Creating a generalist health professional through formative assessment of life-long reflective practice

A transparent mechanism of Formative assessment (only) that documents and validates/restructures a medical-student's reflective practice (more here: http://pediatrics.aappublications.org/content/131/2/204) is a definitive starting point, beginning with day 1 of entry, 

so that all students (future-practitioners) are accountable to their patients from day 1. 

Given current information technology it is not difficult (or cost-cumbersome) to set up a mechanism for this using freely available online-tools. The modules of 'Attitude and communication' development are also subsumed in this approach. 

Currently there is no exit for a student/practitioner till s/he retires or resigns from the profession. Hope to discuss more about it in this upcoming panel discussion here: https://meducon2016.com/programme

The above proposed approach would in effect regularly assess both students and teachers alike from the same online-platform and all our daily work (teaching-learning-patient-care) would be laid bare for public scrutiny. More like regularly playing for an audience in an accountable manner. Perhaps it will force all of us to play to survive (harsh) and not allow us to wallow in the luxury and security of work-related-anonymity and non-accountability? 

There is no need for summative assessments in this this scheme of things although summative-success as a measure of achievement is built into the fabric of our society globally and this is what makes it all the more challenging (if not impossible) to digest?

Some resource links on reflective practice to build the right ATCOM (attitude and communication) in medical students and practitioners: 

Here's something from Harry Potter and i re-quote, "Harry stared at the stone basin. The contents had returned to their original silvery white state, swirling and rippling beneath his gaze. “What is it?” Harry asked shakily.

“This? It is called pensieve,” said Dumbledore. "...One simply siphons the excess thoughts from one’s mind, pours them into the basin, and examines them at one’s leisure. It becomes easier to spot patterns and links, you understand, when they are in this form.” Rowling, The Goblet of Fire (2000, pp.518-519).

http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1655&context=jutlp

"Strategies to Promote Learning in Each Domain of Reflective Practice

	Sample Strategies for Reflection in Action	Sample Strategies for Reflection on Action
Doctor as a person	Preceptor role modeling of self-awareness and vulnerability.	Appreciative inquiry13
	Priming learners to focus on emotions and nonverbal cues in patient interactions.	Narrative writing14
	Skill-building exercises focused on improving “mindfulness,” cultivating “engaged curiosity,” and improving observation of events such as perspective-taking and role-playing workshops.19	Reflections on critical incident reports, formative events, and multisource feedback.20
		Role modeling of reflection
Doctor as an expert	Diagnostic “pauses,” with focus on justifying the differential diagnosis based on discriminating features of illnesses..." Quoted from: http://pediatrics.aappublications.org/highwire/markup/5193/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed

The use of reflection in medical education: AMEE Guide no 44: http://www.medicalteacher.org/medteach_wip/supp%20files/Guide%2044/Sandars%20Appendix%201%20Guide%2044%20Reflection.pdf

Guidelines for online-health-record creation and finally publishing as a case report

1) Data capture and representation hands on training module: http://userdrivenhealthcare.blogspot.in/2016/01/a-65-years-old-woman-with-backache-knee.html

2) From online-patient-record-blog to published journal article: http://userdrivenhealthcare.blogspot.in/2016/03/udhc-case-study-from-online-patient.html

Role of the patient-information-communication-manager PICM in a tertiary care hospital, community, quality improvement, integrative medicine and the business of healthcare

Needed to clarify the role of a 'patient information communication manager' PICM that may have been missed in past blogs. 

Perhaps it would be easier to clarify what it is not first? :-)

S/He is not to be used as a vehicle to get patients to a 'tertiary care hospital' and then leave the patients to fend for themselves hoping that the doctors will be able to do the job from that point (this may be currently happening in many hospitals and may be boosting their short term gains but doesn't go a long way toward sustainable returns?).  

The PICM's role is to help patients by delivering 'Quality-improvement' QI and we believe the return on investment ROI for their work will be in terms of a long-term collective inflow of patients (and money) built up gradually over months to years and this will be directly proportional to the quality of care that we are able to provide as a result of our 'intervention.'

Now let me elaborate again on our 'intervention/tool' that we need to use for QI in your tertiary care set up. One of the commonest problems in tertiary care (and perhaps healthcare in general due to which quality suffers) is the lack of information and communication. 

The PICM will be able to address this gap that will lead to better sharing of clinical information through creation of accessible 'electronic health records' for every patient. Think of the relief to pathologists and radiologists when they are able to access the entire details of the history of a patient in a neatly typed format (instead of trying to figure it out from cryptic one liners in a paper based request form)? Similarly think of the value to clinicians (residents and consultants) who can spend more time in talking to patients rather than maintaining information in files and request forms. Imagine the value to medical student learning as these records can become valuable learning repositories of clinical problems for them (as each record would also contain the biochemistry, pathology, radiology of the patient). 

Interestingly EHRs are not popular with physicians even in US but that is because they have to create these EHRs themselves and are not yet blessed with the concept of having 'patient-information-managers.' I am sure they will get there soon. :-) 

Having a better information and communication workflow will lead to better transparency and accountable decision making that will improve the quality of care. The initial role of well-trained PICM would be more of a trainer for all the existing staff in a tertiary care organization   (obviously even though well trained, one PICM  alone cannot manage all the records and departments in a hospital but if s/he can train even one from each department that should scale very well). 

These staffs that are trained can find an incentive in learning this new tool and utilizing this knowledge to work in the evenings from their homes (E-health centers carrying the name of the tertiary hospital with no additional expense to it's management) and create similar online-health-records in their community at a small fee that they can charge directly from the patient (and provide a receipt in the tertiary-center's letter head for their service). 

