Tuesday, June 22, 2021

Working prototype of a scholarly integration of medical education and research framework

 Scholarship of integration connecting community  patient health care requirements to student learning outcomes toward peer review assessment: 


Illustration from recent real time student teacher patient learning workflow :


Two starting nodes that are at the center of this learning and caring ecosystem :



1) Patient at home in the community connected to teaching hospital



 through 



2) a chain of health professionals starting with medical students at home in their community as well as their teaching hospitals and their faculty coordinator 



A patient in touch with a community connected hospital in Narketpally, Telangana (2000 kms from her place of residence in Bengal, gets in touch with theTelehealth physician and coordinator of the hospital at Narketpally through a whatsapp text query seeking help for her son and this patient is referred to a medical student currently locked down at a distance of 1000 kms from the same patient. 

The medical student proceeds to gather the history from the patient and prepares a brief case report with the patient requirements and shares it with the global CBBLE network from which the patient requirements are further shared in various other Global fora by other interested health professionals both in learning more about the problem presented as well as helping the patient. 

The first example is copied below as it happened:

Box 1:

The telehealth physician faculty coordinator receives a text message from one of his long distance patients who had even made a 2000 kms journey in the past to be evaluated for her spondyloarthrpathy symptoms and this time she needed consultation for her son and below are the deidentified verbatim text messages in Hindi (to provide a feel of the real manner in which this really evolved):



"[5/13, 6:00 PM] Pt Spondyloarthrpathy 30f: Hum ... (location) se


[5/13, 6:00 PM] Pt Spondyloarthrpathy 30f:


 Mera bacha 8 saal ka hai



[5/13, 6:01 PM] Pt Spondyloarthrpathy 30f:


 Sir wo bar bar toilet karta hai



[5/13, 6:03 PM] Pt Spondyloarthrpathy 30f: Test Karwaya koi infaction nhi hai.



[5/13, 6:04 PM] Pt Spondyloarthrpathy 30f: Sir kya problem ho Santa hai



[5/13, 6:05 PM] Pt Spondyloarthrpathy 30f: Par isko constipation ka program hai


The faculty coordinator replied one hour later:

"Humare doctor aapko phone karenge detail mein jaan ne ke liye"


The faculty Coordinator immediately posts this requirement below onto the global CBBLE whatsapp group (a global group of medical students and faculty health professionals with 200 members) :

"

[5/13, 7:21 PM] FC: Anyone here who would like to take a telephonic history from the mother of an 8 year old child with frequent urination and then share the deidentified details here for analysis?

[5/13, 7:22 PM] FC: Mother's language is Hindi


Within minutes there were a few interested medical students texting the faculty coordinator FC in pm and he chose the earliest person and within one and a half hours that student had telephoned the mother and made a summary of the patient's problem representation which was again circulated by the FC into the global CBBLE as well as other healthprofessionals groups such as one even among his batch mates who entered national medical college, Kolkata in 1987 and the subsequent inputs into the patient problem have all been captured by the same student in her E log book here: drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html?m=1

The same student was instrumental in arranging a telecounselling with one of the Psychiatry department faculty members from her Medical College in Narketpally from 2000 kms away and the patients health outcomes currently appear to be evolving to everyone's satisfaction. 

In the next module we shall see how this patient data was utilized in a monthly summative assessment module for the same batch of students to test their competencies in patient care related to clinical problem solving through empathic patient data capture and continuity of communication. 


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Monday, June 21, 2021

Evolution of a model for patient centered, scholarship of integration in Medical education and research "

The participatory case based blended learning ecosystem CBBLE framework that is a model for a patient centered, scholarship of integration in Medical education, has been actively evolving since a few decades in different medical colleges in India and has been described in detailed timeline below (and earlier as an illustration of evolving research around 'medical cognition')   :


2002 Manipal, Pokhara : Contrary to what generalizeable randomized controlled trial data projected, every individual was unique and had unique life trajectories and it was found that medical students were best suited to unearthing these trajectories as documented here: https://www.eubios.info/EJ124/ej124j.htm

Some of these medical students who were now academic faculty, revisited this idea in the last CBBLE paper here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/


2007 Manipal, Melaka : It was gradually becoming clearer that current evidence based medicine needed a more meaningful methodology to answer individual patient requirements here: https://pubmed.ncbi.nlm.nih.gov/17683292/

2008: And soon the first conceptual model for current CBBLE was shared here: http://www.ncbi.nlm.nih.gov/pubmed/19018905

It was called "user driven healthcare" UDHC and described a prevalent phenomenon evolving with the internet and the only difference with the later CBBLE appears to be that the term "blended learning" got added to the same process suggesting that the CBBLE had a strong component of offline connection and locality that was blended to requirements of online users. 

