Workflow for a Blended Learning Medical Elective with BMJ

Here is our workflow ( i am sure you have seen a brief outline here: http://promotions.bmj.com/jnl/bmj-case-reports-student-electives-2/)

Upon joining us you will be required to join our regular ward rounds. The regular workflow in our unit in the department of Medicine, begins with our residents leading the team of medical students and Consultant professors toward collecting data from patients’ bedsides.

Certain immediate decisions are taken on the spot by the Consultants and a few non-urgent ones are kept for processing later. Once the Consultant professors and residents have finished data collection and hands on emergency management rounds of the patients in their bedsides, the data is brought to our office in the research lab for further collaborative processing.

Further processing involves trying to

a) Explore multiple facets of the complex issues around the 'case' in its real-life settings. (See details around this common-sense out-of the-box thinking approach here: http://www.biomedcentral.com/1471-2288/11/100 and here: http://www.pitt.edu/~super1/lecture/lec50421/001.htm)

b) Search for current best evidence for diagnosis and further management of the described condition in each patient. (We prefer Google though Pubmed skills are always welcome). :-)

c) Match the available individual patient data (particular evidence) to generalize-able patient data/current best evidence available online and

d) Help the team come up with a contextually matched patient management plan personalized for each patient.

As mentioned in the BMJ link you will learn on our rounds to:

a) Acquire clinical skills for efficient patient data capture (mostly from our staff accompanying you on the rounds but also from the professor if/when necessary)

b) Acquire efficient clinical data processing skills (as detailed above)
  

c) Acquire skills for individual patient centered clinical audit and feedback to all stakeholders involved in the patient’s care (this may have future entrepreneurial implications...more later below).

d) Acquire skills in writing your individual patient centered experience during the elective as a case report and submit it to BMJ Case Reports for peer review (no Fellowship fee required).

Most of your two weeks will be spent in thinking and writing about the cases that you see with us and would like to publish with us. You will not be allowed to write nurses orders or perform any procedures (as that requires a legal registration with the local medical council here and may also disrupt local functioning). The thinking and writing will continue at your endaround your chosen cases even after your departure. Authorship will be allocated as per these guidelines: http://www.icmje.org/ethical_1author.html

Authorship credit can be obtained for 1) contributions to conception and design, analysis and interpretation of narrative-data around the case 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published.

You will require to write the case right from day one in a blended learning approach even as it evolves (at least the patient's history if not the discussion) and post it right away on a blog (after ensuring that you obtain signed informed consent)  and share the link also with our online processing forum 'tabula-rasa' where you have been already added through your face-book portfolio.

The only important thing we offer you here is an experience in 'patient-centered-learning' and the only reward we expect from you is to contribute to our learning by helping us explore our patients further even as you proceed to write about them. Learning is to a large extent self-directed and dependent on reflective observations and abstract conceptualizations around the concrete events that we experience. Our concrete experiences in turn depend heavily on our curiosity and our ability to ask questions without worrying about giving away our ignorance.

DO’s and DON’T’s during your stay:

Don’t write any prescriptions on the hospital file.

Do write about the case in your own notepad and share it through the online forum after ensuring you have taken the appropriate authorization and informed consent from the patient.

Don’t quarrel with the nurses and other staff

Do interact with them in a positive manner to benefit your patient/s who you shall be researching, reporting and publishing at the end of your elective.

Worst Case Scenario: You may expect us to teach you and not find our case-based discovery-driven learning worthwhile and also find it to be largely a waste of time and money spent in accommodation and travel. Consequently you may not be able to write anything worthwhile around any of the cases you meet in these two weeks.

Best Case Scenario: You may enjoy the daily case-based learning experience, ask difficult questions from our team without fear and help us to find out the answers and learn together using a blended approach and publish y/our case in http://casereports.bmj.com/. At the end of the elective you receive a certificate from us and BMJ other than your published case as a proof of your having completed this elective. Once you begin to publish cases in BMJ you may start getting reviewer assignments and eventually you can work your way into the BMJ editorial board. Following this experience you may even become a social entrepreneur (for example you may open a case-based clinical audit CA firm and much like a Chartered accountant get paid to inspect and set right patient-management patterns of other health professionals. 

Hope your stay with us generates the best case scenario that you can cherish throughout your life.

