Annals 2013 (1)

SRI BALAJI VIDYAPEETH ACADEMY OF HEALTH PROFESSIONS EDUCATION AND ACADEMIC DEVELOPMENT

ANNALS OF SBV Volume 2 Issue 1 Jan - Jun 2013

theme

Recent Advances in Health Professional Education

A Publication of

SRI BALAJI VIDYAPEETH

Annals of SBV Editorial Advisor K R. Sethuraman

Editor-in-Chief N.Ananthakrishnan Core Committee

T.R. Gopalan K.A. Narayan Usha Carounanidy S. Kamalam M. Ravishankar

V.N. Mahalakshmi Karthiga Jayakumar R. Pajanivel R. Jagan Mohan Issue Editor Seetesh Ghose

Satistical Consultant G.Ezhumalai Editorial and Production Consultant A.N. Uma Editorial Assistance M. Shivasakthy A. Kripa Angeline Technical Assistance George Fernandez Published, Produced and Distributed by

Sri Balaji Vidyapeeth Editorial correspondence to Editorial and Production Consultant

Annals of SBV Sri Balaji Vidyapeeth

(Deemed to be University, Declared Under Section 3 of the UGC Act, 1956) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 607 402 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in

From the Desk of the Editor-in-Chief What Ails Postgraduate Medical Education in India?

N.Ananthakrishnan *

The fact that postgraduate medical education in India is far from ideal or for that matter even satisfactory is well known to all those involved in the field. In reality it is on a rapid downhill course which in a few years is likely to cause disastrous consequences to the health of the country. Surprisingly little action is forthcoming from any quarter to set matters right. What is happening is only tinkering at the periphery of the issues without addressing them headlong and trying to find a solution. Some of the glaring deficiencies in the system are worth being mentioned herein. It is impossible, however, in one presentation to cover all that requires attention. In the absence of any fixed norms as entry criteria or a national standard, the quality of postgraduates in any program varies widely from institution to institution depending on the admission process. This makes standardization of the training near impossible and attainment of uniform goals near non-achievable. There is total lack of clarity of what differentiates a diploma course from a degree course other than the duration and the requirement of a dissertation for the latter. The syllabus is more or less the same, the teaching learning activities are more or less parallel and often common and the examination in many instances is not different either in the pattern or the degree of difficulty or the manner of assessment. The diploma course, therefore, has become the refuge of the destitute who do not make it or can’t afford to make it to the degree course and is used as a preparatory phase while waiting to join the degree course at some future period. Originally the diploma was meant as an end qualification to enable doctors to be trained sufficiently to practice as specialists in secondary and primary care areas. It may be better in the light of loss of popularity of the diploma course to abolish it altogether.

The curriculum of the postgraduate courses has not been revised for decades. Archaic contents have not been deleted nor new contents added with any systematicity. This is sought to be obfuscated by saying that one of the papers should be on recent advances. No one knows what is “recent” and what is meant by “advances.” The number of seats is fixed in somewhat of an arbitrary matter and is subject to an annual increase when it should be re-fixed only when the previous batch of increased number of students completes the course. This is the procedure adopted for undergraduates.

Also since eight units have been made mandatory for 250 undergraduate admissions in subjects likely surgery and medicine, linking postgraduate seats to units (say maximum of two per unit) would be better than linking them to number of teachers eligible to be postgraduate teachers. In the latter case far more number of postgraduates are likely to be admitted than the clinical load warrants thus leaving serious deficiencies in training. A serious deficiency is lack of a standard subject specific logbook for monitoring postgraduate training. This is sought to be done to some extent in the courses conducted by the National Board but is absent in the MCI system. Even if adopted in some institutions it finds no place or no weightage in the evaluation process. Surprisingly, in a skilloriented profession like medicine, there is no importance at all given in postgraduate education for continuous internal assessment. It is well known that proper assessment of a postgraduate as regards competency cannot be made in a brief encounter which is what the final examination is. All other professional courses have some weight assigned to internal assessment but not medicine. Why this is so remains obscure? A portfolio would be one method of addressing this issue but unless it becomes mandatory and advised bythe regulator it is not likely be universally adopted. The quality of training in research methodology and biostatistics is abysmal and extends to being non-existent in many institutions. As a result the quality of dissertations is very poor. Since the evaluation system of dissertations is hazy and lacks objectivity in many universities this state continues to persist. The process of objectivising dissertation evaluation has begun in some institutions a decade or more ago but is yet to catch on, once again since there is no mandatory regulation in this regard.

Finally one is forced to mention the archaic examination system which has not changed at all in substantial measure over fifty years or more. It remains more or less largely subjective, norm-referenced and without fixed list of competencies which need to be certified after ensuring their attainment. A postgraduate medical evaluation system should be competency based and criterion referenced. When this would happen remains obscure? Perhaps the stimulus for change has to come from bottom up – from the society, from the outgoing postgraduates who realise their deficiencies when faced with real life situations, from professional associations and from educationists. Surely it has to happen soon.

This issue of annals deals with some of the recent developments in the field of medical education pertinent to this matter.

*

* N. Ananthakrishnan , Dean, Research and Postgraduate Studies, SBV Professor of Surgery, MGMCRI (SBV), Pondicherry

From The Editor’s Desk ‘Recent Advances in Health Professional Education’ Seetesh Ghose *

Medical teaching is a demanding and complex task. It has progressed from simple class room teaching to advance simulator assisted training. This has brought reform in the continuum of medical education for student and for the faculty training them. Expansion of medical education is not only to attain excellence in education but also for maximum improvement of health, and relief of suffering within available resource.So it is essential for the present day teacherto be aware of and become part of far reaching changes that are taking place in medical education. The changes are: shift from conventional role of teacher, changes in learning styles, innovative curriculum models and changes in assessment philosophy, methods and tools.

In an attempt to bring the modern concepts of education nearer to the medical colleges and their faculty a seminar was organised by Internal Quality Assurance Cell of Sri BalajiVidyapeeth in collaboration with Medical Education Unit of MGMCRI, Puducherry on 19 July 2013.

The objectives of this seminar on health professional education were to provide participants with the knowledge skill and academic ground necessary to work professionally within the environment of medical education .By the end of the course participant were expected to yy Understand the recent development that has taken in the curriculum and how theories of learning improve practice in medical education. yy Develop knowledge of the major policies governing the medical education. yy Understand the principles of teaching learning methods within medical education. yy Develop an understanding of assessment of curriculum design, evaluation and feedback methods within medical education. yy Understand how to integrate advancement in computer with the medical education in teaching Web 2 generation.

This seminar was attended by 206 participants, who are directly or indirectly involved with the medical education from different parts of Puducherry, Tamil Nadu and Kerala.The objectives were translated into practice by the use of Didactic short presentation, Plenary sessions the speakers were doyen in the field of medical education. Besides short and interesting power point presentations, the resource person shared their experience for the better understanding of the various topics. They also clarified the queries raised by the participant.Their active participation and sharing of experience made this event more vibrant. The seminar was evaluated using programme evaluation form. The questionnaire involved the subjective assessment of the quality of the program, the useful ness of the subject and general comment.

This program was accredited by 10 seminar credit point by Dr.MGR Medical University, Tamil Nadu.

First let us review the integrated system of healthcare. It starts with prejudice carried by a patient, the doctor and the society. A sick patient, who lives a chaotic lifestyle, wants to get well quickly, turns to modern medicine to help him.

He loses his core value of quality healthy life. The doctor shifts priority to treat symptoms only. The patient recovers, the society endorses the process. So it seems that all is well. On the other hand, traditional systems of healthcare like AYUSH, music therapy, acupuncture etc., also have an equal claim in disease and healthcare management. There are strengths and weakness in modern medicine as there are in above mentioned systems of healthcare practices. One system can be complimentary to other. However, in reality, we have lost the articulation of life process and healthy living by disconnecting ourselves from an integrated system of medicine. This is like the black and white keys of a piano. You take the right combinations, it is a musical harmony and so is one’s health. If so, why is this not happening...…?

Truly, not to the extent expected because of rigidity in the beliefs and undue haste carried by the practitioners and the public, lack of scientific understanding and publicity. When one can complement the other system, let us accept it.

What is a magnet without opposite poles? We need to connect the disconnected systems of healthcare. One best way to do is to scientifically generate an “Evidence-based Complimentary System of Healthcare”. A system of healthcare

complimented by evidence-based clinical practice and research will help us move from discord to harmony.

Second, research in a healthcare scenario is again prejudiced as a ‘not me’ or ‘why should I’ category. It is not just about a physician or surgeon or a scientist but disciplines in healthcare. A virologist doesn’t care about music therapy or a surgeon has ‘nothing to do’ with what a chemist does. It has nothing to do with the spirit of the faculty but isolationism and priorities. The message that a university cannot be fit without innovative research is lost. What the university can do is to create a microenvironment to reflect scientism intellectualism and the philosophy of evidence based complimentary system of healthcare. How can this be done?

Again connect the disconnected departments, disciplines by a common mechanism to focus on sustaining the core values of the university and thereby the society. Let us move from discord to harmony. This would unveil the ‘wholeness’ behind the university’s mission.

Sri Balaji Vidyapeeth is committed to achieve this goal. In this effort, SBV has already made landmarks in a unique and innovative way. This issue of Annals of SBV publishes its achievements in integrating allopathy and traditional system of medicine. Sanjeevita 2013, is an innovative effort by Sri Balaji Vidyapeeth and Central Inter-Disciplinary Research Facility promoting ‘Current Concepts in Integrative Medicine’ that brought together all disciplines and systems of medicine together with one common focus – ‘Patient First: Quality Health for All.’ This issue also covers SBV’s achievements in bringing yoga and music therapy as integral part of patient care and well being. All put together, one can experience this innovative concept of modern and traditional healthcare services provided to the public by Sri Balaji Vidyapeeth based on evidence-based research and practice.

The editors thank the Chancellor Shri M.K.Rajagopalan for promoting integrative medicine and his unconditional support towards organizing Sanjeevita 2013, supporting evidence-based research in Central Inter-Disciplinary Research Facility and Center for Yoga Therapy, Education and Research.. Our sincere thanks to the Vice-Chancellor Prof.K.R.Sethuraman and Dean (Research) Prof.N.Ananthakrishnan for their encouragement and cooperation in making this happen.

We are happy to bring out the deliberations and the write ups submitted for the event as a special issue for the ‘Annals of SBVU’ for wider dissemination and readership.

To carry forward this effort Medical Education Unit is planning to organize workshop on ‘Objectivising the Evaluation Process’ in the month of July 2014.

* * Dr.Seetesh Ghose, MS Coordinator , MEU, Professor & Head Department of O&G, MGMCRI Pondicherry

Index 1. Medical Council of India – Regulations on Graduate Medical Education

1

2.

Transformative Curriculum 23 - Santosh Kumar 3. Problemistics in Health Professional Education Inculcating Holistic Clinical Reasoning and Problem Solving Abilities - K.R. Sethuraman 4. Linking Lesson Plan to Teaching Learning Principles - Gitanjali Batmanabane

24 28

5.

Teaching the Web 2.0 Generation 30 - K.A. Narayan 6. Structure of Objective Learning Outcomes (Solo) Taxonomy - K.R. Sethuraman

39

7. Recent Advances in Medical Postgraduate Evaluation - N. Ananthakrishnan

41

8. Setting standards and Innovations A Road Map of SBVU Examination System - V.N. Mahalakshmi

48

9. Capacity Building for Faculty Empowerment in Aligning Education with Practice of Nursing in 21st Century - K.R. Sethuraman

51

10. Health Information Technology (HIT) and Quality Health Care - K.R. Sethuraman.

56

11. How Mobile Tech Can Influence Cost-Effective Health Care.

- James S. Toreson

59

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MEDICAL COUNCIL OF INDIA REGULATIONSON GRADUATE MEDICAL EDUCATION, 2012

MEDICAL COUNCIL OF INDIA SECTOR-8, POCKET-14, DWARKA, NEW DELHI-110077 Phone Nos. 011-25367033, 25367035, 25367036 Fax Nos. 011-25367024, 25367025 1. The undergraduate medical education programme is designed with a goal to create an“Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a physician offirst contact of the community while being globally relevant.

2. In order to fulfil the goal,the IMG must be able to function in the following ROLES appropriately and effectively: 2.1. Clinician who understands and provides preventive, promotive, curative, palliative andholistic care with compassion.

2.2. Leader and member of the health care team and system with capabilities to collectanalyze, synthesize and communicate health data appropriately.

2.3.Communicator with patients, families, colleagues and community.

2.4. Lifelong learner committed to continuous improvement of skills and knowledge.

2.5. Professional, who is committed to excellence, is ethical, responsive and accountable to patients, community and profession.

3. Competencies: Competency based learning would include designing and implementing medical education curriculum that focuses on the desired and observable ability in real life situations. In order to effectively fulfil the roles as listed in item 1 above, the Indian Medical Graduate would have obtained the following set of competencies at the time of graduation: 3.1.Clinician, who understands and provides preventive, promotive, curative, palliative andholistic care with compassion 3.1.1. Demonstrate knowledge of normal human structure, function and developmentfrom a molecular, cellular, biologic, clinical, behavioral and social perspective.

3.1.2. Demonstrate knowledge of abnormal human structure, function and development from a molecular, cellular, biological, clinical, behavioural and social perspective.

3.1.3. Demonstrate knowledge of medico‐legal, societal, ethical and humanitarian principles that influence health care.

3.1.4. Demonstrate knowledge of national and regional health care policies including the National Rural Health Mission (NRHM), frameworks, economics and systems that influence health promotion, health care delivery, disease prevention, effectiveness, responsiveness, quality and patient safety.

3.1.5. Demonstrate ability to elicit and record from the patient, and other relevantsources including relatives and caregivers, a history that is complete and relevant to disease identification, disease prevention and health promotion.

3.1.6. Demonstrate ability to elicit and record from the patient, and other relevant sources including relatives and care givers, a history that is contextual to gender,age, vulnerability, social and economic status, patient preferences,

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beliefs andvalues.

3.1.7. Demonstrate ability to perform a physical examination that is complete and relevant to disease identification, disease prevention and health promotion.3.1.8. Demonstrate ability to perform a physical examination that is contextual togender, social and economic status, patient preferences and values.

3.1.9. Demonstrate effective clinical problem solving, judgment and ability to interpretand integrateavailable data in order to address patient problems, generate differential diagnoses and develop individualized management plans that include preventive, promotive and therapeutic goals.

3.1.10. Maintain accurate clear and appropriate record of the patient in conformation with legal and administrative frame works.

3.1.11. Demonstrate ability to choose the appropriate diagnostic tests and interpretthese tests based on scientific validity, cost effectiveness and clinical context.

3.1.12. Demonstrate ability to prescribe and safely administer appropriate therapies including nutritional interventions, pharmacotherapy and interventions based on the principles of rational drug therapy, scientific validity, evidence and cost that conform to established national and regional health programmes and policies for the following: a. Disease prevention, b. Health promotion and cure, c. Pain and distress alleviation, and d. Rehabilitation and palliation.

3.1.13 Demonstrate ability to provide a continuum of care at the primary and/or secondary level that addresses chronicity, mental and physical disability.

3.1.14 Demonstrate ability to appropriately identify and refer patients who may require specialized or advanced tertiary care.

3.1.15 Demonstrate familiarity with basic, clinical and translational research as it applies to the care of the patient.

3.2. Leader and member of the health care team and system 3.2.1 Work effectively and appropriately with colleagues in an inter‐professional healthcare team respecting diversity of roles, responsibilities and competencies of other professionals.

3.2.2 Recognize and function effectively, responsibly and appropriately as a health careteam leader in primary and secondary health care settings.

3.2.3 Educate and motivate other members of the team and work in a collaborative and collegial fashion that will help maximize the health care delivery potential of theteam.

3.2.4 Access and utilize components of the health care system and health delivery in amanner that is appropriate, cost effective, fair and in compliance with the national health care priorities and policies, as well as be able to collect, analyse and utilize health data.

3.2.5 Participate appropriately and effectively in measures that will advance quality ofhealth care and patient safety within the health care system.

3.2.6 Recognize and advocate health promotion, disease prevention and health carequality improvement through prevention and early recognition: in a) life stylediseases and b) cancer, in collaboration with other members of the health careteam.

3.3. Communicator with patients, families, colleagues and community 3.3.1 Demonstrate ability to communicate adequately, sensitively, effectively and respectfully with patients in a language that the patient understands and in a manner that will improve patient satisfaction and health care outcomes.

3.3.2 Demonstrate ability to establish professional relationships with patients and families that are positive, understanding, humane, ethical, empathetic, and trustworthy.

3.3.3 Demonstrate ability to communicate with patients in a manner respectful ofpatient’s preferences, values, prior experience, beliefs, confidentiality and privacy.

3.3.4 Demonstrate ability to communicate with patients, colleagues and families in a manner that encourages participation and shared decision‐making.

3.4. Lifelong learner committed to continuous improvement of skills and knowledge 3.4.1 Demonstrate ability to perform an objective self‐assessment of knowledge and skills, continue learning, refine existing skills and acquire new skills.

3.4.2 Demonstrate ability to apply newly gained knowledge or skills to the care of thepatient.

3.4.3 Demonstrate ability to introspect and utilize experiences, to enhance personal and professional growth and learning.

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3.4.4 Demonstrate ability to search (including through electronic means), and critically evaluate the medical literature and apply the information in the care of the patient.

3.4.5 Be able to identify and select an appropriate career pathway that is professionally rewarding and personally fulfilling.

3.5. Professional who is committed to excellence, is ethical, responsive and accountable to patients community and the profession 3.5.1 Practice selflessness, integrity, responsibility, accountability and respect.

3.5.2 Respect and maintain professional boundaries between patients, colleagues and society.

3.5.3 Demonstrate ability to recognize and manage ethical and professional conflicts.

3.5.4 Abide by prescribed ethical and legal codes of conduct and practice.

3.5.5 Demonstrate a commitment to the growth of the medical profession as a whole.

4. In order to ensure that training is in alignment with the goals and competencies listed in items, 1 and 3 above: 4.1. There shall be a bridge course termed as “Foundation Course” to orient medical students to MBBS programme, and provide them with requisite knowledge,communication (including electronic), technical and language skills required.

4.2. The curricular content shall be vertically and horizontally aligned and integrated to the maximum extent possible in order to enhance student interest and eliminate redundancy and overlap.

