Saturday, September 6, 2014

Positive role of Medical Electives in patient centered health care and learning?

I would like to share one recent example of our Medical Elective blended learning program's positive role in patient centered health care and learning. (More details on attending our program here:

This is a real patient (a 16 year old boy) with a long standing problem of fever since 2 years of age, transferred from AIIMS, Bhopal to our institute (primarily because the AIIMS hospital building in Bhopal isn't ready yet) and the learning around the patient is demonstrated in his HIPAA compliant de-identified  'patient centered online health record' here:
The gist of it (reflected in our network's lengthy conversations if you scroll down the above linked record) is that this patient has undiagnosed  recurrent fever and arthritis since the age of two years. We were clueless about the diagnosis until our medical student uploaded it to our website and then inputs started pouring in from Thomas Jefferson University (Prof Meltzer, Rheumatology) followed by feedback from the previously treating physician in AIIMS, Bhopal (Dr Bhavna Dhingra) and further support from Priyank Jain in Harvard and i could see the bigger picture around this patient unfolding layer by layer...childhood periodic fever, arthritis, chronic inflammation, secondary amyloidosis, Cirrhosis of liver, Hepatopulmonary syndrome (as an explanation for the severe clubbing and cyanosis...see the striking images in the above linked record) and finally amyloid angiopathy, intracerebral bleed. He has recovered from the bleed but continues to have fever.

We were also fortunate to have a Phd (and currently MBBS student from the University of Montpelier attending the BMJ elective program in our institute) who helped us to collect the patient's DNA which he shall process further and on his return to the University of Montpelier, let us know if our patient has the suspected mutation in his exon 3 of NLRP3 gene that can help us to make the diagnosis of what we currently hypothesize to be a 'Chronic Infantile Neurologic Cutaneous and Articular Syndrome,' potentially amenable to IL1 blocking agents that can be started once we are sure of the diagnosis.

You may feel that the above approach would be too much to digest for an undergraduate who is still learning the ropes but my counter argument  is that it may not be enough to focus only on the academic learning of a medical graduate (although this case does have elements of biochemistry, pathology and clinical medicine integrated into one patient whole).

Cases such as these can also help us to encourage our medical students to learn to focus on 'how to help their patients as a whole' and not get scared by the diagnosis? Helping them to understand how they can even as medical students learn to help one patient at a time and build up their 'online patient-helping portfolio' can go a long way toward developing a robust healthcare learning ecosystem?

In this learning ecosystem the health professional is no longer at a higher pedestal  delivering care but becomes an equal shared decision maker with the patient and shares both the available certainties in level I evidence as well as the uncertainties.

We are passionate about a 'Patient Centered approach' to learning as it retains an individual patient context and employs a discovery based bottom up approach toward each patient and their attendant uncertainties instead of a  top down service delivery approach (which was fine if medicine knew all the answers).

A 'patient centered approach' can strengthen health systems not only through collaborative learning between multiple stakeholders (patients, relatives, medical students and health professionals) but maintain empathy between all of them and keep them hooked to life long learning and helping (all of which can be easily documented in online shareable platforms and portfolios). More here about patient centered approaches to learning and research.

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