Medical Student Caregiver workflow

As medical student caregivers (see this definition of a medical student: student.bmj.com/student/view-article.html?id=sbmj030241) we discuss and learn from patient cases and practice what is also labeled as 'patient centered learning' and along with this we try to get students (ourselves) to write case-study based qualitative research papers based on our 'patient-centered learning' experiences. We also communicate on emails as there are many emailing online users who may not have the time or inclination to be on all forums. As medical students you can contribute to nurturing  this learning ecosystem by starting to share your cases (patient experiences after obtaining and uploading their informed consent) to our website http://care.udhc.co.in and then discussing them on our online forum of 600+ users. Don't be intimidated by the fact that you may not have been trained to handle cases in college. All you need to evaluate cases is just common sense and if you have good knowledge of anatomy it becomes an added bonus. Everything else can be learned through further online mentoring. Will be looking forward to your inputs and don't hesitate to clarify your doubts either through messaging or preferably through crowd-sourcing them in our online forum. 

Two separate workflows for user interactions?

Two separate workflows to register/allow 'Independent-care-seekers' and 'Caregivers for dependents?'

Independent-Care-seekers would be mostly urban computer users posting their own cases who can register emulating the healthboard pattern of one click registration. http://www.healthboards.com/

Just take a look at how they get 'users' to register for their site:http://www.healthboards.com/boards/register.php

While many of their rules http://www.healthboards.com/boards/faq.php?faq=faq_hb do not apply to our workflow we can emulate their skeleton that works around the problem (of signed-patient-consent-form or one-click-disclaimer dilemma) we are facing now.

Caregivers for dependents (comprising of our Mathabhanga social workers or patient relatives or even medical students and health professionals reporting their cases) will need to go with the current workflow and will not be allowed to post without the uploaded consent form. This workflow is actually borrowed from and currently active in the BMJ Case Reports journal as all the case reports are made by similar caregivers (mostly health-professionals) who have to upload their signed patient consent forms for their case reports to be peer-reviewed.

As currently much of our activity on http://care.udhc.co.in/ is through 'Caregivers for dependents' i guess we would have to make do with the current-workflow (which is mostly based on the BMJ model) but one can think of creating a separate window in the website for the 'Independent urban care-seeker' (Healthboard model) who can get in without the consent form bottle neck with a one-click disclaimer?

Patient Input and outputs on the UDHC site

Patient input

 

http://care.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=223

 

Output posted here: http://care.udhc.co.in/SOLUTION/viewSolution.jsp?topic_id=223&solution_id=23

Every Patient is a research project with quicker perceiveable outcomes?

It may not be clear to the medical student/health professional 'users' on what exactly is their role in solving the queries posted by the patients/their social workers here http://care.udhc.co.in/INPUT/input_directory.jsp

Perhaps if we just think of this as an exercise in utilizing our health professional knowledge and training to 'help a patient' we may be able to build further toward understanding this process automatically?

We are looking for evidence based as well as innovative ideas that can go a long way to helping each and every individual patient. Perhaps we need to think of each and every patient as a 'mini' research project that has immediately palpable 'outcomes' in terms of positive responses in the patient's health arising from our inputs (in the form of evidence based innovative solutions for them)?

In every research project there is a problem statement (the research question). In the UDHC patient inputs we have their problem statements although deciphering them and spelling them out i e structuring them for global understanding is itself a major task and we are grateful to the few students in tabula-rasa who are helping us with it.

To these problem statements we need to offer our collective solutions using our and the internet's evidence based knowledge base to find the optimal solution for them based on our appreciation of the patient values. We are even more grateful to the students who point out where we are going wrong and how this may affect the patient values. :-)

This process of input-processing-outputs is not a single cycle driven process but needs multiple iterations for any given patient to reach a stable solution (even understanding a patient's values may require multiple input-process-output cycles). The best part of this process may be that all these multi-cognitive iterations and hypothesis testings get transparently recorded on a web platform that is beneficial to shared learning?

