Sunday, October 6, 2024

Critical realist heutagogy and the theatre of oppressed in medical education: past celebrations and present failures

In his book, the pedagogy of oppressed, Freire calls traditional pedagogy the "banking model of education" because it treats the student as an empty vessel to be filled with knowledge, like a piggy bank. He argues that pedagogy should instead treat the learner as a co-creator of knowledge.


This was subsequently incorporated in the work of Augusto Boal in "theatre of oppressed" that is a form of "simulated education" where the audience learners (spect-actors) get to learn with the teachers (professional actors).

We often find simulations as an easy way of delivering medical education too and there are currently many tools and tactics to deliver these and yet most medical practitioners and practicing teachers tend to engage more with the primary beneficiaries of medical education (patients) in real time and perhaps even need their students and spect-actors to actually lend them a hand (as in a hands on approach to co-creating knowledge) and thus actually benefiting the primary beneficiaries of medical education, even creating a scope to correlate student and teacher learning outcomes with patient illness outcomes.

Co-creating emancipatory knowledge in real time:

We look back decades before "critical pedagogy" was founded and peer into the life of an Indian hands on Marxist anarchist revolutionary, Bhagat Singh, who for some time in his short existence of 20 years had been exploiting the power of drama as a means to inspire the revolt against the British, purchasing a magic lantern to show slides that enlivened his talks about revolutionaries. 

In 1929, he proposed a dramatic act to the HSRA intended to gain massive publicity for their aims. Influenced by Auguste Vaillant, a French anarchist who had bombed the Chamber of Deputies in Paris,[36] Singh's plan was to explode a bomb inside the Central Legislative Assembly. The actual intention was for the perpetrators to allow themselves to be arrested so that they could use court appearances as a stage to publicise their cause. The Supreme Court of India established a museum to display landmarks in the history of India's judicial system, displaying records of some historic trials. The first exhibition that was organised was the Trial of Bhagat Singh.



Much has happened in the years since then with further evolution of critical pedagogy embracing critical realism that allows healthcare learners to 1) understanding complex outcomes, (2) optimizing interventions, and (3) researching biopsychosocial pathways. Such questions are central to evidence-based practice, chronic disease management, and population health.



Source: https://www.researchgate.net/publication/342246458_Critical_realism_and_constructivism_merging_research_paradigms_for_a_deeper_qualitative_study/figures?lo=1

Full text: https://fenix.iseg.ulisboa.pt/downloadFile/281608120804971/Critical%20realism%20and%20GT%20Hoddy%202019.pdf


There have been as a result, co creation of critical realist pedagogy in real time through team based learning between multiple stakeholders such as health professional learners, faculty, patients and their relatives that has been supported be technology where all these stakeholders co create as online system users, with a username, something that has been labelled user driven healthcare.


This co creation has enabled healthcare educator practitioners to not only remain focused on real patient care centred learning outcomes but develop realist ontologies for medical education and practice such as "real patient OSCEs" that retain whole patient clinical complexity rather than reduce it to smaller parts in order to optimize clinical complexity.


Present failure:

"Many if not most students come to the university in order to gain access to and eventual enfranchisement in 'the establishment,' not to critique and reject its privileges."

Students want to gain, rather than to critique, positions of privilege, as encouraged by critical pedagogues."


Updated terminology:

[06/11, 09:50] Kmcq: Heutagogy!
Pedagogy is outdated


[06/11, 09:52]: It's a heutagogist's strategy of calling heutagogy as pedagogy but yes I realise it would be better to name it heutagogy

@⁨Meta AI⁩ how's heutagogy different from pedagogy?


[06/11, 09:53] Meta AI: Heutagogy and pedagogy are two distinct approaches to learning and teaching:

*Pedagogy:*

1. Teacher-centered
2. Focus on transmitting knowledge
3. Emphasis on instructor's expertise
4. Learners receive information passively
5. Assessment-focused

*Heutagogy:*

1. Learner-centered
2. Focus on self-directed learning
3. Emphasis on learner's autonomy
4. Encourages critical thinking, reflection, and meta-cognition
5. Flexibility and adaptability

Key differences:

1. Control: Pedagogy (teacher) vs. Heutagogy (learner)
2. Focus: Knowledge transmission (pedagogy) vs. Learning process (heutagogy)
3. Role of teacher: Expert (pedagogy) vs. Facilitator/Mentor (heutagogy)

Heutagogy fosters:

1. Self-directed learning
2. Personalized learning paths
3. Collaboration
4. Real-world applications
5. Reflection and meta-cognition

In heutagogy, learners take ownership of their learning, and teachers guide and support.

