CBBLE 2 and an introduction to its information granularity

 

Just to share an example from our regular workflow, "information granularity" in the medical curriculum may be also guaged by online assessment links where if you click on this link here below: https://medicinedepartment.blogspot.com/2020/11/blended-bimonthly-assessment-oct-nov.html?m=0, you may find links to both formative and summative assessment of each individual student, intern and PGs of different years. 

Once you open those links you will find links to the log books of each student that can show the details of each patient they have cared and learned from as a part of a formative assessment of their verbal competency and you will also find links to their offline presentations in the form of online videos as a reflection of their subjective non verbal competency that can be guaged from their body language. 

In our medical education workflow, information granularity appears to begin with the student's online learning portfolio reflecting students learning outcomes and continues (unendingly as learning is a never ending stream) with the patient's healthcare outcomes as the primary beneficiary of Medical education is the patient? 

And then once we dig deeper into the patient's report there are different layers of information granularity about the patient beginning in the macroworld captured by our senses and standard current radio imaging as well those in the microworld of the patient's cells captured through the microscope and the molecular world captured in biochemical tests. 

More here in the link below on the origins of CBBLE2 and I quote:

"Slowly the realization dawned that individual case based experiences were different from the average data being  represented in Clinical trials where each of these individuals was just a number.

2002: Contrary to what 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: 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 patient data 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 

https://www.igi-global.com/chapter/user-driven-learning-environment-botany/49258

2009: 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/

2010-2020--

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/

The 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."

More here: https://medicinedepartment.blogspot.com/2020/07/medical-cognition-research-and-cbble.html?m=1

Blended bimonthly assessment Oct-Nov 2020 results

 Following are the links to the submitted assignments by the students (interns, PGs year 1 and year 2) for the the assignment posted for 7/10/2020 here: https://medicinedepartment.blogspot.com/2020/09/medicine-paper-for-october-2020-first.html?m=1  and the assignment posted for 16/11/2020 here:https://medicinedepartment.blogspot.com/2020/11/blended-learning-bimonthly-assignment.html?m=1 

and in the links below one can find that the summative has been also accompanied by a numerical formative assessment of their online learning portfolios using both verbal and non verbal cues. 

Interns from 2015 MBBS batch posted in the department of Medicine from 

23.09.2020 to 22.11.2020. 

https://docs.google.com/document/u/2/d/1_BNuQlhQ2BXzoKnO_ZL1LUbGAIihInwL3duJ0S_7Xz0/mobilebasic

PGY1s from the 2020 MD General Medicine batch 

https://docs.google.com/document/d/1O4sJDILfqQ0RoGX7f0vR1op7y5JWfLekao9_LsJFtK4/edit?usp=drivesdk&ouid=100497219830377837116

PGY2s from the 2019 MD General Medicine batch :

https://docs.google.com/document/d/1nrUSM2n1wxbtPJIgwYNUIr1GDMc0aWhXK0ikjn4EmHw/edit?usp=drivesdk&ouid=100497219830377837116

The formative assessment has been divided into non-verbal which assesses their competency in procedural domains including empathic communication and body language and verbal which assesses their ability to communicate their work through their day to day E logs.

Most students have done reasonably in the formative assessment in both verbal and non verbal communication domains although a lot remains to be improved on. 

Most students haven't done well at all in the summative assessment as they are still trying to get a hang of how to express themselves in an online open access world where their answers are meant to create a societal impact rather than impress just one examiner who may end up giving good numerical scores in appreciation of their ability to answer from rote memorized facts as per tradition. It's possible that in the current phase of evolution we may find that many have not only plagiarised blatantly from articles on the internet (inspite of express instructions on how not to resort to that) but also copy pasted from each other's log books. 