A patient of acute popliteal artery occlusion and thoughts on the Lancet article: Transforming Education to strengthen Health Systems in an interdependent world

We run a patient centered network that receives patient information from rural remote towns in India often with the intent of offering therapy either in the form of information (even prescriptions) or procedural interventions (for which they are encouraged to attend the nearest feasible set up). Day before yesterday night i got a call from our social worker in one remote town who related the story of a patient of sudden popliteal arterial occlusion (a little on phone and mostly on email along with the doppler reports etc) and a quick review of the evidence based literature ( other than background knowledge) told me this needed urgent popliteal arterial embolectomy as a current best option if performed within hours.

The biggest problem was that he had been given an estimate of 1.25 lakh rupees from the fee-for-service facility in the nearest town/tier2 city that could do the procedure. The patient was a near unemployed young man (surviving on private tuition to school students) and we needed to find a govt facility where the procedure could be done for much less (if not free) and as time was of the utmost essence we activated our web based global network.

The nearest govt medical college was still a few hundred kilometers and we were not sure if it would have facilities for popliteal embolectomy so yesterday morning the patient set out for the nearest metropolitan city to meet one of our network members, an intern in another govt medical college (which had vascular surgery facilities) to find if this could be arranged there on an emergency basis.

One of our US based members skyped me yesterday night to contact another senior vascular surgery colleague who was supposedly in the same metro-city in a Govt Post Graduate institute. Today morning as the patient reached the metro-city i learned that the senior vascular surgeon had been transferred to the same nearest govt medical college the patient came from and also the facility required for a popliteal embolectomy was currently non existent in that govt medical college.

Even as i write the patient and his relative have already boarded the train for Bhopal ( 1,500 kms from their home) because even the health care system in the govt medical college in their nearest metropolitan city (as per available information from the social worker, patients and intern) was not designed to provide emergency popliteal embolectomy (although they had the facility for vascular surgery with even regular Mch courses, so it was perhaps just our inability to approach the correct people in power there).

Our private medical college charges 3000 rupees for any operation (a limb amputation is what this unfortunate patient may possibly now require) and a fee for service vascular surgery practitioner in Bhopal who i contacted said it would cost 30,000 for a popliteal artery embolectomy.This is still much less than the 125,000 estimate the patient was given in the tier 2 city near his hometown.

Now let us take a look at the key components of a health-education-system identified in this Lancet article:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961854-5/fulltext?_eventId=login

(1) stewardship and governance, (2) financing, (3) resource generation
importantly faculty development and (4) service provision

From a bottom-up patient centered perspective we start with (4) and from this evolving case-story it is obvious that we have to equip our rural district hospitals and medical colleges with both equipment and (3) trained health care professionals to enable them to handle any emergency procedure.

Actually the Fogarty catheter http://www.edwards.com/products/vascular/clotmanagement/pages/embolectomycatheter.aspx, http://www.indiamart.com/max-medical-devices/edward-medical-equipments.html that we require for this procedure doesn't seem to be currently available in our medical college also although we are lucky to have a general surgeon with a heart of lion who can tackle most procedures.

It is disappointing to see how so very often doctors are forced to overcharge their patients for a small piece of plastic equipment ( this is to highlight how locally designed low-cost technology can transform health care) and a procedure http://www.youtube.com/watch?v=2WK4Mt__CYs that could have been performed by any general surgeon has been restricted to only a few trained sub/super specialists.

In-spite of the large volume of doctors graduating from the 300+ medical colleges in the country, training in procedures and clinical decision making is finally being provided to a much lesser percentage than the actual need.

In summary: There are issues that need to be addressed from a bottom-up individual patient perspective.on how to optimize our entire workflow (training and equipment to help our individual patients).

At the same time from a policy maker's top-down  population-perspective (1) stewardship and governance and (2) financing can only be optimally implemented for the maximum benefit of a larger population.

Finally to integrate both the patient and population perspectives i leave you with these questions:

How do we ensure that such individual patient stories at the interface of health-science and suffering also have a happy ending?

Could awareness of these stories (collected in an online repository) that otherwise regularly go unsung from every corner of the country help our policy makers to decide better? Can converting district hospitals into 'functioning' medical colleges also address the above problems?