*Evolution of learning approaches:*

1. Pedagogy → Andragogy (adult learning) → Heutagogy (self-determined learning)

*Implications for education:*

1. Shift from standardized to personalized learning
2. Emphasis on developing critical thinking, creativity, and problem-solving skills
3. Integration of technology-enhanced learning
4. Redefining teacher roles and responsibilities

Collective cognition feedback Update:

[08/11, 08:51]drnr : It may be difficult for medical teachers to emulate Bhagat Singh's dramatisation: to allow or kill a patient for explaining the natural history of the disease, and then face the fury of the family, the MCI and the never ending judicial proceedings!

The medical student may not be left with many teachers, unless Hezbollah takes over medical education ((strictly for boys (pun intended))!


[08/11, 08:55]rb: That was an extreme case!😅


[08/11, 08:56]rb: But because of some Western Bhagat Singh's who cleverly designed the randomized controlled trial post pencillin, we can still reap it's benefits

[08/11, 08:59]drnr: You could always have a new GCP, with a slave act enabled


[08/11, 09:07]rb: The existing ones are just that! Slave acts! Yes that's the term to best describe most guideline based medicine vs true evidence based medicine 👏👏

[08/11, 09:10] rb: This makes me reimagine the randomized controlled trial participant as Bhagat Singh on trial (and to be true to medical ethics and patient autonomy, the patient has had a good role in it's design) although it's difficult to predict the random outcome for any of the participants in the trial as that's what equipoise should be all about! The patient Bhagat Singh just stands there, brave and strong ready to meet whatever the dice ordains!
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Mahatama Gandhi's list of CBME competencies

From his autobiography and other's testimonies:


1) CBME procedural competence in surgical dressing and administration of medicines:

"His early experience in healthcare started when his father was suffering from a fistula; he was one of the attendants to his father. He had duties, which mainly consisted in dressing the wound, giving medicine to his father and compounding drugs whenever they had to be made up at home. Gandhi was thus initiated into  medical service!"

Unquote 

2) AETCOM CBME cognitive competence in helping patients and prompt referral for further help:

From his Autobiography, “The question of further simplifying my life and of doing some concrete act of service to my fellowmen had been constantly agitating me, when a leper came to my door. I had not the heart to dismiss him with a meal. So I offered him shelter, dressed his wounds, and began to look after him.” But later he was sent to the government hospital for indentured labourers. He further said, “I longed for some humanitarian work of a permanent nature."

Unquote 

3) AETCOM CBME cognitive competence in history taking and case presentation as well as perceiving healthcare as a calling and finding mental peace as a currency for job satisfaction:

"The work of dispensing medicines took from one or two hours daily, and I made up my mind to find that time from my office work, so as to be able to fill the place of a compounder in the dispensary attached to the hospital… This work brought me some peace. It consisted in ascertaining the patient's complaints, laying the facts before the doctor and dispensing the prescriptions. It brought me in close touch with suffering Indians…”

Unquote

4) CBME procedural competence in Obstetrics:

"There was no time to summon a doctor or nurse because Kasturba got the labour pain so suddenly and the birth came quickly. Once again the birth was difficult but this time Gandhi delivered the baby safely all by himself! Devadas, Gandhi's last son, was born on May 23, 1900. Gandhi said, “The birth of the last child put me to the severest test. The travail came on suddenly. I had to see through the safe delivery of the baby. My careful study of the subject in Dr. Tribhuvandas’ work was of inestimable help. I was not nervous."

5) AETCOM cognitive and procedural competence in Infectious disease epidemic management:

South Africa 1904 , Sjt. Madanjit sent a note to Gandhi saying, “There has been a sudden outbreak of the black plague. You must come immediately and take prompt measures, otherwise we must be prepared for dire consequences. Please come immediately.” The municipality thanked him for this prompt action and supplied him with disinfectants and also sent a nurse. He gave medical aid and cleaned the patient's beds, sat by their bedside at night and cheered them up."

Unquote 

5) CBME procedural competence in Patient transport and administration of medications:

"Gandhi recollected the services rendered in the Boer War, “We soon got work and that too harder than we had expected. To carry the wounded seven or eight miles was part of our ordinary routine. But sometimes we had to carry badly wounded soldiers and officers over a distance of twenty-five miles. The march would commence at eight in the morning, medicines must be administered on the way, and we were required to reach the base-hospital at five. This was very hard work indeed.” 

