Monday, January 15, 2024

UDLCO: NMC driven dynamic E logged learning in healthcare education

UDLCO Summary:

Learning accountability and transparency toward generating further feedback learning continuity loops have in recent times been considerably enhanced by ICT online platforms transforming paper based log books to online learning portfolios where a lot of blended learning happens with the online learning portfolio serving as a key pivot in that process. Recently all major Indian educational policy making bodies have been making this kind of learning mandatory although it's implementation still leaves a lot of room for discord or complacency. 

More than 1000's e logged online learning portfolios are accessible as an open learning platform through medicine departmental dashboard hereπŸ‘‡
These are dynamic e logs connected to PaJR groups where they form the substrate for team based learning and assessment πŸ‘‡
Dynamic e log feedback does away with paper based signatures and even signatures for that matter. The date the student logs their experience and shares it on a social media user driven learning platform can't be changed or decrypted easily and timely assessment of the logging learner is driven by other user driven learners (including faculty)  feedback, which eventually drives learningin the entire ecosystem. 

UDLC transcripts :

1/4, 2:43 PM] Rakesh Biswas: 


NMC December 29, 2023 gazette Quoting from Chapter 5, 5.2 page 34

 "Post-graduate students of broad and Speciality degree courses shall maintain a dynamic e-log book which needs to be updated on a weekly basis about thework being carried out by them and the training programme undergone during the period of training. 
(vii) It shall be the duty of the Post-graduate guide imparting the training to assess and authenticate monthly the 
record (e-Log) books.


[1/4, 3:11 PM] Sridhar DHIA IAMI: Thus, starts the era of Medical education specific apps,beyond e-Learning


[1/4, 3:13 PM] Dr Ravi Nayar Bangalore: Sounds like Tolkien speak



[1/4, 3:34 PM] Sridhar DHIA IAMI: Yeah, I am Lord of the Things



[1/4, 4:19 PM] +91 98: That is good. This happens during training in the UK and across Europe as well. To get our degrees recognized in UK or EU these logbooks are required to provide authentication of the course and experience.



[1/4, 4:20 PM] Sridhar DHIA IAMI: In that case there should be an open platform accessible to educators and students ,so that others can view details



[1/4, 4:25 PM] +91 981: Individual logs are checked.




[1/4, 4:26 PM] +91 981: If one does any fellowship involving surgery or intervention in any of these countries one has to maintain a logbook there as well



[1/4, 4:31 PM] Rakesh Biswas: Here's one of the e logs of one of our students who's joining NHS UK next month :




[1/4, 4:35 PM] Rakesh Biswas: All our more than 1000's e logged online learning portfolios are accessible as an open learning platform through our departmental dashboard here πŸ‘‡




[1/4, 4:35 PM] Sridhar DHIA IAMI: I am certain, few years down the line, the expectation would be that someone has to approve the logs.



[1/4, 4:36 PM] +91 981: Yes logbooks have to be signed by your supervisor



[1/4, 4:38 PM] Rakesh Biswas: These are dynamic e logs connected to PaJR groups where they form the substrate for team based learning and assessment πŸ‘‡





[1/4, 4:40 PM] Rakesh Biswas: With dynamic e log feedback we have done away with paper based signatures and even signatures for that matter. 

Assessment is driven by feedback and that drives learning



[1/4, 4:45 PM] Sridhar DHIA IAMI: Wonder, whether an LMS would better fit , than a blogging system. While blogging is easier and comes naturally to the new generation of medicos, LMS might provide more useful features

[1/4, 4:52 PM] Rakesh Biswas: The blog is the static component of the e log while the dynamic component is the PaJR 

More about it hereπŸ‘‡




[1/4, 4:57 PM] Sridhar DHIA IAMI: Trying to understand how the PaJR concept is different from the EHR


[1/4, 4:59 PM] Sridhar DHIA IAMI: Also,interesting would be , what would be the layer ( like an LMS), a medical college would have over the EMR or HIS


[1/4, 5:00 PM] Sridhar DHIA IAMI: Like ability to extract a particular patients EMR record  which the students are studying and then there is discussion, Q and A or assignments going on in the LMS layer


