Annals of sbv 2017 Vol 6 Iss 1 Jan-Jun 2017 by Dept of Medical Informatics

ISSN 2395 - 1982

SRI BALAJI VIDYAPEETH ACADEMY OF HEALTH PROFESSIONS EDUCATION AND ACADEMIC DEVELOPMENT

ANNALS OF SBV Volume 6 - Issue 1 Jan - JUN 2017 Theme

CHANGING TRENDS IN HEALTH PROFESSIONS EDUCATION

A Publication of

SRI BALAJI VIDYAPEETH

Annals of SBV Editorial Advisor K R. Sethuraman Editor-in-Chief N. Ananthakrishnan Core Committee V.N. Mahalakshmi

M. Ravishankar Premnath Fakirayya Kotur R. Saravana Kumar K. Renuka Issue Editor Adkoli B.V

Karthiga Jayakumar Partha Nandi R. Jagan Mohan

Associate Editor M. Shivasakthy Executive Editor A.N. Uma Statistical Advisor G. Ezhumalai Published, Produced and Distributed by

Sri Balaji Vidyapeeth Editorial correspondence to Managing Editor

Annals of SBV Sri Balaji Vidyapeeth

(Deemed University, Accredited by NAAC with 'A' Grade) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 605 403 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

INDEX From The Editors Desk Changing Trends in Health Professions Education: The need to strike a right balance! - Adkoli B.V.

1. SBV Model of Competency Based Learning and Training (Cobalt) for Post Graduate Education - Ananthakrishnan N, Karthikeyan P, JaganmohanR, Pulimoottil DT, Ravishanker M, Adkoli BV, Sethuraman KR, 5 2. Setting Standards and Innovations - Dr. V. N. Mahalakshmi

3. Infiniti - Mind Mapping Learning Model - Prof. Dr. Renuka K, Mrs. Jayanthi K

4. Inter-Professional Education in Health Sciences - Prof K.R. Sethuraman

5. Integration of Health Professions Concept, Vision, insight and Leadership - Prof. Rajaram Pagadala

6. Enrichment of MBBS Curriculum with Research Component: Road to Professional - Dr.C.Adithan, Dr.B.V.Adkoli

7. Attitude and Aptitude of The First Year Referred Batch of Medical Students - Dr.Swayam Jothi.S, Dr.Kafeel Hussain.A

8. Is Everything Objective Reliable? - Dr. Tejinder Singh

9. Integrating Yoga in Health Professional Education: The SBV Experience - Yogacharya Dr. Ananda Balayogi Bhavanani

10. Bedside Medicine-Victor or Vanquished? - Dr. K N Viswanathan

11. Changing Trends in Health Professions Education - Dr. Karthika Jayakumar

12. How Big A Sample Do I Require? - Dr.G.Ezhumalai

13. Status of Radiology Teaching at Undergraduate Level - Singh C. S., Adkoli B. V, Ezhumalai G, Sethuraman K.R

14. Students Needing Additional Curricular Support and Psychological Support (SNACS, SNAPS) – A perspective Shift - Shivasakthy Manivasakan, K. R. Sethuraman

From the Editors desk

Changing Trends in Health Professions Education: The need to strike a right balance! Fifty years ago, Kothari Commission on Education observed: “The destiny of India is now being shaped in her classrooms.” The statement holds good even now. No one can deny that education is the most powerful tool for nation building. Health is an essential requirement. Health Professions Education, therefore, occupies foremost agenda for a growing nation. It is all the more important agenda for a Health Sciences University such as Sri Balaji Vidyapeeth which strives to remain in the forefront of health professions education in order to produce a high caliber human resource in medical, dentistry, nursing and allied health sciences. However, trends in education change with times. Often they may cause conflict between the new thoughts and old mindset. How do we catch up? It seems reasonable to examine them dispassionately and strike a right balance. Consider the nature, scope and focus of medicine itself. Education in health profession has been influenced not only by the nature of medical science and research, but also by other factors such as changing societal needs/aspirations, socio-economic development, political agenda and most importantly the impact of information technology. Though the response of the education system has been slow, it has been intensified during the last couple of decades. The shift from ‘informative learning’ to ‘transformative learning’ has influenced designing of a competency based approach to learning and training. Conventional teaching is being supplemented with integrated teaching and problem based learning. New areas of competency such as practice based learning & improvement, interpersonal communication, professionalism including ethical behavior, and systems based practice have emerged in addition to traditional medical knowledge and patient care. These developments have triggered a shift in the scope and modalities of assessment. Assessment is considered as a tool for ‘improving’ rather than ‘proving’ students’ learning outcome. Educators have begun to search new modalities of assessment such as e-portfolio to ensure day to day assessment and monitoring of progress. They are also becoming familiar with the use of Multi-Source Feedback (360 ○ assessment) to capture the whole gamut of competence. A right balance between conventional assessment and innovative methods such as Workplace Based Assessment is therefore a much needed step. Yet another unprecedented development is the growth of student enrolment, expanding curriculum, and shortage of faculty to run the system. While the formal education has become expensive, inadequate and too demanding for the teachers, new forms of e-learning and their incorporation in myriad forms such as distance learning, blended learning and MOOC have opened up new windows of opportunities. The traditional courses are being supplemented with new courses with flexible learning opportunities based on Choice Based Credit Systems (CBCS), which are becoming popular among student community. The new revolution is expected to change the role of teachers as well as the students. The traditional role of teacher as an authority or expert is being challenged by new role as feedback provider, mentor and a coach to facilitate student learning. Since this movement is almost ‘threatening’, what is desirable is a smooth transition of striking a right balance! Through this special issue of Annals of SBV dedicated to the health profession, we have tried to capture the changing trends in health profession. The articles reflect the voices expressed by some of the educational stalwarts in the country who participated in a National Conference on Changing Trends in Health Professions Education (18-20, August 2016) organized by the SBV. We have also provided equal space for other educators across the health profession to air their views and share their wisdom. We hope the plethora of articles would stimulate further discussions which will help our University in contributing to the health professions education in the country. Special thanks are due to all the contributors, our team members and specially the leaders of SBV who hold no bar in stimulating our academic journey to new a new height. Adkoli B.V. Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry-607403, India

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Innovation SBV Model of Competency Based Learning and Training (Cobalt) for Post Graduate Education Ananthakrishnan N Dean, Research and Allied Health Sciences, Sri Balaji Vidyapeeth,

Karthikeyan P Professor and Head, Department of Otorhinolaryngology, Mahatma Gandhi Medical College and research Institute,

JaganmohanR Head, Department of Information Technology, Sri Balaji Vidyapeeth,

Pulimoottil DT, Assistant Professor of Otorhinolaryngology, Mahatma Gandhi Medical College and research Institute,

Ravishanker M, Dean, Administration, Mahatma Gandhi Medical College and research Institute,

Adkoli BV Professor and Head, Department of Health Professions Education, Sri Balaji Vidyapeeth,

Sethuraman KR, Vice Chancellor, Sri Balaji Vidyapeeth

Address for correspondence : Dr. N. Ananthakrishnan Dean, Research and Allied Health Sciences, Sri Balaji Vidyapeeth Institute Pondicherry, 607 402,

INTRODUCTION Postgraduate training in medicine occupies a crucial role in the development of the health workforce of the country. It is expected that the postgraduates who have passed out successfully from a medical college are competent and fit enough to practice independently in a variety of settings. By competent, we mean that they constitute a ‘total package’ of medical knowledge, skilled in patient care, endowed with interpersonal communication skills, and professionalism including ethical behavior, adaptable to work in a health system, and with an ability to pursue learning for a life time.1 A reality check of the present status of postgraduate training on the other hand, offers a gloomy picture. The Medical Council of India has no doubt recommended Ann. SBV, Jan-Jun 2017;6(1 )

that the “postgraduate curriculum shall be competency based”.2In spite of this core principle being enshrined in the Council’s Postgraduate Medical Education Regulations, so far no concrete steps have been taken in the country to establish and implement a competency based medical education program. There are a number of reasons for the present state of matters. Firstly, there is no agreed list of skills and competencies required to be attained by the resident during the period of training. The expected standards vary from institute to institute, and even within the same institute, from one faculty to another! Secondly, there is no mechanism for recording or monitoring the progress of individual students on a regular and continuous basis. Thirdly, there is no scope for tailoring intervention based on the levels attained by the Page 5

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individual postgraduate at various intervals of training. Last, but not the least, the assessment is based on the final examination, when it is too late for interventions. All over the world, public demand for accountability is driving a paradigm shift to competency-based medical education (CBME) in the health professions.3 Medical Boards around the world have adopted competencybased frameworks as the underpinnings for new postgraduate training programs. These frameworks include Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) in the United States4, the CanMEDS Framework of the Royal College of Physicians and Surgeons of Canada5, the Scottish Doctor Project in Scotland6 and the Framework for Undergraduate Medical Education in the Netherlands7. Unfortunately, in India, we have not witnessed any major effort to introduce the competency based approach in PG training, though it has been identified as a critical and immediately needed intervention.8 In view of this perceived gap, Sri Balaji Vidyapeeth University, Pondicherry, India, embarked on an ambitious project to design and implement the first competency based medical education programfor postgraduates in medicine in India in January 2016. The main objective of our paper is to describe the steps we took in launching a model what we have termed as Competency Based Learning and Training (COBALT) program for postgraduates.

METHODOLOGY In January 2016, the Deanery of Postgraduate Studies, Sri Balaji Vidyapeeth University, Pondicherry, India, took a conscious decision to launch competencybased postgraduate medical curriculum for the batch entering in 2016-2017. After initial deliberations, it was decided to build on the competency framework of ACGME with modifications specific to the needs of postgraduate medical education in India. Definitions of key words in this context are shown in Table I. The steps involved in designing the COBALT program have been enumerated in Table II. The designing of COBALT was done during the period between January and July 2016. It was initially decided to identify about 25-30 EPAs pertaining to each specialty, map these EPAs to appropriate competency domains, and delineate various levels/milestones Page 6

appropriate to each domain. It was also decided which EPAs require multi-source feedback (MSF). An e-portfolio was developed for formative assessment. The departmental list of EPAs was generated as a consensus of all concerned faculty. Following this, a workshop was conducted for the senior faculty, to deliberate on the EPAs. The participants identified 13 core EPAs which are applicable for all residents, irrespective of their specialty. This was essentially a consensus building exercise across all departments. Working on the selected EPAs, each department mapped the levels of competency appropriate under various competency domains at various stages of training. The last phase focussed on assessment strategies for the competency framework. A second workshop was organized to discuss the various approaches for collection of MSF and to select the most appropriate competencies for MSF. MSF questionnaires were carefully prepared to make them simple, easy to comprehend and complete and maintain strict confidentiality. Further, the role of an e-portfolio for formative assessment was discussed and a general consensus was arrived on the basic design. The challenge here was to optimize the use of right source (faculty, peers, other health professionals, patients, self) with right tool (e.g., case presentation, journal club, seminars) based on the consensus of all faculty. At the end, multiple workshops were convened involving all teaching faculty, sensitizing them to the competency framework and its requirements. The roles expected of the faculty interms of giving feedback and carrying continuous assessment of their residents and strategies were demonstrated through these interactive workshops.