4.3. Teaching‐learning methods shall be student centric and shall predominantly include small group learning, interactive teaching methods and case based learning.

4.4. Clinical training shall emphasize early clinical exposure, skill acquisition, certification inessential skills; community/primary/secondary care based learning experiences and emergencies.

4.5. Training shall primarily focus on preventive and community based approaches tohealth and disease, with specific emphasis on national health priorities such as family welfare, communicable diseases, epidemics and disaster management.

4.6. Acquisition and certification of skills shall be through experiences in patient care,diagnostic and skill laboratories.

4.7. The development of ethical values and overall professional growth as integral part ofcurriculum shall be emphasized through a structured longitudinal and dedicatedprogramme on professional development and ethics.

4.8. Progress of the medical student shall be documented through structured periodic assessment that includes formative assessment. Logs of skill‐based training shall bealso maintained.

4.9. Appropriate faculty development programmes shall be conducted regularly by institutions to facilitate medical teachers at all levels to continuously update their professional and teaching skill; and align their teaching skills to curricular objective.

5. Admission to the MBBS programme 6. Migration: Migration from one medical college to other is not a right of a student and normally shall not be allowed. However, migration from one medical college to another medical college within India may be considered by the Medical Council of India only inexceptional cases, on extreme compassionate grounds, provided the following criteria are fulfilled.

6.1 Both colleges i.e., the one at which the student is enrolled and one to which migration is sought, are recognized by the Medical Council of India.

6.2 The applicant candidate should have passed first Professional MBBS examination in the first attempt.

6.3 The applicant shall submit his application for migration, complete in all respects, to all authorities concerned within a period of one month of passing (declaration of result) the first Professional Bachelor of Medicine and Bachelor of Surgery (MBBS) examination.

6.4 The applicant shall submit an affidavit stating that he/she will pursue 14 months of prescribed study before appearing at IInd Professional Bachelor of Medicine and Bachelorof Surgery (MBBS) examination at the transferee medical college, which should be duly certified by the Registrar of the concerned University in which he/she is seeking transfer.The transfer will be applicable only after receipt of the affidavit.

6.5 Migration shall be restricted to 5% of the sanctioned intake of the college during theyear. No migration will be permitted on any ground from one medical college to another located within the same city.

6.6 There should be clear vacancy that has arisen due to non‐filling of seats. A student who wishes to migrate may

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be accommodated only in the event of vacancy in sanctioned seats strength. Failure of students in examination will not count as vacancy of sanctioned seats strength.

6.7 Migration shall be allowed only for the regular batch.

6.8 Migration during clinical course of study shall not be allowed on any grounds.

6.9 All applications for migration shall be referred to Medical Council of India by collegeauthorities. No institution/ University shall allow migrations directly without the approvalof the Council.

6.10 Council reserves the right, not to entertain any application which is not under the prescribed compassionate grounds and also to take independent decision where applicant has been allowed to migrate without referring the same to the Council. TheMedical Council of India shall communicate its decision within 04 weeks of receipt ofapplication.

6.11 Compassionate grounds criteria: 6.11.1 Death of parent or supporting guardian during duration of first Professional phase(First MBBS).

6.11.2 Illness of candidate causing disability.

6.11.3 Disturbed conditions as declared by Government in the area in which the MedicalCollege is located.

7 Training period and time distribution: 7.1. Every student shall undergo a period of certified study extending over 4 ½ years from the date of commencement of study for the subjects comprising the medical curriculum to the date of completion of examination which shall be followed by one year of compulsory rotating internship.

7.2. Each academic year will consist of a minimum of 240 teaching days with a minimum of 08 hours each working day including one hour for lunch.

7.3. Teaching and learning shall be aligned and integrated across specialties both vertically and horizontally for better student comprehension. Student centered learning methods should include problem oriented learning, case studies, community orientedlearning, self‐ directed and experiential learning.

7.4. The period of 4 ½ years is divided as follows: 7.4.1 Pre ‐ clinical Phase (12 months preceded by foundation course of 2 months): will consist of preclinical subjects – Human Anatomy, Physiology, Biochemistry, introduction to Community Medicine, humanities and early clinical exposure ensuring both horizontal and vertical integration.

7.4.2 Phase 2 (12 months): will consist of Para‐clinical, namely Pathology, Pharmacology, Microbiology, Community Medicine, Forensic Medicine andToxicology, and clinical subjects as detailed below (III MBBS) ensuring bothhorizontal and vertical integration. a. The clinical exposure to students will be in the form of student doctor method ofclinical training. The emphasis will be on primary, preventive and comprehensivehealth care. A part of training during clinical postings should take place at theprimary level of health care. It is desirable to provide learning experiences insecondary health care, wherever possible. This will involve: i) Experience in recognizing and managing common problems seen in outpatient, inpatient and emergency settings. ii) Involvement in patient care as a team member. iii) Involvement in patient management and performance of basicprocedures.

7.4.3 Phase 3 (28 months) a. Part 1 (13 months) ‐ The clinical subjects include Otorhinolaryngology, Ophthalmology, Community Medicine and Forensic Medicine and Toxicology. b. Elective (2 months) ‐To provide students with opportunity for diverse learning experiences, to do research / community projects that will stimulate enquiry, self-directed, experimental learning and lateral thinking [item 9.3]. c. Part 2 (13 months) ‐ Clinical subjects include: i) Medicine and allied specialties (General Medicine, Pediatrics,Tuberculosis and Chest, Skin and Sexually Transmitted Diseases,Psychiatry, Radio‐diagnosis, Infectious diseases). ii) Surgery and allied specialties (General Surgery, Orthopedics includingtrauma, physiotherapy and rehabilitation, Anesthesia, Dentistry,Radiotherapy). iii) Obstetrics and Gynecology (including Family Medicine and FamilyWelfare). iv) Pediatrics.

7.5. Didactic lectures shall not exceed one third of the schedule; two third of the schedule shall include interactive, practical, clinical or/and group discussions. The learning process should include living experiences, problem oriented approach, case studies and community health care activities. The teaching roster should be carefully prepared byeach institution so as to give adequate and justified time for students to learn as well as prepare for their assessments.

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7.6. Universities shall organize admission timing and admission process in such a way that teaching in the first Professional year commences with induction through the Foundation Course by the 1st of August each year.

7.7. Supplementary examinations shall be conducted not earlier than 60 days and not later than 90 days after the declaration of results, so that the students who pass can join the main batch and the students who fail, will appear in the subsequent year.

7.8. A student shall not be allowed to graduate later than 9 years of joining first MBBScourse.

7.9. Passing in the 1st Professional examinations is compulsory before proceeding to Phase II training.

7.10. No more than 04 attempts shall be allowed for a candidate to pass the first Professional examinations. Total period for successful completion of first Professional shall not exceed 04 years. Partial attendance of examination in any subject shall becounted as an attempt.

7.11. A student, who fails in the IInd Professional examination, shall not be allowed to appear in IIIrd Professional Part I examination unless he passes all subjects of IInd Professional examination.

7.12. Passing in IIIrd Professional (Part I) examination is not compulsory before starting 4th year training, however passing of IIIrd Professional (Part I) is compulsory for being eligible for IIIrd Professional (Part II) examination.

7.13. During Phase II and Phase III including prescribed 04 weeks of electives, clinical postings of three hours duration daily as specified in Table is suggested for various departments.

8. Phase Distribution and Timing of examination 8.1. Time distribution of the MBBS programme is given in table 1.

8.2. Phase‐wise distribution of subjects is given in table 2.

8.3. Minimum teaching hours prescribed in various disciplines are as under tables 3‐7.

8.4. Distribution of clinical postings is given in table 8.

8.5. Total weeks of clinical postings will be: 8.5.1 Phase II: 36 weeks 8.5.2 Phase III part 1: 42 weeks 8.5.3 Phase III part 2: 44 weeks 8.6. Time allotted excludes time reserved for internal / university examinations, andvacation 8.7. Second phase clinical postings shall commence after declaration of results of the first professional phase examinations. Third Professional phase I and phase II clinical postings shall start no later than two weeks after completion of the previous phase examination8.8. 25% of allotted time of Phase 3 shall be utilized for integrated learning with pre‐ and para‐clinical subjects. This will be included in the assessment of clinical subjects.

Table 1: Time distribution of MBBS programme

NEET examination will comprise of 60‐70% of the course content from Phase III and rest will be from phase I and II. NEET will be held in the last week of February.

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Table 2: Phase�wise distribution of subjects Phase & year of MBBS training

Subjects & New Teaching Elements

Duration

University examination

Phase 1 I MBBS

Foundation Course (2 months)Anatomy, Physiology and Biochemistry Early Clinical Exposure (12 months) Professional Development including Ethics

2 + 12

Ist Professional

Phase 2 II MBBS

Pathology, Microbiology and Pharmacology, Forensic Medicine and Toxicology Introduction to clinical subjects Professional Development including

12 months

IInd Professional

13 months

IIIrd Professional (Part 1)

Phase 3 III MBBS Part I

Oto�rhinolaryngology, Ophthalmology, Community Medicine and Forensic Medicine and Toxicology Clinical subjects Professional development includingethics

Electives

Electives Skills and assessment*

Phase III III MBBS Part 2

Medicine, Surgery, Obstetrics and Gynecology and Pediatrics and specialties Professional Development including Ethics

2 months

13 months

IIIrd Professional (Part 2)

*Assessment of electives and skills will be included in Internal assessment.

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Table 3: Foundation Course Teaching hours

Self DirectedLearning (hours)

Total hours

Orientation 1

30

0

30

Skills Module 2

35

0

35

Core Subject Orientation3

120

15

135

8

0

8

32

0

32

80

0

80

Subjects/ Contents

Field visit to communityhealth center

Sports and Extracurricularincluding Yoga

Enhancement oflanguage/ computerskills4

320 1. Orientation course will be completed as single block in first week and will contain elements outlined in 9.1.

2. Skills modules will contain elements outlined in 9.1 3. Core subject orientation includes a) Integrated cell biology module �15 hours b) Introduction to Anatomy, Physiology and Biochemistry.

4. Based on perceived need students, may choose language enhancement (English or local spoken or both) and computer skills. This should be provided longitudinally through the duration of the Foundation Course after the orientation block.

Table 4: Phase I teaching hours Subjects

Lectures (hours)

Small Group Teaching/ Tutorials/ Integrated learning/ Practical (hours)

Self directed Learning (hours)

Total (hours)

Anatomy

200

350

30

580

Physiology

170

235

25

430

Biochemistry

90

115

20

225

80

0

0

80

20

27

5

52

Early Exposure Community Medicine

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Professional development including ethics* Sports and extracurricular including Yoga

35

0

0

35

38

Total

1440

Professional development shall be a longitudinal teaching program.

Table 5: Phase II teaching hours Lectures (hours)

Pathology 80 138 12 230

Small Group Teaching/ Tutorials/ Integrated learning Practical (hours)

80

Pharmacology 138 12 230

80

Microbiology 110 10 190

70

Subjects

Community Medicine 20 30 10 60 Forensic Medicine and Toxicology 15 30 5 50 Clinical Subjects Professional development including ethics 35 0 35 35 Sports and extracurricular including Yoga Total

Clinical Postings (hours)

Self directed Learning (hours)

Total (hours)

138

12

230

80

138

12

230

70

110

10

190

20

30

10

60

15

30

5

50

75 35

540© 0

615 35

35

40

40 1440

• At least 3 hours of clinical instruction each week must be allotted to training in clinical and procedural skill laboratories. The hours maybe distributed weekly or as a block in each posting based on institutional logistics.

• © :The clinical postings in the second phase shall be 15 hours per week 3 hrs per day only from Monday to Friday.

The rest of the time shall be used for para‐clinical subjects.

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Table 6: Phase III Part 1 teaching hours Subjects

Teaching Hours

Tutorials/Seminars /IntegratedTeaching(hours)

Self �Directed Learning(hours)

Total (hours)

General Medicine

25

35

5

65

General Surgery

25

35

5

65

Obstetrics and Gynecology

25

35

5

65

Pediatrics

20

30

5

55

Orthopedics

15

20

5

40

Forensic Medicine and Toxicology

25

45

5

75

Community Medicine

40

60

5

105

Dermatology

20

5

5

30

Psychiatry

25

10

5

40

Pulmonary Medicine

18

8

2

20

Oto� rhinolaryngology

25

40

5

70

Ophthalmology

30

60

10

100

Radiotherapy

10

8

2

20

Anesthesiology

8

10

2

20

Radiology and

Clinical Postings

756

Professional development including Ethics

25

Total

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303

401

66

1680

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Table 7: Phase III Part 2 teaching hours Subjects

Teaching

Tutorials / Seminars 125 125

Self ‐ Directed

Total*

General Medicine 70 15 210 General Surgery 70 15 210 Obstetrics And Gynecology 70 125 15 210 Pediatrics 20 35 10 65 Orthopedics 20 25 5 50 Clinical Postings 792 Professional Development 43 including Ethics Electives 200 Total 250 435 60 1760 *25% of allotted time of Phase 3 shall be utilized for integrated learning with pre‐ and para‐ clinical subjects. This will be included in the assessment of clinical subjects

Table 8: Clinical postings Subjects

Period of training in weeks

Electives

Total weeks

8‡ (4 regular clinical posting)

4

General Medicine1

4

4

8+4

20

General Surgery2

4

4

8+4

20

OB/GYN3

4

4

8+4

20

Pediatrics

2

4

4

10

Community Medicine3

4

6

Orthopedics‐ including Trauma4

2

4

Oto‐rhino‐ laryngology

4

4

8

Ophthalmology

4

4

8

Tuberculosis and respiratory diseases

2

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10 2

8

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Psychiatry

2

Radiology5

2

Dermatology, and HIV6

STD

2

2

2

2

Dentistry

2

Casualty

2 36

4

42

2

6 2

44

122

‡ In four of the eight weeks of electives regular clinical postings shall be accommodated..

Clinical postings maybe adjusted within the time framework 1 .This posting includes Laboratory Medicine and Infectious Diseases.

2.This posting includes 2 weeks of Dentistry, surgical dressing, and Anesthesia.

3.This includes maternity training and family welfare (including family planning).

4.This posting includes Trauma, Rehabilitation and Physiotherapy.

5.This posting includes Radiotherapy, where feasible.

6.If HIV clinic is not under the Department of Dermatology – the student must be sent to the appropriate clinical department.

9. New teaching / learning elements 9.1. Foundation Course 9.1.1 Goal: The goal of the Foundation Course is to prepare a student to study medicine effectively. It will be of two months duration after admission.

9.1.2 Objectives: The objectives are to: a. Orient the student to: i) The medical profession and the physician’s role in society, ii) The MBBS programme, iii) Alternate health systems in the country, iv) Medical ethics, attitudes and professionalism, v) Health care system and its delivery, vi) National health priorities and policies, vii) Universal precautions and vaccinations, viii) Patient safety and biohazard safety, ix) Principles of family practice, x) Indian medical graduate document of the Medical Council of India, xi) The medical college and hospital, b. Enable the student to acquire enhanced skills in: i) Language, ii) Interpersonal relationships, iii) Communication, iv) Learning including self‐directed learning, v) Time management, vi) Stress management, vii) Use of information technology. c. Train the student to provide: i) First‐aid, ii) Basic life support.

9.1.3 Elements: The program will include, in addition to the modules listed in the objectives above: a. Training in language and computer skills,

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b. Integrated Cell Biology Module, c. Foundation elements of preclinical sciences.

9.1.4 These sessions must be as interactive as possible.

9.1.5 Sports (to be used through the Foundation Course as protected 04 hours perweek).

9.1.6 Leisure and extracurricular activity (to be used through the Foundation Course asprotected 2 hours per wk) 9.1.7 Students may be enrolled in one of the following programmes which will be runconcurrently: a. Local language programme, b. English language programme, c. Computer skills, d. These may be done in the last two hours of the day for the duration of the Foundation Course.

9.1.8 Subject foundation elements, inclusive of the integrated cell biology module, may start after the first two wk (Anatomy 60 hours; Physiology 40 hours; Biochemistry 20 hours).

9.1.9 Many of these elements will require to be continued beyond the FoundationCourse.

9.1.10 Institutions shall develop learning modules and identify the appropriate resource persons for their delivery.

9.1.11 The time committed for the Foundation Course may not be used for any other curricular activity.

9.1.12 From the 2nd week onwards, until the end of the Foundation Course, the last 02 hours of each day will remain protected for language and computer skill classes.

9.1.13 Every college must arrange for a meeting with parents and their wards.

9.2. Early Clinical Exposure 9.2.1 Objectives: The objective of early clinical exposure of the first year medical students is to enable the student to: a. Recognize the relevance of basic sciences in patient care, b. Provide a context that will enhance basic science learning, and c. Relate to experience of patients as a motivation to learn, d. Recognize ethics and professionalism as integral to the doctor‐patient relationship, e. Understand the socio‐cultural context of disease through study of humanities.

9.2.2 Elements a. Basic science correlation: i.e. apply and correlate principles of basic sciences as they relate to the care of the patient (This will be part of integrated modules). b. Clinical skills: to include Basic skills in interviewing patients, doctor‐patient communication, ethics and professionalism, critical thinking and analysis and self-learning(This training will be imparted in the time allotted for early clinical exposure). c. Humanities: To introduce students to a broader understanding of the socioeconomicf ramework and cultural context within which health is delivered through the study of humanities and social sciences.

9.3. Electives 9.3.1 Objectives: To provide the student with opportunities: a. For diverse learning experiences, b. To do research / community projects that will stimulate enquiry, self‐directed,experiential learning and lateral thinking.

9.3.2 Two months are designated for elective rotations after completion of the exam attend of the IIIrd MBBS part 1 and before commencement of IIIrd MBBS part 2.

9.3.3 It is mandatory for students to do an elective. The elective time may not be usedto make up for missed clinical postings, shortage of attendance or other purposes.

9.3.4 Structure a. The student shall rotate through two elective blocks of 04 weeks each, b. Block 1 shall be done in a pre‐selected preclinical or para‐clinical or other basic sciences laboratory OR under a researcher on an on-going research project. During the electives regular clinical postings shall continue. c. Block 2 shall be done in a clinical department (including specialties, super specialties,ICUs, blood bank and

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casualty) from a list of electives developed andavailable in the institution OR as a supervised learning experience at a rural or urban community clinic. d. Institutions will pre‐determine the number and nature of electives, names of the supervisors, the number of students in each elective based on the local conditions, available resources and faculty.

