Wednesday, February 7, 2024

Real patient OSCE station questions

OSCE stations : 4 (around 4 real patients) 


Total marks: 40 (10x4)

5 osce questions per station (2 marks each) :

Question 1 (Bloom level 1):

Remembering : What are the possible etiologies for this patient's most significant issue?

Sample answer :

Infection (viral, bacterial, protozoal, fungal) 

Immune mediated (autoimmune, secondary) 

Trauma, Toxin, Drug, Metabolic 

Congenital 

Neoplasia 

Question 2 (Blooms level 2)

Understanding : What are the pathophysiologic  mechanisms that explain this patient's most significant issue? 

For example if your patient has ascites then what are it's possible mechanisms or similarly if the patient has headache what are it's mechanisms 

Question 3 (Blooms level 3)

Application :

Prepare a brief, single page, objectively structured (OS) map/report toward clinical evaluation (CE) of the data that you have gathered from this patient in terms of the sequence of events leading to his/her  present illness, your objective findings on physical examination and available further investigational data 

Question 4 (Blooms level 4-5)

Analysis and evaluation:

Analyze this patient's data by extracting the key points/problems that are useful and actionable and create a problem list in order of actionable priority 

Question 5 (Blooms level 6)

Synthesis (of an actionable plan from above OSCE data)  

Create a diagnosis and treatment plan for each one of the patient's problems you have listed above in terms of priority 



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Saturday, January 27, 2024

Thesis definitions of Events, Outcomes, Morbidities, Comorbidities and others

Events : "The occurrence of a dichotomous outcome that is being sought in the study."


Understanding it further :

Automatically the above definition of event begets the definition of dichotomy as well as outcome. 

Let's begin with dichotomy :

It means divided into two parts. 

Such as positive or negative etc 

Human cognition and emotions often tend to label natural or artificially created events as positive or negative, good or bad such as life (good), death (bad) etc but what is important to note is that "events" are occurrences of "change" over a human timeline that can begin with the birth of that human and only stop at his her death. Time is one way to measure the change in human lives and hence there are reported definitions of event rate and "time to events." 

If we want to understand human events further, think of how a human is created from the coming together of two cells  donated by two very different human genders (a past event driving the current human's cellular existence) and how through a series of events over time, that two celled existence, becomes, four, eight, sixteen  and finally a trillion, all inside the body of one human gender following which there is another event when the human is brought out into the world, an event called birth that begins it's existence called life, which is nothing but a sequence of events predictably routine as well as unpredictabily complex all the way till death. In healthcare research we are concerned with health related events although again separating health or illness events into dichotomous outcomes is not always easy. 

Outcomes : 

Often defined as "Health outcomes measure a change in the health status of an individual or a group which can be attributed to intervention."


Borrowing from the previous definition of "events" one can say, Every current outcome is a result of a past event that happened naturally or artificially through human intervention. 

In other words, for any human health research study participant, their current events are their current outcomes, which are a result of their past events, as a result of natural or artificial interventions.

Depending on what happens to the participant, his morbidities and comorbidities at the end of the study, one may further  classify his outcomes as persistent morbidity, recovery or death. Other than these dichotomous outcomes one can also look at what changed in the events that initially shaped his morbidity and comorbidities and how those events are playing out as current outcomes.  

Morbidity : "Morbidity is another term for illness. A person can have several co-morbidities simultaneously." 


Wiki quote below :

Comorbidity—from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together)[1][circular reference]—is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary condition. Comorbidity describes the effect of all other conditions an individual patient might have other than the primary condition of interest, and can be physiological or psychological."

"The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific."

"Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people."

Unquote 

 


For further understanding around similar current  research around the globe, quoting from the Cambridge VanderSchaar lab link below :

"to make discoveries and understand event data, the VanderSchaar lab has driven 
development of personalized morbidity and comorbidity networks that enable us to understand how particular morbidities may trigger other morbidities over time.

Current state-of-the-art morbidity and comorbidity networks in healthcare are only capable of mapping the relationships between different diseases in a static manner at the population level. There is much to be gained from creating models that are both personalized (i.e., they depend on the unique characteristics, such as genetic information, of each specific individual) and dynamic (i.e., they depend on the order in which morbidities occur)."