6) AETCOM CBME procedural competence in silent service driven empathic communication:

"The good Doctor told us that he could not induce Europeans to nurse the Zulus, that it was beyond his power to compel them and that he would feel obliged if we undertook this mission of mercy. We were only too glad to do this. We had to cleanse the wounds of several Zulus which had not been attended to for as many as five or six days and were therefore stinking horribly. We liked the work. The Zulus could not talk to us, but from their gestures and the expression of their eyes they seemed to feel as if God had sent us to their succour.”

7) CBME competence in actionable empathic buy in of a doctor patient relationship:

"Gandhi had a glum, ferocious, uncommunicative African jail mate attendant. One day, he was stung by a scorpion. He was screaming like anything and Gandhi saw this intolerable pain. He immediately took the African's hand and washed it clean and he started sucking the injured area. He was extracting the poisoned blood as much as he could and spitting out. He was relieved from pain. Gandhi applied tincture and bandaged his arm. He became Gandhi's devotee thereafter."

8) CBME cognitive competence in observing procedures (see one, do one, teach one, skipping the latter two):

"Noted in Gandhi's diary on May 15, 1947, “Manu has a severe stomach-ache, she also had vomiting and is running temperature. I therefore called in the doctors who examined her. Manu's complaint was diagnosed as appendicitis. I had her removed to the hospital immediately. She will be operated upon at night. Watched Manu's operation at the hospital. Mridula and Madu were keeping her company. But they were not allowed inside the operation theatre. I had put on a surgical mask and watched the whole operation."

Unquote 

9) CBME competence in medical decision making (such as to operate or not to operate):


In the letter to Jaisukhlal Gandhi, father of Manubehn Gandhi, on the next day, Gandhi said, “I had suspected even in Delhi that it was appendicitis. I had hoped that treatment with mud-pack would help her to get well. But it did not help her sufficiently. I, therefore, called in the doctors yesterday. They advised an operation, and I therefore got her operated upon.”

Unquote 

10) Competence in making career choices:

"It was Gandhiji's elder brother who dissuaded him from pursuing medicine because he said their father would have disapproved of the decision; since the Gandhis were Vaishnavas, they would have nothing to do with dead bodies. His brother suggested instead, it would be wiser to study law and become a barrister, which is what Gandhiji did."

"Later though, even as he practised law, Mahatma Gandhi continued thinking about visiting London to study medicine. However, in 1909, he wrote to a friend saying he had heard from certain doctors that they had killed about fifty frogs while studying medicine. He said, if so, he had no desire to do the same, because he neither wanted to kill nor dissect frogs."

Unquote 

11) CBME competence in enterprise and innovation:

"With the help of three colleagues, Gandhiji put all the patients in a vacant house and took on the role of both doctor and nurse. Even though they did not have the means needed to manage a situation of this magnitude, they did all that they could to help. The Council, on their part, provided a vacant godown for the patients; however, this building was unkempt and filthy. Gandhiji and his colleagues not only cleaned up the building, they also raised money to buy a few beds and other necessary things by reaching out to charitable Indians. Soon, an improvised temporary hospital was set up. The local authorities sent a nurse, who arrived with brandy and other hospital equipment. Instructions were given to provide frequent doses of brandy to the patients. Gandhi had no faith in the beneficial effects of brandy and, with the permission of Dr. Godfrey, who was the doctor in charge, he put three patients who were prepared to forego brandy under the earth treatment, which required applying wet earth bandages on their heads and chests. Two of these patients survived. The other twenty died in the godown. Gandhiji said it was impossible to ascertain how the two patients who had agreed to the earth treatment were saved, but this incident enhanced his faith in the earth treatment as well as strengthened his skepticism for the efficacy of brandy as a medicine."

Unquote

12) CBME competence in putting prevention above treatment:

"I overeat, I have indigestion, I go to a doctor, he gives me medicine. I am cured, I overeat again, and I take his pills again. Had I not taken the pills in the first instance, I would have suffered the punishment deserved by me, and I would not have overeaten again. The doctor intervened and helped me to indulge myself. My body thereby certainly felt more at ease, but my mind became weakened."

Unquote 

13) CBME Competence in designing rural medical learning and practice centers:

"He said the halls for treatment and experiment should be surrounded by huts that could serve as residences for patients and children who were being treated there. He also said the sanatorium should grow fruits, flowers, food grains and vegetables, that it should have cattle sheds and roads good enough for vehicles. He also suggested having a gymnasium, a tank for bathing and other facilities. Gandhiji said it was best to avoid procedures that required electricity, such as hot and cold water and steam regimens."