Workflow for ArogyaUDHC rural user interaction with medical student users managing ArogyaUDHC

Here is the current workflow for ArogyaUDHC rural user interaction with medical student users managing ArogyaUDHC:

As an online-physician in-charge of rural Indian patients located in the area pincode-736 who approach us for help through  ArogyaUDHC, i receive the de-identified patient information along with signed patient authorization through an email from our social worker in Mathabhanga. His current internet access issues make it difficult for him to post directly to our site http://care.udhc.co.in.

I forward all these emails carrying patient data as attachments (with the signed patient consent) alternately to our medical student site managers, Kaustav, Arko and Deepanjan (three current active members but i am sure many more shall join soon and depending on exam demands we may have to rotate our student volunteers).

The subsequent steps for the medical student volunteers are:

a) Transcribe and translate the patient's handwritten letter/history and provide a summary of his problem inputs and paste it to the UDHC narrative page along with uploading the signed 'informed-consent-authorization' from the patient as well as all the reports that are sent to you after de-identification by the social worker (de-identify them further if you find any gaps after close inspection of all the attachments including the patient's handwritten letter).

b) Once this is done and your upload is approved by the moderator/physician in charge for this particular pin-code (which currently is me), please post the link to tabula rasa and try to build up a discussion (aka patient-data-processing) that can benefit our patients to the maximum by chiefly focusing on helping to answer the patient's needs reflected in his/her uploaded narrative. See some of the current ongoing discussions around the ArgoyaUDHC patients in tabula-rasa or perhaps look at this sample case here: http://care.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=273&solution_id=68

Pasted below is how this patient input linked above (input from the father of a 49 day old child) was briefly processed after being posted to tabula-rasa (our social media based processing forum)

A 49 day old baby girl with persistent Jaundice since 3 weeks

care.udhc.co.in

Like · · Unfollow Post · Share · April 12 at 10:53pm

• 
  
• 

  Rakesh Biswas http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724143/

  

  Prolonged neonatal jaundice: When to worry and what to do

  www.ncbi.nlm.nih.gov

  Neonatal jaundice persisting beyond 14 days of age is a common clinical scenario...See More

  April 12 at 11:05pm · Like · 1 · Remove Preview
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  Aakriti Pandita I am not able to make out all reports properly due to internet issues, so 1) Is mother's TORCH screen negative? 2)And the baby has anemia, neutropenia, lymphocytosis with hepatomegaly. Seems like a viral hepatitis. 3)What about the blood culture?

  April 13 at 12:57am · Unlike · 1

This is the processing through our email forum:

Email Input1 below:

Date: Fri, 12 Apr 2013 21:33:06 +0530

What I understood was that this is a 6 weeks old baby born at term and low
birth weight, had some feeding difficulties and has persistent jaundice
that is direct.The important causes to consider are intrauterine infections, i.e. Rubella
and CMV mainly, billiary atresias, intra or extrahepatic as gall bladder
visualised extrahepatic unlikely and also to rule out galactosemia. Out of
all the causes high possibility of CMV Needs a complete physical examination, eye examination, urine for reducing substance and further imaging of liver if indicated. Further prognosis depends on the cause
 

Email Input 2 below:

Date: Sat, Apr 13, 2013 at 11:56 AM

Eye examination should include - e/o cataract, chorioretinitis,
posterior embryotoxon
CMV IgM is essential
LFT- serum albumin and serum gamma glutamyl transferase are important.
Benedict's test for reducing substance in urine should be done after
pretreatment of urine with conc. Hydrochloric acid to be able to
detect lactose.
Regarding the baby's appearance, does she resemble any of her parents
or other relatives? Is her facial appearance- abnormal?
Is the baby feeding poorly now?
If yes, since when?
Is it after starting Gardenal? Is the baby still on Gardenal? If yes,
how many ml in a day?
Is the poor activity only during fever and cold episodes?
How many times does the baby pass urine in 24 hours?
It would be useful to document the weight weekly on follow up.
Has she been prescribed vitamin A & vit D? (it is not clear from the
prescriptions)
It is important to give her weekly vitamin K injections

Email Input processing 3 (A Relevant Note of Dissent during this processing on email that i couldn't help sharing here)

Date: Sat, Apr 13, 2013 at 3:26 PM

...Also this only reflects opinion of one person and does not reflect evidence of any kind (as evidenced by the mail given below). Is this the kind of output UDHC is looking forward to give  ? I thought it is all about evidence based medicine and not opinions !!

I also doubt how impractical these suggestions are.. like CMV IgM.