Unquote 


Was just going through this amazing team work from Cambridge while trying to prepare our own explanatory position paper on our current thesis projects around comorbidity events influenced by diagnostic and therapeutic uncertainty and their outcomes and while we use a predominantly qualitative methodology due to resource constraints (and have to regularly swallow our pride due to the miniscule impact of what we do), I found these people are exactly working on similar areas albeit using AI driven quantitative methods that are surely more promising in terms of impact! 


The webpage also has free joining options for their weekly synchronous sessions (unfortunately I'm asynchronous to a fault and am desperately looking for their email or whatsapp group) and if any of you happen to join their sessions do share what you learn. 

Other standard definitions in clinical research :





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Sunday, January 21, 2024

Thesis protocol : Outcomes of patients with HYPOALBUMINEMIA, their associated comorbidities AND their OUTCOMES

Title : Outcomes of patients with HYPOALBUMINEMIA, their associated comorbidities AND their OUTCOMES 
Introduction :

Hypoalbuminemia is a medical sign in which the level of albumin in the blood is low. This can be due to decreased production in the liver, increased loss in the gastrointestinal tract or kidneys, increased use in the body, or abnormal distribution between body compartments. Patients often present with hypoalbuminemia as a result of another disease process such as malnutrition as a result of severe anorexia nervosa, sepsis, cirrhosis in the liver , nephrotic syndrome in the kidneys, or protein losing enteropathy in the gastro intestinal tract. (ref) 

Problem statement :

"Three theoretical constructs drive current collective  medical cognition around the relationship between hypoalbuminemia and comorbidities and outcomes. 

First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor  outcomes. 

Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor patient outcomes. 

Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. 

A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization." (Entirely quoted from ref 1)

Also there are very few studies available that have evaluated the diagnostic and therapeutic event factors  which influence the comorbidities in patients with hypoalbuminemia (ref number 1) and our study aims to bridge this gap.


Aim

To Learn About  Factors Influencing the  Clinical Profile and Comorbidities in the Development of Hypoalbuminemia and It's outcomes and correlating team  learning outcomes with patient improvement outcomes 

Objectives :


1) To collect and document hypoalbuminemia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.

2)To match collected individual particular patient event data with past  generalizable data around hypoalbuminemia 

3)To evaluate each thematic category of hypoalbuminemia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time

4) To synthesise new learning outcomes over what is currently available and documented globally for patients with hypoalbuminemia and establish the relationship, if any, between the newly synthesized learning outcomes from each hypoalbuminemia patient participant and their or their subsequent hypoalbuminemia patient's healing outcomes.


MATERIALS AND METHODS :

STUDY DESIGN :

Qualitative, Prospective and Observational study that evaluates each thematic category of patient illness event data into diagnostically labeled morbidities as well as comorbidities and establishes a relation between their intervention outcomes over time

METHODOLOGY : 

1) Patients having low serum albumin are selected from CASUALTY, OPD, IPD  in ... Institute of Medical Sciences

2) Consent is taken for study participantion as well as deidentified data sharing from the patient and their advocates/relatives after explaining the potential harms and benefits along with need for further follow up. 

Sample informed Consent forms:

1) For deidentified case reporting 


2) Patient information sheet :

English:


Telugu:



Template of this "patient information sheet" is borrowed from👇


And modified according to the thesis topic.

CONSENT FORMS




3) Methodology of data collection and analysis illustrated through a Sample case report form to demonstrate thesis objectives:

Please see this sample case report form/proforma (collected and suitably archived albeit semistructured case data):

Thesis participant is a 50M Hypoalbuminemia, Viral thrombocytopenia comorbidities Diabetes 10 yrs CAD CCF 



Demonstration of thematic analysis and objectively structured clinical evaluation(OSCE) data extraction process from the above single case report proforma in line with the objectives below :



1) To collect and document hypoalbuminemia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.


Morbidities : 

Fever 3 days 
Body pain 3 days 
Shortness of breath 1 day

Subsequently :

Hypotension 
Severe thrombocytopenia 

Impression: Viral fever with thrombocytopenia, hypoalbuminemia 


Comorbidities :

Trunkal obesity 
Diabetes 10 years 
Hypertension 1 year 
CAD 
CCF 
Renal failure AKI on CKD 
Albuminuria 
Hypoalbuminemia 


Diagnostic and therapeutic Outcome interventions :

Diagnostic:

Fever pattern monitoring 

Platelet monitoring 

Vitals and Respiratory parameters monitoring 

Urine output monitoring 

Therapeutic :