Implementation of COBALT Soon after the admission, the incoming batch of residents (2016-17 batch) underwent a three day intensive structured orientation program in which they were trained in the use of EPAs, and how to work with the LMS and the e-portfolio system. Every resident was registered with the Universityâ&#x20AC;&#x2122;s portal (Garuda) for getting access to LMS. A list of core competencies and specialty specific competencies were distributed to all residents and they were asked to grade their perceived competency under five levels. After watching the performance of residents for about four weeks, the faculty rated the residentsâ&#x20AC;&#x2122; entry Ann. SBV, Jan-Jun 2017;6(1)

SBV Model of Competency Based Learning and Training (Cobalt) for Post Graduate Education

levels. The discrepancy in levels if any, between selfassessment and faculty assessment served as a feedback to the residents and tocustomize teaching as per the needs of a resident. Another key feature of implementation was the assignment of an individual faculty member as a mentor on admission who would continue to mentor the student till the completion of the course. The mentors were entrusted with the task of recording the progress of the resident on the EPA at three monthly intervals during the first year and six monthly intervals thereafter. All activities of the residents involving academic and patient care activities were expected to be recorded in the electronic portfolio on a daily basis, which were examined by the mentor on a weekly basis for giving detailed feedback.The details recorded in the e-portfolio are shown in Fig. I. The assessment grading was done on a three point scale, viz., below par (not satisfactory), at par (satisfactory) and above par (highly satisfactory). Any student who was found lagging behind, viz., below par (not satisfactory) in the given task was given feedback and additional exposure to remedy the deficiencies in order to reach the satisfactory level. In addition to the mentors’ feedback, the residents were also able to obtain feedback from other faculty members, to enrich their learning experience. However, the main plank of learning rested with the residents, who were encouraged to raise questions about their

doubts and difficulties to the mentors who responded in a week’s time. The cycle of working on various EPAs, documenting the resident work, assessment and feedback given by the faculty has been continued successfully for the last ten months. The prima-facie evidences coming from our observations of the whole process for the last ten months reveals that COBALT approach is a feasible and effective way of introducing CBME, though it is too early to decide on the outcome and the impact of our project.

CONCLUSION We conclude that COBALT approach to the postgraduate training is much needed timely intervention for overcoming some of the chronic deficiencies. Our experience shows that with a committed leadership and concerted effort of faculty across various disciplines, it is possible to design and implement a system that is functional and sustainable. While the country is debating on the role of regulatory bodies and the need for introducing common exit examination across the country, we find it extremely important to address the most fundamental issue of developing competency as a true hallmark of postgraduate training.

Table I: Definitions of Keywords KEY WORD

DEFINITION

Competency

“Competence is defined as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served.”- Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287:226-35.

Domains of competence

These are broad distinguishable areas of competence that in aggregate constitutes a general descriptive framework for a profession. The ACGME/ ABMS framework identifies six domains of competence: Patient care (PC), Medical Knowledge (MK), Interpersonal and Communication Skills (ICS), Professionalism (P), Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). This same format was retained for the COBALT program.

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Entrustable Professional Activity (EPA)

Since competencies are not directly measurable, they need to be rewritten in a format which is observable and measurable. This format is called “Entrustable Professional Activities” or “EPAs”. EPAs describe a measurable activity or task for medical practice that requires specialized knowledge and skills, and encompasses multiple competencies. They are “critical activities” in the professional life of physicians that the specialty community agrees must be assessed and approved at some point in the ongoing formation of physicians.

Levels of EPAs

These represent five sequential stages in the development of competency from novice to the expert level. Level 1 – expected ability of a novice, mostly limited to observation only Level 2 – ability to perform the activity under strict supervision Level 3 – ability to perform the activity under loose supervision Level 4 – ability to perform the activity independently Level 5 – expertise in the activity; ability to perform the activity independently and teach others.

Milestone

It is a significant point or an observable marker of an individual’s ability along a developmental continuum.

TABLE II: Steps involved in designing COBALT STEPS INVOLVED IN DESIGNING COBALT

1. The competencies required to be attained by a resident in individual subjects are identified and stated after a detailed discussion by the respective departmental faculty. 2. The competencies are converted in to a series of measurable “Entrustable Professional Activities (EPAs)” 3. EPAs which are common to all disciplines are grouped together followed by EPAs which are specific to the department concerned. 4. For each EPA an expected level of performance is fixed at the end of each year of the course. a. These levels may involve reaching certain ‘milestones’ which are also stated wherever applicable b. The criteria for grading the levels is as follows; i. Level 1 – expected ability of a novice, mostly limited to observation only ii. Level 2 – ability to perform the activity under strict supervision iii. Level 3 – ability to perform the activity under loose supervision iv. Level 4 – ability to perform the activity independently v. Level 5 – an expert in the activity who besides being able to perform the activity independently can also teach it to others. c. These levels are fixed after detailed discussion amongst the faculty of the concerned department. 5. The expected satisfactory level for these EPAs is generally fixed at Level 4 for most of the EPAs and Level 3 for complex EPAs which would require post-doctoral training.

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SBV Model of Competency Based Learning and Training (Cobalt) for Post Graduate Education

6. The EPAs are made available to the postgraduate residents immediately after joining the program. 7. The residents are expected to self- grade their perceived level of competence at admission on these EPAs. 8. The students are also graded by the faculty four weeks after admission and the difference in levels if any between self-assessment and faculty assessment serves as a stimulus to give a feedback to the student about the differences in possible assessment between oneâ&#x20AC;&#x2122;s own perspective and that of the trainer. 9. Each student is allotted an individual faculty mentor on admission who will continue with the student till completion of the course. 10. Each mentor is assigned the task of recording the progress of the student on the EPA at three monthly intervals during the first year and six monthly intervals thereafter. 11. Any student who is found lagging is selected for intervention in the form of a feedback and additional exposure to learning resources and skill training. 12. In addition to the mentor the studentâ&#x20AC;&#x2122;s progress is also monitored by other faculty who are encouraged to give a feedback to the student 13. All activities of the postgraduate residents on a daily basis involving all academic and patient care activities is record on an electronic portfolio which is examined by the mentor on a weekly basis and for giving his feedback. 14. The students are encouraged to raise questions about their training, the difficulties they perceive in the course and also ask any doubts they have either about the program or about the subject. 15. The mentor is expected to give a response to their queries and record his observations /answer within a week. 16. The cycle of working on EPAs, individual monitoring and feedback followed by remedial practice continues till the final examination. Fig. I: Format of E-portfolio

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REFERENCES: 1. Accreditation Council of Graduate Medical Education (https://www.acgme.org/acgmeweb/tabid/430/ProgramandInstitutionalAccreditation/NextAccreditationSystem/ Milestones.aspx) 2. Medical Council of India Postgraduate Medical Education Regulations. 2000. [Last accessed on 2017 Mar 19]. Available from: http://www.mciindia.org/RulesandRegulation/Postgraduate-Medical-Education-Regulations-2000.pdf . 3. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361–367. 4. Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29:648–654. 5. Frank JR, ed. The CanMEDS 2005 Physician Competency Framework. Ottawa, Ontario,Canada: Royal College of Physicians and Surgeons of Canada; 2005. http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf. Accessed March 19, 2017. 6. Scottish Deans’ Medical Curriculum Group. Learning Outcomes for the Medical Undergraduate in Scotland: A Foundation for Competent and Reflective Practitioners. 3rd ed. 2007. http://www.scottishdoctor.org/resources/ scottishdoctor3.doc. March 19, 2017 7. Laan RFJM, Leunissen RRM, van Herwaarden CLA. The 2009 Framework for Undergraduate Medical Education in the Netherlands. GMS Z Med Ausbild. 2010;27(2):Doc35. 8. Modi JN, Gupta P, Singh TS. Competency-based Medical Education, Entrustment and Assessment Indian Ped 2015;52:413-20

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Innovation Setting Standards and Innovations Dr. V. N. Mahalakshmi, Vice Principal (Curriculum),I Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India

Introduction As a part of the quality initiatives involving TeachingLearning-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.

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

UG exams 1. 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. SBVUAHEAD, 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 question papers based on the specific learning objectives (SLO) in mind. This is used as a template for the question paper setters. Ann. SBV, Jan-Jun 2017;6(1 )

• The paper setters are given elaborate blue print guidelines specific to the learning objectives of the subject being evaluated and also weightage 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. 2. 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. 3. The actual conduct of exams • Secure online transmission and printing of question papers to off campus institutions in Page 11

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secure, encrypted form ½ an hour before the start of exams. 4. 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. 5. 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 – Item Marking. 6. Post validation of learning outcomes is done through Evaluation of the group performance by 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. Also, the triple feedback loop helps the curriculum planners to evaluate the validity of the learning process. • 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 Dr.Mahalakshmi under the able guidance of our Vice- Chancellor, Prof.K.R. Sethuraman, in collaboration with the Department of Information Technology to suit our local needs and has an error free rate of six sigma.

Practical / Clinical exams Having restructured the theory exams and systemized the exam process, we set out to objectivise the practical / clinical / oral exams. This is by introducing OSCE / OSPE and structured viva in the exams. A series of

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workshops on Objectivising the clinical /practical /Oral exams on OSCE / OSPE for faculty of the constituent colleges planned for in Feb-June 2014 and robust OSCE / OSPE blueprints and subject wise question banks developed. A national level, nodal meeting was held to present the SBV’s plan to align with MCI and seek experts opinion on the project, in May 2014. The model blueprints with the expert groups’ comments have been submitted to MCI for approval.

Oral Exams The oral / viva-voce exams for UG students have been restructured as ‘Structured Viva’ examinations, which follow a definitive blue print and specific mark allocation pattern for different topics. The successful introduction of changes in the MBBS exams has helped us to carry forward the changes in the UG Dental & Nursing courses.

PG exam reforms The following innovations/changes were brought about in the PG exam process. i. To eliminate ambiguity in the setting up of question papers, detailed blue printing of the question papers has been done and is followed. ii. The long essay type questions are replaced by ‘10 Brief Essay’ questions, to improve the sampling. iii. To eliminate bias, all answer sheets of all students are being evaluated by all the examiners (4 times valuated) iv. The evaluations of PG dissertations have been made more objective by using a designing checklist for examiners to evaluate the dissertations. The data from the evaluators is shared with the subsequent batch of PG students in the ‘Dissertation Writing’ workshops, so that such shortfalls can be minimized and eliminated.

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Innovation Infiniti - Mind Mapping Learning Model Prof. Dr. Renuka K, Dean, Nursing Faculty, Principal, KGNC. Mrs. Jayanthi K, Asst. Professor, Dept. of Mental Health Nursing. Kasturba Gandhi Nursing College, Mahatma Gandhi Medical College and Research Institute Campus, Pillaiyarkuppam, Puducherry – 607403, India.

Abstract  IINFINITI - Mind Mapping Learning Model is designed with the objective of enhancing

the learning skills of all students and especially students needing additional curricular support and as innovative method of teaching learning process. Creating learning experiences that facilitate reflection, knowledge building, problem solving, inquiry, and critical thinking is vital. Mind Mapping is an active learning process and innovative technique to facilitate student learning. Students focus on vision, show their creativity and contextual knowledge, and connect with central them. It is used for taking notes, completing home based assignments, for exam preparation, analyzing, and reflecting nursing practice. Mind maps can be executed in nursing curricula as an alternative learning experience.