[1/4, 5:01 PM] Rakesh Biswas: It's patient driven learning

Students create the record and learn during and immediately after the encounter and if admitted on repeated offline encounters blended to the online PaJR


[1/4, 5:04 PM] Sridhar DHIA IAMI: Well, this needs a lengthy discussion. A very important topic . Healthtech for Academic hospitals and other institutions


[1/4, 5:05 PM] Sridhar DHIA IAMI: Another CPS @⁨Uma Nambiar CEO, IISc Medical School⁩



[1/4, 5:09 PM] Rakesh Biswas: The PaJR is also instrumental during follow up informational continuity driven learning as in an asynchronous persistent clinical encounter :







UDLCO : AI LLM as CDSS point of care support to infuse meaningful EBM understanding of drug efficacies at the point of care

Summary : 

UDLCO Summary : 


What if we can train LLMs to utilize the EBM PICO rubric that can provide useful point of care CDSS EBM support by providing insights on the efficacy of each drug (a bad but contemporary analogy would be the current ADR point of care EMR CDSS alarms that largely turn out to be clinically non significant as they are non contextual to individual patient centered medical cognition)? On the other hand savor this: 
 
What are the evidence of efficacy for these ubiquitous prescription drugs Montek LC and pulmoclear! 

I guess this question needs to go to LLM as our human ecosystem is really averse to understanding clinical significances in simple pico formats partly due to badly done RCTs (again blame it on human resource constraints) 

@#Project LLM PaJR supported healthcare workflows 


Below posted on Jan 14, 2024:


Pending journal club for the day :






[1/12, 10:56 PM] : 3% hypertonic saline was more efficacious than mannitol in the initial 12 h and equally or more efficacious than mannitol therapy later.
Decrease in coma hours was a significant additional finding in the group treated with 3% hypertonic saline



[1/14, 8:36 PM] Rakesh Biswas: Share this in a PICO format

Help @human participants of this CBBLE 



 No human takers for this reiterating the fact that humans may not be suitable alone to establish an evidence based medicine framework but it also provides an idea to rapidly scale the LLM project in a impactful manner. 

Hypothesis : What if we can train LLMs to utilize the EBM PICO rubric that can provide useful point of care CDSS EBM support by providing insights on the efficacy of each drug (a bad but contemporary analogy would be the current ADR point of care EMR CDSS alarms that largely turn out to be clinically non significant as they are non contextual to individual patient centered medical cognition)



What are the evidence of efficacy for these ubiquitous Montek LC and pulmoclear! 

I guess this question needs to go to LLM as our human ecosystem is really averse to understanding clinical significances in simple pico formats partly due to badly done RCTs (again blame it on human resource constraints) @#Project LLM PaJR supported healthcare workflows 


[1/15, 9:39 AM] 2023 Med PG: 


S C/o Decreased urine output since 9 days - improved


C/o sob since 9 days  - no improvement 


C/o pedal edema since 6 days - no improvement 


C/ cough  with sputum since 20 days - improved 



pt conscious coherent cooperative
Temp - 100°F 
PR - 88 bpm
BP - 100/70 mmHg 
Rr - 20 cpm 
GRBS - 81 mg/dl
Spo2- 94% at room air 
Cvs - s1s2 heard ,no murmur 
R/S - b/l air entry +nt 
fine crepts in 
Rt - AA,MA
Lt - diffuse 
CNS - no fnd 
I/O -1050/1000 ml



?TB PERICARDITIS WITH MODERATE PLEURAL EFFUSION


POLYCYSTIC KIDNEY DISEASE WITH AKI 





INJ LASIX 20mg IV OD 
INJ NEOMOL 1GM IV SOS 
TAB MONTAK LC PO HS
TAB PULMOCLEAR PO BD 
TAB PCM 650MG PO TID 
NEB WITH IPRAVENT 8TH hrly 
BUDECORT -12TH HRLY 
PROTEIN POWDER 2 SCOOPS IN 1 GLASS OF WATER/MILK 
2 EGGS PER DAY




[1/15, 9:40 AM] PG Medicine 2021: Mention the input and output also



[1/15, 9:50 AM] Rakesh Biswas: Daywise serial intake output trends since admission and daywise average respiratory rate to objectively follow the static nature or increasing problem of his heart failure both due to his CAD as well as pericardial restriction

Glossary of frequently used "medical cognition" terminologies : http://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1


Adding review of literature resources to this project :

"case studies to understand current capabilities for applying AI/ML in the healthcare setting, and regulatory requirements in the US, Europe and China.