Blended learning Bimonthly assignment for November 2020

Answer all questions                                                      

Max Marks: 100 

Submit by:                                

Date: 16/11/2020 9:00 AM 

Below is an online formal question paper to be answered online using all available resources at your online disposal over a period of days and E logged in a manner demonstrated by past examinees in the link here https://medicinedepartment.blogspot.com/2020/09/blended-bimonthly-assessment-september.html?m=1

Please go through the patient data in the links below and answer the following questions:

1) "55 year old male patient  came with the complaints of 

Chest pain since 3 days

Abdominal distension since 3 days

Abdominal pain since 3 days and decreased urine output since 3days and not passed stools since 3days 

https://sreejaboga.blogspot.com/2020/11/is-online-e-log-book-to-discuss-our.html?m=1

a) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes. 

a1) Added 17/11/2020 Mention the optimal diagnostic interventions in the patient done and that you may further order in a low resource setting to fathom the etiologic possibilities. 

b) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them? 

Past 2-4 PM discussion videos 

Intern's presentation: https://youtu.be/Pn5tidICB8A

PGs discussion:

https://youtu.be/9caUzjXYuqo

2) A 55 year old male, shepherd by occupation, presented to the OPD with the chief complaints of fever (on and off), loss of appetite, headache, body pains, generalized weakness since 2 months, cough since 2 weeks and vomitings and pain abdomen since 2 days. 

https://aakansharaj.blogspot.com/2020/11/55-year-old-male-with-anemia.html?m=1

a) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes. 

b) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them? 

Past 2-4 PM discussion videos 

Intern's presentation: 

https://youtu.be/9bmV2Tmunqk

PGs discussion:

https://youtu.be/4WqrsnVj92w

3) 51 Year old man with complaints of B/L pitting pedal edema from 5 to 6months,abdominal distension from 2 to 3 days,SOB from 3days.

nithishaavula.blogspot.com/2020/11/51-yr-old-male-with-hfref.html?m=1

a) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes. 

b) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them? 

Past 2-4 PM discussion videos 

Intern's presentation: 

https://youtu.be/c-6HWzXyzy8

4) 31 yr old man with B/L pedal edema with scrotal and penile swelling since 2 months

https://nairaditya97.blogspot.com/2020/11/31-yr-old-male-with-bl-pedal-edema-with.html?m=1

a) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes. 

b) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them? 

Medicine learning competencies through a USMLE LOR lens 2

Dear Program Director,

It is with great pleasure that I endorse Dr. ______, one of our very bright students, for your Internal Medical Residency Program. 

I currently look after the Department of General Medicine at xyz Institute of Medical Sciences and other than a graduate residency training and undergraduate program, we also host a global elective learning program supported nominally by the BMJ group detailed here: https://promotions.bmj.com/jnl/bmj-case-reports-student-electives-2/

Our department has known ______ since her second year General Medicine rotations, and she has interacted with us most heavily in her final year posting in General Medicine. 

As part of her clinical rotations, she was assigned a medical ward and single handedly managed the case study, care, report follow up, and diagnostic work up of more than twenty in-patients at a time. One such 11:00 AM to 1:00 PM regular ward round with students like her is archived here: https://youtu.be/ls-h6vdW4XU

Her interest in the subject went far beyond the necessary academic requirements and led to many in-depth discussions in the 2:00 PM to 4:00 PM sessions archived here: https://www.youtube.com/playlist?list=PLvOgc9_v4PCKsIrVK4laA3_rUJOMPAYKJ

During her rotations, she along with her batchmates submitted records documenting many cases she examined—including Rheumatic heart disease with valvular defects, diabetes, liver cirrhosis, pleural effusions, and cerebro-vascular accidents leading to hemiplegia. Many such cases are recorded in the virtual case bank hosted by the post graduate residents of our department to which our students and interns regularly contribute and is linked here:https://karnativaishnavi.blogspot.com/2020/09/httpsmedicinedepartment.html?m=1

Her unit team members report being impressed with her systematic and meticulous approach to assessing a large caseload, and are certain that she has a strong aptitude for the internal medicine field. 

______ has undergone intensive training in acute medical care, Basic and Advanced Life Support, and can handle most medical emergencies efficiently. 