For thrombocytopenia : platelets 

For hypotension :  iv vasopressors 

Hypoxia : adjusted fio2

Diabetes : Insulin short acting 

CCF : iv loop diuretics 
AKI : conservative 



2)To match collected individual particular patient event data with past  generalizable data around cardiac arrhythmias and associated comorbidities and their outcomes 


The above patient data was matched to past available data around similar clinical scenarios with similar hypoalbuminemia and comorbidities and following learning themes emerged that needed to be pursued further:


Diagnostic uncertainties:


Hypoalbuminemia in this 50M with Diabetes, CAD, CCF, AKI, CKD, albuminuria and a recent fever with thrombocytopenia can be due to:

Diabetic nephropathy glomerular injury or even a recent onset non diabetic kidney disease due to acute glomerular injury 

Negative acute phase reactant 

Liver failure 

Unlikely malnutrition or malabsorption 



Therapeutic uncertainties :

Role of platelet therapy 

Role of albumin therapy 

Absence of afterload reducing agents for his left heart failure management 

Role of indiscriminate antibiotics in  absence of definite  microbiological drivers 

 Role of CAD prophylactic agents and their stopping in indirectly precipitating the current outcomes of arrhythmias 



3)To evaluate each thematic category of hypoalbuminemia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time


The patient timeline that is usually displayed daywise in a single fever chart along with soap notes is currently missing from the above sample case report proforma and hence this third objective is not met at this point of time  


4) To synthesise new learning outcomes over what is currently available and documented globally for patients with hypoalbuminemia and establish the relationship, if any, between the newly synthesized learning outcomes from each hypoalbuminemia patient participant and their or their subsequent patient's healing outcomes.


From the above diagnostic and therapeutic uncertainty themes extracted from the single sample case report form and on review of literature of existing knowledge around these, it's clear that  more research using similar clinically complex patient data is needed to synthesize information over what is currently available. In this given individual patient the hypoalbuminemia appears to appears to have multiple influences, namely: a 
Diabetic nephropathy glomerular injury or even a recent onset non diabetic kidney disease due to acute glomerular injury or as a negative acute phase reactant due to the recent viral fever or due to liver failure again due to the acute febrile inflammatory illness and his outcomes needs to be gathered meticulously over time using currently available "medical cognition" tools.



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Thesis protocol : Clinical Profile, Comorbidities and Outcomes in patients with Cardiac Arrhythmias

Title


Clinical Profile, Comorbidities and Outcomes in patients with Cardiac Arrhythmias

Problem statement :

The impact of a given arrhythmia in a given situation depends on the patient’s cardiac physiology and function. 

Similarly, urgency and type of treatment are determined by the physiological impact of the arrhythmia as well as by underlying cardiac status.(ref) 

All the above "events" suggesting diagnostic and therapeutic urgency and uncertainty are dependent on "patient event factors" that influence the comorbidities in patients with cardiac arrhythmias and there are very few studies that have addressed this in the past (ref) and our study aims to bridge this gap.



Aim

To Learn About  Factors Influencing Clinical Profile and Comorbidities in the Development of Cardiac Arrhythmias and It's outcomes and correlating team  learning outcomes with patient improvement outcomes 

Objectives :


1) To collect and document arrhythmia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.

2)To match collected individual particular patient event data with past  generalizable data around cardiac arrhythmias 

3)To evaluate each thematic category of arrhythmia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time

4) To synthesise new learning outcomes over what is currently available and documented globally for patients with cardiac arrhythmia and establish the relationship, if any, between the newly synthesized learning outcomes from each cardiac arrhythmia patient participant and their or their subsequent patient's healing outcomes.


MATERIALS AND METHODS :

STUDY DESIGN :

Qualitative, Prospective and Observational study that evaluates each thematic category of patient illness event data into diagnostically labeled morbidities as well as comorbidities and establishes a relation between their intervention outcomes over time

METHODOLOGY : 

Patients having irregular pulse and irregularities in ECG are selected from CASUALTY, OPD, IPD  in ... Institute of Medical Sciences

Consent is taken for study participantion as well as deidentified data sharing from the patient and their advocates/relatives after explaining the potential harms and benefits along with need for further follow up. 

Sample informed Consent forms:

1) For deidentified case reporting 


2) Patient information sheet :

English:


Telugu:



Template of this "patient information sheet" is borrowed from👇


And modified according to the thesis topic.