Methods

A targeted narrative literature review of AI/ML based digital tools was performed. Scientific publications (identified in PubMed) and grey literature (identified on the websites of regulatory agencies) were reviewed and analyzed."



From Wikipedia :

An LLM is a language model, which is not an agent as it has no goal, but it can be used as a component of an intelligent agent[35]

 Researchers have described several methods for such integrations.

The ReAct ("Reason + Act") method constructs an agent out of an LLM, using the LLM as a planner. The LLM is prompted to "think out loud". Specifically, the language model is prompted with a textual description of the environment, a goal, a list of possible actions, and a record of the actions and observations so far. It generates one or more thoughts before generating an action, which is then executed in the environment.[36] The linguistic description of the environment given to the LLM planner can even be the LaTeX code of a paper describing the environment.[37]

In the DEPS ("Describe, Explain, Plan and Select") method, an LLM is first connected to the visual world via image descriptions, then it is prompted to produce plans for complex tasks and behaviors based on its pretrained knowledge and environmental feedback it receives.[38]

The Reflexion method[39] constructs an agent that learns over multiple episodes. At the end of each episode, the LLM is given the record of the episode, and prompted to think up "lessons learned", which would help it perform better at a subsequent episode. These "lessons learned" are given to the agent in the subsequent episodes.





Tuesday, January 2, 2024

UDLCO: Riddle driven learning in physiology

1/1, 7:51 PM] Dr Ankala V Subbarao: 


Medical Riddle of the day...…..Subject: PHYSIOLOGY....






[1/1, 8:28 PM] Rakesh Biswas: 


Sympathetic nervous system



[1/2, 7:14 PM] Dr Ankala V Subbarao: Thank you for your response, Dr Rakesh Biswas...…. I was thinking of PRE OPTIC NUCLEI of HYPOTHALAMUS.. when composing the riddle..



[1/2, 8:06 PM] Rakesh Biswas:

 Absolutely right! 

The sympathetic nervous system output has been widely held to originate in the hypothalamus, more specifically, "a network of neurons connecting pre optic and dorsomedial nuclei aka hypothalamic visceromotor pattern generator (HVPG) with outputs to selective pools of autonomic neurons in all hypothalamic subdivisions (collectively considered as preautonomic cell groups). 

The above nuclear outputs descend to the sympathetic nervous system through  efferents to the brainstem reticular formation formed by the dorsal longitudinal fasciculus and periventricular system whose axons descend to the brainstem to innervate visceral motor, sensory and somatic  and accessory spinal  autonomic sympathetic and parasympathetic preganglionic neurons in the spinal cord."


Monday, January 1, 2024

Generalized feedback for internship completion assessment Nov to December 2023

Nov to Dec 2023 internship assessment result summary :

Total appeared : 9

Passed : 3

Extension 15 days : 3

Extension 30 days 3

The interns were assessed through a daily 360 degree formative assessment format and graded according to the following headings :

Patient care impact : x/20

Learning ecosystem impact: x/20

OSCE : x/30

AETCOM : x/20

Log book : x/10

Expectations from the interns to excel in each category :

Patient care impact :

OPD and IPD  individual patient data capture and entry into a PaJR group toward finally preparing an electronic  summary that can be archived in their online learning portfolio (log book). 

The above is a vital document of the information surrounding their overall impact on patient care also reflecting their ownership of those particular patients. 

Learning ecosystem impact :

Once the interns enter the data in the group from day 1 around the patients they own, it is immediately processed by the group members through further Socratic questioning and analysis of the themes isolated around each patient's diagnostic and therapeutic uncertainty generating substantial potential learning outcomes depending on how each intern responds to the questions raised and tasks assigned. 

OSCE:

The above two workflows are vital to each patient's data being objectively structured and clinically evaluated that  generates sufficient learning outcomes driving better patient outcomes and this is to be archived as an osce document for each patient in the interns learning portfolio.  