Unquote 

1-9 points above have been quoted from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515737/, which again has collated quotes from sources such as:

1. Bandopadhyaya A. Bahuroopi Gandhi. Popular Prakashan, Bombay. 1964 [Google Scholar]
2. Gandhi A. Mumbai: Jaico Publishing House; 2000. Untold Story of Kasturba. [Google Scholar]
3. Gandhi M. New Delhi: Publications Division, Ministry of Information and Broadcasting, Govt. of India; The Collected Works of Mahatma Gandhi; p. 20002001. [Google Scholar]
4. Gandhi MK. Ahmedabad: Navajivan Publishing House; 1927. An Autobiography or The Story of My Experiments with Truth. [Google Scholar]

10-13 have been quoted from:

Notes:

Abbreviations used:

Competency-based medical education (CBME).

CBME is an outcomes-based approach to the design, implementation, and evaluation of education programs and to the assessment of learners across the continuum that uses competencies or observable abilities. The goal of CBME is to ensure that all learners achieve the desired patient-centered outcomes during their training.

Unquote:

https://www.aamc.org/about-us/mission-areas/medical-education/cbme

AETCOM: An Indian abbreviation coined by the Indian medical council, a medical education regulatory body, which stands for Attitude, Ethics and Communication and is designed as (AETCOM) modules to develop a foundation of positive attitude, ethics and communication in the Indian medical graduate.


"Gandhi was able to walk about 79000 km in his lifetime which comes to an average of 18 km per day and is equivalent to walking around the earth twice."


Past lectures on "Indian informal healthcare" , Patient centered CBME as a game changer, Generalism in medical education and The ultimate "role playing in education" in the search box in our departmental website here: medicinedepartment.blogspot.com




Creative commons license: https://commons.m.wikimedia.org/wiki/File:Gandhi_suit.jpg#

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Wednesday, October 2, 2024

2024 LOR narratives between LOR seekers and a grumpy LOR giver

UDLCO summary:


These are dyadic narratives between "letter of recommendation" aka LOR seekers and an LOR giver where many themes such as the correlation between patient centred learning outcomes and patient illness outcomes interplay in the background while the dyadic narrative shows a tussle between the seeker and potential giver in terms of trade offs around transparency and accountability integrating medical education and practice.

UDLCO Keyword glossary:


Conversational Transcripts:

June 2024:

[28/06, 11:15] anonymized medical student aka AMS: Good morning sir. I’m ..., from ... batch, completed 4th year and internship under you in ... and ... I’m applying to match in US this cycle and I wanted to ask if you can give me a letter of recommendation LOR. I will draft everything . The letter has to be uploaded by you in a website. I’ll be providing you with all the instructions . Please let me know, if it’s possible sir. Appreciate the help. Thank you


[28/06, 11:36] CBBLE moderator: Here's how my LOR looks like 👇


We provide a link to your online learning portfolio in the lor so that the program director can also assess it


[28/06, 11:38] AMS : Sure sir:) I will draft in this way and will provide the process to upload it. It’s that uploading should be done by department


[28/06, 11:40] AMS : Is it okay sir? I’ve explained it to medicine department office clerk, the uploading process


[28/06, 11:42] LOR giver LORG: I've done them myself many times in the past from my mobile

However few things

The lor should contain the link to your online learning portfolio

I will need to go through the link to your online learning portfolio to decide your formative assessment percentile if you can share it asap


I can only sign the document as a Professor of medicine without any other mention of my administrative position.

[28/06, 11:43] AMS: Okay sir

[28/06, 12:20] AMS: IM SEL format, do you give in this format sir




[28/06, 12:37] LORG: Yes but for this I need to assess the students here for a few weeks as elective trainees here.


[28/06, 12:46] AMS: Okay sir. Can I know what’s the role of global elective learning program?


[28/06, 14:33] LORG : Sure

Here's more about it 👇


July 2024:

[21/07, 04:07] Anonymous medical student lor seeker aka AMS LORs: 

Hello Sir,
Good morning, hope you are doing fine.Can I have a letter of recommendation from you for the Internal Medicine  residency application in United States in  ... 2024.It would be of great help if possible.
Thank you.


[21/07, 13:12] LOR giver aka LORG: Here's how our LOR looks like 👇


We provide a link to your online learning portfolio in the lor so that the program director can also assess it


[22/07, 03:56] AMS LORs: Yes sir it will be a unique approach and will also be having credibility.Can I provide you with a draft of the letter  so that I can submit in the office  after your signature.