CONSENT FORMS




Sample case report form to demonstrate thesis objectives:



For thesis "Clinical Profile, Comorbidities and Outcomes in patients with Cardiac Arrhythmias"




Please see this sample case report form/proforma (collected and suitably archived albeit semistructured case data):




Demonstration of thematic analysis and objectively structured clinical evaluation(OSCE) data extraction process from the above single case report proforma in line with the objectives below :



1) To collect and document arrhythmia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.


Morbidities : Cough, SOB (COPD ac ex)  since 5 days


Comorbidities :


CAD  since 2 yrs not using any medication since 2 months 


Heart failure current admission 


Years of Significant Alcohol intake, stopped 7 months back. 


Years of significant Smoking stopped 1 year back.


Interventions :


For arrhythmia : Inj adenosine 6mg iv stat followed by 

Inj Adenosine 6mg iv stat 

 Tab digoxin 0.5 mg stat followed by 0.25 mg 


For COPD : Neb with ipravent 6 th hrly , budecort 12 th hrly, Tab pulmoclear BD 

Inj Monocef 1 gm IV BD 


For CAD : Tab ecospirin  AV 75/10 po hs 


For CCF : Inj Lasix 20 mg IV TID if bp is less than 110 mmhg.


2)To match collected individual particular patient event data with past  generalizable data around cardiac arrhythmias and associated comorbidities and their outcomes 


The above patient data was matched to past available data around similar clinical scenarios with similar arrhythmias and comorbidities and following learning themes emerged that needed to be pursued further:


Diagnostic uncertainties:


COPD and it's associated arrhythmias due to particular structural involvements in the pulmonary hypertensive right heart or simply due to metabolic and blood gas factors (data absent in this sample case report proforma).  


CAD CCF and associated arrhythmias due to particular structural involvements in the left heart (this patient had significant left heart structural involvement in chambers, contractility and valve function but Echo data was incomplete due to it's not reporting the right ventricular parameters).


Therapeutic uncertainties :


Absence of afterload reducing agents for his left heart failure management 


Role of indiscriminate antibiotics in  absence of microbiological drivers 


 Role of CAD prophylactic agents and their stopping in indirectly precipitating the current outcomes of arrhythmias 


 Role of mucolytics and mucokinetics in COPD acute exacerbations 



3)To evaluate each thematic category of arrhythmia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time


The patient timeline that is usually displayed daywise in a single fever chart along with soap notes is currently missing from the above sample case report proforma and hence this third objective is not met at this point of time  


4) To synthesise new learning outcomes over what is currently available and documented globally for patients with cardiac arrhythmia and establish the relationship, if any, between the newly synthesized learning outcomes from each cardiac arrhythmia patient participant and their or their subsequent patient's healing outcomes.


From the above diagnostic and therapeutic uncertainty themes extracted from the single sample case report form and on review of literature of existing knowledge around these, it's clear that  more research using similar clinically complex patient data is needed to synthesize information over what is currently available. In this given individual patient the cardiac arrhythmia appears to have multiple influences, namely the blood gas changes from COPD and or heart failure as well as due to structural changes due to CAD and his outcomes needs to be gathered meticulously over time using currently available "medical cognition" tools. 



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2023 MD General Medicine trainees online learning portfolios

2023 PG Online learning portfolios beginning with  thesis protocols:

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Saturday, January 20, 2024

NMC reg CBME 2019 MBBS UG university exam papers and build up to practicals

The CBME 2019 batch General medicine university final theory question papers are released and finished today:










More about the Competency Based Assessment Module for Undergraduate Medical Education 2019 can be downloaded from the 8th document in their website here : https://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/


To quote from the  "Excerpts from proposed GMER 2019
University Examinations"


"11.2.1 University examinations are to be designed with a view to ascertain whether the candidate has acquired the necessary knowledge, minimal level of skills, ethical and professional values with clear concepts of the fundamentals which are necessary for him/her to function effectively and appropriately as a physician of first contact. Assessment shall be carried out on an objective 
basis to the extent possible.

11.2.2 Nature of questions will include different types such as 
structured essays 
(Long Answer Questions - LAQ), 
Short Answers Questions (SAQ) and 
objective type questions (e.g. Multiple Choice Questions - MCQ). 

Marks for each part should be indicated separately. MCQs shall be accorded a 
weightage of not more than 20% of the total theory marks. In subjects that 
have two papers, the learner must secure at least 40% marks in each of the 
papers with minimum 50% of marks in aggregate (both papers together) to 
pass.