I couldn't resist sharing the last input above in spite of the danger that it is disruptive and can cause confusion understanding the workflow.  The dissenter (it is always useful to have them around) raises interesting issues around practice based evidence. The fact that even a patient's history and reports are a 'particular' piece of 'individual' evidence currently remains unacknowledged by mainstream Evidence based medicine EBM (although Dr Huw, Editor of the Oxford Handbook of Clinical Specialities has recently discussed this on the Oxford UK based EBM listserv).

c) Once the medical student volunteer managing the case-information online is satisfied that the discussion/data-processing has reached an optimum climax to generate a reasonable initial output for the patient please prepare a summary output and (this part is very important) after sharing it with the online-physician in charge of this area-pin-code

Based on these inputs our Outputs to the patient and his local physician is posted here:

http://care.udhc.co.in/SOLUTION/viewSolution.jsp?topic_id=273&solution_id=80

d) Very often we can take care of most of our patients' requirements this way online but once in a while these patients may want to visit us to seek direct care and the same patient (49 day old child) also came for a visit and by that time he had become a week older and here is the current update posted on 26 May, 2013 http://care.udhc.co.in/SOLUTION/viewSolution.jsp?topic_id=273&solution_id=68

e) The entire case can be written for BMJ or IJUDH and co-authored by those involved in the care of this patient (including the medical students managing the website) and authorship will be allocated as per these guidelines:

See link: http://www.icmje.org/ethical_1author.html

Authorship  credit can be obtained for 1) contributions to conception and design, analysis and interpretation of narrative-data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published.

An Indian MD-Phd program vs a Translational clinician-scientist entrepreneur TCSE India program

This idea (below) not only emerged from the recent discussion on developing an MD-Phd program in India but also with a subsequent realization that there was a large population of MSc and MBBS graduates who were unable to join Phd or MD programs in India due to the standard entrance bottle-necks and they could benefit from an entrepreneurial career path. The idea is to develop an entrepreneur program for this large segment of students that enables them to stand on their own feet and helps India to stand on its own feet. Perhaps one can write a DBT/DST/ICMR project proposal to gain permission for beginning this? The focus of this program would lie in answering patient health-care requirements through innovative low cost solutions that the student entrepreneurs would develop and incubate through a start up that can be supported by the DBT/DST/ICMR funding (or bank loans obtained by the student entrepreneurs). This can by backed by an Institute providing the bench/laboratory with academic guide (such as Indian Institute of Science, PGIMER or IIT etc) as well as an Institute providing the bedside clinical platform with clinician-academic guide (my university in Bhopal where i practice?). Brief outline of Structure/Curriculum: At the very beginning of the TCSE program students can be coached through a clinical rotation to identify requirements (problems that require doable solutions) in specific patient-populations. Through a case study approach, these students could make attempts to find which of these patient-problems can be offered optimal innovative solutions by the MSc or MBBS students themselves. Here is a brief outline designed by us on the different clinical areas these students would need to touch on in order to get a good idea of the patient's requirements: http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml Although the outline highlights what medical students may learn on a short elective, it very much covers what is essential clinical learning to approach any clinical problem. This is detailed further in a recent lecture to KMC Manipal here:http://www.pitt.edu/~super1/lecture/lec50421/001.htm We have already incubated an entrepreneurial solution to patient-problems using a web based information sharing platform http://care.udhc.co.in/ that engages a “Trained Community Health Entrepreneur”(TCHE) under an income generating, social-enterprise model for rural India (details here: http://www.missionarogya.org/p/arogyaudhc.html) and the TCSE model is in many ways an extension of this, only the TCHE may require just a high school background whereas a TCSE is a post graduate and potential Phd-MD who is willing to take the entrepreneurial route. This course may not have a fixed time bound curriculum and the TCSE can choose to take the necessary amount of time required to achieve his/her entrepreneurial aspirations that would depend on a) his/her identification of the problem for which s/he would like to develop a solution ( this would be during the clinical rotation phase in an Institute providing the bedside clinical platform and clinical academic guide) b) Developing the solution (the bench phase in an institute providing the bench/laboratory and academic guide) and c) marketing the solution to the identified patient population( a large fraction of who could be tapped from the patient population in the institute where the TCSE learned to identify the patient problem). If we can obtain the official permission formalities, I can guide the initial clinical phase of this program voluntarily and if you are willing to guide the bench phase in your institute (or suggest someone close to Bhopal) we could quickly pilot this? Do let me know your thoughts.