AETCOM :

The promptness with which each intern does the above detailed steps to create patient care and learning impact demonstrating optimal attitudinal, ethical and communication competence determines the overall impact of the intern on our learning and caring ecosystem. 

Log book :

The log book assessment is based on their online learning portfolio replete with their archived electronic discharge summaries generated from day 1 in their initial workflows around each patient, their daily logs of hourly activity, reflections and self performed procedural videos.

Interns performing all the above satisfactorily don't get training period extension while those who don't perform, get a variable period of 15-30 days depending on their self documented and faculty validated performance listed above under the various headings.  

OSCE assessment abstract : Pragmatic OSCEs were conducted for each of the following interns listed below who were interned to the department of medicine for 45 days largely in November and December 2023, everyday in batches of four, while assessing them summatively on the days they were working face to face with the assessor both at OPD and IPD as well as following them up formatively everyday through their work logged in their online learning portfolios as well as PaJR groups in a user driven manner.  

OSCE points and questions that all must be prepared to answer in their patients:

What bothers your patient the most and what are his active concerns? 


List the problems in your patient in order of patient priorities and requirements 

Sequence of events :
What was your patient's hourly workflow before the illness and how did it change after? 

What are the current diagnostic and therapeutic gaps and what more can the treating team do to fill those gaps?

More here : 




And user driven submissions of online portfolio links on learning themes for 360 degree peer feedback and assessment submitted here :  https://medicinedepartment.blogspot.com/2023/09/submitted-internship-competence.html?m=1


More about the modified osce format that preserves clinical complexity and realism: http://medicinedepartment.blogspot.com/2023/11/mbbs-general-medicine-revised-practical.html?m=0

Current batch list of interns and their quantitative and qualititative  assessments :

10) A SATHWIKA

Quantitative evaluation:

OSCE : 5/30

AETCOM : 5/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if she's trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

Extension recommended 30 days 

11) ANILA REDDY


Quantitative evaluation:

OSCE : 10/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if she's trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

Extension recommended 15 days 

12) ANKUR KUMAR



Quantitative evaluation:

OSCE : 15/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 10/20

Qualitative evaluation  : Trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

Passed 

13) Anurag

Quantitative  evaluation:

OSCE : 5/30

AETCOM : 5/20

Log book : 3/10

Patient care impact : 5/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if he's trainable 

Can focus on asking more questions and sharing and communicating more about his patients in an accountable manner maintaining continuity and consistency of work done around them  

Chose to stay away from assigned work and scrutiny by not communicating at all about his patient's follow up and didn't take ownership of his patients neither communicate about them in a transparent and accountable manner. 

Extension recommended 30 days 

14) SHIVAPAL REDDY

Quantitative evaluation:

OSCE : 10/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if he's trainable 

Can focus on asking more questions and sharing and communicating more about his patients in an accountable manner maintaining continuity and consistency of work done around them  

Extension recommended 15 days 


15) PREETHAM REDDY

Quantitative  evaluation:

OSCE : 5/30

AETCOM : 5/20

Log book : 3/10

Patient care impact : 5/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if he's trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of assigned work. 

Chose to stay away from assigned work and scrutiny by not communicating at all about his patient's follow up and didn't take ownership of his patients neither communicate about them in a transparent and accountable manner. 

Extension recommended 30 days 


16) LASYA PRIYA

1) Self reflective writing on their medical student career 



2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links 


3) Anecdotal self reflections on their internship learning with some video  evidence of procedures performed 



4) Case based OSCE along with Bloom's learning levels achieved 


Quantitative evaluation:

OSCE : 10/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 5/20

Qualitative evaluation  : Needs more extension to see if she's trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 



Extension recommended 15 days 

15 days 

17) THOSHITHA



Quantitative evaluation:

OSCE : 15/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 10/20

Qualitative evaluation  : Trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

Passed 


18) SWAGATH


Quantitative evaluation:

OSCE : 15/30

AETCOM : 10/20

Log book : 5/10

Patient care impact : 10/20

Learning ecosystem impact: 10/20

Qualitative evaluation  : Trainable 

Can focus on asking more questions and sharing and communicating more as well as maintaining continuity and consistency of work done 

Passed