The CBBLE idea as a subset of the UDHC phenomenon was to build a Case based reasoning database that could offer any individual, a platform for obtaining comparisons between other individual patients who had similar data patterns and then see if near matches of individual trajectories would offer similar outcome trajectories in those group of patients and this was inspired by a seminal paper on case based reasoning linked here: https://pubmed.ncbi.nlm.nih.gov/15533257/

The pursuit of clinical problem solving using online user driven learning was a polymathic pluralistic activity and we derived a lot of lessons from other fields as illustrated in chapters of the UDHC book here 


2009 PCMS Bhopal : The model could be scaled to the last mile primary care and act as an efficient bridge between primary and tertiary, individual home, community collaborative center and academic institutions as proposed here:   https://pubmed.ncbi.nlm.nih.gov/19811603/

2010-2021 (Connecting multiple medical colleges with last mile patients)--

Many such cases started getting logged by last mile workers in various parts of India particularly West Bengal and they were processed by a CBBLE that fed case based problems to a global forum for conversational learning as shared here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117104/

2008-2014: PCMS, Bhopal 

While one of the faculty coordinator for the CBBLE was in the above Medical College location, the actual forum was made by global medical and engineering  students and there is more about them in the above article as well as in the UDHC book and journal issues here https://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022 as well as their own web pages 




2012 the team presented our work in TEDx Kolkata here https://youtu.be/76AVUQOK9LM

One of the organizers of the conference, Mr Shoubhik Bose created a website for UDHC that is currently archived here :

It displayed a pseudonymisation "Telemedicine" workflow with patient names replaced by botanical names and patients asked to plant their namesakes. 


There were issues (weaknesses) in the form of questions such as :

Other than patients and caregivers what are the chances that others with malintent will be able to identify these patients? 

These are still important issues that we are trying to grapple with and improve upon daily. 

These health records were also multilingual with advice in Bengali (other than English as demonstrated here 

The Online links to other currently surviving patient records can be found in the online learning portfolios of the last mile worker users here below:


(The number in the URL reflects the area pin code from where the last mile worker operates). 


These last mile workers had begun a new genre of multilingual, deidentified online patient records that were partially structured and managed in most instances to convey individual patient requirements and their work was further shared globally in published case studies linked below:

The paper below is a collated depiction of cases emailed by some of our last mile workers and how their differently structured patient histories were still useful to develop a learning ecosystem between the offline patient and online healthcare learner and helper. 



With the steady progress of our last mile workers abilities to create web based logs of patient records, the abilities of the medical students in our learning ecosystem remained at par by translating quite a few, perhaps 50-70 of these online patient records into journal publications accessible here https://pubmed.ncbi.nlm.nih.gov/?term=Rakesh+Biswas+

2013 one of the activities of a team member who looked after the editorship of BMJ Case reports was to spread the word about case based learning and how every individual patient was an independent research project and below are links to some of the lectures delivered in 







2014 year saw the inauguration of the BMJ Case reports Elective program (detailed here: https://casereports.bmj.com/pages/bmj-case-reports-student-electives/
from PCMS Bhopal and hosted initial students from India and France (shared here: http://userdrivenhealthcare.blogspot.com/2014/09/positive-role-of-medical-electives-in.html?m=1, with their patient described in the lecture here: : http://www.pitt.edu/~super1/lecture/lec53081/001.htm ), before it shifted to another medical college, LNMCH, Bhopal where a group of students from US and India published their first global health case report here : www.ncbi.nlm.nih.gov/pmc/articles/PMC4785487/


2015 was particularly important as LNMCH was the first medical college that started funding research assistants who were more conversant with Hindi to take this work forward and below are some of their work in their multilingual online learning portfolios along with their assessments by the faculty coordinator :

RA1: Hindi online patient record 


RA2: Link to online patient logs:


RA2: Link to one time assessment:


RA3: Link to one time assessment:


RA4: Link to online patient logs:


RA4: Link to one time assessment:


RA5: Link to online patient logs:


RA5: Link to one time assessment:


2016 saw another shift in base this time to a medical college in West Bengal, Durgapur where a few ideas around patient centered scholarship of integration in Medical education and research were consolidated in the form of the lectures below and shared in various forums such as medical education conferences organized by JIPMER, Pondicherry and "International Society for Evidence-Based Health Care" Kisch island around the same time. 