9.3.5 Each institution will develop its own mechanism for allocation of electives.

9.3.6 It is preferable that elective choices are made available to the students in the beginning of the academic year.

9.3.7 The student must submit a learning logbook based on both blocks of the elective.

9.3.8 75% attendance in the elective and submission of log book maintained during elective is required for eligibility to appear in the final MBBS examination.

9.3.9 Institutions may use part of this time for strengthening basic skill certification.

9.3.10 All electives are required to be done in India ONLY. 9.4. Professional Development including Ethics and Medical Humanities 9.4.1 Objectives of the programme: At the end of the programme, the student mustdemonstrate ability to: a. understand and apply principles of bioethics and law as they apply to medical practice and research, b. understand and apply the principles of clinical reasoning as they apply to the care of the patients, c. understand and apply the principles of system based care as they relate to the care of the patient, d. understand and apply empathy and other human values to the care of the patient, e. communicate effectively with patients, families, colleagues and other health careprofessionals, f. understand the strengths and limitations of alternative systems of medicine, g. respond to events and issues in a professional, considerate and humane fashion h. translate learning from the humanities in order to further his / her professional and personal growth 9.4.2 Learning experiences: a. This will be a longitudinal programme spread across the continuum of the MBBS programme including internship, b. Learning experiences may include – small group discussions, patient carescenarios, workshop, seminars, role plays, lectures etc.

9.4.3 75% attendance in professional development program is required for eligibility to appear for final examination in each professional year.

9.4.4 Internal Assessment will include: a. Written tests comprising of short notes and creative writing experiences, b. OSCE based clinical scenarios / viva.

9.4.5 At least one question in each paper of the clinical specialties in the university examination should test knowledge competencies acquired during theprofessional development program 9.4.6 Skill competencies acquired during the professional development program must be tested during the clinical, practical and viva.

9.5. Student doctor Method of Clinical Training 9.5.1 Goal: To provide students with experience in: a. Longitudinal patient care, b. Being part of the health care team, c. Hands‐on care of patients in outpatient and inpatient setting.

9.5.2 Structure: a. The first clinical posting in phase II shall orient students to the patient, their roles and the specialty, b. The student doctor programme will progress as outlined in the table 9, c. The student will function as a part of the health care team with the following responsibilities: i) Be part of the unit’s outpatient services on admission days, ii) Remain with the admission unit until 6 PM except during designated classhours, iii) Be assigned not more than 2 patients admitted during each admission dayfor whom he/she will undertake responsibility as outlined in the table above, under the supervision of a senior resident or faculty member, iv) Participate in the unit rounds on its admission day and will present the assigned patients to the supervising physician, v) Follow the patient’s progress throughout the hospital stay until discharge,

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vi) Participate, under supervision, in procedures, surgeries, deliveries etc. ofthe assigned patients (according to responsibilities outlined in the tableabove), vii) Participate in unit rounds on at least one other day of the week excluding the admission day, viii) Discuss ethical and other humanitarian issues during unit rounds, ix) Attend all scheduled classes and educational activities, x) Document his/her observations in a prescribed logbook / case record. d. No student will be given independent charge of the patient. e. The supervising physician will be responsible for all patient care decisions.

9.5.3 Assessment: a. A designated faculty member in each unit will coordinate and facilitate the activities of the student, monitor progress, provide feedback and review thelogbook/ case record. b. The logbook/ case record must include the written case record prepared by the student including relevant investigations, treatment and its rationale, hospital course, family and patient discussions, discharge summary etc., c. The logbook should also include records of outpatients assigned. Submission ofthe log book/ case record to the department is required for eligibility to appear for the final examination of the subject.

Table 9: Student Doctor program Year of Curriculum

Focus of Student Doctor programme

Year 2

History taking, physical examination, assessment of change in clinical status, communication and patient education.

Year 3

All of the above and choice of investigations, basic procedures and continuity of care

Year 4

All of the above and decision making, management and outcomes.

10. Competencies 10.1. Preamble: The salient feature of the revision of the medical curriculum in 2012 is the emphasis on learning which is competency‐based, integrated and student‐centered acquisition of skills and ethical and humanistic values.

Each of the competencies described below must be read in conjunction with the goals of the medical education as listed in item 2 and 3.

10.2. Integration must be horizontal (i.e. across disciplines in a given phase of the course) and vertical (across different phases of the course). As far as possible, it is desirable that teaching/learning occurs in each phase through study of organ systems or disease blocks in order to align the learning process. Clinical cases must be used to integrate and link learning across disciplines.

10.3. For clinical subjects, it is recommended that didactic teaching be restricted to less than30% of the total time allotted for that discipline. Greater emphasis is to be laid onhands‐on training, symposia, seminars, small group discussions, problem‐oriented andproblem‐based discussions and self‐directed learning. Students must be encouraged totake active part in and shared responsibility for their learning.

10.4. Pre‐clinical Subjects 10.4.1. Human Anatomy a. Competencies: The undergraduate must demonstrate: i. Understanding of the gross and microscopic structure and development ofhuman body, ii. Comprehension of the normal regulation and integration of the functions ofthe organs and systems on basis of the structure, iii. Understanding of the clinical correlation of the organs and structures involved and interpret the anatomical basis of the disease presentations. b. Integration: The teaching should be aligned and integrated horizontally and vertically in organ systems with clinical correlation that will provide a context for the student to understand the relationship between structure and

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function and interpret the anatomical basis of various clinical conditions and procedures.

10.4.2. Physiology a. Competencies: The undergraduates must demonstrate: i. Understanding of the normal functioning of the organs and organ systems ofthe body, ii. Comprehension of the normal structure and organization of the organs and systems on basis of the functions, iii. Understanding of age‐related physiological changes in the organ functions that reflect normal growth and development, iv. Understand the physiological basis of disease. b. Integration: The teaching should be aligned and integrated horizontally and vertically in organ systems in order to provide a context in which normal function can be correlated both with structure and with the biological basis, its clinical features, diagnosis and therapy.

10.4.3. Biochemistry a. The course will comprise Cellular Biochemistry and Molecular Biology. b. Competencies: The student must demonstrate an understanding of: i. biochemical and molecular processes involved in health and disease, ii. importance of nutrition in health and disease, iii. biochemical basis and rationale of clinical laboratory tests and Demonstrateability to interpret these in the clinical context. c. Integration: The teaching/learning programme should be integrated horizontallyand vertically, as much as possible, to enable students to make clinical correlations and to acquire an understanding of the cellular and molecular basisof health and disease.

10.4.4. Introduction to Community Medicine a. Competencies: The undergraduate must demonstrate: i. Understanding of the concept of health and disease, ii. Understanding of demography, population dynamics and disease burden in National and global context, iii. Comprehension of principles of health economics and hospital management.

10.5. Phase 2 (Para‐Clinical) 10.5.1. Pathology a. Competencies: The undergraduate must demonstrate: i. Comprehension of the causes, evolution and mechanisms of disease, ii. Knowledge of alterations in gross and cellular morphology of organs indisease states, iii. Ability to correlate the natural history and structural and functional changeswith the clinical manifestations of diseases, their diagnosis and therapy. b. Integration: The teaching should be aligned and integrated horizontally andvertically in organ systems recognizing deviations from normal structure andfunction and clinically correlated so as to provide an overall understanding of the etiology, mechanisms, laboratory diagnosis and therapy of disease.

10.5.2. Microbiology a. Competencies: The undergraduate student demonstrates: i. Understanding of role of microbial agents in health and disease, ii. Understanding of the immunological mechanisms in health and disease, iii. Ability to correlate the natural history, mechanisms and clinical manifestations of infectious diseases as they relate to the properties ofmicrobial agents, iv. Knowledge of the principles and the application of infection control measures, v. An understanding of the basis of choice of laboratory diagnostic tests andtheir interpretation, antimicrobial therapy, control and prevention ofinfectious diseases. b. Integration: The teaching should be aligned and integrated horizontally andvertically in organ systems with emphasis on host ‐ microbe ‐ environmentinteractions and their alterations in disease and clinical correlations so as toprovide an overall understanding of the etiological agents, their laboratory diagnosis and prevention.

10.5.3. Pharmacology a. Competencies: The undergraduate must demonstrate : i. Knowledge about essential and commonly used drugs and an understandingof the pharmacologic basis of therapeutics, ii. Ability to select and prescribe medicines based on clinical condition and the pharmacologic properties, efficacy,

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safety, suitability and cost of medicines for common clinical conditions of national importance, iii. Knowledge of pharmaco‐vigilance, essential drug concept and list, sources of drug information and industry‐ doctor relationships, iv. Ability to counsel patients regarding appropriate use of prescribed drug and drug delivery systems b. Integration: The teaching should be aligned and integrated horizontally andvertically in organ systems recognizing the interaction between drug, host anddisease in order to provide an overall understanding of the context of therapy.

10.6. Phase III Part 1 10.6.1. Forensic Medicine and Toxicology a. Competencies: The student must demonstrate: i. Understanding of medico‐legal responsibilities of physicians in primary and secondary care settings, ii. Understanding of the rational approach to the investigation of crime, based on scientific and legal principles, iii. Ability to manage medical and legal issues in cases of poisoning / overdose, iv. Understanding the medico‐legal framework of medical practice and medical negligence, v. Understanding of codes of conduct and medical ethics. b. Integration: The teaching should be aligned and integrated horizontally and vertically recognizing the importance of medico‐legal, ethical and toxicologicalissues as they relate to the practice of medicine 10.6.2. Community medicine a. Competencies: The student must demonstrate: i. Understanding of physical, social, psychological, economic and environmental determinants of health and disease, ii. Ability to recognize and manage common health problems including physical,emotional and social aspects at individual family and community level in thecontext of National Health Programmes, iii. Ability to Implement and monitor National health programmes in the primary care setting, iv. Knowledge of maternal and child wellness as they apply to national healthcare priorities and programmes, v. Ability to recognize, investigate, report, plan and manage community healthproblems and emergencies, vi. Ability to recognize, investigate, report and manage community healthproblems and emergencies. b. Integration: The teaching should be aligned and integrated horizontally andvertically in order to allow the student to understand the impact of environment, society and national health priorities as they relate to the promotion of health and prevention and cure of disease.

10.6.3. Otorhinolaryngology a. Competencies: The student must demonstrate: i. Knowledge of the common Oto‐rhino laryngological (ENT) emergencies andproblems, ii. Ability to recognize, diagnose and manage common ENT emergencies andproblems in primary care setting, iii. Ability to perform simple ENT procedures as applicable in a primary care setting, iv. Ability to recognize hearing impairment and refer to the appropriate hearing impairment rehabilitation programme, b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to allow the student to understand the structural basis of ENTproblems, their management and correlation with function, rehabilitation andquality of life.

10.6.4. Ophthalmology a. Competencies: The student must demonstrate: i. Knowledge of common eye problems in the community, ii. Recognize, diagnose and manage common eye problems and identify indications for referral, iii. Ability to recognize visual impairment and blindness in the community andimplement National programme as applicable in the primary care setting. b. Integration: The teaching should be aligned and integrated horizontally andvertically in order to allow the student to understand the structural basis of ophthalmologic problems, their management and correlation with function,rehabilitation and quality of life.

10.7. Phase III (Part 2) 10.7.1. Medicine a. Competencies: Must demonstrate ability to do the following in relation tocommon medical problems in the adult in the community: i. Demonstrate understanding of the patho‐physiologic basis, epidemiological profile, signs and symptoms, of

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disease and their investigation andmanagement, ii. Competently interview and examine an adult patient and make a clinical diagnosis,iii. Appropriately order and interpret laboratory tests, iv. Initiate appropriate cost‐effective treatment based on an understanding of therational drug prescriptions, medical interventions required and preventive measures, v. Follow up patients with medical problems and refer whenever required, vi. Communicate effectively, educate and counsel the patient and family, vii. Manage common medical emergencies and refer when required, viii. Independently perform common medical procedures safely and understand patient safety issues, b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to provide sound biologic basis and incorporating the principles of internal medicine into a holistic and comprehensive approach to the care ofthe patient.

10.7.2. Pediatrics a. Competencies: The student must demonstrate: i. Ability to assess and promote optimal growth, development and nutrition ofchildren and adolescents and identify deviations from normal, ii. Ability to recognize and provide emergency and routine ambulatory and First Level Referral Unit care for neonates, infants, children and adolescents and refer as may be appropriate, iii. Ability to perform procedures as indicated for children of all ages in theprimary care setting, iv. Ability to recognize children with special needs and refer appropriately, v. Ability to promote health and prevent diseases in children, vi. Ability to participate in National Programmes related to child health and in conformation with the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) Strategy, vii. Ability to communicate appropriately and effectively. b. Integration: The teaching should be aligned and integrated horizontally andvertically in order to provide comprehensive care for neonates, infants, children and adolescents based on a sound knowledge of growth, development, disease and their clinical, social, emotional, psychological correlates in the context of national health priorities.

10.7.3. Psychiatry a. Competencies: The student must demonstrate: i. Ability to promote mental health and mental hygiene, ii. Knowledge of etiology (bio‐psycho‐social‐environmental interactions), clinical features, diagnosis and management of common psychiatric disorders across all ages, iii. Ability to recognize and manage common psychological and psychiatric disorders in a primary care setting, institute preliminary treatment in disorders difficult to manage, and refer appropriately, iv. Ability to recognize alcohol/ substance abuse disorders and refer them to appropriate centers, v. Ability to assess risk for suicide and refer appropriately, vi. Ability to recognize temperamental difficulties and personality disorders. b. Integration: The teaching should be aligned and integrated horizontally andvertically in order to allow the student to understand bio‐psycho‐social environmental interactions that lead to diseases/ disorders for preventive,promotive, curative, rehabilitative services and medico‐legal implications in the care of patients both in family and community.

10.7.4. Dermatology, sexually transmitted diseases and HIV a. Competencies: The undergraduate student must demonstrate: i. Understanding of the principles of diagnosis of diseases of the skin, hair, nailand mucosa, ii. Ability to recognize, diagnose, order appropriate investigations and treat common diseases of the skin including leprosy in the primary care setting andrefer as appropriate, iii. A syndromic approach to the recognition, diagnosis, prevention, counselling, testing and management of common sexually transmitted diseases including HIV based on national health priorities, iv. Ability to recognize and treat emergencies including drug reactions and refer as appropriate. b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to emphasize the biologic basis of diseases of the skin, sexually transmitted diseases and leprosy and to provide an understanding that skin diseases may be a manifestation of systemic disease.

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10.7.5. Tuberculosis and respiratory diseases a. Competencies: The student must demonstrate: i. Knowledge of common chest diseases, their clinical manifestations, diagnosis and management, ii. Ability to recognize, diagnose and manage pulmonary tuberculosis as contemplated in National Tuberculosis Control programme, iii. Ability to manage common respiratory emergencies in primary care setting and refer appropriately. b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to allow the student to recognize diagnose and treat TB in thecontext of the society, national health priorities, drug resistance and co‐morbid conditions like HIV. 10.7.6. Surgery a. Competencies: The undergraduate student must demonstrate: i. Understanding of the structural and functional basis, principles of diagnosisand management of common surgical problems in adults and children, ii. Ability to choose, calculate and administer appropriately intravenous fluids,electrolytes, blood and blood products based on the clinical condition, iii. Ability to apply the principles of asepsis, sterilization, disinfection, rational useof prophylaxis, therapeutic utilities of antibiotics and universal precautions insurgical practice, iv. Knowledge of common malignancies in India and their prevention, early detection and therapy, v. Ability to perform common diagnostic and surgical procedures at the primary care level, vi. Ability to recognize, resuscitate, stabilize and provide advanced life support to patients following trauma, vii. Ability to administer informed consent and counsel patient prior to surgical procedures, viii. Commitment to advancement of quality and patient safety in surgicalpractice. b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to provide a sound biologic basis and a holistic approach to thecare of the surgical patient.

10.7.7. Orthopaedics a. Competencies: The student must demonstrate: i. Ability to recognize and assess bone injuries, dislocation and poly‐trauma andprovide first contact care prior to appropriate referral, ii. Knowledge of the medico‐legal aspects of trauma, iii. Ability to recognize and manage common infections of bone and joints in the primary care setting, iv. Recognize common congenital, metabolic, neoplastic, degenerative and inflammatory bone diseases and refer appropriately, v. Ability to perform simple orthopedic techniques as applicable to a primarycare setting, vi. Ability to recommend rehabilitative services for common orthopaedic problems across all ages. b. Integration: The teaching should be aligned and integrated horizontally and vertically in order to allow the student to understand the structural basis of orthopedic problems, their management and correlation with function,rehabilitation and quality of life.

10.7.8. Radio‐Diagnosis a. Competencies: The student must demonstrate: i. Understanding of indications for various radiological investigations incommon clinical practice, ii. Awareness of the ill effects of radiation and various radiation protective measures to be employed, iii. Ability to identify abnormalities in common radiological investigations. b. Integration: Horizontal and vertical integration to understand the fundamental principles of radiologic imaging, anatomic correlation and their application in diagnosis and therapy.

10.7.9. Radiotherapy a. Competencies: The student must demonstrate understanding of: i. Clinical presentations of various cancers, ii. Appropriate treatment modalities for various types of malignancies, iii. Principles of radiotherapy and techniques. b. Integration: Horizontal and vertical integration to enable basic understanding of fundamental principles of radio‐therapeutic procedures.

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10.7.10. Obstetrics and Gynaecology a. Competency in Obstetrics: The student must demonstrate ability to: i. Provide peri‐conceptional counselling and antenatal care, ii. Identify high‐risk pregnancies and refer appropriately, iii. Conduct normal deliveries, using safe delivery practices in the primary andsecondary care settings, iv. Prescribe drugs safely and appropriately in pregnancy and lactation, v. Diagnose complications of labor, institute primary care and refer in a timely manner, vi. Perform early neonatal resuscitation, vii. Provide postnatal care, including education in breast‐feeding, viii. Counsel and support couples in the correct choice of contraception, ix. Interpret test results of laboratory and radiological investigations as they apply to the care of the obstetric patient, x. Apply medico‐legal principles as they apply to tubectomy, Medical Termination of Pregnancy (MTP) and Pre‐ conception and Prenatal DiagnosticTechniques (PC PNDT Act). b. Competency in Gynecology: The student must demonstrate ability to: i. Elicit a gynecologic history perform appropriate physical, pelvic examinationand PAP smear in the primary care setting ii. Recognize diagnose and manage common reproductive tract infections in the primary care setting, iii. Recognize and diagnose common genital cancers and refer themappropriately. c. Integration: The teaching should be aligned and integrated horizontally andvertically in order to provide comprehensive care for women in their reproductive years and beyond, based on a sound knowledge of structure function and disease and their clinical, social, emotional, psychological correlates in the context of nation health priorities.