Key Words: INFINITI - Mind Mapping Learning Model, additional curricular support, innovative

INTRODUCTION INFINITI - Mind mapping and Learning Model is an intellectual way to guide students to methodize learning message on any theme. It makes subjects easier to understand. Making use of different colour and pictures help students focus their attention and concentration and assists in creating newer concepts and directs them to go forward to other topics.1 Mind maps equip students to shape, form and finish learning. The Mind Mapping follows the work of Tony Buzan who promoted mind mapping as learning and thinking tool.2 A Mind Map is a compelling graphic execution that acts as a universal key to liberate the inherent abilities of the brain. It initiates the abilities of written, drawing, numerical, logic, rhythmic, selecting colours as a specific skill. It creates the way to precede the brains abilities independently. It is applicable for each aspect Page 13

in life where advancement in learning and luminous thinking will better the human performance.3 Ed Emberley4 says that if you can depict some fundamental construct like a circle, triangle and square then able to depict all the essential pictures that you need. Austin Kleon4 is a poet with a difference; he takes newspaper articles and blacks out the words he doesn’t want with a thick black marker to create his poems. Cunningham(2005)5 in his study, in which 80% of the students viewed that mind mapping helped them to understand about the ideas and concepts in science. Farrand et.al. (2002)6 illustrated that spider diagrams when compared to concept maps resembles same, but significant and had effects on recall memory in undergraduate students. Ann. SBV, Jan-Jun 2017;6(1)

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MIND MAPPING It is a pictorial illustration of cogitative process of the students that makes competent way of innovatory drawing of the script. It is a malleable means for planning, implementing and communicating the concept.7 The concept is moved from the core theme to the other direction in achieving the goal.8

BENEFITS By understanding the way the brain really works and applying the Laws of Mind Mapping to organize and develop thinking,9 Mind Maps help to: • Plan assignments, projects and other activities in a fraction of the time normally needed • Work creatively either individually or in a team to generate innovative new ideas on demand • Communicate issues, ideas and concepts easily and quickly • Study more effectively and significantly improve learning results • Capture and comprehend vast amounts of information relevant to their focus

STATEMENT INFINITI - Mind Mapping Learning Model helps the students to learn the subjects in easy way. Students gain better understanding and retention of studied content for obtaining good academic outcome.10

DESCRIPTION INFINITI - Mind Mapping Learning Model developed by our institute, nowhere found across the globe. • With the objective of enhancing the learning skills of all students and especially students needing additional curricular support and as innovative method of teaching learning process, our institute had designed this mind mapping learning model from July 2016 onwards, and being provided to our nursing students. • This model is a powerful graphic technique that guides the students to understand and retain Page 14

information on deepest level of any topics in Nursing with lesser study time. • If the students don’t understand the subjects, they keep reading the same sentence over and over again and waste time during examination, This INFINITI - Mind Mapping Learning Model acts an effective tool to study and gives confidence to meet the challenges in examination • This Model is the guideline for the Nursing students/Learners to teach how to learn complex contents or study materials in a simplest way; to understand easily and to sustain in the memory which could be reflected in their examination results. • Nursing students are taught with this model to apply in their day-to-day • Self- Learning Practice. • Mind mapping model also helps teacher to teach certain complicated topics for students better understanding.11 INFINITI - MIND MAPPING LEARNING MODEL As the name implies, learning is an infinite process which takes place all through the ages. Learning component in Teaching, Learning & Evaluation (TLE) process of education is very hectic process for the students. Hence, KGNC developed and designed this INFINITI - Mind Mapping Learning Model for Nursing Students to enhance learning skill. It also helps to ease learning in every student and to enjoy learning process.12 INFINITI Model involves series of activity as follows.

IDENTIFICATION This Phase starts with identification process after skimming and reading the course. Identification process involves identifying the central idea and related ideas which radiates out from the core idea. Learners need to concentrate on the structure, hierarchy, order and outlines of the content.

NOTE MAKING This phase is done based on the concepts with choices of key words that connected using linking words forming Ann. SBV, Jan-Jun 2017;6(1)

Infiniti - Mind Mapping Learning Model

propositions. This gives the maximum space for the other ideas to radiate out from the centre. Propositions making is a skill out of critical and creative thinking without deviating from the text concepts.

FINDING CREATIVITY This phase involves real challenging tasks. Choice of style, use of icons, colour, dimensions, codes on the concepts, keywords, propositions. By drawing the map with own design using symbols helps to built visual and meaningful connections between ideas which will help in understanding and recall.

INTERRELATIONSHIP LINKAGES It is promoted by the use of main branches, subbranches, cross links, show interrelationship between different map segment. The lines and arrows show connection between ideas generated on mind map. This relationship may be important in understanding newer information.

THOROUGHNESS OF INFORMATION It emphasis checking the totality of learned information used and ensures the presence of entire content adequately, if it is inadequate, it directs to modify the learned information and it creates association between the ideas. UNIQUENESS INFINITI - Mind Mapping Learning Model developed by our institute nowhere found across the globe.

INFINITI - Mind Mapping Learning Model is learning guideline or tool developed exclusively for Nursing students to explore a variety of concept in nursing. INFINITI - Mind Mapping Learning Model is unique in its design with the idea of simplicity, user-friendly strategic guide, stimulating critical thinking process and creativity in designing their own maps.13 ADVANTAGES Students of all ages can utilize this INFINITI Model to study more effectively, with their creative potential and get ahead in their educational career. It develops critical thinking and allows the students to reflect the reasoning process to ensure the delivery of safe Nursing practice and quality care.14

CONCLUSION INFINITI - Mind Mapping Learning Model is an alternative approach, in which brain tackles its powers of visualization and association, and improves both memory and creative thinking. It helps to make the relationships, hierarchies and connections between the learned information. It provides a broad overview of a topic in one single page with more meaningful notes. Taking notes in a mind map acts as a shortcut than actual work. It is proved that mind-mapping can improve learning and study efficacy up to 15% then conventional way of note-taking.15

REFERENCES 1. Annemarie Rosciano. The effectiveness of mind mapping as an active learning strategy among associate degree nursing students. The journal of Teaching and learning. April 2015,Volume 10, Issue 2, Pages 93-99 2. Buzan, T. (1991). The Mind Map Book. New York: Penguin. Chapter “Mind Mapping Guidelines” 3. Tony Buzan. Modern Moindmap for smarter thinking, BBC Worldwide, 2000 4. Jane. Visual note-taking for people who think they can’t draw-in Creativity, Mind mapping, Study Techniques. 2012, 22 5. Glennis Edge Cunningham (2005). Mindmapping: Its Effects on Student Achievement in High School Biology (Ph.D.). The University of Texas at Austin. 6. Farrand, P.; Hussain, F.; Hennessy, E. (2002). “The efficacy of the mind map study technique”. Medical Education. 36 (5): 426-431. 7. Brian Holland, Lynda Holland, Jenny Davies (2004). An investigation into the concept and the use of mind mapping to improve student academic performance. 8. Buzan claims mind mapping his invention in interview. Knowledge Board retrieved Jan. 2010. 9. Willis, CL. ‘Mind maps as active learning tools’, Journal of computing sciences in colleges. ISSN 1937-4771. 2006. Volume: 21 Issue: 4 10. Beel, Jöran; Gipp, Bela; Stiller, Jan-Olaf (2009). “Information Retrieval On Mind Maps - What Could It Be Good For?”. 11. Nesbit, J.C., Adesope, O.O. (2006). “Learning with concept and knowledge maps: A meta-analysis”. Review of Educational Research. Sage Publications. 76 (3): 413 12. Buzan, T., Buzan, B. Radiant thinking. in: The mind map book:. Penguin, New York, New York; 1996:53-58 13. Boley, D.A. Use of mind maps to enhance simulation learning. Nurse Educator. 2008;33:220-223 14. Billings, D.,Halstead, J. Selecting learning experiences to achieve curriculum outcomes. in: T. Wilhelm (Ed.) Teaching in nursing a guide for faculty. 2nd ed. Elsevier, Philadelphia, Pa; 2005:187–212. 15. Farrand, et.al. (May 2002). “The efficacy of the ‘mind map’ study technique”. Medical Education. 36 (5): 426-431

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Review Inter-Professional Education in Health Sciences

Prof K.R. Sethuraman. Vice-Chancellor,

SBV - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India

Health care delivery in every country is beset with the challenge of providing the best quality at an affordable cost. We also expect that the care should be easily accessible and often customized to the specific needs of the individuals. However, with growing complexity of the health system and increased inter-dependency, we realize that this goal cannot be achieved by any single health profession and requires a concerted effort by the whole gamut of health profession. This brings us to the fore, the need for inter-professional education. The need for inter-professional education is obvious in the Indian context as we face the challenge of providing health care to billions of people through a huge network of health workforce that is skilled differently and trained in different context, controlled by different regulatory bodies. What is inter-professional education? When different health professionals belonging to medical, dentistry, nursing and allied health sciences come together, share their learning, and collaborate with each other to improve the quality of health care, they are engaged in inter-professional education. India is not a stranger to team based Inter-professional Health care. During early 1900’s, there were mission hospitals in India that sent out teams of physicians, nurses, and auxiliaries to remote communities. An article published in 1915 advocated a team of doctor, educator, and social worker 1. Despite early recognition of the need to train doctors, nurses and other health workers in common settings, especially community settings, no major initiative was taken to nurture this concept any time during post-independence era. The early effort in defining the positive outcomes of interdisciplinary studies were made by small group

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of research workers Annual Meeting of the American Educational Research Association, Chicago, 19972. According to the consensus arrived by this group, interdisciplinary studies enabled better understanding and retention. They helped in getting a holistic view of the care. They promoted critical thinking and decision making irrespective of their fields. Other attributes developed were ability to solve problems, work effectively in community and enhanced level of motivation. My own epiphany, or ‘eureka’ moment was during a WHO funded workshop on Society and Medicine in 1991. Primary care practice in Sweden was compared with that in Sri Lanka by Goran Tomson (Medicine) and Lisbeth Sachs (Anthropology). Their observations were remarkable: Medically 80% of Sri Lankan practice was irrational and 80% of Swedish practice was rational, while Anthropologically ≥90% of Sri Lankan practice was commendable and only around 10% of Swedish practice was acceptable. The take home message was that one group needed to learn how to practice rationally, while the other group needed to learn how to practice humanistic Medicine. According to McMurty, inter-professional education deals with taking responsibility in one’s own area in an interprofessional team. It does not mean that your should take charge of other’s work. There is no need for a professional to be cross trained to perform a different role3. Current Scenario is disheartening and is in dire need of improvements. I have discussed with nearly 700 PG students, during 1994-2005, a case of paralyzedbut-aware-patient on operating table who wiggled his toes, noted by the OT nurse, who indicated it to the

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Inter-Professional Education in Health Sciences

OT team but was ignored as reflex movements. Later the patient sued the hospital for negligence. Only two PGs out of 700+ suggested that perhaps the operating surgeon could have been more receptive to the warning by the nurse. (Personal notes of NTTC workshops for PGs 1994-2005 ) George Thibault has made a strong plea in favour of IPE. According to him IPE is a tool that helps to achieve three things at a time, viz., better patient centered care, better health outcomes and more efficient deployment of educational as well as health care delivery systems.4 The term inter-professional professionalism is used to describe the professional attributes required for fostering inter-professional education and later practice. According to David Stern, inter-professional professionalism denotes abilities to demonstrate core values evidenced by professionals’ coming together and working in a spirit of compassion and caring for the patients with mutual respect and trust. The professionals should be able to communicate with their team members without using jargons. They should shed their ego and show humility. They should place patients on top while deciding their priorities. It is also necessary to function as whistle blowers in case their colleagues behave in an inappropriate manner. Thus ethical principles should be kept in mind rather than the professional hierarchy.

applicable in wider contexts. The formation of Interprofessional Professionalism Collaborative is a welcome development in this direction5. The mismatch between education and practice is major barrier to bring inter-professional education. The way out is to build in community orientation to the training in all health professions education courses. While the courses are governed by the regulatory agencies, if there is opportunity for study of electives, they can be utilized for a course that involves interdisciplinary study. Presently we don’t have any tested models of credit based courses embedded in the curriculum. However, elective training has been introduced to a small extent in medical and nursing education which can be explored as a common course. George Thibault a member of the Global Forum on Innovations in Health Professional Education made six recommendations for promoting IPE based on the lessons learned.6 The foremost requirement is effective leadership. Secondly, IPE activities need to be planned extensively utilizing community settings. Thirdly the entire curriculum should incorporate the learning experiences and not in piecemeal approach. Fourthly, the ultimate goal of IPE should be to improve the system. The fifth step is effective use of technology in all activities. Lastly, faculty development should play a key role.