[25/07, 07:14] AMS LORs: Hello Sir 
I have sent the draft.
If needed I will send it in the form of document or PDF.
I have a request sir.
My name in the table is mentioned as ...It will be very helpful if changed to "..." if possible.
Thank you Sir.


[25/07, 08:35] LORG: Here are my edits below to what you shared and I had to delete a few statements you used because we can make those statements only for a few students in the top 1% in our assessment, who have particularly worked with us here in the campus and we have given them a recommendation that allowed them entry to a paid research fellowship as well as faster processing of their green card. They passed out as interns from your batch (from a different college, although they spent time in your college too as an elective for nearly a month and helped us publish our flagship publication about our learning program)

Check out my edits below to what you shared 👇

Dear Program Director,

Dear Program Director, I am pleased to write a letter of reference for Dr... in his application for your program.


I am currently a full Professor in the Department of General Medicine at the ... Institute of Medical Sciences, India from where Dr... trained as an undergraduate 
and other than a graduate residency training and undergraduate program, we also host a patient centred, global elective learning program.

Our department has known ..., since his second year General Medicine rotations, and he has interacted with us ever since in his group and most of his verbal
and non verbal interactions can be accessed from his online learning portfolio in our departmental (entry year wise) dashboard
here: at [https://medicinedepartment.blogspot.com/2022/02/?m=0 ] with comparable performances of his group members accessible from the same platform, where his performance in our
personal assessment ranks at the top 25% of his batch.

Our department can strongly attest to most of our students’ abilities as we've had the opportunity to oversee them in both the In-patient and Out-patient setting and work with them during their
internship.

We wish him well in this new learning journey in your own institutional program.


[08/08, 23:50] AMS LORs: Hello Sir,
I have been given the Opportunity to speak in the symposia on Aug 14th


[11/08, 22:43] LORG: What about sharing our original work with the PaJR network? 

What you are planning doesn't sound like an original work?


[11/08, 22:45] AMS LORs: Yes Sir but I didn't know how to present that
Should I make a blog about the cases or any other way


[11/08, 22:45] LORG: Discuss this with our SR who is also presenting in the same session


[11/08, 22:46] AMS LORs: Yes Sir Got it
We will discuss about that 
Thank you.


[11/08, 22:48] LORG: Hope you will YouTube your presentation and share the link soon after


[14/08, 02:04] AMS LORs: Sorry for the delay Sir.
Is this presentation acceptable.


[14/08, 07:26] LORG: Well done 👍👏👏

[14/08, 07:28] LORG: Emphasize in the very beginning that this is an age old technique that builds on the "case report as the unit of medical knowledge" model and the cases are meticulously deidentified as per global HIPAA guidelines

[15/08, 09:21] LORG: How was it yesterday? Hope all went well?

[15/08, 20:23] AMS LORs: Yes sir it was good 
Thank you for the opportunity Sir !!!
Sir should I create a channel and post the video

[15/08, 21:32] LORg: Yes please. I'm looking forward to it

[16/08, 10:26] AMS LORs: video link 

[16/08, 10:26] AMS LORs: Sir is the title and description fine or should I change

[16/08, 10:28] LORG: Looks good 👏👏

[18/08, 15:07] LORG: Summary: Below are links to videos and slides of our PaJR team presentation at NCBS Bangalore on 14th August, 2024 focusing on our PaJR platform methodology that is largely about integrating diverse paths of knowing through team based learning and their archival in online learning portfolios. This is followed by video links to Prof Sudhir Krishna's presentation of integrating  modern science benches to clinical bedsides where diversity of approaches already abound.



[21/08, 05:50] AMS LORs: Hello Sir, Good Morning.
I have a request regarding the Letter of Recommendation for my Internal Medicine residency application.
Is it possible to provide it in the format of IMSEL ( Internal Medicine Structural Evaluation Letter) that I have provided below.

Thank you.


[21/08, 06:58] LORg: Yes for that I would need to evaluate you on our current patients and you would have to work for us for 3 months


[21/08, 11:09] AMS LORs: Yes Sir, but Currently I am doing clinical rotations in united States and recently  I got to know about IMSEL for September application.
Okay Sir, I will communicate with medicine department clerk regarding previously mentioned format.
Thank you Sir !!!


[24/08, 08:12] AMS LORs: Yes Sir I have sent the LOR request for the above mentioned mail ID.
Thank you !!!