11. Assessment 11.2. Eligibility to appear for Professional examinations 11.2.1. The performance in essential components of training are to be assessed, basedon: a. Attendance i. Attendance requirements are 75% in theory and practicals/clinical combinedfor eligibility to appear for the examinations in that subject, ii. In subjects that are taught in more than one phase – the student must have75% attendance in theory and 75% in practical in each phase of instruction inthat subject, iii. When subjects are taught in more than one phase – the internal assessment must be done in each phase and must contribute proportionally to finalinternal assessment, iv. If an examination comprises more than one subject (for e.g., Surgery andallied branches), the candidate must have 75% attendance in each subject and clinical posting, v. The final internal assessment in a broad clinical specialty (e.g., Surgery andallied etc.) shall comprise of marks from all the constituent specialties. The proportion of the marks for each constituent specialty shall be determined by the time of instruction allotted to each, vi. Students who do not have at least 75% attendance in the Foundation Coursewill not be eligible for the phase I examination, vii. Students who do not have at least 75% attendance in the electives will not be eligible for the phase III ‐ part 2 examination. b. Internal Assessment: Internal assessment shall be based on day‐to‐day assessment. It shall relate to different ways in which students participate in learning process including assignments, preparation for seminar, clinical casepresentation, preparation of clinical case for discussion, clinical case study/problem solving exercise, participation in project for health care in the community, proficiency in carrying out a practical or a skill in small researchproject, a written test etc. i. Regular periodic examinations shall be conducted throughout the course. There shall be no less than two internal assessment examinations ineach non‐clinical subject and no less than one examination in each clinical subject in a professional year. An end of posting clinical assessment shall beconducted for each clinical posting in each professional year. ii. In subjects that are taught at more than one phase, proportionate weightage must be given for internal assessment for each Phase. For example, Medicine must be assessed in 3rd, 4th and 5th years independently.

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iii. Day to day records should be given importance during internal assessment.iv. Students must secure at least 50% marks of the total marks (separately intheory and practicals / clinicals) fixed for internal assessment in a particular subject in order to be eligible to appear in final university examination of that subject. v. Internal assessment marks will determine eligibility for appearing for university examination. Internal assessment marks will not be added to thefinal examinations marks to determine pass or fail.

11.3. University Examinations 11.3.1. University examinations are to be designed with a view to ascertain whether the candidate has acquired the necessary knowledge, minimum skills, ethical and professional values with clear concepts of the fundamentals which are necessary for him/her to function effectively and appropriately as a physician of firstcontact. Assessment shall be carried out on an objective basis to the extent possible.

11.3.2. Nature of questions will be structured essay, short answer type/objective type and marks for each part indicated separately.

11.3.3. Practical/clinical examinations will be conducted in the laboratories or hospital wards. The objective will be to assess proficiency and skill to conduct experiments, interpret data and form logical conclusion. Clinical cases kept in the examination must be common conditions that the student may encounter as a physician of first contact in the community. Rare syndromes and disorders are to be discouraged. Emphasis should be on candidate’s capability in elicit a history demonstrate physical signs write a case record, analyze the case and develop a management plan.

11.3.4. Viva/oral includes assessment of management approach and handling of emergencies, ethical and professional values. Candidate’s skill in interpretation of common investigative data, x‐rays, identification of specimens, ECG, etc. also is to be assessed.

11.3.5. There shall be one main examination in a year and a supplementary to be held not earlier than 60 days and no later than 90 days after the publication of its results.

11.3.6. A student shall not be allowed to graduate later than 09 (nine) years of joining first MBBS course.

11.3.7. University Examinations shall be held as under:‐ a. First Professional i. The first Professional examination shall be held at the end of Phase 1 training(2 +12 months), in the subjects of Anatomy, Physiology and Biochemistry. ii. Maximum number of attempts allowed at the first Professional University examinations will be four; the first Professional course must be completed within 4 years of admission. Partial attendance in an examination in any subject shall be counted as an attempt. b. Second Professional i. The second Professional examination shall be held at the end of Phase 2training (12 months), in the subjects of Pathology, Microbiology, andPharmacology. c. Third Professional i. Part 1 shall be held at end of Phase 3 (Part 1) of training (13 months) in the subjects of Ophthalmology, Oto‐ rhino‐laryngology, Community Medicine andForensic Medicine and Toxicology ii. Third Professional Part II ‐ (Final Professional) shall be at the end of Phase 3 oftraining (15 months including 2 months of electives) in the subjects ofMedicine, Surgery, Obstetrics & Gynecology and Pediatrics. “The discipline of Orthopedics will constitute 25% of the total theory marks in Surgery. The questions will form a separate section in Surgery Paper II. The student must secure at least 40% marks in the Orthopedics Section with the proviso ‘toobtain 50% of marks in total as pass percentage’. The discipline of Psychiatry and Dermatology, Venereology and Leprology(DVL) will constitute 25% of the total theory marks in Medicine. The questions will form a separate section in Medicine Paper II. The student must secure atleast 40% marks in the Psychiatry and DVL Section with the proviso ‘to obtain 50% of marks in total as pass percentage’. d. Examination schedule is in table 1. e. Marks distribution is in table 10.

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Table 10: Mark distribution for various subjects Written‐ Theory – 200

Phase – I Anatomy ‐ 2 Papers

Practicals/Orals/Clinicals‐ 100

200

100

Physiology ‐ 2 Papers

200

100

200

100

200 200

100 100

200

100

100 100

100 100

100

100

200

100

200 200 200 100 200

200 200 200 100 200

Phase of Course

Bio‐Chemistry & Molecular Biology ‐ 2 papers Phase – II Pharmacology ‐ 2 Papers Pathology ‐ 2 papers Microbiology and Virology ‐ 2 papers Phase – III Part ‐ I Forensic Medicine ‐ 1 paper Ophthalmology – 1paper Otorhinolaryngology – 1 paper Community Medicine ‐ 2 papers Phase – III Part ‐ II Medicine ‐ 2 papers Surgery ‐ 2 papers Paediatrics – 1 paper Ob. &Gy. ‐ 2 papers

Pass Criteria

Internal Assessment: 50% separately in theory and practicals for eligibility to appear for University Exam University Exam Mandatory 50% marks in theory and practical (practical = practical/ clinical + viva)

Note: At least one question in each paper of the clinical specialties should test knowledge ‐competencies acquired during the professional development program; Skill ‐ competencies acquired during the professional development program must be tested during the clinical, practical and viva.

11.3.8. Criteria for Passing in a Subject: A candidate shall obtain 50% marks in University conducted examination separately in Theory and Practical (practical includes:practical/ clinical and viva voce) in order to be declared as passed in that subject.

11.3.9. Appointment of Examiners a. No person shall be appointed as an examiner in any of the subjects of the Professional examination leading to and including the final Professional examinations for the award of the MBBS degree unless he/she has taken at least eight years previously, a doctorate degree from a recognized University or an equivalent qualification in the particular subject as per recommendation of the Council on teachers’ eligibility qualifications and has had at least eight years of total teaching experience in the subject concerned in a college affiliated to a recognized University at a faculty position. b. There shall be at least four examiners for 100 students, out of whom not less than 50% must be external examiners. Of the four examiners, the senior most externalexaminer will act as the Chairman and coordinator of the whole examination programme so that uniformity in the matter of assessment of candidates is maintained. Where candidates appearing are more than 100, two additional examiners for every additional 50 or part thereof candidates appearing, be appointed. c. Non‐medical scientists engaged in the teaching of medical students as whole timeteachers, may be appointed

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examiners in their concerned subjects provided they possess requisite doctorate qualifications and five year teaching experience of medical students after obtaining their postgraduate qualifications. Provided further that the 50% of the examiners (Internal & External) are from the medical qualification stream. d. External examiners shall not be from the same University and must be fromoutside the state. e. The internal examiner in a subject shall not accept external examinership for a college from which external examiner is appointed in his/her subject. A University having more than one college shall have separate sets of examiners for each college, with internal examiners from the concerned college. f. External examiners shall rotate at an interval of 2 years. g. There shall be a Chairman of the Board of paper�setters who shall be an internal examiner and shall moderate the questions. h. Except Head of the Department of subject concerned in a college/institution, allother with the rank of reader or equivalent and above with requisite qualifications and experience shall be appointed internal examiners by rotation in their subjects; provided that where there are no posts of readers, then an Assistant Professor of 05 years (total 08 years after MD/MS) standing as AssistantProfessor may be considered for appointment as examiner. i. The grace marks up to a maximum of five marks may be awarded at the discretion of the University to a student who has failed only in one subject but has passed in all other subjects.

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Transformative Curriculum Santosh Kumar * The word transformation means “a marked change in nature, formor appearance”.1 Thus the word transformative would mean something that causes a marked change. A learning that causes a marked change in leaners can be called transformative learning and a curriculum that causes a marked change in learners can be called transformative curriculum.

Transformative learning involves a realization that one’s presumptions are incorrect which leads to assumption of new roles and learning of new skills.2 The Report of Lancet Commission on Education of Health Professionals for the 21st Century has described three types of learning.3 If there is acquisition of knowledge and skills, it leads to production of experts and it is called informative learning. If there is development of desirable beliefs, attitudes and values, it leads to production of professionals and it is called formative learning. If there is acquisition of leadership qualities and skills, it leads to production of leaders or change agents and it is called transformative learning.3The three types of learning have a hierarchical relationship.

The Report of Lancet Commission, using a global, multiprofessional (medical, nursing and public health professions) and systems approach, has identified problems in health system and education system. 3 Problems identified in health system include inequities between and within countries. Problems identified in education system include lack of development of competencies required for the needs of patients and populations. The Report of Lancet Commission has suggested instructional reforms for dealing with problems in education system.3 Taken together, these instructional reforms may be called transformative curriculum. However one has to keep in mind that only curricular guidelines are given and not full curriculum because there are no outcomes/objectives, teaching-learning methods and assessment methods.

The instructional reforms of the Report of Lancet Commission include application of competency-based approach, interprofessional and transprofessional education, using information and communication technology for education, fostering a new professionalism, augmenting educational resources and using global resources.3 Competency-based approach should emphasise development of competencies adapted to local needs and they should be determined by all relevant stakeholders.3It will need outcome-based education in which outcomes determine the course content.

The competencies may include leadership and management skills, communication skills, critical thinking skills, research skills, self-directed learning skills and life-long learning skills.3Interprofessional education involves teambased learning among medical, nursing and public health professional students.3 Transprofessional education involves team-based learning including professional students and basic and ancillary health students.3 Use of information and communication technology needs informatic skills of searching and evaluating information for application and includes partial and full online courses which are easy to verify and modify. New professionalism includes patient and population centredness, continuous quality improvement, evidence informed practice, service orientation and effective team work.3 Educational resources to be augmented include financial, infrastructural and material resources. There is a need for faculty development. Global resources should be utilized but they should be adapted locally.3These global resources include open educational digitized resources which are offered freely and openly for learning.

The feasibility of implementation of transformative curriculum will depend on available resources which are inequitably distributed. However, a beginning can be made in most of places by starting digitization education materials.

References

1. Concise Oxford English Dictionary, Eleventh Edition, Oxford:Oxford University Press 2004.

2. Sethuraman KR. Adult learning principles-In:Medical Education-Principles and Practice Eds: NAnanthakrishnan, KRSethuraman, Santosh Kumar, Second Edition, 2000:37-38.

3. Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet, 2010. At http://www.thelancet.com/commissions/education-ofhealth professionals.

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* Dr. Santosh Kumar , Senior Professor of Urology and Former Head of Departments of Urology and Medical Education,JIPMER, Puducherry Annals of SBV

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Problemistics in Health Professional Education Inculcating Holistic Clinical Reasoning and Problem Solving Abilities KR Sethuraman * Introduction

Although the practice of medicine is not a pure science, it is based on science and is always striving to become more scientific. Teaching of clinical practice is based on pragmatic considerations, educational theory, experience, and even on ‘trial and error’. There is no justification to apologize for these attributes, because despite these shortcomings, our medical programs do yield practitioners who excel in clinical problem solving and who effectively navigate the complexities of diagnosis and treatment. There are no double-blind controlled studies of clinical reasoning or of any of the programs designed to teach clinical reasoning. We may not know precisely how our students become expert problem solvers, but over time most of them do so.Our job as educators is to continue to evolve our teaching methods in the hope that our students become more efficient and more accurate problem solvers (JP Kassirer, 2010) Problem Based Learning (PBL) and Problem Solving Exercise (PSE) The Essence of Problem Centred learning Schmidt (1983) summarized PBL in terms of three essential principles: 1. Activation of prior learning via the problem; 2. Encoding specificity such that the resemblance of the problem to intended real-life application facilitates transfer of learning and 3. Elaboration of knowledge via group-discussion and reflection to consolidate learning experiences.

A characteristic of PBL, which follows from these attributes, is that it is unconfined by discipline boundaries, encouraging an integrative approach to learning which is based on requirements of the problem as perceived by the learners themselves and their identification of learning needs. Prior knowledge-base needed to solve the problem is not necessary for PBL. PBL is a major component of innovative PBL or Hybrid –‘SPICES’- curricula.

In contrast, problem solving exercises (PSE) merely involve application of a priorilearnt material. They are designed to consolidate prior learning and to scale up the level of student learning from knowledge to application and problem solving. PSE is a part of traditional curricula.

Fidelity Issues in PBL However, the reality of PBL-scene in this region is not all that rosy. Jayawickramarajah (1996) did content analysis of six problem documentation sets of three medical schools. It revealed a number of factors influencing the construction of problem fidelity: i. Presentation format may vary from patient simulations and video recordings of cases (high fidelity) to “written simulations” in which the case is described on paper (exhibiting low fidelity). ii. Manifestation may be ill structured with a range of possibilities (high fidelity) or may be a comprehensive list of the pool of manifestation possibilities (low fidelity & textbook-like). iii. Associated problems -”noise”- may be included which complicate the scenario -”signal”- with possibly unrelated factors such as symptoms produced by medication or behavioural problems (high fidelity); alternatively, the problem may be filtered to present an isolated set of conditions (low fidelity). iv. Context may resemble that of actual situations such as those that afford the opportunity to talk to family members of the patient (high fidelity), or may be more contrived (low fidelity). v. Objectives may be defined in terms of the health of the patient (high fidelity and integration across disciplines) or may be discipline-bound (low fidelity and artificial).

He found that low-fidelity problems such as those stylistically borrowed from textbook models of problems to be “counterproductive in terms of the objectives of PBL. In this context textbook derived health problems are not considered very appropriate” One of the important ways to improve the construct of problems for learning is for educators to understand the newer developments in the science of problem-dealing known as Problemistics.

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* Prof. .Sethuraman MD, Vice-Chancellor, Sri Balaji Vidyapeeth, Puducherry Page 24

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Problemistics Problemistics is the science of dealing with problems. It is an activity aimed at the recognition, identification and resolution of a problem and the development of Well-Being.

Problemisticsis concerned with -

¾¾ Problem Framing – i.e., context and terms of reference (agenda) ¾¾ Problem Finding – i.e., identify the problem/s in all its dimensions ¾¾ Problem Solving – i.e., choose appropriate ways to resolution ¾¾ Problem Acting – i.e., act on the problem in a systematic way It takes place in the following Spheres of life experience (life-world):

¾¾ Biomedical-sphere ¾¾ Socio-sphere ¾¾ Techno-sphere

- - -

nature and environment (e.g., infections) individuals and groups (e.g., phobic neurosis) tools and artifacts (e.g., implant malfunction)

It is apparent that most of the problem-based-learning involves only the second and third components of problem solving, usually limited to biomedical sphere only. In order to equip students with problem-dealing capabilities in a holistic manner, we need to expand the scope of PBL and PSE to include all the four components and the three spheres of life-world.

Problem dealer (The Healthcare Professional)needs development of the following characteristics: ¾Dimensions ¾ emotive, cognitive, volitive ¾Qualities ¾ thrill, skill, will o Thrill emotive dimension i.e. rapport building, empathy o Skill cognitive dimension i.e. critical thinking, creativity o Will volitive dimension i.e. patience, perseverance ¾Purposes ¾

wisdom, wealth, health

Wisdom

Wisdom is appropriate understanding and judgement of reality, based on deep Knowledge that reaches the core and essence of reality of the problem on hand.

Wealth of Options

Wealth is freedom, richness and meaningfulness of choices and is not to be confused with abundance of material goods (affluence). Wealth emerges in the process of Design (Problem Solving) as a result of the shaping of Solutions to a continuous series of Problems with which the human being is confronted.

Health

Health is biosocial (environment) and psychophysical (person) soundness and is not to be mistaken for simple lack of social ills or absence of physical/mental illness. Health emerges in the process of Planning (Problem Acting) as a result of the actuation of solutions to the problem.

(For further study of Problemistics, visitwww.problemistics.org ) When one applies the concept of problemistics to clinical problem-solving, then the following list emerges: 1- Problem sensing 2- Problem hypothesizing 3- Problem searching & refining - rule in / rule out - prognostic and severity info - clues for most appropriate management option - new problems - biological, psycho-social, technical or economic 4- Problem identification (definite, single/multiple or indefinite) 5- Problem resolution (implement one or more of several Rx options) 6- Problem (resolution) verification

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- problem(s) resolved fully - not fully resolved and try another Rx option - problem initially identified seems incorrect: redo from step-2 - in emergencies, initially a hypothesis for life-saving Rx; do a detailed work-up later

Components of cognitive skill: ¾Attention ¾ to problem cues - mindfulness ¾Knowledge ¾ of relevant data ¾Skill ¾ in data gathering ¾Analysis ¾ and interpretation of data ¾Evaluate ¾ and prioritize the significance of the findings ¾Synthesize ¾ data in to diagnostic conclusions ¾Knowledge ¾ of available interventions ¾Selection ¾ and application of appropriate intervention ¾Evaluation ¾ of outcomes ¾Identification ¾ of the need for and application of changes in management as indicated (BJ Andrew, 1972) The above list of problem-solving skills can be further split in to diagnostic clinical reasoning and therapeutic clinical reasoning (Jerome P. Kassirer, 2010). The list will help educators to adopt micro-component skills training strategies to systematically cultivate clinical reasoning abilities in the learners.