Also check "Annexure 2" :

Examples of theory questions
Sl. No.
Type Explanation Examples
1
Long essay 
question

The question should pose a clinical/practical 
problem to the students and require them to apply knowledge and integrate it with disciplines. 
Avoid giving one liners as 
questions. The question stem should be 
structured and marking distribution should be provided. 

Use action verbs from higher domains 
as given in this document.

Please avoid simple recall based questions. 

What is asked in the examination generally sets the agenda of what and how the students learn. 

A 6 days old term neonate has presented with jaundice noted at 3 days of age. He is born out of normal delivery 
at home. 

On examination, he looks pale, has a liver of 5cms and spleen of 2 cms. Other systemic examination is 
normal. 

a. What is your provisional diagnosis?
b. Which other conditions need to be considered?
c. Enumerate the lab tests that you will order and 
their likely reports in each of the diagnosis that you 
considered.

d. Explain the physical findings in the light of 
underlying derangements.
- Describe the clinical features, complications and 
management of type 2 diabetes mellitus. (3+3+4=10)

The current above papers don't appear to conform? 

Check out more examples of competence based assessment questions in various flavors shared here earlier in the links below :




Quoting again from the NMC document linked earlier and downloadable from the 8th document in their website here : https://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/


"Practical/Clinical examination:

This part should include assessment in psychomotor and affective domain.
Assessment of clinical and procedural skills should be based on direct observations 
by the examiners. 

Avoid making this assessment mainly targeted to knowledge 
domain only. e.g. by asking a learner in a room away from actual patient, “how 
history was taken”. Instead, learner should be observed while he/she is taking history. 

The competencies dealing mainly with skills and affective domains in each 
subject must be included. Many of the tools mentioned for formative assessment may not be usable / feasible at the University examinations e.g. mini-CEX. 

However, multiple tools like case presentations, OSCE and/or OSPE should be 
employed.11,14,18-22."

Past formulations and IA (internal assessment) pilots of the practical exams as per the above NMC as well as KNRUHS guidelines archived here :



More about osce as a "medical cognition tool :



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Wednesday, January 17, 2024

Medical cognition CPD, OSCE, Thesis learning objectives and aim (Blooms levels and kolbs cycle)

Aim :


To collect, document and share patient illness (insert your illness here) event data followed by thematic analysis and evaluation to achieve a synthesis toward correlating improved learning outcomes with patient illness outcomes. 

Objectives :

1) To collect and document patient illness (morbidities and comorbidities) data in their historical timeline (Bloom's level 1 memory feed and Kolb's concrete experiences)

2) To match the collected individual particular patient event data with past  generalizable data around similar illnesses (Bloom's and Kolb's conceptual understanding)

3) To apply available knowledge based on one's experiences and past general knowledge concepts (level 1 and 2 above) through communicating (declarative knowledge) and performing (procedural knowledge) necessary procedures to improve diagnostic or therapeutic  outcomes in the particular illness under study (Blooms level 3 and Kolb's team based reflective observations and active experimentation)

4) To analyze particular patient event data by extracting them into thematic categories for further evaluation (Blooms level 4) 

5) To evaluate each thematic category of patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time (Blooms level 5)

6) To synthesise new learning outcomes over what was available globally prior to the above (level 1-5) learning exercises with relevance to the particular illness under study and establish a relationship between the newly synthesized learning outcomes with that of the study patient's healing outcomes.(Blooms level 6)


More about the CPD :

The aim is to improve medical cognition in health profession students. 

Participants of our CPD and our case based blended learning ecosystem CBBLE learn to utilize medical cognition tools to integrate medical education and practice and eventually improve

global learning  toward local caring.

This year's theme is "Blooming real patient OSCEs."


More about the OSCE:

The apparently new OSCE we are trying to promote is hands on professional skill development in objectively structuring (OS) real patient centered subjectivity toward optimal clinical evaluation (CE) in improving real patient outcomes in real time!

There's nothing new to it as it's an age old routine real clinical workflow for every physician that often goes unsung and we are probably trying to add a song here! 

More WIP about the real patient osce project here:

https://medicinedepartment.blogspot.com/2023/12/ongoing-project-draft-optimizing.html?m=1



More about the Thesis:

Ongoing projects in medicine other than the departmental post graduate thesis are all centred around "medical cognition" and optimizing clinical complexity using medical cognition tools. 


 



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