No doubt there are many challenges involved in developing inter-professional skills. The hierarchy issue causes a lot of damage in the Indian setting. Often the decisions are taken by the doctor, irrespective of the fact that other support staff may be more mature and wise in dealing with psycho-social, economic and cultural issues. Knowledge and skill gap between the professionals is yet another issue. You can’t expect a technician to be proficient in diagnosis. Similarly the doctor may not be as effective as a social worker in counselling skill. There could be some kind of hesitation in the mind of a professional to work with the health team member for personal or social reason. All these can be overcome by organizing effective faculty development program. Such a program should be organized in a community setting rather than class room setting for better learning and application.

Models which are effective for IP Education (Colorado University)

An essential requirement for training in IPE is development of tools for assessing the professionalism in inter-professional education. While the development of such a tool requires good amount of research, the challenge here to make them generalizable and

Summing up

Ann. SBV, Jan-Jun 2017;6(1)

• Traditional model of the facilitated discussion • Group projects • Problem-based learning • Michaelson’s team-based learning model Inter-professional education has to travel a long way in India. The effort made by SBV University in launching higher programs like Diploma, M Phil and Ph D is a progressive step in training a new cadre of health professions educators who will be able to lead and strengthen IPE in our country.

Students who gain a better understanding and appreciation of one anothers’ roles in the provision of health care services, and who learn to respect Page 17

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and value the input of other disciplines in the team decision making process, will be better prepared for Inter-professional collaboration following graduation. Therefore we are committed to providing high quality Inter-professional experiences to health professional

students during their education. (http://piper. mcmaster.ca/about_intro.html ) The higher programs in health professions education introduced by SBV is a modest beginning in spreading this concept.

References 1. Baldwin D. Some historical notes on interdisciplinary and Inter-professional education and practice in health care in the U.S.A. J Interprof Care. 1996;10:187-201 2. Mathison S., Freeman M. The logic of interdisciplinary studies. Presented at Annual Meeting of the American Educational Research Association, Chicago, 1997 http://www.albany.edu/cela/reports/mathisonlogic12004.pdf Accessed on 8/6/2017 3. McMurty A. Reinterpreting interdisciplinary health teams from a complexity science perspective. U Alberta Health Sci J. 2007;4:33-42 4. INTERPROFESSIONAL EDUCATION FOR COLLABORATION WORKSHOP SUMMARY Patricia A. Cuff, Rapporteur Global Forum on Innovation in Health Professional Education Board on Global Health NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. https://www.nap.edu/read/13486/chapter/4 Accessed on 8/6/2017 5. Inter-professional Professionalism Collaboration http://www.interprofessionalprofessionalism.org/behaviors.html Accessed on 8/6/2017 6. Global Forum on Innovation in Health Professional Education; Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice: Workshop Summary. https://www.ncbi.nlm.nih.gov/books/NBK207103/ Accessed on 8/6/2017

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Review Integration of Health Professions Concept, Vision, insight and Leadership Prof. Rajaram Pagadala, Chancellor, SBVU* SBV - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India

Summary Healthcare Professional Development is facing challenges. It is necessary that the administrators should be deeplycommitted and their involvementshould be with the understanding of the concept. The model that emerges should be based on a vision aiming at achieving academic excellence towards attaining universal healthcare. Therefore, there is a need of leadership by the experienced professionals pledging and obliged to develop future trained healthcare manpower. Consequently, one should not hesitate in suggesting to bring about drastic changes in the recruitment of students, revamping the curriculum, changing training methodologies and appropriate faculty development. Introducing ‘Integration’ for “Achieving Academic Excellence”: There is a need to bring together educators in medical, dental, nursing, and allied health sciences to achieve academic excellence through faculty development.It is true and is also realistic to achieve. But merely training and awarding degrees are not enough. Theproduct, healthcare personnel, that come out must be motivated to understand and practice realities that are engulfed in delivering modern healthcare. Community healthcare must be considered as fundamental and not merely serving individual patient.Leadership by an institution is required. To achieve this, one should work with definitive objectives. One can and must assume leadership in the profession.The definition of ‘integration’ has been clearly quoted by WHO that is: “The management and delivery of health services, so that clients receive a continuum of preventive and Ann. SBV, Jan-Jun 2017;6(1 )

curative services, according to their needs over time and across different levels of the health system.” Integration at All Levels: There is another important factor that must be considered. Integration of organizations must be at all levels; intradepartmental within an institution and inter-institutional of various professional groupsmedical, dental, nursing and allied health sciences. Though we talk about working together there is always disagreements between the specialties. Estrangement at various levels and dissatisfaction between different sections of allied sciences exists. Resistance and lack of communication has led to present day scenario of living in isolation. These improper and inadequate inputs is disrupting the development of modern medical education that is to be practiced at community level. But tomorrow’s physician, perhaps, isbeing sent in to the community with a narrow outlook. At present, healthcare services are suffering. Primary Healthcare is in disarray. The poor and pathetic picture of healthcare can be best seen and appreciated at the Primary Health and Community Health Centers. Integration or Discrimination; Instead of integration, it appears that many institutions including dental, nursing are meted with second rate treatment. The benefits of practice of Yoga and Music are not recognized across the board. However, Sri Balaji Vidyapeeth University is an example where we are surging forward in spite of all odds and perfect harmony is being created towards integration of allied sciences. Bring in integrationat all levels beginningwithin once own unit-environment of work. Only then an atmosphere will be created for various Page 19

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specialties to interact for mutual understanding; thereby integrating from basic workers to highly place professionals, from social workers to nursing personnel will take place. Only then inter-disciplinary teaching and training leading to community based research. No doubtthere is a need to bring together educators in medical, dental, nursing, and allied health sciences to achieve academic excellence through faculty development.

Yoga and Music are for promoting health of body and mind. It helps in physical and spiritual exercise providing appropriate nourishment to body and brain. Teachings of Greek physician, Hippocrates, shows how he wasable to change the societies in their approach to many diseases. The Hippocratic oath demonstrates the essence of practices of the past that are so relevant even for today.Today many diseases like Diabetes, hypertension and many cancers could be prevented.

Leadership Required Not Training and Awarding degrees:

Empower Healthcare Manpower

Merely training and awarding degrees are not enough. The trained must be able to restore the health of their clients from disease and help maintain normal physical and mental wellbeing. They must be motivated to modern realities of community healthcare requirements. Simply managing individual patient is not the aim. Institutions must assume leadership in the profession. Charaka, in his famous ‘CharakSamhitha’ described two types of diseases; One ‘Internal’that describes the ‘loss of faith in divine’which leads to suffering in ‘Spiritual, Mental and Physical diseases’and the second: ‘External’ that ‘varies with time of the day, seasons, diet and life styles’. How true they are even today.Teaching and training methodologies that were in vogue in ancient Indiawere not explored for our advantage. Even the history of medicine is not being taught. Simple healing methods practiced in the olden days are still good to treat simple ailments at home;use of garlic, turmeric, ginger etc., for example, that are being re-introduced globally. Many healthcare workers either are ignorant or shy to prescribe. One should re-examine them to see how useful they are in the context to achieve today’s global healthcare system. Maintain Ethical Standers: In the past, Physicians were multi-skilled and the ethical standards practiced were of highest order. If we follow at least few of methods, we can turn out excellent primary care physicians.Some of our ancient sciences like Yoga and Music which are enriched with ethical values and practices, are being adopted for the management of diseases all over the globe. But in India it is yet to find a place in curriculum. Page 20

Nursing profession that came in existence some 150yrs ago is assuming greater responsibility, all over the globe, in caring the patients. Dental Professionals are being approached by Head and Neck Surgeons to team up for treatment. Rehab professionals are taking over the patients soon after major surgeries and managing for quick postoperative recovery. However new challenges as, a a result of army conflicts and terrorism witnessing rapid spread of diseases and disabilities. Also as a result, hunger and food shortages causing unexpected health related problems creating new challenges for training healthcare professions. These are few examples about which the modern physicians must trained to deal with. Population Health: Understand and Teach: Unfortunately, healthcare professionals have failed to understand the importance of population health. Unless the faculty gets involved in the health management of the community and teach the very basic concept of maintaining health they will not be able to prepare the future physicians. Therefore, population sciences must be included in undergraduate curriculum to expose students to the community health problems. Prospective specialists, must be trained extensively at community level before certifying them as specialists. Healthcare professionals must also be trained to help implement public health programs like ‘Swatcha Bharat’. Healthcare administrators must make sure that their surrounding areas including restrooms and toilets are kept clean, setting example. A clean environment within the working surroundings will send a message to all to keep their eyes opened. Teacher, Taught and Training: Reforms are needed in the methodology by which we select medical students, recruit teachers and the way they Ann. SBV, Jan-Jun 2017;6(1)

Integration of Health Professions Concept, Vision, insight and Leadership

train the students. We must connect with the past, explore good practices that are being practiced in some countries and absorb the good.To bring about changes, however, there is a struggle and there will be resistance. But today’s mandate is to produce the physicians of tomorrow.We must be preparade not to shy in pronouncing reprimands. Review the qualifications needed and training required for faculty. We must be prepared to go beyond the bedside teaching to family healthcare establishing the community based communications. The revolutionary ideas presented by the Sir Bhore Committee, in India and the changes that were brought in USA following Flexner Report are some of the best examples one must follow. One should pursue for perfection for professional excellence. Only then there is future. Revamping of Medical Education Required: Emphasis in teaching on the proper utilization of the infrastructure that is already available and ensure proper and effective referral services. Therefore, there is a need for the young doctors to work for 6-12 months in rural areas independently after passing but before getting theircertification to practice. Also, a minimum of two years during their post graduation studies before they qualify o be specialists. (European models). There is an urgent need to overhaul healthcare services that we see and we manage. To bring a change, initiate modified teaching and training and make today’s physicians tomorrows futuristic physicians. Rural and urban slum population must be taken care. Therefore, revamp and revitalize curriculum to focus on issues that affect the health. Governments, at the beginning of its fiscal year, always pronounce polices of ‘ambitious plans for improving health and bettering diseases, exhibiting its commitment improving and upgrading healthcare services’. But it often fails to translate into reality to its full extent of commitment. It is to be stressed that medical professionals must take the advantage of the call and constantly remind the politicians and bureaucrats to live up to their commitments that will help promote research and rehabilitation. To implement healthcare policies of a country, it is essential for the Govt. to have strategy to train

Ann. SBV, Jan-Jun 2017;6(1)

healthcare professionals from not only medical but also integrate dental, nursing, rehab, nutrition, paramedical. Involve social workers, counselors etc.in the system, at all levels. Future healthcare professionals should also be trained to take part in promoting healthy life styles to prevent diabetes, hypertension, cancer etc.The healthcare professionals must play a leading role in the community teaching and explaining the advantages of healthy life styles for promoting quality health to have a ‘Quality of life’. KYC (Know Your Client) and KYP (Know Your Patient): There is a case to emphasis on reducing the global burden of disease for which we must emphasize on preventive aspects. Hence, I argue and suggest that there is a need for us to implement a program like KYC (Know Your Client) as in, banking sector. Here in Healthcare sector it could be KYP (Know Your Patients) in public health sector. Teacher, Taught and Training: Therefore, there is a need for reforms in many areas beginning with the way in which we select the medical students. The methods we use to teach and the way in which they train future physicians. Sweeping changes incorporating some old traditional methodsof teaching and training integrating various related departments is necessary. We must connect with the past, explore the present good practices and adapt them. There will be resistance, however, to bring about far-reaching changes. But these changes are for good and we must manage to overcome the odds in order to produce the physicians of tomorrow for the country. The revolutionary ideas presented by the Sir Bhore Committee, in India and the changes that were brought in USA following Flexner Report are some of the best examples one must follow. One should pursue for perfection for professional excellence.Review the qualifications needed and training required for faculty. We must be prepared to go beyond the bedside teaching to community based teaching involving community. We must be preparade not to shy in pronouncing reprimands. Only then there is future.