Medical Education Curriculum: How do we change the game? http://www.pitt.edu/~super1/lecture/lec54091/001.htm, 

Generalism in Medical Education:  What and Why? http://www.pitt.edu/~super1/lecture/lec54101/001.htm  

Assessment of Generalist Learning Competency: http://www.pitt.edu/~super1/lecture/lec54111/002.htm 

Current challenges in Evidence based Medical Education and the way forward :


One of the fall outs of the above consolidated ideas was to action it in the form of a curriculum that would blend seamlessly with existing curricula and this was illustrated at that time here in the form of a "Case-Based-Online-Learning-Portfolio in an MBBS student of WBUHS" 

The elective learning program was furthered here in this global health case study linked below, by two visiting medical students from UK and it highlights our workflow of sharing "open access patient records with de-identified patient documentation such as doctors’ notes, diagnostic test results and the patient’s perspective" toward improving their outcomes along with students learning outcomes. 


The original online patient record blog prepared by our community health worker, that was foundational to the published case study is accessible here: https://ebpc-udhc-debasishacharjee.blogspot.com/2017/07/38-year-old-woman-suffering-from-tb.html?m=1


2017 location shifts to another medical college near Hyderabad and the CBBLE projects are further strengthened as detailed here:https://medicinedepartment.blogspot.com/2021/02/medicine-department-projects.html?m=0

The BMJ Elective student visits continued and some of their videos below depict our current workflow for scholarship of integration in a vivid manner here : https://youtu.be/xvE5b8Xk3vM (presented by our elective students in a medical education conference in AIIMS, Bhuvaneshwar, early 2020)


And here: https://youtu.be/csF8VQbOYRo(presented by our elective student to a medical college in California, early 2021) 

Other than a few of our patient centered case studies as Global health case reports linked below :

Middle-aged man who could not afford an angioplasty. BMJ Case Reports CP. 2019 Mar 1;12(3):e227118.https://www.ncbi.nlm.nih.gov/pubmed/30936331

Traumatic Subdural Hematoma: Integrating Case Based Clinical Judgement with Guidelines:

Other than the BMJ Elective program students who added immense inputs to this 'scholarship of integration' detailed in the institution project log linked above, the pandemic drove newer opportunities to explore online learning with our students that added considerable data to our work around scholarship of integration facilitated by the CBBLE tool as portrayed here :

The pandemic made us take our classes live globally and we regularly connect with our students live during our 10:00 AM to 12:00 PM morning rounds as videoed and archived in the link below where we are presenting our cases to a global audience:



And here's a sample of our regular class videos of case presentation lectures during our 2-4 PM sessions. 






Here's a summary video of what we do 


We can share recorded sessions in a more structured way rather than the impromptu manner in which it has been filmed but then we need a film maker who will do it for us. 

Meanwhile till then our student user driven online learning portfolios that keep getting updated regularly in real time keeps reflecting their competencies that we have showcased in this link here : https://medicinedepartment.blogspot.com/2021/07/?m=0


Above is the background that sets the stage for the description of the current framework for scholarship of integration with a most recent example in the next module.


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Sunday, June 20, 2021

National Medical Integration and the role of scholarly integration in Medical education and research

 

India is uniquely posed toward a "national medical integration of it's existing non mainstream medicine (grouped under an acronym ayush) streams with that of mainstream medicine. This is also a nationalist resurgence of Indian Medicine, Ayurveda that was slowly and systematically weakened during India's dominion by the British. This resurgence is partly inspired by our neighbor China who have successfully integrated many areas of Traditional Chinese medicine with Western medicine and successfully under Prof Tu spearheaded the application of Traditional Chinese Medicine at the time of a malaria epidemic in the 1960s which eventually led to a Nobel Prize. The Chinese Medical Association wholeheartedly supported this as a matter of national pride. (Ref:Su X-Z and Miller LH. The discovery of artemisinin and the Nobel Prize in physiology or medicine. Sci China Life Sci 2015; 58: 1175–1179.)


As a part of this resurgence in India every national laboratory, especially those belonging to medical institutes and other government-funded institutions, will be encouraged to research AYUSH systems, collectively funded by national agencies to ensure that the discoveries from traditional Indian Medicine receive acknowledgement, much like the Nobel prize-winning work of Chinese Prof Tu Youyou. (Reference: journals.sagepub.com/doi/full/10.1177/09727531211009800)


British bridge course and spurt of national medical integration in intermittent 100 year cycles:


Just to address the question of when mainstream Indian medicine (the ideal integrative medicine of that time), became disintegrated we may need to review the fascinating 200 year old history of an apparent bridge course floated by the British for getting native Indian students for its newly opened college to begin training the natives who were practicing Ayurveda. Ayurveda was much more popular in India than Western Medicine at that time and the British worried themselves silly that there would be no takers among the natives for the mbbs course that they were planning to begin for the first time in India. At that time a popular course for learning Ayurveda was the Baidyak discipline in Sanskrit College, Kolkata. In 1835, the British set up the (Modern? British?) Medical College near Sanskrit College, Kolkata.