[24/08, 08:43] LORG : Something has gone wrong with the portal. It's not allowing me to the exact site now after I clicked to upload the LOR although the site is shown me as logged in

[24/08, 09:20] LORG: I guess there's some problem with their website

With great difficulty I was able to log out of it by deleting all my browser cache etc but now it's not allowing me to sign in and putting me in a loop. It's saying my username or password is wrong.When I'm entering my forgot username option it's sending me the same username that I was entering!

Not sure how to reach out to AAMC to report this


[24/08, 09:26] LORG: Your account has been temporarily locked. It will be unlocked after 10 minutes for you to log in. In case you have attempted to login before the account is unlocked, please wait and try again later.

[24/08, 09:28] AMS LORs: Sorry for the inconvenience sir
After it gets unlocked if you are unable to reset the password can you please fill your details in the link i have sent you.

[24/08, 09:32] LORG: It's the same link that takes me to AAMC where I have to sign in with my un and password

[24/08, 09:40] AMS LORs: Yes sir
Once you fill the details,they will reach out to you Sir.

[24/08, 09:40] LORg: I know I've done this countless times.

Only this time I'm unable to sign in

[24/08, 09:42] AMS LORs: Yes sir got it
I will try calling them and explain the situation.

[24/08, 09:52] AMS LORs: Okay Sir may be it will be better to do it from their side.
As tomorrow is a holiday for their office I will contact them on monday 
and tell your  name and email address so they will be able to contact you and resolve the issue.

[24/08, 10:02] AMS LORs: Sir will you be able to contact them through the link provided in this page

[24/08, 11:13] LORG: The same link is through what I have been trying and it's sending me into a loop

[24/08, 19:44] AMS LORs: Sir I am not understanding what to do about this...and this is the First lor for my application.

[24/08, 20:13] LORG: Some of the students are using different lor portals such as sophas

[24/08, 21:22] AMS LORs: Yes sir I have checked that out may be it is only for public health courses

[24/08, 21:28] LORG: 👆 Let's hope this plan of yours works out

[24/08, 22:10] AMS LORs: Yes Sir 
I will let you know after speaking with them.
Thanks a lot !!!

[26/08, 23:03] AMS LORs: Hello Sir,
I have contacted them and they told to send an email regarding the issue to them so they can register a case and solve the issue.

The email Id  is :
I have told them already that the username they are sending is not helping to log into the account.

Thank you Sir.

[27/08, 06:56] LORG: 
Date: Tue, 27 Aug 2024, 06:55
Subject: Inability to log in to my AAMC account to provide an LOR


I could log in initially with my old user name and password on 24/8/24 and was about to submit the LOR when suddenly the webscreen disappeared and then i was unable to log out as well as perform no other function.

With great difficulty later , I was able to log out of it by deleting all my browser cache etc but now it's not allowing me to sign in and putting me in a loop. 

It's saying my username or password is wrong.When I'm entering my forgot username option it's sending me the same username that I was entering!

Please help.

best regards,


Professor of Medicine
India

[27/08, 07:06] AMS LORs: Yes sir thanks a lot !!!

[27/08, 08:52] LORG: 

Dear LORG,

Thank you for contacting AAMC Services. We have received your request. Typically, responses are sent within one business day.   

Your case number is ...


[27/08, 09:58] AMS LORs: Yes sir if there is a delay I can follow up with this case number.
Thank you.

[27/08, 21:06]LORg: Done

Uploaded

[27/08, 21:22] AMS LORs: Yes Sir 
Thanks a lot !!! 🤗

Early September 2024:


[10/09, 01:26] Anonymous medical student LOR seeker aka AMS LORs: Hello sir!

[10/09, 01:26] AMS LORs: Hope you’re well.

[10/09, 01:27] AMS LORs: Coming to my request of your personalised LOR. As u told me to I made a draft of it with all the things I did over time with you. 

Can you please sign it for me? I would send it with a student. 

It would mean the world to me and my application for my residency. 

I’m applying this match cycle for internal medicine here in the USA. 

Hoping for a positive response.


[10/09, 09:41] LOR giver aka LORG: As discussed earlier I can't endorse this because I don't have any evidence to support the claims it makes. 🙂🙏

Sharing the last LOR i did last few days back below and it's what most of our students have had time to gather evidence for during their tenure with us. It's not their fault. It's just that no one told them earlier that gathering evidence is crucial.


[10/09, 09:46] AMS LORs: Sir I am involved in the care of our ... patient.
Part of many PaJR  groups. 
I did present some cases in the college 
I did do a couple of central lines and abgs in the rotations. 
I play sports , a lot of them Infact 
I have proofs on watsapp and as pictures. 
You told me that I could involve things I actually did. I just included them and detailed them into a better vocab. That’s all 🥲


[10/09, 09:47] LORg: I can empathise with it but trust me program directors see it all the time!