Meeting information needs: The role of clinical case reports

This was my response to queries posted on this topic in the forum HIFA2015.

"Would such a database be useful as a reference or learning tool to support the delivery of health care in low-resource settings?"

It would be the most useful database ever utilized in medical practice be it the developing or the developed world.

To quote Dr Smith's editorial in the same journal, 'GPs might, and will, use their experience - as they have done for centuries. Their experience might be supplemented with evidence from high quality databases that follow every one of a cohort of patients. But they might also search our journal and database to find a patient just like theirs and see how the patient was treated and what happened to him or her (follow up will be very important).'

"Who might use it - health professionals, researchers, policymakers? How might it be used?"

It would be utilized by multiple stakeholders in the patient's journey though his/her illness. These would include among others the patients, their relatives, their immediate primary care as well as their referral physicians.

"How might it be used?"

One way to better the usage would be to create portfolios of contributors be it patients contributing their own disease perspectives or health professionals reflecting on their day to day activity and then link these with web 2.0 tools commonly available in social networking sites such as Facebook. In this way patients and health professionals can remain in touch just by following their status updates (thus maintaining informational continuity or follow up which as Dr Smith pointed out is vital to positive health outcomes).

"What features would such a database require to provide maximum benefit for end-users in developing countries?"

Free to publish (I am sure it will be for those in HINARI countries but that leaves a lot of poor Indian academics in the lurch due to Indian's newfound non HINARI exalted status).

How would an Indian villager access it to share his stories? Well a villager could go to the nearest internet kiosk and his story could be uploaded by the kiosk operator (that would also create an employment opportunity).

Finally do we have a quicker and easier way of doing this instead of having to go through a lengthy peer review process (which could be better performed in the post publication rapid responses from those who happen to discover the story as it matches theirs)?

We have tried to create a similar model where we have health professionals and patients as group members with their individual portfolios and these health professionals and patients stay in touch with each other by just following each others status updates.

Many of the patients have chosen user names (one such is "English Patient" that you will find on the site) to protect their identity.

Feel free to join the group, add the patients or health professionals to your contacts and start following their status updates. I am sure you will find that just sharing your concern with these patients (with or even without sharing your expertise) may make this a different experience.
http://www.facebook.com/group.php?gid=77835023213

You could begin with by adding "English Patient" to your contacts, read her notes, (which are categorized into an unstructured one she created and the structured summary that her physician did) and finally do go through her status updates and the comments of the health professionals who responded to them.
We have another similar group for our medical students as well:
http://www.facebook.com/group.php?gid=102177045567

warm regards,
rakesh
http://peoplesgroup.academia.edu/RakeshBiswas

Experiences on Medical Education networking

To share experiences on medical education networking I guess I won't have to go back further than when I was an undergrad medical student.

I always thought the best way to crack the assessments would be to know what our examiners knew. A bit of networking with them would have allowed me to know what was on their minds but then getting to get to know them was a major challenge in our college where even the internal examiners were actually from a different college (although from the same university).

So we had to restrict ourselves to knowing what was general knowledge ( I believe the MCI calls them "must know").

However a bit of networking with our hostel seniors did allow us a sneak peak into the previous assessment scenarios with interesting tit bits on the examiners as well.

Hostel life that way was a great place for networking.

I soon grew out of the assessment networking fever after having completed UG although I could never grow up from being a medical student: http://student.bmj.com/issues/03/02/reviews/41.php

In my clinical practice I realize that networking is essential to success and each and every new workplace offers its own challenges in setting up networks from scratch ( I have changed a good many places from Kolkata, Chandigarh, Nepal, Bangalore, Malaysia and finally Bhopal).

However online networking gives me an opportunity to maintain older networks with ease. My facebook contacts ( 250 and growing) are mostly people who I met on my previous institutions, many of them students sharing their life pictures ranging from holidaying in US or Borneo to getting married or having children etc etc.

Wish I could have kept in touch with my patients in the same manner.

Facebook gives me a hope that some day in the distant/near future we shall be able to network more meaningfully with our students and patients.