Components of Diagnostic Clinical Reasoning • Hypothesis generation • Context formulation • Hypothesis refinement • Test interpretation • Bayesian reasoning • Probabilistic, physiologic, and causal reasoning • Differential diagnosis • Assessing for adequacy, coherence, and parsimony • Working (final) diagnosis • Cognitive errors Components of Therapeutic Clinical Reasoning • Treatment under conditions of uncertainty • Tradeoff between the risks and benefits of tests, and of treatments • Choices based on the relation between the likelihood of disease and therapeutic risk • Treatment thresholds • Test-treatment thresholds • Decisional close calls and “toss-ups” when faced with uncertainty • Therapeutic trial as a diagnostic test • Watchful waiting versus immediate action Common difficulties in problem solving “Pseudodiagnocity” is the tendency to seek data relevant to a single disease, while ignoring information that point to alternative diagnoses. Human mind may have a tendency to test hypotheses sequentially rather than concurrently; therefore relate evidence only to the current hypothesis. I call it the “can-occur syndrome”, very prominently noted in novices: a new finding which is characteristic and even sine qua non of an alternate diagnosis is considered as a ‘canalso-occur-finding’ of the currently suspected diagnosis. Thetendency of pseudodiagnocity, of jumping to premature conclusion and to stick to a single hypothesis and is called “Freezing” in clinical psychodiagnosis. (L Kern & ME Doherty, 1982) “Shot Gun approach” is another common tendency seen in novices: to try as many diagnostic and treatment options as possible so that one or more hits the ‘bull’s eye’ and help in resolution.

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“Tunnel vision” problem solving is another common shortcoming in novices. They look at the problem from a narrow biomedical view and miss out on psycho-social and economic issues.

Problem-Knowledge coupler (PKC) The use of Problem-Knowledge coupler (PKC) is a strategy to open the minds of learners to holistic dealing with problems.

Patient centred approach mandates a bio-psycho-social approach to consider all aspects of how the problem has affected the patient. Evidence based approach examinesall the current scientific evidence for diagnosing and managing the problem. Combining both approaches permits synthesis of a solution to the patient problem that is specific the particular case.

Table. Some characterizations of the conventional and PBL approaches Issue: 1. Class time to “cover subject” 2. Learning objectives 3. Subject focus 4. Student focus [learning style] 5. Mode of Problem solving 6. Number of problems dealt with in a given time.

7. Assessment.

Conventional PSE PBL 100/100 80/100 Selected by the faculty. Students Students generate about 60% of the see clearly 100% of the objectives objectives. planned.

One subject at a time. Difficult to Great for integration but difficult integrate but easier to be sure of what for students to resolve depth versus is expected. breadth.

Tend to learn the facts and try to Learn a systematic problem solving collect as many example, typical cases process and subject knowledge in the as possible. context of solving a problem.

Focus is on pattern matching – ‘fit’ Current focus places little emphasis the problem with a memorized data on pattern recognition. base of cases.

10

1

Traditional written & oral examinations. Students have clear idea of what to expect.

No formal exams - Self-assessment.

Summing Up Given the complexity of healthcare and the piecemeal approach to managing patient problems, teaching-learning of how to deal with healthcare problems and solve them in a holistic manner is more important now than ever before. A thorough understanding of current concepts in clinical reasoning and problem dealing by the educators of 21st Century will equip them to effectively plan and implement relevant problem-oriented learning.

References BJ Andrew. An_approach_to_the_construction_of_SPMP. J Med Edu, 1972; 47:952-8 Jayawickramarajah PT. Problems for Problem-Based Learning: a comparative study of documents. Medical Education, 1996;30:272-282 Jerome P. Kassirer. Teaching Clinical Reasoning: Case-Based and Coached. Acad Med. 2010; 85:1118–1124 L Kern and ME Doherty. J Med Edu 1982; 57:100-4 Schmidt HG. Problem-Based Learning: rationale and description. Medical Education.1983;17:11-16.

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Linking Lesson Plan to Teaching Learning Principles Gitanjali Batmanabane * Abstract

A lesson plan is a basic part of a planned teaching-learning (T-L) activity. The advantages of preparing a lesson plan include improved clarity for the teacher and student regarding the objectives of the session, evaluation and organized logical progression of content and audio visual (A-V) aids. A lesson plan also allows the teacher to refine and revisesubsequently to improve his teaching. However, it is possible that even well-constructed lesson plans may fail if they are not linked to T-L principles. Every teaching session should have an opening that will grab the attention of learners and get them to concentrate on the following lesson, a closing that sums up the lesson and focuses on the take home messages and a body that forms the major part of the T-L activity. A induction of short videos, historical facts, photographs, anecdotes can be used to establish the pace of the lesson. The introduction to the lesson should strive to build on knowledge that is already known to the learner and take the learner from the known to the unknown. A good lesson plan not only accounts for the content being broken down into presentable portions but uses active learning techniques, and methods that combine different A-V aids and T-L methods. Taking learners from simple to complex concepts and from concrete to abstract concepts are tips that should be incorporated in a lesson plan as they promote a meaningful flow of learning. A well thought out lesson plan should also take into account thesag in attention seen mid-way in a one hour class and tweak students’ attention by using humor, anecdotes, or some activity.Overloading a lesson with content should be avoided by giving prior assignments to read up on background information (like anatomy, physiology of a system) or looking up specific information (as a part of self-learning). Following the “five to seven rule” of a lecture wherein only five to seven “big points” which are outlined at the beginning of the lecture are taught; each “big point” further explained or clarified using five to seven points to maximize learning and remembering. It is also a good practice not to have more than five to seven minutes of continuous didactic talk. Therefore, breaking up the lecture with activity is a good strategy. Finally, the use of good quality A-V aids, well lit lecture halls, comfortable seating arrangement and environmental temperature all go to show students you care and will complement your lesson.

Incorporating these T-L principles will facilitate learning and give the learner and the teacher immense satisfaction.

A lesson plan is an integral part of any planned teaching-learning (T-L) activity. It is unfortunate that many medical teachers equate planning for a T-L activity with content preparation and preparation of audiovisual(A-V) aids.

Most medical educators focus only on delivery of content that they fail to realize that the objectives of their lesson are not met. The advantages of preparing a lesson plan include the following: (a) improved clarity for the teacher and student regarding the objectives of the session (b) organized logical progression of content and audio visual (A-V) aids (c) sufficient time being allotted to each part of the content and evaluation of student learning (d) the teacher may reflect, refine and revise subsequently to improve his teaching (e) documentation of what was taught. Not preparing a lesson plan may lead to a lack of clarity of the objectives of the lesson, a dissatisfaction and frustration for the teacher and the taught, poor time management and a failure to utilize good practices. Hence every T-L session should have a lesson plan. As the focus of this session is on linking T-L principles to a lesson plan, the mechanics of preparing a good lesson plan and its components will not be elaborated much.

Well-constructed lesson plans may fail if they are not linked to T-L principles. Every teaching session should be organized and presented like a stage performance so that the time spent on the lesson is optimally utilized and learning is maximized. Each lesson should have an opening that will grab the attention of learners and get them to concentrate on the ensuing lesson, a closing that sums up the lesson succinctly and focuses on the take home messages and a body that forms the major part of the T-L activity. Clarity of the objectives of the session and a T-L method that best fits each objective along with an evaluation of learning are important aspects of a lesson plan. There are usually eight components to a lesson plan (a) Objectives and goals (b) anticipatory set (c) direct instruction (d) direct practice (e) independent

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* Dr Gitanjali Batmanabane MD PhD, Professor of Pharmacology Head of the Department of Medical Education, Jawaharlal Institute of Medical Education & Research, Puducherry Page 28

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practice (f) required material and equipment (g) assessment and follow-up. It is usually a good idea to decide on the assessment after writing the objectives. In a lecture class assessment may mean questioning a few students, putting up a few MCQs on the content covered, asking students to write a few of the the take home messages and submit after class or home-work. This is upto the teacher to plan for this.

A well thought out set induction will establish the pace and enthusiasm for the lesson. It should be relevant and interesting enough for learners to relate to the following objectives and content. Short videos, historical facts, photographs, anecdotes, cartoons can be used as triggers. At times, teachers in their enthusiasm tend to overdo this section and this goes on for ten to fifteen minutes. This should be avoided as this is not the objective of a set induction.

The introduction to the lesson should strive to build on knowledge that is already known to the learner and take the learner from the known to the unknown. A good lesson plan not only accounts for the content being broken down into presentable portions but uses active learning techniques, and methods that combine different A-V aids and T-L methods. Taking learners from simple to complex concepts and from concrete to abstract concepts are tips that should be incorporated in a lesson plan as they promote a meaningful flow of learning. Asking students to come after revising the anatomy or physiology of a system that will be taken is one way of saving time revising the areas already taught and reinforcing previous knowledge.

The attentiveness of students’ is not static and will change depending on the time of the day and also during a single class. A well thought out lesson plan should take into account the sag in attention which is seen mid-way in a one hour class (about twenty minutes into the class) and tweak students’ attention during this time by using humor, anecdotes, some activity such as a buzz session, questioning etc. Using these different techniques five to six time during a one hour theory lecture will ensure students stay alert and focussed. The teacher should have the flexibility and experience to cope with students’ body language signalling they are bored, not interested or have other things on their mind like a test in another subject later in the day. Overloading a lesson with content should be avoided by giving prior assignments to read up on background information (like anatomy, physiology of a system) or looking up specific information (as a part of self-learning). Following the “five to seven rule” of a lecture wherein only five to seven “big points” which are outlined at the beginning of the lecture are taught; with each “big point” being further explained or clarified using five to seven points to maximize learning and remembering is a good principle to follow. It is also a good practice not to have more than five to seven minutes of continuous didactic talk. Therefore, breaking up the lecture with activity is a good strategy.

Hence lesson plans can be so structured that small bits of information which fit into themes or “big points” can be arranged to complete the body of the lecture.

The closure of a lecture is equally important. Use this time to reinforce what was taught. “tell them what you are going to tell, then tell them, then tell them what you have told them” is an age-old teaching principle that has withstood the test of time. The take home messages should be reiterated and further reading or assignments should be handed out.

One may want to give a small test or ask a few questions to check learning. Some teachers ask one question every ten or fifteen students when taking attendance at the end. It is also important to keep sufficient time to clarify the doubts of students. The number and quality of questions is a good indicator of students’ interest and understanding of what has been taught. Lesson plans should not be so “tight” that taking time out of the next lecture or class becomes inevitable.

This is unprofessional as it takes away the time of another lecturer.

Lesson plans are incomplete without the listing of teaching aids and equipment, sources of information and other paraphernalia required for the class. All principles of good quality T-L aids and their use must be followed during preparation and display of slides, models or use of equipment like manikins. Since lectures demand students remain seated for a long period of time, comfortable seating arrangement and environmental temperature should be ensured.

Well lit lecture halls, good audio equipment and a non-threatening atmosphere will facilitate learning, complement your lesson and show students you care. Incorporating these few T-L principles into a lesson plan will facilitate learning and give the learner and the teacher immense satisfaction.

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Teaching the Web 2.0 Generation K.A.Narayan Introduction

We are in the midst of a dramatic technological revolution, centered on computer, communication, information, and multimedia technologies. These have been changing the ways people work, communicate with each other and spend their leisure time. This has resulted in a knowledge or information society with education playing a central role.

Educators in general and health professional educators in particular, are faced with the challenge of using and deploying these technologies in a creative way. Educators need to rethink their basic tenets and restructure curricula and methods to match these changes.

What are the revolutions in Education?

Throughout human history, education has been shaped by the societal needs of the societies in which it is set.

Education, after all, is the attempt to convey from one generation to the next the skills, values, and knowledge that are needed for successful life. Education was largely a matter of observing and participating in the work of one’s parents, or apprenticing to a local craftsperson.

The first revolution was a more structured and formal form of instruction by a teacher. Knowledge was expressed through stories, legends, folklore, rituals, and songs, without the need for a writing system. Tools to aid this process included poetic devices such as rhyme and alliteration.

The development of writing, starting in about 3500 BC, ushered in the second revolution. Various writing systems developed in ancient civilizations around the world. Script was used on stone monuments. Other cursive scripts were used for writing in ink on papyrus. Surfaces used for early writing include wax-covered writing boards, clay tablets,

sheets or strips of bark from trees, parchment made of goatskin, vellum, made from calfskin, and wax tablets which could be wiped clean to provide a fresh surface The development of the printing press in Europe in the last years of the 15th century vastly increased the amount of available reading material. Printing promoted the growth of literacy, and made possible new forms of societal and economic participation within a growing middle class.

The fourth revolution in education occurred early in the twentieth century by a growing understanding of how people learn. The pioneering work of the Russian scientist, Lev Vygotsky, in the 1920s, demonstrated the importance of the social

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* K.A. Narayan, MD, DPh , Vice Principal, MGMCRI and Head of Community Medicine Page 30

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environment to the learning process. Jean Piaget, the Swiss psychologist, showed that cognitive development in children proceeded in a predictable sequence of steps. This theory of learning, known as constructivism, had profound implications for the way instruction should be organized. Building from Piaget’s work, Bloom formulated his now-famous taxonomy.

In the 1990s, as a result of the advent of the personal computer and the Internet, virtually every sector of the world economy experienced both profound dislocations and unprecedented opportunities. Geographical and cultural boundaries were broken. The desktop provided tools to teachers to have “user generated content” in text and graphic form. The internet provided a platform to host this content and share it. The biggest value addition was the way that text, and later, images was indexed, made searchable and retrievable. Netscape pioneered the browser which made the content shareable. Google exploited the “user generated” content to offer web search using its “Page rank” algorithm.

The term Web 2.0 which has brought in the current revolution in education, was initially championed by bloggers and by technology journalists, culminating in the 2006 TIME magazine Person of The Year (You). That is, TIME selected the masses of users who were participating in content creation on social networks, blogs, wikis, and media sharing sites. Web 2.0 websites allow users to do more than just retrieve information. By increasing what was already possible in “Web 1.0”, they provide the user with more user-interface, software and storage facilities, all through their browser. This has been called “network as platform” computing. Major features of Web 2.0 include social networking sites, user created web sites, self-publishing platforms, tagging, and social bookmarking.

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Have there been changes in how medicine is to be taught?

1st generation : The Flexner Report, a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation recommended a science-based curriculum based on scientific research.

2nd generation : The PBL-era problem-based instruction which evolved in the 1970’s, encouraged self-directed learning skills, placing emphasis on a person’s ability to seek out information to tackle a problem at hand. In this approach learners analyze a given clinical scenario, formulate and prioritize key learning objectives within that scenario and then collect whatever additional information they think will be needed to address those objectives. All this takes place within a group setting so that every member of the group contributes to the learning process at every stage.

3rd generation : An independent commission of 20 academic leaders from around the world recommended comprehensive reform in the training of healthcare professionals, in a major report published in The Lancet on 4 December 2010. The report called for competency-based curricula, creative use of information technology, transformative learning, and inter-professional teamwork, as well as a systems approach to institutional reforms. The learners are required to • adapt core competencies to specific contexts • be systems based to improve the health systems • draw on global knowledge and expertise

Three generations of Educational Reforms: Informative, Formative, Transformative.

Need to evolve from informative to formative to transformative learning Informative learning: acquiring knowledge & skills, to produce ‘experts’ Formative learning: values based education, to produce ‘professionals’.

Transformative learning: developing leadership attributes, to produce enlightened change agents for healthcare.

How can we globally achieve this is the BIG question.

What are the differences between Web 1.0 and Web 2.0?

Web 1.0 users (consumers) were limited to the passive viewing of content that was created for them. In contrast, a Web 2.0 site allows users to collaborate with each other as creators -“prosumers”- of user-generated content in a virtual community.

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Web 2.0 websites allow users to do more than just retrieve information. By increasing what was already possible in “Web 1.0”, they provide the user with more user-interface, software and storage facilities, all through their browser.

This has been called “network as platform” computing. Major features of Web 2.0 include social networking sites, user created web sites, self-publishing platforms, tagging, and social bookmarking.

Function

Web1.0

Web2.0

Differences between Web 1.0 and Web 2.0

Publishing

Participating

Web 1.0 : read and download Web 2.0: share and upload Traditionally, expert posses the right to classify the resources via the internet.

But in Web 2.0, everyone can decide how to classify what you want(tag)

Bookmarker

Directories

Tagging

Central Idea

They, the content

We, the content

User Attitude

Controlled by website

Examples

Individual large scale website

In Web 2.0, user defines and design the content

Collaboration also involves the meaning of cooperation.

We share knowledge Cooperation Collaboration whenever it is needed and wherever it is located through the web Everyone are both editor and receiver Blog, wiki

Web 2.0 tools are free and easy to use.

Who is WEB 2.0 Generation?

Gen-Y Teenagers growing up with participatory media known as Web 2.0 social networking, photo- and videosharing, blogging, podcasting, remixing, wikis, user-generated content, online games and social worlds, and so on These have not replaced older media young people still spend more time watching TV than they spend online. Many of them still read printed books! (Ofcom, 2008)

What are the Pros and Cons of Web education?

Since 2000, the schools raced to connect students to the Internet in broadband. But now, professors urge leaders to “free students from their enslavement to web-2 technology”. Why this turn around within a decade? The reasons Web-2.0 Distracts from Class. Students trade stocks, do shopping, and see video clips. They obsessively watch their mobile, i-pad or laptop screens to check for any mails, sms-es, or tweets. During seminars, at any time, 3 of 8 students were browsing on laptops instead of listening to their peers. They think they can multi-task but it hinders their learning.

Multi-taskers are not good at switching tasks, ignoring irrelevant information, writing well, using complex ideas/issues.

Multi-taskers are more easily distracted & bored; have short attention span. Multi- taskers are ‘socially autistic’, less

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emotionally attuned to others. In student centers, they peer at their i-pad screens instead of talking to each other.