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Review Enrichment of MBBS curriculum with research component: Road to Professional Achievements Dr.C.Adithan1 and Dr.B.V.Adkoli2 Director â&#x20AC;&#x201C; CIDRF and Professor of Pharmacology, MGMCRI

1 2

Professor & Head, Department of Health Professions Education MGMCRI, Puducherry - 607403

1.What is research? Medical research is the mother of the evidence based medical practice. We have progressed from empirical therapy based on anecdotal medical knowledge to rational and more scientific therapy. Few diseases like small pox has been eliminated and other diseases like leprosy are under control. This advancement was possible by medical research. Significant contributions for medical research were made not only by qualified medical practitioners and scientists, but also undergraduate students as illustrated by the discovery of insulin by Best and Banting1.

2. MCI vision document 2015 and the need for research in MBBS course It is a common perception that the main objective of a medical student is to obtain a post-graduate degree especially in a clinical discipline. Overwhelming majority of them do not have time or interest in research. They are also ignorant about the potential utility of research in their clinical practice. The MCI Vision document 2015 recognized the need for introducing study of electives among which research methodology has been included as one such subject.. The vision document has emphasized that a doctor should be a life long learner with ability to search data, do a critical appraisal of medical literature in order to tackle a research question. Further the MBBS student should be familiar with basic, clinical and translational research as applied to patient care. A question arises : is it possible to develop such a competency within the frame work of existing curriculum? Perhaps not. We need to therefore look at this issue in a different ways and come out with a multi-pronged approachto Page 22

develop research competency within the existing framework.

3. Scenario in Western, Asian and African countries Many medical schools in Western Countries made research as an essential scholarly component during undergraduate (UG) course. In USA, National Institute of Health supports Medical Student Research Fellowship and the Doris Duke Clinical Research Fellowship program2,3. Research specific skills are fostered during UG medical course. Some universities have introduced research program of four months duration as a mandatory requirement. 4 Others expect the UG students to develop, design and implement a primary care project as a part of their curriculum. In many Universities of Canada, Norway and UK, the medical UG students are involved in short term research program5,6. In The Netherlands students undertake full time research projects between 4th and 6th year. It is interesting to note that a few Universities in Bangladesh and Indonesia have incorporated research component in the medical curriculum. In Sri Lanka during the II phase of MBBS curriculum, a dedicated time has been earmarked for data collection and report writing7. In Malaysia, the curriculum is community oriented and includeselements of research and evidence based medicine. A study ofmedical education in 30 medical colleges in the Gulf Co-operation Council (GCC) Countries reported that research methods were apart of the curriculum in 10 colleges, and in 7 colleges, it was a separate course. In UAE university, University of Sharjah and Gulf Medical University, research methods are an integral part of UG medical curriculum8,9. African medical schools are deficient in research component in their curriculum10. Ann. SBV, Jan-Jun 2017;6(1)

Enrichment of MBBS curriculum with research component: Road to Professional Achievements

4. Status at India The undergraduate medical curriculum largely governed by the 1997 MCI Regulations have too little to say on the development of research competency. MCI Vision document 2015 states that research methodology can be included as one of the elective subject. But research is not considered as a formal component of curriculum till now. There are no guidelines available for the medical faculty as to how the research competency can be fostered in the MBBS Course. A few studies have been published on the status of undergraduate research training in India and the awareness of the faculty or students regarding this critical issue. Harsha Kumar et al conducted a survey among medical students at Mangalore. According to their findings a vast majority of students whose awareness about research was high were mostly involved in the medical curriculum11. It is interesting to note that the pressure for including research has started coming from the students, the direct consumers of the curriculum. A research paper presented by Reddy et al inthe South East Asian Regional Association for Medical Education, Coimbatore (2012) stated that about 77% of students favoured inclusion of research training in the MBBS curriculum12. There is a positive development among the students and they actively participate in the National Medical Students Research Conference conducted under the banner of After attending 5 such conferences the students have taken a lead and established. Authors had addressed few student national conferences and they found new enthusiasm amongst young medicos to pursue research as a career pathway.

A study by Garg et al expressed concerns regarding the poor state of affair and given some reasons such as lack of mentorship, inadequate infrastructures & resources and lack of writing skill for biomedical publication13. It is essential to address these issues to come out with tangible solutions. Opportunities availablefor the students to pursue research There are many opportunities for Indian UG medical students to undertake research during the vacation period (Table 1). Few of them briefly described below. Short-term Research by Indian Council of Medical Research (ICMR-STS) is very popular program. It calls for proposal in January and provides stipend of Rs.10000 per month for 2 months. The number of ICMR-STS fellowships are increasing every year. More details are available at the ICMR website (www.icmr. nic.in). National Science Academies such as Indian Academy of Sciences, Bangalore and Indian National Science Academy, New Delhi provides two-month Summer Fellowships to work with scientists in fields of Life Sciences. This is not specific for medical students. Visiting Students’ Research Programme offered by Tata Institute (TIFR) also offers opportunity for research in life sciences.

5. Suggestions for improving research by UG medical students The need for advocacy, sensitization and buy in by the stakeholders: Curricular changes are too slow to happen. They are often riddled with bureaucracy, and often old mind set. Research cant’ be left to postgraduate

Table 1. Research opportunities available for undergraduates • ICMR Short Term Research Studentship : ICMR-STS (1979) • SUMMER RESEARCH FELLOWSHIP: ( Jawaharlal Nehru Centre for Advanced Scientific Research, Bangalore, www.jncasr.ac.in ), Stipend: Rs. 4000/- per month for 2 months • SUMMER RESEARCH FELLOWSHIP: Indian Academy Of Science, Bangalore And Indian National Science Academy, India • KISHORE VAIGYANIK PROTSAHAN YOJNA, Indian Institute Of Science, Bangalore, India. KVPY DST, Govt. of India • SUMMER FELLOWSHIPS IIT Mumbai VISITING STUDENTS RESEARCH PROGRAM (VSRP) TIFR-Web site: http://www.tifr.res.in/ • Conferences for Medical Students ′ MEDICON ′ UGCON ′ OSMECON ′ KARMIC etc Ann. SBV, Jan-Jun 2017;6(1)

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training alone. The seeds of research and critical enquiry should be sown right from day 1 of a medical education. Most important requirement for training undergraduate is the availability of trainers, and mentors who can role model, initiate, coach, mentor, handhold and empower the medical students with the tools and techniques for a long term journey. While many medical education centres have introduced workshops training courses at the PG level, it is time to induct UG students in these activities. A dedicated time should be assigned to the PG teachers to mentor each of the UG candidate in the pursuit of a research project that can be funded by the institute or by extra-mural agencies. The medical colleges should upgrade their library facilities in tune with the emerging requirements such as access to journals, thesis and dissertations, to be made availablefree on 24×7 basis. With the availability of smart phones and a host of new gadgets, dissemination of resources cannot be a major problem. What is required is the ‘will’ to do it! How do we introduce research in to the existing overloaded curriculum? While some experts tend to suggest formal courses during para-clinical phase, others are in favour of integrated approach. Formal courses are difficult to introduce. They may also create ‘silos’ of learning. Integrated approach is a futuristic trend. The recent development of introducing Attitude and Communication as modules in various phases is a progressive way forward to build research skills too. This step requires a very intensive faculty development program in which the faculty members across the departments sit togetherand design modules linked with their content areas to come out with projects that addresssimple research questions. For example, early exposure of UG students through the community

postings can have in-built project in which they can learn about various tools including quantitative and qualitative tools which help them in exploring an issue or describing the same in a real life context. Research skill expected at this level is not as rigorous as expected in the PG level where the emphasis will be laid on explanation, controls and prediction. The elective training in Research Methodology also can’t be left alone to the students. It should be accompanied by a mentorship arrangement. The use of e-portfolio comes as a potential instrument for monitoring the progress of the student. A student is expected to record all his/her activities, observations and reflections which are assessed by the mentor with a comprehensivefeedback to help in improvement. The incentives for the research in terms of institutional support for attending conferences, and incentives for publication in genuinejournals go a long way in encouraging research efforts.

6. Conclusion Enriching undergraduate students in research skills is an essential step, if we are serious about the competency of the graduates and postgraduates that we produce from the portals of medical colleges. It is worthwhile to mention that quality assurance and accreditation are essential components for the existenceand survival of academic institutes. Many of the accrediting agencies consider research output as the key performance indicator. If that is to happen, it is imperative that we introduce proactive strategies to foster research skills. This movement requires not only readiness and training of the faculty, but also support from the institutes, amendments from our regulating agencies, and ultimately a culture of recognizing, respecting and rewarding research efforts at all levels of education.

REFERENCES 1. Stringer MD, Ahmadi O. Famous discoveries by medical students. ANZ J Surg.2009 Dec;79(12):901-8. 2. Solomon SS, Tom SC, Pitchert J, Wasserman D, Powers AC. Impact of medical student research in the development of physician_scientists. J Invest Med 2003; 51: 149-56. 3. Gallin EK, Le Blancq SM. Launching a new Fellowship for Medical Students: the first years of the Doris Duke Clinical Research Fellowship Program. J Invest Med 2005; 53: 73-81. 4. Fennimore TF. Structured research activity as a vehicle for fostering reflective Practice among Medical students. JIAMSE 2009; 19 (2S): 7-16 5. Van Eyk HJ, Hooiveld HW, Van Leeuwen TN, Van der Wurff BL, De Craen JM, Dekker FWet al. Scientific output of Dutch medical students. Med Teach. 2010; 32: 231-5 6. Sreedharan J. Introduction of a Research component in the undergraduate medical curriculum - Review of a trend. Nepal J Epidemiol 2012; 2(3):200-204. 7. WHO/SEARO. Review of Preventive and Social Medicine/Community Medicine/ Community Health curriculum for undergraduate medical education. Report of the Expert Group Meeting SEARO, New Delhi, India. 27–28 August 2009, New Delhi. 8. Abdulrahman KA. The current status of medical education in the Gulf Cooperation council countries. Ann Saudi Med 2008; 28(2): 83-8. 9. Hamdy H, Telmesani AW, Al Wardy N, Abdel-Khalek KN, Carruthers G, Hassan F, et al. Undergraduate medical education in the Gulf Cooperation Council: A multicountries study (Part 1). Medical Teacher 2010; 32: 219–24. 10. Ibrahim A, Asuku ME. Stimulating medical students interest in research: a neglected craft in Africa. Pan Afr Med J. 2012;13:12 11. Harsha Kumar H, Jayaram S, Kumar GS, Vinita J, Rohit S, Satish M, et al. Perception, Practices Towards Research and Predictors ofResearch Career Among UG Medical Students from Coastal South India: ACross-Sectional Study. Indian J Community Med. 2009 Oct;34(4):306-9. 12. Reddy MVR, Khan MS, Goswami, P. Anshu D. How do undergraduate medical students perceive research? Conference Proceedings of “South East Asian Regional Association for Medical Education (SEARAME), Coimbatore” 2012, page 61 13. Garg R, Shobha Goyal S, Singh K. Lack of research amongst undergraduate medical students in India: It’s time to act and act now. Indian Pediatr 2017;54: 357-360

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research Attitude and Aptitude of The First Year Referred Batch of Medical Students Dr.Swayam jothi.S1, Dr.Kafeel Hussain.A2 1 Professor & HOD,2Assistant Professor Department of Anatomy, Shri Sathya Sai Medical College and Research Institute, (A unit of SBVU), Ammapettai, Kanchipuram District, Tamil Nadu

INTRODUCTION The complexity of the medical curriculum and the sudden transition from studying smaller text books to a considerably larger volume textbooks, places unprepared pressure on the young medical student. Baker,2003[2] noted that the undergraduates are faced with many new interpersonal, social, and academic demands during the transition from secondary school life to university, which is stressful for many of them.To give the student, the benefit of not losing an academic year, the medical curriculum had come up with the idea of conducting another exam within 6 weeks of failing the first exam. On passing the exam, the medical student can join his peers, and progress to the second year of study. If the student fails to clear the exam, he or she will need to resit the exam along with next batch of students.