A smaller endorsement could actually make it better for you is what I sincerely believe

[10/09, 09:47] AMS LORs: No sir! They want

[10/09, 09:47] AMS LORs: That written dramatically

[10/09, 09:47] AMS LORs: That’s when they consider

[10/09, 09:48] AMS LORs: The things written in it makes all the difference

[10/09, 09:48] AMS LORs: And that coming from my mentor(I feel so) and someone who has seen me for so many years

[10/09, 09:48] LORg: That's what the people who you have paid to hear are telling you. Trust me they have no idea what even they want!

[10/09, 09:50] LORg : Trust your mentor to put the things he believes will be useful in your LOR


[11/09, 01:48] AMS LORs: Sir, Could I please provide you evidence for those things? And you would help me with that LOR?

[11/09, 07:05] LORg: Your online learning portfolio is the best evidence


[11/09, 07:09] LORg: Other than the single ... patient, please share with online dated traces (audit trails)what were your inputs and attempts to maintain informational continuity about the other 1000s of patients in our PaJR groups. 

To me even your performance with that one patient was inspirational and i can put that into the LOR


[11/09, 07:25] AMS LORs: Sir I haven’t updated that in years because I got busy.

[11/09, 07:26] AMS LORs: I am mainly involved with our patient 
And v v few inputs or conversations regarding other few but I don’t have the clinical texts cause they got deleted. Like many other due to some watsapp chat updating thing, unknowingly.


[11/09, 07:27] AMS LORs: I am so sorry to be asking like this, but I feel helpless.


[11/09, 07:32] LORg: Have you thought about why the others are happy with the standard format i gave them? 

Can you talk to them and find out?


[11/09, 07:33] AMS LORs: Sir, if you want me to be honest . 
they aren’t happy sir. 
Not sure if they ll upload it even. 
I’m speaking up because I know you and I feel that freedom with you to speak the truth.


[11/09, 07:34] AMS LORs: They won’t upload cause every other letter is very detailed and everything 
Can’t have a standard letter cause it would hurt the application 
Because you’re the only doc that has seen us the longest

[11/09, 07:55] LORg: I'm only talking about those who have already uploaded it.

We have also given special LORs to people junior than you who finished their internship later and straightaway joined in a paid research associate position in USA.

He spent a month here in our campus during his MBBS and achieved so much for our primary beneficiaries of medical education that most of our own students can't dream of achieving in 5 years with us. Also his father was admitted as a patient with us all the while.


[11/09, 07:55] LORg : I have seen that student the longest in one month that I couldn't see any of you in 5 years

[11/09, 08:06] LORg: What you have done with the single case of ... is nothing short of ground breaking but there are a few students in our campus who have done that with many more cases

[11/09, 10:49] AMS LORs: Sir, can you please give me the LOR of your choice? With the one PaJR and any other things you approve I did? Thank you :)

[15/09, 21:15] LORg: 👆Ask our medicine department clerk to prepare the draft of the standard format in which i shall make my positive additions

[15/09, 21:28] LORg: Ask him to show me the draft tomorrow and I shall edit it while in OPD

[15/09, 21:28] AMS LORs: Done sir. Will do.

[16/09, 09:23] LORg: Gave you an assignment in the PaJR group to test your patient centred EBM skills before I provide your LOR.

Will be looking forward to your inputs whenever you can

[16/09, 09:28] AMS LORs: Sir saw the assignment.

[16/09, 09:29] AMS LORs: I’m sloshed with work and application and so many deadlines

[16/09, 09:29] LORg: Where are you working currently?

[16/09, 09:30] AMS LORs: University of...

[16/09, 09:30] AMS LORs: Doing a cardiology Rotation sir

[16/09, 09:30] AMS LORs: Really hectic coming at 9pm at night

[16/09, 09:33] LORg: What kind of work do they make you do in that rotation? Knowing that  would help me to formulate my individualized LORs better

[16/09, 09:38] AMS LORs: Take patient histories,  examination , case presentation and do the EMR notes sir

[16/09, 09:38] AMS LORs: And case discussions

[16/09, 09:38] AMS LORs: I’m doing cardiology consult, so all the cardio cases in the entire hospital first come to us and we have to handle them

[16/09, 09:38] AMS LORs: Only one fellow me and one resident.

[16/09, 09:39] AMS LORs: That’s why v hectic.