A few PICMs are already doing this in one location in West Bengal (although they may be doing it on faith and not providing a receipt of any organization to their patients). Once patients are engaged in this detailed manner (that automatically happens during the process of creating the online-record) and if/when they receive an online feedback from the doctor who can deal with their mentioned problem) they are more amenable toward subsequent adherence to quality care. 

In summary one can utilize online-patient-record creation as an important tool/intervention to improve quality of healthcare both in the tertiary set up as well as the community and help our medical students and staff learn in a patient centered manner from all the valuable patient data that otherwise goes undocumented and wasted in paper files (fit for dead-letter-offices?). This quality improvement QI in terms of learning will translate into earning for the tertiary-hospital-owners with time (but yes this may not be reflected through short term gains but only through long term sustainable returns). 

Reaching out an innovation-incubator’s ‘integrative medicine’ services through global E-health (incubatee) centers

Objectives/Goal: Transforming healthcare through transparency, accountability and shared learning between health professionals and patients with chronic illnesses globally.

Focus areas:

Evidence informed health-professionals Education

Health innovation and Wellness Centers

Tertiary health care through Medical Hospitals

Reverse Medical Tourism

Remote and Home-Health Care

Motto/Slogan: “Global learning toward local caring.’

Strategy: We begin with a patient-centered training program for E-health entrepreneurs (incubatees), also designated, ‘patient information communication managers,’ PICMs who shall be interested graduates in any discipline, chosen from their community of residence (rural-urban) globally. These trained E-health entrepreneurs will run the Innovation incubator’s E-health and wellness centers set up in their residences in the community where they shall interview patients, and create an online record using their patient’s history, clinical images and past investigation records (after removing patient identifiers to nurture patient privacy) and share it online with the Innovation incubator’s global-learning team for them to suggest solutions to support the patients and their locally practicing doctors with evidence based information to promote ‘remote-healthcare’ that in the near future will be augmented toward a tertiary-level, home-healthcare. The entire learning transactions between the global and local learning team around the individual patient’s treatment (including data from innovative ‘n of 1’ trials around the patient) is shared in the patient’s online-record (as a web logged case report) taking care to remove all identifiers as per HIPAA guidelines: http://cphs.berkeley.edu/hipaa/hipaa18.html . Many such online records and patients and care-providers are thus connected transparently and accountably in a participatory blended learning eco-system.

More here on the business model and call for students for this course: http://userdrivenhealthcare.blogspot.in/2015/06/global-learning-toward-local-caring.html

Training workflow and steps to patient-centered, discovery based learning and innovation outlined in a past lecture here: http://www.pitt.edu/~super1/lecture/lec54091/001.htm,

What is a generalist E-health entrepreneur and why we need them as incubatees for our incubation center? Link to a past lecture here: http://www.pitt.edu/~super1/lecture/lec54101/001.htm

Past lecture on assessment of Generalist Learning Competency: http://www.pitt.edu/~super1/lecture/lec54111/002.htm

Sample case record uploaded in spring 2014 by our PIMC here: http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1593

Same case record published (with a suggested innovation) as a case-report by our global elective students here: http://casereports.bmj.com/content/2016/bcr-2015-211127.full?keytype=ref&ijkey=GrkuudGK4zzuAwk

Sample case record (uploaded in summer, 2016) here: http://ebpc-udhc-debasishacharjee.blogspot.in/2016/06/24-year-old-man-suffering-from-renal.html

Sample case record (uploaded in Spring 2016) here: http://globaludhc07.blogspot.in/2016/02/a-18-years-old-girl-with-lower.html

Past lecture on Informal healthcare providers here: http://www.pitt.edu/~super1/lecture/lec53961/001.htm

Value Addition to the Innovation incubator’s group:

1) Better patient outcomes for chronic complex patients seeking health care services from the Innovation incubator’s Group. Global E-health centers managed by trained E-health entrepreneurs and citizen scientists in global locations will support medical tourism where a few complex issues that cannot be tackled online can be called to the Innovation incubator’s tertiary care hospital for further interventions.

2) Transparent and Informed health care for patients will mean better health outcomes for patients (E health centers will become wellness centers) and better financial outcomes for Innovation incubator’s Group.

3) This is a novel project and perhaps the need of the hour. This will also provide an opportunity for a training program in this area and developing a future work force for this form of health care delivery.

Risks: 1) As this is novel and aims for transparency and better health care outcomes for people it may upset other stakeholders with different motives.

2) Extreme care shall be required to nurture patient privacy according to HIPAA guidelines: http://cphs.berkeley.edu/hipaa/hipaa18.html and at the same time promote transparency.

3) We would have to have a strong and committed network of health professionals to sustain the high standard of ‘care’ we are promising.

Requirements to start the Project:

Financial investment required for this from the Innovation incubator’s Group will be minimal.

Currently this has already been piloted in a Tertiary Medical hospital and Medical college in Bhopal with an E-health center in Mathabhanga, West Bengal.

WORKFLOW for project at the Innovation incubator’s hospital and its local community:

Trainee selection, trainee provided with laptop and data card

Trainee posted to Medicine ward with current PICM and

Training received on how to capture patient data and share it in http://www.udhc.co.in/ to enable further online network processing of patient data

Training completed and execution of the same workflow in other Innovation incubator’s E health centers that can be gradually scaled in the community, state, nation and globe.

Past Publications on this work: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4587042/

http://www.ncbi.nlm.nih.gov/pubmed/19811603, 

http://www.ncbi.nlm.nih.gov/pubmed/19018906