 15%-25% of patients on steroids are

expected to have lasting remission;

The remainders have disease characterized by

frequent relapses and remissions.

Thiagarajan, P. (2006) Platelet disorders, E-medicine from web MD,

Web document last downloaded on August 16, 2007.

We enter the zone of empirical evidence that

tells us what intervention to choose for our

patient at hand utilizing population-based

data from collective experimentation.

The layer of Individual experience

Surviving and healing phase

Patient voice :

"The next round of IVIg was less successful in

raising my counts. The round after that had

almost no effect. I agreed to have my

spleen removed, hoping again for a quick

fix and to put an end to the endless round

of doctor appointments, hospitalizations

and the constant fear of bumping my head

and dying. Before I left for the hospital I

placed my will on my dresser."

Collective experience and its

conceptual layers

IV (Intravenous) IgG (Immunoglobulin G)

(0.8–1 g kg-1 for 2 d) can cause adverse

effects of IgG include fever, nausea,

vomiting, and, occasionally, renal failure.

Chronic ITP patients who fail to maintain

normal platelet count are eligible for Elective

Splenectomy. Splenectomy is effective

because it removes the major

site of destruction and the major source

of antiplatelet antibody synthesis.

Approximately 10%-20% of patients

who undergo splenectomy remain

thrombocytopenic and continue to have a

bleeding risk.

Patient voice :

My surgery was successful in that I survived,

my spleen was removed and the wound

eventually healed. However, it was not

successful in raising my platelet count.

Three weeks after the surgery I had as few

platelets as before the operation. Now I

was without a spleen bruised, and still on

the seizure meds.

Collective experience and its

conceptual layers:

A number of treatments have been

proposed for splenectomy and steroid

failures. Most of them are not based on placebo-

controlled studies, and evaluating the

efficacy of these treatments in a disease

associated with spontaneous remissions

and relapse is difficult.

Other treatment regimes:

High dose corticosteroids (iv)

High dose iv Ig

Rituximab

iv Anti-RhD

Danazol, colchicine

Vinca alkaloids

Immunosuppresive drugs: Azathioprine,

Cyclosporine, Dapsone

Patient Voice 

My hematologist recommended Danazol...

No luck . . . Colchicine failed too. We even

tried another course of IVIg hoping that my

body would respond to it differently now

that I didn’t have a spleen. It responded

differently all right. I was hospitalized

following one of the treatments for a

nosebleed that didn’t stop. I went to an ITP

specialist in . . . and he berated my local

hematologist for not putting me in the

hospital.

I reluctantly agreed to a course of vincristine

(chemotherapy) followed by a series of Prosorba.

A blood cleansing treatments. They sneaked

in more of the dreaded prednisone.

At the same time I also took up alternative wellness techniques that gradually began to enrich my life. I returned to work at the end of March, part time wearing a wig, on the day that my short-term disability insurance ended. My counts were still low, but I was thrilled to have parts of my life back. In a few weeks, I began full time work again.

The above expert patient has subsequently published another paper with our team members where she elaborated on her cure and the integration of multidisciplinary interventions that was brought about to effect it. She subsequently utilized the power of online integration to provide a voice to similar stories from many patients around the world. 

Reference link:

https://www.irma-international.org/article/caught-middle-divide-between-conventional/52621/

Please click on the link below to get back to the first layer of the chapter:

https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1