[16/09, 09:45] LORg: You appear to be now doing all that we hoped you would have done as an MBBS student as well as Intern here. Tell me frankly how difficult would it have been for you and your batchmates to do all this with us here and what are the reasons it's not done here anywhere


[17/09, 06:51] AMS LORs: Hello sir. Makes sense. I asked this question to myself and about everyone else as well. 
But I did try my best doing things there. I think it’s the lack of knowledge for me at that point, the responsibility we have when compared to the PGs and the patient load . And the utmost thing, I think is the desperation for us to come here as residents sir. We did not have the compulsion to do it sir. And that’s a bad thought. 
And I think the entire curriculum not being organised and set on a lot of levels. 
Like here it’s mandatory to document, being a doctor comes with the paperwork. 

There when you introduced it , it was an extra effort people have to put and they did not receive it well. For a lot of reasons.

[17/09, 06:52] AMS LORs: And also, the SOAP notes u introduced is exactly what happens here

[17/09, 06:52] AMS LORs: That’s basic and that needs to be done every single day.

[17/09, 07:42] lorg: How about doing a project where you raise awareness in Indian UGs to reform themselves toward patient centred learning rather than rote memorization and indifference to patient requirements?

[17/09, 07:43] AMS LORs: Absolutely sir! 
That’s my plan. To educate them

[17/09, 07:43] AMS LORs: Those are my future goals.

[17/09, 07:43] AMS LORs: Just not at the moment sir. I’m mentally sick myself handling all the things here. In a couple of months for sure.

[17/09, 09:41] LORg: Till our curriculum policy makers here learn to work for the primary beneficiaries of medical education in their program schedules and mandates, we shall continue to take things for granted at every faculty student level

Was just discussing with pan India medical education faculty around this today morning 👇


[19/09, 21:15] AMS LORs: Sir I was included in the quality improvement project also

[19/09, 21:15] AMS LORs: And presented it in the conference.

[19/09, 21:18] LORg: Do you have any link to that presentation?

[20/09, 19:43] AMS LORs: Sir I did the QIP as well.

[20/09, 19:43] AMS LORs: Can u pls add it!

[20/09, 22:27] LORg: It was not shared with our learning ecosystem at that time.

Academics is meant to be done to impact local and global learning ecosystems. 

Academics is not done for LORs but if done to make an impact on the ecosystem, it automatically gets into the LoR

[20/09, 22:31] AMS LORs: Okay sir! Done! 

I didn't do it for the LOR but just thought it would be a good addition since I did it. 
But that’s fine sir.

[20/09, 22:31] AMS LORs: You will see the impact in the future from my end for sure.

[20/09, 22:31] AMS LORs: Thank you for the letter!!! :)

Late September 2024:

[26/09, 22:23] AMS LORs: Hello sir, 
I am ..., I was a previous student of yours sir. I was wondering if you can write me a strong LOR because you have observed me during my time in the clinical rotation and also during my 3rd year of medical school with all the presentations and blogs. I am applying to Internal medicine this year sir. So if it is okay with you, would you be willing to provide an LOR sir? I am looking forward to hearing from you. 
Thank you so much


[26/09, 22:45] LORg: Please share your online learning portfolio link.

This is how your LOR would look like 👇



[26/09, 23:01] AMS LORs: Sir, I would be really grateful if you wrote me a strong LOR, including some other moments you have seen with me

[26/09, 23:02] AMS LORs: It would really help my application

[26/09, 23:02] AMS LORs: I was just wondering because you have seen me from the 3rd year, so I think you would have more to say about me

[27/09, 06:58] LORg: Where are the outcomes of each patient in your learning portfolio?

For example this one?👇

...

Did you email the signed informed consent to ... for all your case reports?

Please share them with me.

[27/09, 07:02] lorg: In this LOR shared here, i remember knowing this girl much more than you largely because of the impact she had on our learning ecosystem for one patient. I can't recall yours having any impact on our learning ecosystem pivoting around any patient. If there are any WhatsApp transcripts of our learning ecosystem discussions around any patient that you participated please share those


[27/09, 07:06] LORg: None of the case reports in your online learning portfolio contain any discussion (learning outcomes) or follow up (patient outcomes)!


[27/09, 09:21] LORg: We remember this particular student's portfolio often as we have cited it many times in our global learning ecosystems.👇


The more your work is cited the more it creates impact and then you don't have to worry about your LOR as everyone would automatically write a good report on your good work!

[27/09, 12:26] AMS LORs: Okay sir






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