AIM This study aims to analyze the causes to results of this new amendment to the existing system.

MATERIALS AND METHODS 69 students of Shri Sathya Sai Medical College and Research Institute, who did not clear the first yearend examination in 2016 in the subject of Anatomy, were taken in this study. They were offered intensive personalized coaching in Anatomy with daily classes and weekly assessment of their progress. All 69 of them attended classes regularly and were taught by the same faculty on all days. At the end of 6 weeks they took a re-exam in the subject of Anatomy. A questionnaire

Ann. SBV, Jan-Jun 2017;6(1 )

which comprised of questions pertaining to the factors responsible for the failure and factors that influenced them to pass was administered to the students after the results to prevent any bias in the information retrieved from the students. OBSERVATIONS AND RESULTS 66 out of 69 students cleared the exam. Studentâ&#x20AC;&#x2122;s feedback received after the examination on the factors that helped them to succeed and the reasons for their failure are tabulated in chart 1 and 2.

DISCUSSION 69 out of the 150 students failed (pass percentage 54%) in their I MBBS examination. In contrast, when an examination was conducted within 6 weeks, 66 out of 69 of them passed (96%). When we analyzed the data collected from the proforma served to them, they could reflect on what went wrong in the earlier examination. Most of them realized that it was because of their attitude (carelessness and not being regular to classes). Among university students, study motivation was found to be a positive influence on general study habits of students, Crede & Kuncel, 2008[3]; Nagaraju, 2004[7]. This study has uncovered the reasons that had driven students to work hard and perform better. A change in their attitude, brought a behavioral change in being regular to classes. Their hardwork supplemented by support and attention by the staff members, parents helped them to walk out successfully.

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Chart 1.Reasons received from students for their success 30

Reasons

25 20 15 10 5 0

Teacher's A en on

Hard A endend Be er Tests Work Classes Prepara on

Easy Realiza on Parent/ Ques on and Social Paper Correc on Support

Self Aim Confidnce to enter 2nd year

Chart 2.Reasons received from students for their failure

Reasons

20 15

15 10

13 8 4

5 0

Carelessness/ Lack of lack of Selected Exam No Not Fear/lack Did not Lack of Joined Playfulness Prepara on A endance Learning Tough Time Well of confidence Write Tests Revision Late

STUDENTS FEED BACK FORM MBBS 2015-16 BATCH NAME: DATE: 15/11/2016 REASON FOR POOR PERFORMANCE IN THE UNIVERSITY EXAM HELD IN JUNE 2016 FACTORS WHICH HELPED YOU IN SUCCEEDING IN THIS CURRENT ATTEMPT SIGNATURE Page 26

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Attitude and Aptitude of The First Year Referred Batch of Medical Students

A Chance given to them to clear the subject was well utilized and the fear of losing the batch also lead to self realization. Ebbinghaus,1880[5] found that as time passed, the memory of syllables faded likewise. Hence, the role of an early supplementary examination also did have a role to play in it. Further, several research findings have thrown light on the fact that high achievers have better study habits than low achievers, which explains their continuous good academic performance, Aluja & Blanch, 2004[1]; Culler & Hollan, 1980[4]; Elliot et al., 1990[6]. Whether, realization of students of the current study is shortlived or will have a longterm effect will need follow up of their performance into the second year as

well. Nevertheless, students with poor study habits will benefit from study habit training on goal setting and prioritization.

INFERENCE The consolidate view of these students will be an eye opener for future students. Intense coaching and special attention from teachers coupled with regular attendance of classes and genuine interest in learning from student’s side (springing out of realization and introspection) had driven them to work hard and perform better towards achieving their goal.

References 1. Aluja, A., & Blanch, A. (2004). Socialized personality, scholastic aptitudes, study habits, and academic achievement: Exploring the link. European Journal of Psychological Assessment, 20, 157–165. 2. Baker, S. R. (2003). A prospective longitudinal investigation of social problem-solving appraisals on adjustment to university, stress, health, and academic motivation and performance. Personality and Individual Differences, 35, 569–591. 3. Crede, M., & Kuncel, N. R. (2008). Study habits, skills, and attitudes: The third pillar supporting collegiate academic performance. Perspectives on Psychological Science, 3, 425–453 4. Culler, R. E., & Holahan, C. J. (1980). Test anxiety and academic performance: The effect of study-related behaviors. Journal of Educational Psychology, 72, 16-20. 5. Ebbinghaus H (1880) Urmanuskript “Ueber das Gedächtniß”. Passau: Passavia Universitätsverlag. 6. Elliot, T. R., Godshall, F., Shrout, J. R., & Witty, T. E. (1990).Problem solving appraisal, self-reported study habits and performance of academically at-risk college students. Journal of Counseling Psychology, 37, 203-207. 7. Nagaraju, M. T. V. (2004). Study Habits of Secondary School Students. New Delhi: Discovery Publishing House.

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Review IS EVERYTHING OBJECTIVE RELIABLE? Dr. Tejinder Singh, Professor of Pediatrics and Medical Education and Vice Principal, CMC Ludhiana

There is a common belief that for reliable results, only ‘objective’ assessment should be used. A fallout of this belief is that anything which cannot be objectively assessed is ignored. Competencies like communication, professionalism, inter-personal relations and ethics are the sufferers of this belief. There is enough data accumulating that this is not necessarily true. Objective assessments have their advantage that they allow a large sample to be tested in a relatively short span of time but they use a norm referenced approach and work in a limited domain with lower level of simulation. Subjective assessments, on the other hand work with a criterion referenced approach at a higher level of simulation. Objective assessments require well-structured standard problems but in actual practice, most of the times, the physicians encounter non structured problems. They thus limit the ability of the student to deal with variability of clinical practice. Very commonly, reliability is seen as a measurement issue and is often limited to reproducibility of the results. In its true sense, reliability should be a decision making issue. A truly reliable assessment is one, which can be relied upon. This reliance can come only with an adequate sample size of domain, tasks and assessors.

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The major threat to reliability comes from inadequate sample rather than from marker variability. In a true sense, there is nothing like objectivity in assessment because all assessments are colored by the values, beliefs and philosophy of the assessor and the institution. All we do is to prepare assessments subjectively but try to measure them objectively. This has been called as ‘objectification’ and hardly contributes to reliability. Expert subjective judgment, on the other hand, deals with real life situation, exposing the students to variability of clinical practice. In that sense, it is more valid than purely objective assessments. It also helps us to assess a number of competencies which are essential to the practice of medicine. They encourage students to engage in deep learning contrasted to superficial learning promoted by objective assessments. Subjective ratings are not less reliable has been shown repeatedly by many studies. While objective assessments can be used for selection type of assessment, for better learning, subjective ratings hold the key. Subjectivity is not synonymous with bias and we would be well advised to start viewing reliability as consistency of performance rather than as consistency of marking

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Review Integrating Yoga in Health Professional Education: The SBV Experience Yogacharya Dr Ananda Balayogi Bhavanani Deputy Director Centre for Yoga Therapy, Education and Research (CYTER) Email: yoga@mgmcri.ac.in Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India.

Introduction Medicine has been regarded as a noble profession since time immemorial and its practitioners equated with the divine by ill and needy. (1) Divine qualities expected in a medical practitioner include wisdom, competence, humility, magnanimity, empathy, selfless service and care. A compassionate heart, a listening ear coupled with a warm caring hand is known to make all the difference between a successful or not so successful return to health for many. In recent times however this image of the medical profession has suffered badly through many scandals and news reports highlighting the lack of humanistic values in medical professionals. Modern medicine has moved from being an art (with a heart) to a science (with a brain) and now sadly to being a mere business with neither. It is bemoaned commonly that instead of treating the individual who has the disease we have moved on to treating the disease and now to even only treating the medical reports.(2) The Government of India though the Ministry of AYUSH is strongly propagating the integration of Yogain the health professional educationand Sri Balaji Vidyapeeth (SBV), a deemed-to-be university in South India has been in the forefront of this integration of ancienthealing wisdom with modern scientific medicine.(3) SBV was awarded the coveted “A”Grade by NAAC in 2015 and found place in the top 100 universities of India in the NIRF 2016 and 2017 ranking.

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About CYTER The Centre for Yoga Therapy, Education and Research (CYTER) has been functioning at MGMC&RI since 2010 and more than 36000 participants have benefited from the Yoga and Yogatherapy sessions held in its premises.4All Master Health Checkups of the Corporate Health Services wing have Yogaconsultation and Yoga therapy is often offered for in-patients in many of the wards themselves. More than a dozen research projects have been completed with another dozen ongoing with a high impact academic publication of 61 papers, five compilations and 21 abstracts published till date. This ‘one-of-its-kind’centre functions under the auspices of the Deanery of Allied Health Sciences and is guided by its dean, Prof N Ananthakrishnan and its founding director Prof Madanmohan who is one of the first medical professionals to attempt the symbiotic integration of Yoga in the medical curriculum and had to this purpose organized a National Workshop on Introducing Yoga in Medical Curriculum at JIPMER, Pondicherry in March 2009. (5, 6) National Seminar on “Integrating Yoga in Health Professions Education”: A National Seminar was organized by CYTER and Department of Physiology on “Integrating Yoga in Health Professions Education” at MGMC & RI on 21 June 2016 (7). National experts in medical, dental and nursing education as well as Yoga and allied experts participated in the deliberations that unanimously adopted the following recommendations:8

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1. There was a consensus that Yoga deserves a prominent place in the curriculum ofall health professionals education, though further deliberations may be needed towork out the modalities of how, when and by whom it should be taught andassessed. 2. From the point of view of not burdening the existing curriculum which is already topheavy, attempts may be made to integrate the teaching of Yoga at appropriateplaces in the curriculum such as foundation courses, basic sciences particularlyphysiology, community medicine and clinical disciplines such as physiotherapywhere therapeutic benefits can be integrated. 3. Integration of Yoga studies requires much effort from the faculty across variousdisciplines which rest on training and preparation of faculty in the form ofFaculty Development Programs. The existing mechanisms of faculty developmentshould address and incorporate this issue before implementing Yoga training in astructured manner. 4. The efforts to implement Yoga require a concerted and coordinated effort in theform of inter-professional education. This requires effective leadership and teamworkfrom the faculty across various disciplines, backed by curricular changes supportedby the respective councils (MCI, DCI, NCI). 5. The Seminar laid special emphasis on the fact that Yoga is a holistic approach. Assuch, it should encompass the whole gamut of lifelong education, starting fromearly school stage extended up to higher education and workplaces to embracethe entire life span. 6. The existing Centers of Yoga, especially CYTER with help from other Centers inIndia should take lead in initiating the process of Training of Trainers (ToT) inorganizing Faculty Development Programs with support from Government andNGOs, to speed up the process of implementation. 7. It was recommended and concluded that CYTER be made a “nodal centre” to leadin activities pertaining to Health Professions Education and necessary steps betaken by the concerned authorities.