The Baidyak discipline was discontinued at the Sanskrit College and one of its Ayurvedic teachers joined Medical College as an assistant teacher. He studied Western medicine along with the students and passed in 1840. In 1845, he became the Superintendent of the Hindusthani medium. In 1848, he was promoted to a first class sub-assistant surgeon. In 1852, the Bengali medium was opened at the Medical College for the first time. Gupta took charge as the Superintendent of the Bengali medium. https://en.m.wikipedia.org/wiki/Madhusudan_Gupta

First attempt at national medical integration in India 100 years back :

Further reading on nationalist movements in medical education may take us to 1921 when national medical college was born from an earlier experience of its allopath founder who previously served as a principal of Baidyasastra Pathi." While Kabiraj Bachaspati was the principal of the Ayurvedic section, Sundarimahan was the principal of the allopathic section of the institution. Sundari Mohan advocated independent research in Ayurveda on scientific lines. His greatest contribution along this line was the establishment of the "Jatiya Ayurbigyan Vidyalaya" in 1921, (also known as Calcutta National Medical College) founded as a product of the Non-cooperation movement. It was inaugurated by Subhas Chandra Bose. Calcutta National Medical College was nationalized in 1967. Perhaps the first private medical college in India to be nationalized. https://en.m.wikipedia.org/wiki/Sundari_Mohan_Das


Exactly 100 years later this year Indian national  health policy makers are all set to create a fresh framework for national medical integration. Scholarly integration of Medical education can offer that framework. 


In the next section we proceed to describe that framework. 



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Saturday, June 19, 2021

Pandemic driven acceleration of scholarly integration between ways of knowing and doing in healthcare

Quoting verbatim from a recent essay in Lancet global health particularly focused on India although very relevant globally,


"Academic institutions and professional medical societies should reflect on their roles. A range of recommendations and treatment algorithms from norm-defining medical institutions and societies are circulating on social media. These institutions are notable by their failure to share the evidence that informs these recommendations, discuss nuances of implementation, or present conflicts of interests of those involved in developing these recommendations. These recommendations give fillip to low-value care and provide medical practitioners with a justification to use them."

More here:
The current chaos in modern medical healthcare reflects a failure of evidence based medical education and research directed at the end beneficiary of Medical education, that is the patient and the time is ripe for scholarly integration to develop the optimal adaptive systems framework for it. More about it in the description but before that a quick look at the history of "integration of medical education and research" from 200 years in India with the British integrating their system of Western Medicine with that of the pre existing Indian system with near total demise of the Indian system. 

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Failed political integration attempts at different roads to healing in the USA

Quoted verbatim from the reference link below :

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


In 2000 President Clinton, mindful of rising healthcare costs and growing evidence of the benefits of complementary and alternative medicine (CAM), commissioned a panel to study the possibility that CAM could reduce healthcare costs as well as improve the general health of the American population (White House Commission on Complementary and Alternative Medicine Policy, 2002)

 The leaders of the White House Commission on Complementary and Alternative Medicine Policy gathered an esteemed panel, solicited public input, and navigated the differences of opinion between those who believe in the worth of CAM and those who were skeptical or downright negative, or so they thought.  After years of negotiation, two of the committee members felt their views were not sufficiently considered and wrote a letter to the secretary of Heath and Human Services that negated the heart of the panel’s conclusions….there was the possibility of benefit from a more holistic, far-reaching, and often long-standing approach to healing and more research was warranted. (Fins and Low Dog, 2002) The committee’s recommendations were effectively tabled and forgotten."  


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Individual integration of different roads to healing

 

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/


Sharing the same patient voice from the article linked above, we quote below:


"the large doses of prednisone I took to try to resolve my ITP, plus the usual factors of age, hormones, and genetics resulted in a diagnosis of osteoporosis.   

For both of these conditions, I am sorting through the medical hype, trying to determine the validity and meaning of the sometimes conflicting diagnostic tests, and weighing the different approaches for improving my health.  What I’m finding is no different from what I found 20 years ago. The treatments suggested by the endocrinologists and alternative doctors are often very different. The patient experiences do not match the published literature.  There are significant pharmaceutical profit motives that may skew the diagnosis, research, and treatment suggestions (Shomon, 2000).  Once again, I’m balanced in the middle with one foot in the conventional world and one in the alternative world, trying to find a secure and reliable place to heal.  And there are millions of us who feel this way."



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

Brief :


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. 

Scholarship of integration in Medical education and research 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. 


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. 


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


Scholarship of integration focuses on outcomes 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. 



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