The solution - ban access by cell phones or wireless. Further the technology may not always be reliable, inefficient for student’s time and inappropriate information may become more readily available if certain sites are not blocked (i.e.

Youtube) However it is a powerful educational tool if we attract them – not Ban Web-2. Ban on technology is only a temporary fix. We are ignoring the root of the problem. Ban of the web is more convenient for educators but it is NOT what is best for students. The web can enhance student engagement, improve communications among students and teachers It is a more diverse way for students to connect with other students and teachers, makes learning more interesting to students - visually stimulating. It can enhance exploratory learning, just in time learning, writing and communication skills and creativity.

Want to know how a 21st Century learner learns?

Ask them. You will be amazed at what you hear and if you are smart- you’ll act upon it.” 7 Solutions for Educators Who Want 21st Century Students to Tune In -by Lisa Nielsen Ideas for Educators - 1 Problem: Students do web-2.0 instead of listening to the class.

Solutions: How have you changed your classroom management techniques? Do you let students know when they should and should not open their lap-tops? Do you give a break for them to catch up with web-2.0? Do you make student groups discuss with & without lap-tops?

Ideas for Educators - 2 Problem: You are not engaging your web-enabled students Solutions: Educators who stand at the front of the room lecturing are not engaging students. Even if they are interested in the topic they can’t listen for a long time. Provide accountable interactivity. e.g., at the end of your lecture have students Tweet relevant thoughts, ideas, and links using a hashtag (#) provided by you. Raise a question on a blog site for students to answer.

Ideas for Educators - 3 Problem: You complain about technology, but you don’t incorporate it into instruction.

Solution: Teachers could make a Facebook page and use that as a hub for students to connect and share during instruction.

Perhaps the teacher sets up some discussion boards or Wall Wishers to share ideas. Many 21st century students aren’t content sitting and listening to the teacher. Make your teaching more interesting, and your students will reward you by being more interested. Teachers could adopt Facebook as an effective T-L medium

yy 10 Educational Apps for Facebook o Share Learning Resource Files o ‘Study Hall’ – a whiteboard app o ‘Slideshare’ - presentation o ‘Flashcardlet’ - flashcards to study o ‘Quiz Monster’ o ‘Zoho’ Online Office o ‘Webinairia’ for screencasts o Book-tag o To-Do-List o Skype interface for tele-conference

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yy Use groups like Google groups: Users can use groups to more easily:

o Communicate and collaborate with groups of people. For example, groups can be useful for departments, project teams, classes, office locations, special-interest groups, and more. o Manage access to your documents, sites, videos, and calendars. Users can share their content with groups instead of entering individual addresses. With a group, they can add or remove members once, and the changes are applied to all the Google documents, sites, videos, and calendars that they shared with that group.

• Use a Learning Management System such as MOODLE or DOKEOS Ideas for Educators - 4 Problem: Use class time more productively Solution: Record your lectures for students to listen to on their own time. This may be in the form of video or a PowerPoint presentation converted to interactive mode with free tools like Wink. Spend class time doing interactive problem solving.

Class time can be used for the teacher to help students having difficulty with their work.

Ideas for Educators - 5 Problem: Are you still trying to be a provider rather than a facilitator of learning?

Solution: No need to tell students something they can find on the internet Give them the link and use class time to have discussions, solve problems, or construct their learning.

Extend discussions outside the class room through blogs and wikis.

Incorporate blogs into the classroom as a form of instructional help. With blogs students have a backup place for all kinds of information they need and provide a place for collaboration with other peers on an assignment Blogs can be used to showcase student’s works.

Wikis: Wikis can allow students to collaborate and combine pieces of information and generate pages full of knowledge.

Ideas for Educators - 6 Problem: You don’t own the learning.

The ownership is with your students.

Solution: If they’re not interested in what you say, find out a way to say it that makes them interested. Adopt neuro-linguistic program (NLP technics) Ideas for Educators - 7 Problem: Technology is just too distracting for some students Solution: A teacher is to help prepare students be successful in their world of the present, not your past.

Remember how Calculators have changed the way maths is taught and assessed.

Is the era of the book over?

Some make the extreme claim that the era of the book and print literacy are over. In the emerging informationcommunication technology environment, traditional print literacy takes on increasing importance. People need to critically scrutinize and scroll tremendous amounts of information, putting new emphasis on developing reading and writing abilities. For instance, Internet discussion groups, chat rooms, e-mail, blogs, wikis, and various Internet forums require writing skills in which a new emphasis on the importance of clarity and precision is emerging. Book and print literacy provide these skills.

What is media literacy?

The current technological revolution, however, brings to the fore more than ever the role of media like television, Annals of SBV

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popular music, film, and advertising, as the Internet rapidly absorbs these cultural forms and creates new cyberspaces and forms of culture and pedagogy. With Internet and media culture becoming ubiquitous, it is impossible for educators to ignore these forms of socialization and education. It has become important for teachers to provide media literacy and to discern the nature and effects of media culture.

Media culture is a form of pedagogy that teaches proper and improper behavior, gender roles, values, and knowledge of the world. A media literate person is skillful in analyzing media, criticize stereotypes, values, and ideologies, and competent to interpret the multiple meanings and messages generated by media texts. Media literacy helps people to use media intelligently and to discriminate and evaluate media content.

What are the two views on media literacy?

A traditionalist “protectionist” approach would attempt to “inoculate” young people against the effects of media addiction and manipulation by cultivating a taste for book literacy, high culture, and the values of truth, beauty, and justice, and by denigrating all forms of media and computer culture. This approach would put restriction or bans on usage of devices, Wi-Fi, media, internet and social networks.

A “media literacy” movement, by contrast, attempts to teach students to read, analyze, and decode media texts, in a fashion parallel to the advancement of print literacy.

What do I need to do to be Web 2.0 savvy?

1) Build out Excuses. Asses where you are with reference to change. Push yourself to the next stage.

2) The stage of change will match the level of implementation (for any activity) • No Use • Awareness • Exploration • Infusion • Integration (Mechanical) • Integration (Routine) • Expansion • Refinement 3) Leading by Being • I Believe in This • Transfer of knowledge from one subject area to another seemingly unrelated one.

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• • • • • •

Both being the change and being receptive to change Creating epicenters of community learning Making information and thinking process secondary and thinking and process primary Using the right tool for the right job at the right moment.

“Realia” make it real and relevant as often as possible.

Have the passion.

Web 2.0 Tool for the Classroom Glogster Prezi Diigo Blogger Voki Penzu Skype Edmodo

Purpose Share images and posters created with fellow students Share presentations with PowerPoint Popular social bookmarking site Educators and students can collaborate, share instructional resources, connect to mainstream social media channels like YouTube Students share knowledge of a topic in 60 seconds or less; great way to have students organize their thoughts to focus on essential details Encourages online journaling Bring presenters that could not otherwise make it to the classroom into the room virtually Has the look and feel of Facebook (something that most students are using in their personal lives)-- educational perspective, polls, assignments, gradebook, quizzes

4) Create a Network Does your network include more than one of the following?

•Microblogging (Twitter, Plurk, etc.)

•RSS Reader •Social Bookmarking •Your own blog •A social networking service (Ning, Facebook, etc.)

5) Have the passion.

Where do i acquire the tools?

If you are still at the Web 1.0 phase o Introduction to Frontpage o Frontpage Advanced o Using Digital Photography in your Classroom o Podcasting o Introduction to the Interactive Whiteboard o Alternate Uses for PowerPoint o How To use United streaming in Your Classroom o Windows Movie Maker, parts I and II o MS Office Ins and Outs For shifting to Web 2.0 • Administrator’s Introduction into Web 2.0 • Tablet Teacher’s Toolbox • Presenting with Google Earth in the Social Studies Classroom • Introduction to Social Networking and Personal Learning Environments: Using Smarter People to Raise your Level of Thinking • The Media Rich Classroom: Using Video to Engage and Assess students

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• • • • •

o o o o o o o o

Feedback Matters: How student feedback can change your lesson design: before, during, and after The Wiki Way: Using Wikis as Collaborative Environments Internet Safety: What you need to know about keeping your students safe online Google Docs and Spreadsheets: Track Student Writing and Foster collaboration through GoogleDocs Introduction to Social Networking and Personal Learning Environments: Using Smarter People to Raise your Level of Thinking Web 2.0 Teaching Strategies Google Docs and Spreadsheets: Track Student Writing and Foster collaboration through Google Docs Research 2.0 with RSS: How to get information to Find You Copyright or Copy Wrong Google School: How to Plan, Implement and Create Using Google for Educators Using Wikis to Extend the Walls of your Classroom Tablet Teacher’s Toolbox Using the Wisdom of Crowds to Mine the Web: Social Bookmarking

Points to Ponder for Google-savvy 21st Century Educators…

Since “exams drive student-learning” -• To assess Problem solving ability, can we adopt ‘open-book’ or ‘open-access’ exams where the students can access e-library to solve problems and show their cognitive capacity. There would be no need to ban electronic media and cell phone jammers in the examination hall.

• To assess practical skills, can we adopt portfolio assessment of the learning process and an objective assessment of skills and competencies (OSCE-OSPE)?

The key question is “How do I make the change?”

“If it can be communicated in an email, it doesn’t belong in a faculty meeting.”

“Great leaders shine brilliant lights away from broken places to inspire another trek to finer peaks - where learning captures minds.” -Angela Maiers

Resources

Douglas Kellner: New Technologies / New Literacies:Restructuring Education for a New Millennium. (http://www.gseis.ucla.edu/faculty/kellner/) Change in Education – A Letter to my Colleagues http://21stcenturylearning.typepad.com/blog/2008/06/letter-to-my-co.html Frenk, Julio, Lincoln Chen, Zulfiqar A. Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, et al. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet 376(9756): 1923-1958. http://nrs.harvard.edu/urn-3:HUL.InstRepos:4626403 https://sites.google.com/site/childrenseducationweb20/home History of education http://en.wikipedia.org/wiki/History_of_education Sethuraman KR TEACHING THE I-PAD GENERATION – Health-Professional Education in the “Web-2.0 Era”. Talk given at Eden Roc, Miami Invited Keynote Address on August 6th, 2011 Patricia Higgins jr. http://www.slideshare.net/pjhiggins/tech-forum-ny08-presentation Patricia Higgins jr. Making it Happen. How our Imaginations can give us the schools we want. Effective Technology Leadership. http://www.slideshare.net/pjhiggins/tech-forum-ne09 Web 2.0 http://en.wikipedia.org/wiki/Web_2.0

Images

aristotle:http://commons.wikimedia.org/wiki/File:Spangenberg_-_Schule_des_Aristoteles.jpg Bloom’s Taxonomy: http://epltt.coe.uga.edu/index.php?title=Bloom%27s_Taxonomy Wax Tablet: http://historicconnection.webs.com/historyofwriting.htm VedicSystem: http://www.krishnasmercy.org/dotnetnuke/News/Blog/tabid/57/EntryId/214/Higher-Education. aspx School of Aristotle, fresco by Gustav Spangenberg.

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Structure of Objective Learning Outcomes (Solo) Taxonomy KR Sethuraman * Assessment of fulfillment of learning outcomes is central to the focus of any learning outcome. Theexaminer needs to know that the learning outcomes have been reached by the student, in orderto give a pass.Also the student needs to know exactly how to answer a question based on what the teacher expects out of a question.

In the format of evaluation whether it is formative or summative, short or long answer essay questions form an integral part and usually has the most proportion of theory marks allotted. Based on the answers given by the students, it is important for the teachers to be able to assess how much of the learning outcomes have been reached. Once having done that there calls for a scope for improvement in the performance of the student.

SOLO stands for the Structure of Observed Learning Outcomes. It was developed by Biggs and Collis (1982).

Biggs describes SOLO as “a framework for understanding”.

SOLO identifies five stages of understanding. Each stage embraces the previous level but adds something more.

yy Prestructural– the student acquires bits of unconnected information that have no organisation and make no sense. yy Unistructural – students make simple and obvious connections between pieces of informationsimple and obvious connections are made, but their significance is not grasped. yy Multistructural – a number of connections are made, but not the meta-connections between them yy Relational – the students sees the significance of how the various pieces of information relate to one another yy Extended abstract – at this level students can make connections beyond the scope of the problem or question, to generalise or transfer learning into a new situation Unistructural and multistructural questions test students’ surface thinking (lower-order thinking skills). Relational and extended abstract questions test deep thinking (higher-order thinking skills) SOLO describes level of increasing complexity in a student’s understanding of a subject, through five stages, and it is claimed to be applicable to any subject area. However, not all students get through all five stages, of course, and indeed not all teaching (and even less “training”) is designed to take them all the way. However it is an attempt to understand, in a more objective way, whether the learning outcomes and how much of the learning outcomes have been fulfilled.

If students were oriented to SOLO taxonomy using prototypical examples, then it would provide them an opportunity to understand the hierarchy of cognitive competence and some of the factors that teachers consider while marking descriptive responses. Consequently, students may be motivated to take this into consideration when preparing for tests and in composing descriptive responses.

The students who receivethe grade pass, or pass with distinction, or anything in between are said to have reached the learning outcomes. But is it necessarily so? In order to know whether the student really has fulfilled the outcomes, * to balance the cognitive demand of the questions asked the outcomes have to be possible to assess. SOLO allows one

* Prof. .Sethuraman MD, Vice-Chancellor, Sri Balaji Vidyapeeth, Puducherry Annals of SBV

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and to scaffold students into deeper thinking and metacognition.SOLO is a true hierarchic taxonomy – increasing in quantity and quality of thought.SOLO allows teachers and learners to ask deeper questions without creating new ones.

SOLO can be used as a true a powerful metacognitive tool.Since bulk of the evaluation in medical education is done by short or long essay type questions, SOLO assessment can be utilised by all of us in accurate and a more objective assessment of individual answers.

Suggested Reading: 1. Biggs JB and Collis KF. Evaluating the Quality of Learning. New York & Sydney: Academic Press, 1982 2. Hattie JAC, Brown GTL. Assessment Tools for Teaching and Learning Technical Report #43. Cognitive Process in asTTle: the SOLO Taxonomy (online). http://www.tki.org.nz/r/asttle/pdf/technical-reports/techreport43.pdf [2 August 2010].

3. Brabrand B, Dahl B.Using the SOLO taxonomy to analyze competenceprogression of university science curricula. Higher Educ58: 531–549,2009.

4. E. S. Prakash, K. A. Narayan, and K. R. SethuramanStudent perceptions regarding the usefulness of explicit discussion ofStructure of the Observed Learning Outcome” taxonomyAdvPhysiolEduc34: 145–149, 2010

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Recent Advances in Medical Postgraduate Evaluation N. Ananthakrishnan * Recent publications have stressed the importance of evaluation of professionalism in medical postgraduates as opposed to the conventional areas of knowledge and skills. Harden (2011) has emphasized that postgraduate evaluation should shift from assessment of learning to assessment for learning. The postgraduate Medical Education and Training Board of the United Kingdom lays stress on the fact that any postgraduate evaluation method should provide feedback to the trainee to enable self improvement. Globally, the World Federation of Medical Education in 2003 itself had said that postgraduate assessment should focus on formative in-training methods and constructive feedback.

Postgraduate evaluation, therefore, should be multi dimensional and should serve all the following purposes(Duffield and Spencer, 2002).

yy Certification yy Ensuring competence yy Ensuring professionalism yy Assessing predetermined quality yy Monitoring progress yy Motivating and guiding learning yy Assessing effectiveness / weakness of curriculum yy Providing feedback yy Predicting performance as a qualified doctor

Two concepts require definition in this context – viz. competence andprofessionalism.These are two major areas to be focused on in professional assessment.

A competent professional is one who possesses required skill, knowledge and attitude to perform a desired function.

Competency is defined as the values, attributes or qualities required by a professional to perform effectively, efficiently and satisfactorily in his profession.

The American college of graduate medical education (ACGME) mentions six domains of competence in a medical professional, viz.

• Medical knowledge • Patient care • Professionalism • Communication and interpersonal skills • Practice based learning and improvement • Systems based practice In this context, three terms require a more detailed definition. Professionalism is manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Practice-Based learningand Improvementinvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence for improvements in patient care and Systems-Based practice refers to actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value (give reference) If postgraduate evaluation is to serve all these purposes, it is necessary to distinguish between a norm referenced and criterion referenced method of evaluation. The differences between the two are shown in the following table.

*

* Prof. N. Ananthakrishnan , Dean, Research and Postgraduate Studies, SBV Professor of Surgery, MGMCRI (SBV), Pondicherry Annals of SBV

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Criterion referenced evaluation

Norm referenced evaluation

Candidate is assessed against fixed acceptable level of performance without reference to other candidates

Candidate is assessed against arbitrarily fixed norms (pass marks) and generally in comparison to his peers

Acceptable level of performance is high for must know and must do areas

Level of acceptability is irrespective of importance of outcome being tested

Consensus between examiners is mandatoryas to what is the acceptable level

Less emphasis on consensusbetween examiners on what is acceptable

Is applicable to areas where skill assessment is very important

Is more applicable for knowledge assessment

It is seen, therefore, that only a criterion referenced system of evaluation can meet needs of postgraduate assessment as per recent requirements.

Several questions need to be asked before a postgraduate evaluation (Swing, 2002). These are • What are the competencies to be assessed?

• Is there a need to assess some or all of them?

• Is the competency assessable?

• Is (are) there (a) suitable method(s) / tool(s)?

• Should assessment be continuous or terminal?

• What should be the size of sample for reliability?

• What is the purpose of the score obtained?

• To the individual • To the institution • To society It is necessary to ask ourselves whether the current methods of postgraduate assessment meet these requirements.

The current methods of postgraduate assessment and the problems with these are shown in the following table.

Conventional methods of postgraduate Assessment

yy Theory yy Practical yy Clinical yy Viva Voce yy Ward Rounds yy OSCE yy Dissertation yy Logbook

Issues with conventional methods of postgraduate assessment

yy Lack concurrent, construct and predictive validity yy Are tested in an unreal situation yy Are not in conformance with Miller’s pyramid and do not test the higher levels yy Lack direct observation yy Have little or no scope for feedback to trainee

To some extent the deficiencies of the listed methods can be compensated by internal evaluation on an ongoing and continuous basis. Unfortunately internal assessment has no weightage at all in the current scheme of things as far as postgraduate evaluation is concerned in India.