She has imbibed from our department a patient centred approach to medical care, and shall always makes it her priority to ensure their comfort. 

______ was also an active participant in the pulse polio program among several other social and welfare activities conducted regularly by our hospital for our rural outreach population. 

She was even part of a select group of students who wrote up case studies of patients similar to what has been published by our students here:https://casereports.bmj.com/content/13/9/e233197.full?ijkey=j97rohET1rNJeZm&keytype=ref

I am confident that her strong subject foundation and passion towards the profession will make her an irreplaceable addition to the medical community and I whole-heartedly recommend ______ as an excellent candidate for your Internal Medical Residency Program. 

best regards,

Learning objectives in an average medicine training curriculum globally through the lens of a USMLE residency application

Standard letter of recommendation LOR template:

September 30th, 2020

Dear Program Director,

    I am pleased to write a letter of reference for Ms. _________ in her application for residency. I’ve had the pleasure of guiding Ms. _____ for the past four years. She completed two-month General Medicine rotations, every year, during her clinical years in medical school training, at PQRS Hospital, India. During that time, she was responsible for managing patients by taking patient history, conducting complete clinical examinations, calling in consults, reviewing lab reports, and monitoring patient care. Ms. _____ carried out these responsibilities with diligence and skill. She also attended various academic sessions and actively participated in daily rounds.

    I can strongly attest to Ms. ______ abilities as I’ve had the opportunity to oversee her in both the In-patient and Out-patient setting, taught her in class and worked with her during internship. She has gained experience in diagnosing and managing common medical conditions such as, Diabetes, Hypertension, Tuberculosis, Pneumonia, COPD, Stroke, poisonings and various infectious diseases. She has performed procedures such as pleural and ascitic tap, central line catheterizations, endotracheal intubation and local nerve block administration. She is also well practiced in procedures such as nasogastric tube insertions, IV-line insertions, Foley’s catheterization and drawing arterial and venous blood samples. She had taken the initiative to present various topics such as, ‘Epilepsy’ and Rheumatic Fever’ and actively participated in their discussions during academic sessions. Her enthusiasm to learn, team attitude, and professional work ethic was well appreciated, and she had hence been described as one of the best students on our team by our residents and attending physician.

    Apart from Ms. ______ impressive list of attributes, one well-appreciated trait is her willingness to take initiative. An example of such an instance was during her internship year, when due to unforeseen circumstances, a Health Camp had to be organised last minute. Ms. ____ was one of the few interns who volunteered to attend this Health Camp immediately after completing a night shift at the hospital. She spent the day taking history and examining over 100 patients of a homeless shelter for the mentally ill. Her dedication and passion for Medicine was apparent in her work ethic.

    Ms. ______ has a sound knowledge of general medicine and its various disciplines. In addition, she is hardworking and highly motivated with a good sense of ethics and responsibility. Her communication skills and the respect she demonstrated towards patients, staff and colleagues were impressive. I am confident of her capability of working in a team effectively and efficiently, as she had demonstrated good leadership on multiple occasions. Ms. _____ is a well-rounded and promising student whom I have no hesitation in recommending for your residency program. If you have any further questions regarding Ms. _____ or my experience with her, please do not hesitate to contact me.

Sincerely,

Dr. Xyz, MD

Professor & HOD of General Medicine

Pqrs Institute of Medical Sciences

,  State, India

Mobile No

E-mail: 

Blended bimonthly assessment September 2020 results

Following are the links to the submitted assignments by the students (interns, UGs, PGs year 1 and year 2) for the September bimonthly assignment posted for summative assessment on 7/9/2020 here:https://medicinedepartment.blogspot.com/2020/09/medicine-blended-assessment-biweekly.html?m=1

and in the links below one can find that the summative has been also accompanied by a numerical formative assessment of their online learning portfolios using both verbal and non verbal cues. 