Yoga in MBBS curriculum For the past two years (2015 and 2016) all 1st MBBS students have received exposure to Yoga during their Page 30

10 day orientation program at the Mahatma Gandhi Medical College and Research Institute. During these daily sessions, they received lectures detailing the foundations of the philosophy and psychology of Yoga as well as science behind the effects of Yoga. They also received practical training in various techniques aimed at stress management including Jathis, Kriyas, Asanas, Pranayamas and contemplative relaxation practices. These lectures and practice sessions were also conducted for the 1st MBBS students of Sri SatyaSai Medical College and Research Institute through an intensive one day programme. Feedback from both years showed excellent response to the Yoga lectures and practical sessions with more than 80% rating it as excellent and another 18% as very good. Students reported that the Yoga sessions had helped them adjust to the college life better and also that the stress management techniques enhanced theirability to do well in curricular and extracurricular activities. They requested for more such sessions on a regular weekly or biweekly basis. As a result, MBBS students are currently receiving Yoga classes for one hour twice a month on alternate Saturdays. Many of them are attending the regular practical sessions conducted in the evenings at CYTER for the faculty, staff and students of SBV. More than 4000 participants have benefited from these free sessions conducted twice daily from 6-7am and 4.30 to 5.30pm since September 2015.(9) From 2014 onwards 1stMBBS students were also given a series of lectures on the Yogic aspects of lifestyle as well as physiological aspects of Yogapractices such as Asana, Pranayama and therapeutic potential of Yoga.(10,11)These lectures and lecture-demonstrations took place during physiology hours of the timetable under guidance of Prof Madanmohan. A CME was also organized at SSMC&RI with departments of physiology, anatomy and biochemistry collaborating so that all these topics were covered for the students by the CYTER team in a single day. Three of the students have also taken up ICMR student research projects on Yoga in the past year. In order to facilitate a general awareness about Yoga and its role in health and disease amongst students and health professionals of SBV and other institutions, CYTER in collaboration with Department of Physiology organized national level CMEs, seminars and workshops in the past four years. These include the ones on “Yoga and Lifestyle Disorders” in 2013, “Sleep, Consciousness and Meditation: Neurological Correlates” in 2014(12), “Therapeutic Potential of Yoga” in 2015(13) as well as an International symposium on Yoga and Wellbeing in 2016. As a result of these Ann. SBV, Jan-Jun 2017;6(1)

Integrating Yoga in Health Professional Education: The SBV Experience

initiatives two MD dissertations have been taken up on Yoga as adjuvant therapy in General Medicine and Psychiatry. International Day of Yoga was celebrated in a grand manner in 2015 and 2016 at SBV with multifaceted events involving faculty, staff and students of SBV as well as the general public. As per directives of the UGC, the SBV Yoga Fest 2016 was organized by CYTER in May 2016 with poster, essay, quiz and cultural events to enhance awareness of Yoga. (4,14) Demonstrations of the Common Yoga Protocol devised by the Ministry of AYUSH as well as lecturedemonstrations by experts were organized to give a holistic perspective of the Yoga to all students. This was further facilitated by enthusiastic support of Dean and Vice Principals of MGMC&RI. Speaking on the occasion, Prof KR Sethuraman, Vice Chancellor of SBV expressed the need for health professionals to look towards salutogenesis, an understanding of the internal and external factors that induce health rather than mechanically focusing on pathogenesis of disease. (14,15) “Human beings are flawed as they are always susceptible to disease. Yet, some stay healthy even in the worst of conditions. This is because they have a sense of coherence within themselves, find meaning in their lives and hence are more at ease with their lives” said he. All the events were geared towards giving the students a view of Yoga as an ancient system that enables one to create a positive environment both within oneself as well as in the external environment. Such harmonious and dynamic balance between both worlds educes the manifestation of health and wellbeing.

Yoga in BDS curriculum Since 2015 all 1st BDS students have received exposure to Yoga during their orientation program at the Indira Gandhi Institute of Dental Sciences (IGIDS). They were given lectures on the philosophy and psychology of Yoga as well as science behind the effects of Yoga. They also received practical training in stress management techniques such as Jathis, Kriyas, Asanas, Pranayamas and contemplative relaxation practices. Feedback from both years showed excellent response to the Yoga lectures and practical sessions.As a result, BDS students are receiving two hours of Yoga training at CYTER twice a month on alternate Thursdays. Many of them have also continued to attend the regular practical sessions conducted in the evenings at CYTER. Thanks to the support of the Principal and Vice Principal as well as faculty members, students of IGIDS also participated Ann. SBV, Jan-Jun 2017;6(1)

enthusiastically in the SBV Yoga Fest 2016 as well as International Day of Yoga celebrations thus giving them an opportunity to experience the wholesome nature of Yoga.(8, 14) The interest generated at IGIDS and the support from the faculty have also resulted in an MDS dissertation being taken up on Yoga in autism spectrum disorder and oral hygiene.

Yoga in BSc Nursing curriculum The authorities of Kasturba Gandhi Nursing College were amongst the first to understand the value of Yoga and started giving Yoga training to students of their college right from 2012. Initially it was given as an optional extracurricular activity and later became a co-curricular activity. A study done with 60 students who receivedYoga training twice weekly for 6 months showed significant beneficial changes in quality of life indices as well as hematological and biochemical parameters and these changes correlated positively with attendance.(16) On the basis of this study it was recommendedthat Yoga be made an integral part of medical and paramedical collegiate education. (17)All nursing students took part enthusiastically in the first and second International Day of Yogacelebrations in 2015 and 2016 and also bagged majority of prizes in the events held during the SBV Yoga Fest 2016.(8,14) The avant-apres (pre-post) comparison elicited from the students by our Vice-Chancellor after their training in January to March 2015 showed how Yoga has transformed their personalities as well their sense of wellness. Initial feelings expressed as heavy, inability, breathlessness, anxious, hesitant and scattered transformed through Yoga into feelings of being capable, respected, contentment, confident, composed, happy and peaceful. Based on positive changes experienced and expressed by students, teachers and administrators, it was proposed to include Yogaofficially as a part of the nursing curriculum and the first meeting of the duly constituted Board of Studieswas held on 20 July 2016. The board approved inclusion of Yoga in nursing curriculum through a specialized course namely “Foundation in Yoga Therapy”. It was decided that lectures and training would be given during hours of co-curricular activities for 1st year BSc (N) while it would be under Medical Surgical Nursing I & II subject hours during 2nd and 3rd year BSc (N). A total of 45 hours were earmarked for the 1st year, 30 hours for the 2nd year and 15 hours during the 3rd year thus Page 31

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making up a total of 90 hours during the entire BSc (N) course. The training commenced in August 2016 and the first 45 hours have been completed. 2nd year students are regularly posted to CYTER for a full week on rotational basis and this has enabled them to receive comprehensive training and get hands-on experience in how Yoga therapy is imparted for the patients through CYTER. To further enhance this integrative process, the theme chosen for 6th Foundation Day celebrations of CYTER on 2 November 2016 was “Introducing Yoga in Nursing Education”.(18) Dr K Renuka, Dean Nursing Faculty and Principal KGNC gave the thematic address highlighting innovations in nursing curriculum at Sri Balaji Vidyapeeth that for the first time anywhere included Yoga Therapy as a subject in the BSc Nursing curriculum. Presiding over the event, Prof KR Sethuraman, VC of SBV reminded nursing students of their vital role in healthcare as the primary caregivers for patients and stressed the importance of Yoga in their personal and professional life.

Undergraduate Education

Conclusion Modern medical advancements provide the rationale for integration of various traditional healing techniques like Yoga, Naturopathy, Ayurveda, Siddha and Music to promote health, healing and longevity.(19,20) Government of India is currently promoting indigenous systems of health in an active manner through Ministry of AYUSH. The limitations of modern medicine in managing stress induced psychosomatic, chronic illnesses is the strength of these traditional healing systems and hence a holistic integration of both systems enables best quality of patient care. It is imperative that advances in medicine include the holistic approach of Yoga to face the current challenges in health care. The antiquity of Yoga must be united with the innovations of modern medicine to improve quality of life throughout the world. No wonder that Dr. Dean Ornish, the eminent American doctor who has shown that Yogic lifestyle can reverse heart disease says, “Yoga is a system of perfect tools for achieving union as well as healing”.(19, 20)

Postgraduate Education

Yoga for BSc Nursing Student (2012)

PG Diploma in Yoga Therapy 2014

Yoga & Lifestyle (2013)

Yoga for MBBS Student (2014)

PG Certificate courses in Yoga Therapy (2016)

Sleep & Meditation (2014)

Yoga for BDS Student (2015)

MPhil in Yoga Therapy (2016)

Therepeutic Potential of Yoga (2015)

PhD in Yoga Therapy (2017)

Yoga in HPE (2016)

Fig 1. Summary of CYTER activities for integrating Yoga in Health Professions Education at Sri Balaji Vidyapeeth. Year of starting the courses in brackets.

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CMEs/ Seminars/ Workshops/ Symposia

Yoga & Wellbeing (2016)

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Integrating Yoga in Health Professional Education: The SBV Experience

For probably the first time anywhere in the world, all medical, dental and nursing students of a medical university are receiving regular training in Yoga. This is happening at Sri Balaji Vidyapeeth where all students of SBV’s constituent colleges are getting exposed to the integrative potential of Yoga with the modern healthcare system. We can proudly state that it is only in the supportive and innovative milieu of Sri Balaji Vidyapeeth, Pondicherry, India that the holistic art and science of Yoga, our cultural heritage, has been able to reach both the classes and the masses of our society optimally, effectively and holistically.

ACKNOWLEDGEMENTS Support of the benevolent management and visionary administrators of Sri Balaji Vidyapeeth University who setup the CYTER in 2010 is gratefully

acknowledged. Heartfelt gratitude is offered to our Hon’ble Chairman & Chancellor, Vice-chancellor, Dean of Research & Allied Health Sciences and Registrar SBV for their constant support and encouragement. The CYTER team is ably guided by Prof Madanmohan, Founder Director CYTER and blessed by Ammaji Yogacharini Meenakshi Devi Bhavanani, Director ICYER. Integration of Yoga in medical, dental and nursing curriculum was possible with the support of the respective faculty Deans and Vice-Principals of the constituent colleges as well as faculty of SBV AHEAD. The energy of CYTER activities stems from the efforts of our Deputy Director Dr Meena Ramanathan who has nurtured CYTER through her motherly affection right from the beginning. The entire past and present CYTER team deserves a special word of appreciation for their tireless efforts in motivating our students as well as for conducting the practical sessions in an admirable manner.

REFERENCES 1. Aggarwal KK. Medical Profession – A noble profession. http://drkkaggarwal.blogspot.in/2013/07/medical-profession-noble-profession.html 2. Bhavanani AB, Madanmohan. Restoring human values in medicine: Role of Yoga.National Conference on Changing Trends in Health Professions Education (NC-CTHPE 2016). SBV, Pondicherry. 18-21 Aug 2016. pp.85-86. 3. Now, yoga, sports part of MBBS curriculum. (21 may 2012) http://timesofindia.indiatimes.com/home/education/news/Now-yoga-sports-part-of-MBBS-curriculum/ articleshow/13323559.cms 4. Harbingers in harnessing healing touch of yoga. www.thehindu.com/news/cities/puducherry/Harbingers-in-harnessing-healing-touch-of-yoga/article14434854.ece 5. Madanmohan.Introducing yoga to medical students: the JIPMER experience. Yoga Vijnana, 2: 71-78, 2008 6. Madanmohan (Ed). Proceedings of the National Workshop on Introducing Yoga in Medical Curriculum.ACTYER, JIPMER, Pondicherry.19-20 March, 2009. www.icyer. com/documents/Proc_Ntl_Workshop_Yoga_Medical.pdf 7. Souvenir of International Day of Yoga 2016 celebrations at Sri Balaji Vidyapeeth, Pondicherry.www.slideshare.net/anandabhavanani/souvenir-of-international-day-ofyoga-2016-celebrations-at-sri-balaji-vidyapeeth-pondicherry 8. Report on SBV's International Day of Yoga 2016 celebrations. www.slideshare.net/anandabhavanani/report-on-sbvs-international-day-of-yoga-2016-celebrations 9. Yoga programme for medicos launched (25 September 2015). www.thehindu.com/news/cities/puducherry/yoga-programme-for-medicos-launched/article7688031. ece0 10. Yoga therapy enters medical curriculum. (30 April 2015) www.thehindu.com/news/cities/puducherry/yoga-therapy-enters-medical-curriculum/article7156934.ece 11. Introducing medicos to therapeutic use of yoga (26 May 2015). www.thehindu.com/news/national/tamil-nadu/introducing-medicos-to-therapeutic-use-of-yoga/ article7246603.ece 12. An in-depth examination of sleep, consciousness and meditation (28 November 2014). www.thehindu.com/news/cities/puducherry/an-indepth-examination-of-sleepconsciousness-and-meditation/article6642728.ece 13. Going beyond the yoga postures (29 June 2015). www.thehindu.com/todays-paper/tp-national/tp-tamilnadu/going-beyond-the-yoga-postures/article7366018.ece 14. SBV Yoga fest: A report. www.slideshare.net/anandabhavanani/sbv-yoga-fest-2016-a-rreport 15. Yoga and salutogenesis, Yoga Day oration by Prof KR Sethuraman.www.youtube.com/watch?v=-RO6Mwv4WNU 16. Bhavanani AB, Ramanathan M, Madanmohan, Srinivasan AR. Hematological, biochemical and psychological effects of a yoga training programme in nursing students. Int Res J Pharm App Sci 2013; 3(6):17-23 17. Ramanathan M, Bhavanani AB, Renuka K. Yoga for nursing students: rationale and psychophysical benefits. National Conference on Changing Trends in Health Professions Education (NC-CTHPE 2016). SBV, Pondicherry. 18-21 Aug 2016. pp.95-96 18. Now, Yoga becomes part of nursing curriculum - The Hindu. www.thehindu.com/news/cities/puducherry/Now-Yoga-becomes-part-of-nursing-curriculum/article16437461. ece 19. Bhavanani AB. Yoga and modern medicine: possible meeting points. Proceedings of the symposia on “Role of Yoga in enhancement of human performance and Yoga in contemporary medicine”. JIPMER, Puducherry. Dec 2005. Pp. 6-19. 20. Bhavanani AB. Integrating yoga and modern medical science.Souvenir of the National Seminar and CME on Introducing Yoga in Health Professions Education. SBVU, Puducherry. 19-21 June 2016. Pp. 48-55.