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A new term has, therefore, evolved in the context of postgraduate evaluation. This is Workplace based assessment (WPBA). WPBA implies • The assessment of working practices based on what doctors actually do in a clinical setting, predominantly carried out in the workplace itself • Collecting information on performances from various sources both for assessment and for feedback. (PGME & Training board, UK) An excellent review of methods of WPBA has recently been published(Singh and Sood, 2013). There are other very perspicacious articles on WPBA and assessment of competencies. This presentation has drawn heavily from some of the landmark publications listed at the end.

In general WPBA, • Focuses on skills • Is less subjective since it uses multiple sources of information • Provides feedback • Provides a broader and more representative sampling, hence more valid • Enable longitudinal assessment • Is in alignment with learning in work place There are several examples of WPBA each applicable to a different requirement of evaluation, for e.g.

• Documentation of work experience • Logbooks, clinical encounter cards (CEC), • Observation of individual clinical encounters • Mini-cex, DOPS, video-consultation assessment, standardized patients, • Discussion on individual clinical cases • Case based discussion (CBD), chart-stimulated recall (CSR), mini PBAs • Audits • Multi source feedback (360⁰), patient satisfaction surveys, • Portfolios The following section gives some details about the various methods of WPBA. Clinical encounter cards (CECs): In this method, the student fills up computer readable cards, one for eachpatient and enters all data about that patient in thecard including initial and followup details. These cards are read by assessors / tutors at regular intervals largely with the purpose of determining whether the candidate has sufficient clinical exposure.

If the tutor finds that there are areas which are inadequately covered either by way of variety or number, then a feedback sis given so that the areas of deficiency may be made up.

Mini clinical evaluation exercise (Mini-Cex):It is similar to a case presentation with few differences. The encounter between the assessed and the assessor lasts for 10-15 minutes while a patient is being examined and focuses on skills such as history taking, physical examination, clinical judgment, communication with patients, time management and overall decision making. As is normal for all WPBA methods there is a session at the end for feedback. Mini-cex has been found to be a reliable method of assessing clinical examination and decision making skills, Direct Observation of Procedural skills (DOPS): This is similar to mini-cex but instead of focusing on examination skills, targets adequacy of procedural skills. The duration is same as for mini-cex. It has an advantage over OSCE in thatit is not constrained by the artificial time limit imposed on an OSCE station which isusually a maximum of about 5 minutes. OSCE does not permit observation of skills whichrequire a longer duration. Once again since there are multiple such encounters annually involving multiple assessors, validity is increased and subjectivity reduced. Feedback is once again a mandatory part of the process.

Case based Discussion (CbD) and Chart Stimulated Recall (CSR):The purpose of CbD and CSR are different although the process is essentially the same. In CSR the focus is on ability to defend and justify one’s line of management

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concerning a patient who has been seen and managed in the past and whose details are retrieved from the medical charts whereas in CbD, the focus is on planning and management of a freshly admitted patient. Both procedures involve sessions of about 15 minutes for encounter and are followed by detailed feedback highlighting errors.

Mini-peer assessment tool (m-PAT):This is done by a assessors from peers / supervisors who periodically fillup appropriate forms focusing on technical / interpersonal / team works skills and professionalism. Comments from patients, if considered relevant, may be included verbatim. M-PAT is a limited method of multisource feedback since the assessors are limited to peers and supervisors.

MSF (360⁰): This is by far the most significant aspect of postgraduate assessment from the point of view of professionalism. It is similar to mini-PAT but involves a larger pool for feedback – peers, other health care professionals, patients, relatives, etc. The aim is to obtain insight into trainee’s work habits, team work, interpersonal relations, professionalism etc. It is generated confidentially and may include written feedback, verbatim reports, narratives etc Portfolio: This is atool for collecting, storing and presenting comprehensive evidence regarding competence at all stages of training. It contains both educational experiences (procedures, case presentations, seminars, journal clubs etc.) and reflections of the student on those learning experiences. This latter aspect makes it different from log books.

Portfolios also contain all academic records found in logbooks such as record of publications, critical incidents during training, performance on WPBA and other evaluation tools. Portfolios are assessed periodically and feedback is given to the candidate.

Portfolios are very useful for assessing professionalism, practice based improvement and clinical performance over a period of time. They are a true reflection of work place performance. However, portfolios are very labor intensive and requires trained faculty.

Advantages of portfolios: • Assesses what is not easily assessed • Assesses range of curricular outcomes • Facilitates learning • Is continuous • Authentic / real life • Multiple assessment methods • Identifies poor performers early • Assesses extent of learning • Demonstrates self expression / creativity • Gives feed back To summarize WPBAmethods have several advantages such as: • High validity and reliability (correlates well with other measuring instruments) • Subjectivity is reduced by multi-sourcing encounters and feedbacks • High degree of feasibility • Generally requires less time for individual encounters • Highest degree of feedback One important requirements of postgraduate evaluation is to match the evaluation tool with the objective.

Unmatched evaluation tools would neither have validity nor would they be reliable indicators of performance. The following are suggested tools for evaluation of various competencies (Reference).

Competence: Thinking critically, decision making, problem solving • Problem oriented objective items • Mini PBAs • Simulated Patient Management Problems (SPMP) • Chart based discussion

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• • • • • •

CbD, CSR MSF Viva voce – higher order Field work Project work Group work

Competence:Procedural skills • DOPS • OSCE • Bedside clinics • Standardized patients • Performance on Simulators with check lists • Portfolios and logbooks Competence: Accessing and managing information • Dissertation • Journal clubs • Topic reviews • Projects • Case logs Competence: Demonstrating knowledge and understanding • Written examination – Essays – SAQs – MCQs • SPMP • Oral examination • Writing a report • Topic presentation and response to questions • Reviewing a journal article • MSF Competence: Listening and communication skills • 360° • Peer assessment • Video recorded patient encounter / or relatives encounter • OSCE with checklists • Field work • Oral presentation / oral examination / case presentation • Written presentation • Summarizing • Discussion / debate / role play • Ward rounds • Taking UG classes / giving health education talks Competence: Attitude, ethics andprofessionalism • Multi source feedback • Patient surveys • Video recorded patient or relative encounter • Direct observation of performance • Attendance and regularity

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Competence: Managing and developing oneself, self learning, CPD • Portfolio • Group work • Attendance at CMEs, conferences, interdepartmental meetings • Faculty feedback • Projects • Problem solving exercises Competence: Originality and creativity • Portfolio • Ward rounds • Projects • Faculty feed back Competence: Systems based practice • MSF • Record reviews • Patient surveys • Portfolios Competence: Practice based learning and improvement • Portfolios • CSR • Record reviews • MSF • Case logs • Patient surveys To summarize, it is necessary considering the needs of society,amongst whom postgraduates will ultimately serve, the methods chosen to make sure that they fully meet the requirements of the job of expected of them should not only becriterion referenced, a system in which they are judged not in comparison to their fellows but against fixed standards, but also should have other characteristics.

Those who have the role of certifying adequacy of training must be able to match newer methods of assessment to the competency to be evaluated, critically examine these newer methods with reference to their applicability to their own disciplines for formative evaluation initially and subsequently for summative evaluation fully understanding the relationship between purpose of assessment, competency to be evaluated and the tool selected for that purpose.

Suggested further reading 1. Selecting methods of assessment (unpublished material. http://www.brookes.ac.uk/services/ocsld/resources/methods/html 2. Toolbox of Assessment methods – ACGME Outcomes project, American Board of Medical Specialties, version 1.1, September 2000.

3. Ballie S,Rhind S. A guide to Assessment Methods in Veterinary Medicine. Version 1.1, September, 2008.

4. Swing SE. Assessing the ACGME General Competencies: |General Considerations and Assessment Methods. Academic Emergency Medicine2002; 9: 1278-1288.

5. Wass V, Van der Veuten C, Shatzer J, Jones R. Assessment of Clinical competence Lancet 2001; 357: 945-9.

6. Norcini J, Burch V. Workplace-based assessment as an education tool: AMEE Guide No.31.Medical teacher 2007; 29:855-871.

7. Norcini J, McKinley DW. Assessment methods in medical education. Teacher and Teacher Education 2007; 23:239-50 8. Lamber W, Schuwirth T, Van der Vleuten C. Programmatic assessment: From assessment of elarning to assessment for learning. Medical Teacher 2011; 33: 478-485.

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9. Epstein RW. Assessment in Medical Education.The New England Journal of Medicine 2007; 356: 387-396.

10. Norcini J. Current perspectives in assessment: the assessment of performance at work. Medical Education 2005;39:880-889.

11. Shumway JM, Harden RM. The assessment of learning outcomes for the competent and reflective physician.

Medical Teacher 2003;25: 569-84.

12.Harden RM. Trends and future of postgraduate medical education. Emergency Medical Journal 2006; 23:798-802.

13. Singh T,Sood R. Workplace based assessment: Measuring and shaping clinical learning. The National Medical Journal of India 2013;26:42-46.

14. Duffield KE and Spencer JA. A survey of medical students’ views about the purposes and fairness of assessment.

Medical Education 2002; 36:879-86.

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Setting Standards and Innovations A Road Map of Sbvu Examination System V N Mahalakshmi * As a part of the quality initiatives involving Teaching- Learning-Evaluation systems, the Exam division of Sri Balaji Vidyapeeth University, under the able guidance of our honorable Vice-Chancellor, Prof. K.R. Sethuraman, an educationalist par excellence, has taken initiatives to benchmark standards and innovations in the evaluation process.

Fact File

The Sri Balaji Vidyapeeth University exam wing currently evaluates 15,000 student-evaluations per year. The Under Graduate exams carry single valuation and the Post Graduate exams carry double valuation in all the disciplines (medical, dental and nursing streams).

The process of standardization started with an analysis of the strengths and weaknesses of the existing system and search for technically and logistically viable options. The analysis identified the following defects in the system.

The major rate – limiting steps in the traditional exam process include the manual double stamping of dummy numbers in the answer books and the process of decoding of dummy numbers. This requires manual verification of all dummy numbers allotted to a particular student, against his/ her register number [For eg. : if a student writes 6 papers – each with 2 sections, the total no. of dummy numbers allotted to the is = 2X6=12 sets]. This process is a potential source of human errors.

The other potential sources of pitfall is involved in the exam process include, 1. Printing & sending the Question papers to other constituent colleges of the University prior to the day of exams.

This could result in • Potential leak of papers • non – availability of question papers at the start of exams due to natural calamities accidents, etc., 2. Manual entry of marks in the system is also prone to human errors, although we have put in checks mechanisms at this level by verifying the marks entered against the mark list.

3. Analysis of group performance on a single item basis is also difficult, as it involves manual entry of marks for individual questions for all subjects and candidates, which would involve handling the huge amount of data. This step is again prone for errors in transcription.

Innovations in the exam process Once the analysis of the strengths and weaknesses of the existing system was complete, the following innovations/ standardizations are introduced in the exam process.

1. EXAM SCHEDULES are drawn at the beginning of academic year and circulated in the academic calendar.

2. The Students’ Information System is updated on regular basis. SIS Garuda, an in-house developed program, also helps student to fill in their exam application on-line. The exam division of the University uses this information for generating personalized exam schedules for students and to print the Examinee identity cards. A 10 digits Unique Identity Number is generated and assigned to all students, across all disciplines for the identification purposes.

3. Eliminating Ambiguity in questions - As a part of the quality initiatives, the SBVU exam division is set about eliminating ambiguity in questions. The question papers pattern is changed to include very short objective questions, focused short answers and structured essay questions. SBVU-AHEAD, the Academy Of Health Education And Development, organized and conducted workshops on “Question paper setting and validation” to all faculty of the constituent colleges. As a follow-up of this work shop, all the Departments prepared the blue print guidelines of

*

* Dr Mahalakshmi V N, MS., MCh.,, Professor of Pediatric Surgery, MGMCRI. Controller of Examinations, Sri Balaji Vidyapeeth University Mahatma Gandhi Medical College & Research Institute Campus, Pillaiyarkuppam, Pondicherry, India – 607 402 Page 48

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question papers based on the specific learning objectives (SLO) in mind. This is used as a template for the question paper setters.

• The paper setters are given elaborate blue print guidelines specific to the learning objectives of the subject being evaluated and also weight-age for various systems. They are asked to fill in an item card analyzing the distribution of questions and marks across systems, level of difficulty and type of knowledge being tested – recall, understanding or application. They are also asked to submit a relevant answer key covering the key points to be discussed in the answer.

The paper setters are asked to frame specific and relevant questions, without ambiguity.

4. Vetting of the question papers -The question paper received from the examiners are subjected to a 3 stages vetting process involving, • Matching against the blue print guidelines & • Looking for grammatical errors, errors in the framing of questions and repetition – to be done by COE’s office.

And also • Checking for relevance and validity by the concerned subject expert.

• All question papers are subject to scrutiny and approval by the Vice- Chancellor, for their global relevance and applicability to the student population being tested.

A checklist encompassing these details is evolved and is being filled by the exam division. A standard template with unique, non reproducible fonts is used for printing the question papers.

5. Examiners database- Extensive database of eligible external examiners has been collected from MCI recognized Institutions in the state and neighboring states.

6. The actual conduct of exams • Secure online transmission and printing of question papers to off campus institutions in secure, encrypted form ½ an hour before the start of exams.

• Guidelines of conducting theory exams- An exam hand book, covering all the rules and regulations of exams, standard operating guidelines to be followed in specific situations, exam day checklist etc., has been developed and introduced into practice.

7. Redesign of Answer Booklets - To expedite the exam process, OMR coding of answer books is introduced to code student and exam information. Each booklet has an unique barcode to tag examinee information and valuation. The new answer booklets are also aesthetically re-designed with inclusion of safety features like University logo watermark, index tab for tracking question numbers, safety stitching and tamper proof stickers.

8. The answer booklets are subjected to central evaluation. To eliminate ‘examiner bias’, each examiner is asked to correct the same question in all the answer booklets.

9. Blinding of the answer papers is by the process of aligning a preprinted bar code on the answer sheet to the examinee information. The marks are also entered in OMR sheets having the barcode. The practical examinations are conducted by the external and internal examiners and marks are entered in a barcoded, OMR sheet. Then all the OMR sheets containing student information, evaluated theory marks and practical marks are scanned and the output emerges as excel file to be tabulated by the software for analysis of the results.

10. Evaluation of the group performance includes plotting of the marks scored by all the students in the group to total marks awarded for each question. This process can identify the potential faults in the evaluation tool i.e., the question themselves or the evaluation process (examiners). This also helps in the need for moderation of the group score if there are flaws in the system / tools.

• Though this system has been used extensively in many Universities & Colleges across India, our evaluation is unique, that it allows analysis of marks awarded to individual questions. This robust system was conceived and developed by the Exam division in collaboration with the Department of Information Technology to suit our local needs.

• The process is structured with an error rate of six sigma.

11. After analysis, board meeting is conducted and results are declared online and a SMS information is sent to the candidates.

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The Advantages of the new system • Quality control in the process - reduction of errors to ‘zero’ i.e. Zero tolerance of human errors such as data entry errors, wrong assignment of marks, etc., Performance of this system has an error rate of less than six sigma.

• Efficiency: Speeding up the entire process so that the time lag between the end of the exams and declaration of results is reduced to less than 48 hours. It also improves human efficiency and reduces the need for human intervention.

This helps us to o Resume classes / course early o Helps in our resolve towards a greener, paperless office.

• Most importantly, this system satisfies the NAAC & UGC requirements.

• This would also help us in the wake of increases intake of students and enable the University grand design to start a no. of new courses.

• Introduction of these reforms in examination system has resulted in a positive feedback from students and examiners.

An Analysis of the revised exam pattern: Strength • Improves Quality; • minimises error; • Decrease turn – around time • Positive feedback from students and examiners Weakness Requires • Special equipment • Software • Skilled personnel • Training Opportunity • Automatation of the process • Economically viable Challenges • Short time frame available before December 2013 exams has been overcome by expediting matters Plan ahead 1. Having restructured the theory exams and systemized the exam process, we are now set out to objectivise the practical/clinical/oral exams. This is by introducing OSCE/ OSPE and structured viva in the exams. A series of workshops on Objectivising the clinical / practical / Oral exams on OSCE /OSPE for faculty of all constituent colleges is planned for in Feb – Mar 2014.

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Capacity Building for Faculty Empowerment in Aligning Education with Practice of Nursing in 21st Century K R Sethuraman * The objectives for this session are to i. Compare nursing scene of the West with that here in India ii. Consider what changes are needed to train the “Nurse of the 21st Century” iii. Consider “content overload” and some ways of curbing the “content tyranny” iv. Discuss ‘theory-practice gap’ and methods to plug the gap The IOM Report, “The Future of Nursing” released in 2010 has four key messages: The report says that the “Nurses should i) practice to the full extent of education & training; ii) achieve higher levels of education & training through seamless academic progression, iii) be full partners in redesigning health care, and iv) do effective workforce planning through better data collection & information flow. These messages are meant for the USA but are equally applicable to India.

The IOM report also dwells on the role of Deans & Directors of Nursing: it says that they should i) Promote lifelong learning and academic progression; ii) Partner with other Deans to launch educational collaborative initiatives, iii) Develop strategies for flexible student-centered learning environments, iv) Promote practice-integration into curriculum at all levels of education, and v) Support the Councils by participating in requested surveys to enable evidence-based policy making. These messages too are applicable to India.

Indian Nursing scene

Nursing in India - the deficit: Acute shortage of nurses is mind boggling indeed. Of the 2.4 million nurses needed for optimum availability, there is a gross deficit of 2 million or >80% of the total needed. The nurse: population ratio in India is 1:2,500 and ten times less than the ration of 1:250 in the West. The nurse: doctor ratio is 0.5 nurse/doctor in India is also ten-times less when compared with 5 nurses/doctor in UK. One of the major reasons for such nursing shortages in South Asia, is the desire to avoid the “stigma associated with basic nursing tasks” forms a strong cultural backdrop (cited in http://www. biomedcentral.com/1472-6955/12/8 ) Nursing in India - other issues: i. Lack of clear career pathways and mechanisms for promotion ii. In-service training to learn new skills is rare iii. Pay is low, esp. in small private hospitals iv. Working environment is often poor v. Lack of sufficient staff, equipment & infra-structure, personal security vi. Very high patient to nurse ratio (50 patients/nurse according to a survey in N-Delhi) India: Nursing Education – 12-Key Issues: i. Several Centres of Excellence in nursing education do exist in India; however, very little published data are available on their achivements. * Prof KR Sethuraman MD PGDHE, Vice Chancellor, Sri Balaji Vidyapeeth.