Interns from 2015 MBBS batch posted in the department of Medicine from 23/06/2020 to 22/09/2020:

https://docs.google.com/document/u/2/d/1ouy_gqzmCw82ammZSucemG-75qa6x9nvNi6FovJ2FYI/mobilebasic

PGY1s from the 2020 MD General Medicine batch 

https://docs.google.com/document/d/1pEGZsz3VH9yjE_lDVBQwi7BjbxKFdFVsD2gCux2SAa4/edit?usp=drivesdk&ouid=100497219830377837116

PGY2s from the 2019 MD General Medicine batch :

https://docs.google.com/document/d/11jjVEcnHNlfLpFbfU-eTybTRfp1LPn38NFjA3hbhTvGU/edit?usp=drivesdk&ouid=100497219830377837116

UGs 2016 batch:

https://virtualmedicalcases.blogspot.com/2020/09/medicine-blended-assessment-45-year-old.html

https://rhea9895.blogspot.com/2020/09/two-similar-cases-yet-very-different.html

https://caseopinionsbyrollno156.blogspot.com/2020/09/medicine-blended-assessment.html

https://chitrasrinivas.blogspot.com/2020/09/biweekly-clinical-case-assessment.html

http://shivani2401elogbookmedicine.blogspot.com/2020/09/the-curious-case-of-anasarca.html

The formative assessment has been divided into non-verbal which assesses their competency in procedural domains including empathic communication and body language and verbal which assesses their ability to communicate their work through their day to day E logs.

Most students have done reasonably in the formative assessment in both verbal and non verbal communication domains although a lot remains to be improved on. 

Most students haven't done well at all in the summative assessment and many have not only plagiarised blatantly from articles on the internet (inspite of express instructions on how not to resort to that) but also copy pasted from each other's log books. Some of the top UG students have predictably done well on all fronts including avoidance of plagiarism. 

Medicine paper for October 2020 first week of blended assessment bimonthly

Answer all questions                                                      

Max Marks: 100 

Submit by:                                

Date: 7/10/2020 9:00 AM 

Below is an online formal question paper to be answered online using all available resources at your online disposal over a period of days and E logged in a manner demonstrated by past examinees in the link here https://medicinedepartment.blogspot.com/2020/09/blended-bimonthly-assessment-september.html?m=1

Please go through the patient data in the links below:

"57 year old man with jaundice, pedal edema and abdominal distension since three years and bleeding gums since three days"

https://swathibogari158.blogspot.com/2020/09/chronic-decompensated-liver-disease.html

1) What is the reason for this patient's ascites? 

2) Why did the patient develop bipedal lymphedema? What was the reason for the recurrent blebs and ulcerations and cellulitis in his lower limbs?  

3) What was the reason for his asterixis and constructional apraxia and what was done by the treating team to address that?  

4) What was the efficacy of each treatment intervention used for this patient? Identify the over and under diagnosis and over and under treatment issues in the management of this patient. 

A 54 year old male with cough,abdominal tightness,pedal edema and diarrhea.

https://sainiharika469.blogspot.com/2020/09/hello-everyone.html?m=1

1) Why were his antitubercular therapy stopped soon after his current admission? Was he symptomatic for ATT induced hepatitis? Was the method planned for restarting antitubercular therapy after a gap of few days appropriate? What evidence is this approach supported by? 

2) What were the investigational findings confirming the diagnosis of pulmonary TB in this man? 

3) What was the cause of his ascites?

4) What are the efficacy of each intervention mentioned in his treatment plan and identify the over and under diagnosis as well as over and under treatment issues in it. 

47 year old man with bipedal edema since one year and abdominal distension since one month

https://sushma29.blogspot.com/2020/09/ascites-secondary-to-nephrotic-syndrome.html?m=1

1) What will be your further approach toward managing this patient of nephrotic syndrome? How will you establish the cause for his nephrotic syndrome? 

2) What are the pros and cons of getting a renal biopsy for him? Will it really meet his actual requirements that can put him on the road to recovery?