Puducherry 607 402 . (mail to <vc@sbvu.ac.in> ) Annals of SBV

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ii. Inadequate educational monitoring & governance iii. Serious teaching staff shortages iv. Poor physical infrastructure v. Poor educational resources, esp for clinical skills vi. Lack of continuing professional development for faculty members vii. Lack of promotion opportunities for faculty viii. Over-cluttered curriculum ix. Reliance on didactic teaching approaches x. Poor student living accommodation xi. Poor links between clinical areas and educational institutions xii. Inadequate clinical experiences (cited in http://www.biomedcentral.com/1472-6955/12/8) Status issues in Clinical Education is another area of concern. For students of BSc & MSc, the fact that most staff nurses are diploma-holders creates status ambiguities. Therefore, clinical education is seen as the responsibility of nursing faculty member and the Staff nurses often do not see it as their duty to support students’ learning.

Equipment for teaching clinical procedures is not provided by the service staff.

If theory is taught without effective clinical correlation, the result is “Theory-Practice gap”. Lack of resources, capacity and infrastructure also create a wide and deep theory-practice gap. Ultimately, the students learn about nursing assessments, care planning or clinical procedures that have no relationship to the real-life practice. This is reflected by the teaching staff at times telling their students, “You all Do as we Say; Don’t do as we do.”

The Future of Nursing Education is through a Collaborative approach. We need constructive dialogue on how education and practice could work towards a win-win partnership.

Reforms in Nursing Education are clearly needed due to several factors: Nursing profession is now Global & multi-cultural; The new pedagogies in the info-tech-era, and adult learning (Andragogy, Heutagogy etc); Preparing future professionals to push the healthcare-transformation agenda forward; Call for ‘student-friendly’ Curricula; To prepare “the nurse for the 21st Century”.

Why do we need “a New Kind of Nurse”? There are several reasons for it. Some of the important ones are as follows.

I. Changing nursing practice environment: i. Increasing complexity & acuity ii. Quicker patient turn over (shorter-stay) iii. Shift of care to home & community II. Exponential growth of knowledge III. Explosion of technologies IV. Identification of the “Quality Chasm” – to close the ‘theory-practice gap’ V. Changing demographics: i. Aging population ii. Increased load of chronic illnesses iii. Families increasingly engaged in care-giving VI. Nurse – a trainer of care-giver, not a provider of care VII. Increased attention to health-promotion and public health initiatives (DOTS etc) The New Nursing Curricula should have the following features: - Emphasize deep understanding of the most important ‘Core concepts’ - Purposefully REDUCE content and select of content based on the Prevalence of condition.

- Integrate learning outcomes across competencies (e.g. universal precautions, patient safety, ethical issues, clinical judgment, evidence-based practice, health systems & leadership, etc) - Promote self-directed learning and active learning through case-based instruction; provide for integration among theory, clinical and simulation.

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- Authentic formative and summative performance assessment.

Challenges in Clinical Education are many; the major ones among them are i. Dependent on placement opportunities & limitations ii. Insufficient placements for “total patient care” iii. Acute/severely-ill cases are at greater risk with neophyte students handling them iv. Challenge of supervising students in rapidly changing situations - the ‘service or supervision?’ dilemma v. Learning is dependent on “Chance-Factors”: a. Availability of “teaching-cases” b. Availability of the Facility (OT, Skills Lab, Wards etc) c. Availability of faculty-staff with required expertise Nursing Education: Taming of the ‘Content Overload’ or ‘Content Tyranny’ Health professions education has reached content saturation. There is more content than can possibly be taught within any given traditional curriculum. The causes of content saturation are i) Explosive increase in knowledge base Information Age, ii) Changes in Health Care Delivery, iii) Teacher-centred Pedagogy, and iv) Academic-Practice gap resulting in even more teaching to try and fill the gap. Covering too much content tends to make the learners overlook the concept.

A solution for this is to adopt “Concept Learning” model. What is a Concept? A concept is an organizing principle or a unifying classification of information. Concept Learning are of two types: i. Cognitive concepts, which are knowledge-based, e.g., ‘error-free medication’ and ii) Perceptual concepts, which are based on sensory perception, e.g., the feel of a soft or a hard lump, auscultation of foetal heart sound, etc.

The benefits of Concept-based Curriculum are several: i. Focus is on concepts; not merely on facts ii. Concepts are applicable across diverse populations and situations, e.g., Safe-Medication, Universal precautions etc. iii. Conceptual learning: unlike facts, concepts are retained Life-long iv. Stimulates critical thinking & deep learning v. Meets needs of diverse learners Challenges of Concept-based Curriculum that block its widespread adoption: i. It is different ii. Faculty lack understanding iii. Faculty resistance to change iv. Requires different level of coordination v. Lack of literature detailing steps vi. Easier to convey Facts than impart Concepts If the teaching staff learn the skill and know-how of teaching concepts, rather than mere facts, it would go a long way.

Nine-Steps of “Concept Attainment” Model of teaching include the following: - Select and define a concept - Select the attributes - Develop positive and negative examples - Introduce the process to the students - Present the examples and list the attributes - Develop a concept definition - Give additional examples - Discuss the process with the class - Evaluate

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Addressing the Theory - Practice Gap Theory and practice are reciprocally related: “Theory without Practice is purposeless & Practice without Theory is blind” Theory practice gap – how does it affect the learners?

This affects the professional development of learners and may results in their inability to solve problems, rigidity of approach and dependency in providing patient care, fragmentation of patient care and an apathetic attitude in clinical practice.

Role of Educators in improving theory-practice correlation: The nurse-educators need to i. Identify appropriate clinical problems for problem solving & decision making. ii. Demonstrate to learners how to apply theory to real-life practice. iii. Engage students in critical analysis & guide their own thinking process (meta-cognition) iv. Use effective strategies to embed theoretical knowledge relevant to solving practical problems (Miller’s Pyramid) v. Provide realistic learning environment in which learners can correlate theory and practice vi. Demonstrate to learners – how to individualize nursing care (Problem-Knowledge coupling: www.pkc.org ) vii. Have learners work together to help them to apply skills to a diversity of problems Four proven teaching strategies to enhance theory practice integration are 1. Problem based learning (PBL) - Makes students responsible for their learning - Student learning is organized around problems - Barrow’s Taxonomy gives a wide scope for educators to adopt PBL 2. Practice based Assignments to include real-life clinical problems.

3. Group discussions on practical evidence-based problem-solving .

4. Reflective practice Future Trends in Nursing Education in 21st Century are i. Increased collaboration between nursing practice and nursing education ii. Increased student & nurse mobility, including increased licensure mobility iii. Increased distance (online) learning iv. Schools of nursing providing continuing professional development v. Increased teaching of evidence-based practice.

Summing Up Our New Graduates should – - Think critically and be able to solve complex, real-world problems - Find, evaluate, and use appropriate learning resources - Work cooperatively in teams and small groups - Demonstrate versatile and effective communication skills, both verbal and written - Become life-long learners to update their knowledge and skills acquired at the university Can we achieve this? We can do it, if only we have the self-belief in our ability to motivate our students to achieve all the intended learning outcomes that will enable them to be competent nurses of the 21st Century.

Bibliography 1. IOM Report The Future of Nursing – downloadable from http://www.nap.edu/catalog.php?record_id=12956 (accessed on 28-10-2013) 2. The Nursing Education Partnership Initiative (NEPI) – downloadable from http://www.fic.nih.gov/programs/ training_grants/mepi/index.htm (accessed on 28-10-2013) 3. Commission on Education of Health Professionals for the 21st Century http://www.thelancet.com/journals/ lancet/article/PIIS0140673610604503/fulltext?rss=yes 4. WHO global recommendations for the retention of health workers http://www.who.int/hrh/retention/guidelines/ Page 54

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en/index.html 5. Report on the WHO/PEPFAR Planning Meeting on scaling up nursing and medical education, Geneva, 13-14 October 2009. http://www.who.int/hrh/resources/scaling-up/en/index.html 6. Wanted: 2.4 million nurses, and that’s just in India. Bull World Health Organ. 2010 May 1; 88(5): 327–328. doi: 10.2471/BLT.10.020510 7. Evans et al. Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh. BMC Nursing 2013, 12:8. http://www.biomedcentral.com/1472-6955/12/8 (accessed on 20-102013) 8. SE. Thorne. Nursing education: Key issues for the 21st century. Nurse Education Today (2006) 26, 614–621 9. Karen Ousey and Peter Gallagher. The theory–practice relationship in nursing: A debate. Nurse Education in Practice (2007) 7, 199–205.

10. Sandee L. Hicks-Moore. Clinical concept maps in nursing education: An effective way to link theory and practice. Nurse Education in Practice (2005) 5, 348–352.

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Health Information Technology (HIT) and Quality Health Care K.R. Sethuraman * “When a thing is new, people say: “It is not true”.

Later, when its truth becomes obvious, they say: “It’s not important.”

Finally, when its importance cannot be denied, they say “Anyway, it’s not new.”

(William James - 1842 - 1910)

Six elements of Quality Healthcare: Safety, Effectiveness, Efficiency, Timeliness, Patient centeredness and Equitability (Scottish Health Authority) Public engage in e-Health in four ways: 1. health information on the Internet; 2. custom-made online health information; 3. online support (active engagement in social computing is the most visible) 4. tele-health Five factors that act as barriers or facilitators for use: 1. characteristics of the users; 2. technological issues; 3. characteristics of eHealth services; 4. social aspects of use; 5. eHealth services in operation.

Capacity Building in HIT involves five stages 1. Knowledge building 2. Professional development 3. Organisational strengthening 4. Directive reforms 5. Facilitative reforms

Knowledge building

For Knowledge building, Informatics Competency is needed. Its components are the following: Informatics Knowledge: Aware of the importance of healthcare data for improving practice Informatics Knowledge - Privacy/Security: Aware of the secure ways of handling confidential patient data. Aware of patients’ rights in computerized information management Computer Skills: Documentation/Data capture: Uses an application to document/capture patient care data. Uses an application to plan care for patients.

Computer skills: Decision Support: Uses decision support systems, expert systems, and aids for clinical decision making or differential diagnosis Informatics: Evidence-based Practice: Use optimal search strategies to locate clinically sound and useful studies from information sources. Identify, evaluate, and apply the most relevant information. Critically analyze data, information, and knowledge for use in site-specific evidence-based practice

Hierarchy of Information-communication technology (ICT) simplified: i. Office Automation - (data entry, data capture) ii. Transaction Processing - (data processing) iii. Management Information – Analyze data to be usable information iv. Decision Support - Health/Healthcare

*

* Prof KR Sethuraman MD PGDHE, Vice Chancellor, Sri Balaji Vidyapeeth, Puducherry 607 402 (mail to <vc@sbvu.ac.in> )

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The Paradox of Professionalism and Error in Complex Systems

Professionalism & expertise are needed to prevent/mitigate errors in complex & risky work such as medicine, aviation, and military operations but there are two paradoxes: 1. They increase the risk of errors by breaking procedural rules to suit the circumstances 2. Professionals tend to ignore or hide critical information about unsafe conditions and create ‘blind spots’ within organizations. (Journal of Biomedical Informatics 44 (2011) 395–401) The paradox of HIT productivity HIT is perceived as a means to improve productivity, quality & system efficiency. However, the current study results are contradictory: Some studies do confirm HIT as a means to greater productivity and efficiency, while other studies remain inconclusive. Some studies even show that HIT can be counter-productive / hazardous. (International journal of medical informatics 80 (2011) 102–115) Is HIT Ineffective Or Is It Sub-optimally Used By Us? This is a Billion $ query at present.

HIT in Chronic Care

With current HIT with distributed IT systems, powerful portable computing and mobile e-communication we can design a system that is patient focused, integrated and holistic in approach, and offers objective evidence-based care based on intended outcomes incorporating proactive quality assurance & error reduction in a dynamic & turbulent home environment of chronic care.

In Chronic Care, HIT can help achieve true patient-orientation and “seamless information flow for seamless care”, quality in care delivery, viz., give the right treatment to the right patient, at the right time and in the right place, regularly and reliably.

We have not been able to do it till now using only traditional paper records and communication. If HIT has to achieve it, we need to ensure appropriate form and effective functioning of the technology.

Patient Centered HIT ideally needs a trans-disciplinary approach to healthcare. It creates new challenges.

We need – i. a common language that really integrates the various health care professions (HCPs) ii. to use terms and language as commonly understood (tackling the acronyms maze!) iii. to learn how to effectively link various professions iv. integrated record as a means of clinical communication to all HCPs

Organisational Barriers:

i. Non-conducive structure of organizations ii. Tasks that are not feasible in the set up iii. People policies which retard progress and block innovation iv. Lack of proper incentives v. Defunct decision processes and lack of information We need to do more studies on organizational structure, end-users’ HIT competency, incentives, liability issues, & work process issues that facilitate or retard effective implementation of HIT to enhance quality care.

Bad Health Informatics Can Kill

HIT can have positive impact on health care. But there is also negative impact of HIT on efficiency and even outcome quality of patient care. Medical ‘informaticians’ should feel responsible for the effects of HIT on patients and public. We need to conduct systematic analysis of HIT errors and failures to design better quality systems.

The problems can be overcome by developing & applying human-centered design, implementation, & evaluation adapted to the point-of-healthcare delivery. Such a systematic approach has been achieved in aviation, the military, nuclear power, and the consumer software industry. It can, and must, be achieved in HIT as well.

National HIT: Patient Safety Initiatives

i. Currently, there are significant gaps in the safety initiatives for HIT systems. ii. The safety of HIT (EHR, CPOE etc) is not being explicitly addressed in most nations iii. Standardization and monitoring of safety in system design, implementation & use of HIT is critical to ensure patient-safety.

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Key Components of Successful Health IT Policy (USA-Cana da) I. Setting clear goals and intended outcomes of HIT without being overly prescriptive.

II. Adopt an iterative-incremental management approach with strong leadership and governance model.

III. Defining frameworks for guiding policy improvement in a continual and systematic manner.

IV. Addressing meaningful use of the existing legacy health IT systems in use.

V. Capitalizing on the value of data for use in performance and quality measures, public health and research.

Summing up:

Effective HIT and quality healthcare: we do need them â&#x20AC;&#x201C; Our Lives May Depend on it!

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How Mobile Tech can Influence Cost - Effective Health Care.

James S. Toreson * “An Ounce of Prevention is Worth a Pound of Cure” - Benjamin Franklin 1735

The Benefits of Mobile-Health Technology

Mobile tech’s impact on medicine will be more profound than the pc’s impact on mainframe computing. Some of the important features are listed below: •Moving the Clinic to the Patient for Many Clinical Functions: Mental, Physical, Sociological •Access to Large Population, Family Histories, and Lots of Data •Enables “Community Level Healthcare” and Holistic Health through Local Support Systems •Enables Automation to Transition from “Crisis-Care” to “Preventive-Care •Lower Facility Expense •Higher Physician Productivity •Less Time and Cost to the Patient •Higher Frequency of Care, Exams, and Patient Communications

Mobile Tech & Preventive Healthcare:

•Intelligent Data Acquisition Systems •Genomic Data •Current, Accurate, Electronic Health Records: Medical Data, Family Data, Patient Behavior, Lifestyle, Environment, etc.

•AI driven, Clinical Decision Support Systems •Knowledge Base

The Knowledge Base

•Continuous Improvement & Review – Peer and AI •Litigation History and Avoidance •Comprehensive: Genomics, Drugs, Treatment, Symptoms, Behaviors, Family Data, Environment., etc.

•Technically Layered Search for the end-users: • Consumer; Doctor; Researcher.

System Strategy:

•Translational Bioinformatics, fueled by Genomics, Patient Data, Family Histories, and Environmental Data •Automation Intensive – Physician Empowering •Artificial Intelligence Enabled •Pervasive, Advanced, Quality Control •Continuous Improvement at all Levels •Cloud Based •Ultra-Secure

Cost Control Elements:

•Low-Cost Systems, with “Zero Defect” Quality •Minimize Skilled Personnel •High-Quality Outcomes •Reduce Time and Cost for Patient

* Dr. James S. Toreson, Co-Founder, Robo Clinics, Nevada, USA Annals of SBV

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•Timely, Efficient, and Accurate Care •Patient Involvement: Knowledge, Life Style, Behavior, & Family History •Patient Experience and Satisfaction

System Development:

•Disease Assessment •Set Priorities Based on “80-20 Rule”: the 20% of Diseases that Cause 80% of Cost •Disease Control that is Quick to Deploy •Other Parameters e.g., Contagious diseases, Epidemics, etc.

HOLISTIC HEALTH

•Integration and Optimization of Psychological, Physical & Social health.

MENTAL HEALTH

•Brain (Mental) and Body Physiology are Connected •“Distributed Treatment” through Patient Empowerment: Education, Communication, Meditation, Music, Social, etc.

Genomics - Predictive :

•Currently Constrained to Single Gene (Monogenic or “Mendelian“) Disorders •Complex Diseases Caused by Combinations of Genetic Information (Polygenic) •Complexity of Genome Requires Massive Computing Power, Sophisticated Algorithms, and Artificial Intelligence (AI)

Translational Bioinformatics:

Translational bioinformatics = informatics methods that link biological entities (genes, proteins, small molecules) to clinical entities (diseases, symptoms, drugs)--or vice versa. (Professor Russ B. Altman, MD, PhD Stanford University)

An Example of AI Software:

•“eXtasy” - Software Breakthrough (Oct 2013) •Advanced artificial intelligence Based •Detection of Disease-Causing Mutations •20X Improvement in Accuracy •Developed at KU Leuven in Belgium

Conclusion

Quantifiable Data from Mobile Tech is Critical for Advancing: •Translational Bioinformatics •Genomics •Epidemiology •Health Care to the Masses Evaluation is Vital “If You Can’t Measure It, You Can’t Improve It” - Lord Kelvin

Page 60

Annals of SBV

Annals of SBV Sri Balaji Vidyapeeth

(D eemed

to be

U niversity , u / s 3, UGC A ct , 1956)