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Review Bedside Medicine-Victor or Vanquished? Dr K N Viswanathan DNB (Med); FACTM,AB,FACP (USA); FRCP (Glas); FRCP (Lon); FIACM Prof of Medicine, Shri Sathya Sai Medical College and Research Institute, (A unit of SBVU), Ammapettai, Kanchipuram District, Tamil Nadu

Abstract  One should never forget that the most cost-effective tool in medicine is communication. The cutting-edge of patient-physician relationship is health-care which must be extremely compassionate. Nowadays many physicians refer their patients to all sorts of modern but extortionate investigation gadgets, which not everyone in this country can afford and this necessitates a compelling and immediate need to resurrect the olden general practitioners’ ways of providing panacea. Those doctors have been caring for several generations by being familiar with the entire family history and just by hearing the complaints and conducting basic physical examination and acting as their friend, philosopher and guide, facilitate recovery without or with minimal investigations. Hippocrates advocated to “cure rarely, comfort mostly, but console always” and this still holds good to these days of modern technological practice. The doctor must be an effective communicator to follow his principles.

Historical facts In the 18th century, physicians from France transformed medical learning from information in books and from teachers and placed them only after human bodies, insisting on hands-on experience gained through constant bed-side examinations and autopsies. Pierre Cabanis (1757-1808) insisted on the golden rule of reading little, seeing much and doing much. Percussion was introduced by Auenbrugger in 1761 and stethoscope by Laennec in 1819 and these paved ways for the 19th century physicians to make anatomical and patho-physiologic diagnosis. In the first half of the 20th century bed-side evaluation was the prime means of diagnosis. Even today it is the quintessence of medical practice and comprises of history taking and performing a detailed physical examination.

History Taking Sir James Spence noted that the “nitty-gritty” of medical care delivery is the trust placed by the

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person who is ill or believes to be ill on the other in whom he has immense faith. Medical consultation resulted from the meeting of these two individuals and discussions held between them. Eliciting the history from the patient is an art and and the body language while giving the history reflects his problems and his personality. After hearing the patient’s history, the doctor probes further by posing more questions for extracting the exact information about his symptoms. Certain words uttered by the patient regarding his symptoms are likely to misguide the physician when clarity is lacking and these need to be made unambiguous. Fear about a particular disease may make patients conceal essential details when help is sought especially for heart ailments or malignancy. Any likely intervention should be properly explained to the patient and informed consent obtained. Patient should be able to give a detailed history including the treatment given. After this the physician arrives at the diagnosis and differential diagnosis.

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Bedside Medicine-Victor or Vanquished?

A study published in BMJ showed that diagnosis is made from the patient’s history obtained in 80% and in 10% physical examination helped in the same and 10% by investigations.

Physical examination Physical examination is essential to make out the clinical features of the diseases. A correctly done and interpreted physical examination is a skilled art. It is acquired through experience and the five senses according to Osler. Moreover the eyes do not see what the mind does not know and perfection is attained only by constant practice. Only physical examination can diagnose Bell’s palsy, Parkinsonism, motor neuron disease and many other diseases. Medical practice has dramatically changed in recent years. Even textbooks and clinical manuals in medicine talk extensively on investigations and clinical methods have been compromised at the expense of color nowadays. Classes in medicine are not conducted at the bedside but have become mini- didactic lectures in side rooms. The examiners too do not examine candidates at the bedside in clinical examinations but only across tables in viva-voce. Physical examination should be performed meticulously and methodically and the system involved, as suggested by the history, should be explored in detail. The doctors of modern days spend very little time at the bed-side, instead ordering several investigations before scrutinizing the patient and most of the times with no provisional diagnosis being formulated. Redundancy is attributed to the bed-side examination and it is also felt that precious time is wasted; rather time is spent looking at the battery of investigations than reaching out to the patient. More time is devoted to inspecting the monitors and ventilatory settings than the patient during the rounds in the intensive care units. While helping us in a great way, these newer gadgets also pose fresh and threatening challenges. The cost of medical care is rising enormously and the common man is made unaffordable and inaccessible to modern day physicians. It is also mounting because of the present electronic medical records in vogue in several hospitals.

Ann. SBV, Jan-Jun 2017;6(1)

Limits to Investigations and advantage of bed-side medicine “Health-care system” has been replaced by the “disease cure system” and in the modus operandi of diagnosis and treatment the patient is consigned to oblivion. The human body has been equated to a contraption with spare parts. Unnecessary investigations tend to detect insignificant granulomas in CT or small hepatic or renal cysts in the ultrasound aggravating patient’s anxiety. Asking for these investigations without examination of patient is dispassionate and bureaucratic. Patient-doctor relationship which is developed by the bed-side medicine is essential for the proper management of the cases. Extortionate investigations are mostly not needed, unsafe and catty and this is very important in developing countries where clinical diagnosis can be had by history, physical examination and rational investigations. Medical expertise which is the science and sagacity which is the art have to join hands to benefit the patient to the maximum. While the science of medicine is expanding rapidly, the art of medicine, has been buried in oblivion. Why have several doctors forgotten bedside medicine which is the basis of the time-honored physician-patient relationship and a paramount aspect of good patient care and why would anyone cold-shoulder any skill that will enhance his diagnostic capacity? All present-day doctors are trained in five-star hospitals where their teachers give more importance to modern gadgets forgetting basic clinical care and those doctors will depend on modern gadgets to practise medicine in years to come. The monomania is being promoted by the industry through their advertisements indirectly in the facade of scientific data. Decades ago, we sincerely followed the footsteps of our teachers by observing the way they managed patients as out-patients and in the wards. This mannerism is absent today and moreover that breed of teachers have vanquished like the ancient dinosaurs. Why eulogize bedside-medicine? It

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1. Establishes the central role of the patient Involves patients who prefer to be so 2. Shortens presentations Allows real time clarification of history Improves our ability to learn physical exam Allows us to observe each other’s interactions with the patients Allows the teacher to demonstrate “the art of medicine”

Future of Bed-side Medicine Many clinical research data in modern medicine have emerged from the bed side. A problem on the bedside and the pressing need to search for that solution is clinical research. The number of hours the students on the bedside spend will blossom in the future to make them altruistic doctors. They should view every patient as a human being in tribulation and provide compassion before actual treatment. Books teach a good physician how to treat, a better physician when to treat, but only bedside experience makes the best physician. Our biggest dilemma nowadays is overmedication resulting in adverse drug reactions, drug resistance and unwarranted interventions. When the patient is to be discharged, a different routine should be resorted to on that day. The doctor should put a chair and be seated near the patient and this makes the patient feel that the physician is going to be with him for sometime and is not going to attend to any other work immediately. This while instilling chutzpah in the patient will also attract him to the doctor.

Conclusion The time-honoured physician-patient relationship is established by the art of medicine making the patient revere and divulge extra information to him. Patients will not fear getting a surgery done and accept a complication, if at all one occurs. The patients will remain faithful to their physicians and legal issues will not arise. They will also send their consorts and comrades to their doctor. Patient-based practice is the most secure one a physician can develop. Hence a glorious and roaring practice for the physician can be brought about by satisfied patients. The battle between experience-based and evidencebased medicine will still continue but whatever is being practiced, a balance should be struck between them and bedside communication should be made mandatory in the health-care setting. So bed side medicine will come back to be the vanguard in the forthcoming years. There were times when the doctor was equated with the Almighty performing whatever he thought was right for the patient. But nowadays an equal partnership is observed and the patient asserts his right in his /her management. It is imperative for the physicians of today to be good communicators to know about their patients in detail. A casual ward round by the duty doctor in the evening asking the patients about what they had to eat, their bowel habits of the day and a little of personal information about their ways of life and treatment at home will go a long way in bringing about effective communication and build up the patient’s trust in the doctor other than assuaging their symptoms. This also tends to promote professionalism from the physician’s point of view. Certainly bedside medicine is to be resurrected.

References 1. Michael E. Glasscock, MD and Eric M. Kraus, MD: “The Lost Art of Medicine: Patient care is paramount in practice”. ENT today, August 2, 2011. 2. Hampton JR, et al. Role of history taking, physical examination and investigation in medical out-patient diagnosis. BMJ 1978:11:486-489 3. Dr BM Hegde: “Bedside Medicine- a forgotten art” April 4, 2012: www.moneylife.in Maiya M: “Bedside Medicine-Forgotten entity?” JAPI, January, 2012, Vol 60, pp 27-28

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Review Changing Trends in Health Professions Education Dr. Karthika Jayakumar, VP ( Pre & Para Clinical ), Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus SSSMC&RI, Kanchipuram District -60310

Abstract  Today’s health profession’s education must change with respect to altered T/L methods,

competency based learning & assessment. Health care delivery to change the focus from institution level to community level.From teacher centered to learner centered. Assessment to be shifted from knowledge acquisition to work based assessment.

Today’s medical students are tomorrow’s health care providers, these learners are trained, molded, sculptured by the teachers & faculties of medical colleges. Education by itself is a powerful tool, that enhances, the capacity of the learner to effectively execute & contribute to the efficient health care delivery in the community. Learning not only imparts knowledge, skill, but also brings a change in behavior & attitude of the learners. Therefore it becomes,“the most powerful weapon that can change the world”. Does it need a change in medical college ? YES Teaching in a medical college, face several challenges: a. Changing health related issues b. Change in Curriculum from mere acquisition of knowledge to competency development c. Teaching shifted from teacher centered to student centered d. Assessment need to be tailored on daily, work based activities e. Learning & health care delivery to be shifted from institution level to community forum. Changing of health related issues, has several influencing factors, like the frequent migration of people from endemic geographical areas to other countries, facing changing patterns of the diseases & Ann. SBV, Jan-Jun 2017;6(1 )

depletion of safe, sensitive drugs leading to chronicity of illness. This fact has to be highlighted in the teaching, for the proper handling of the different case scenarios. Curriculum must be altered from acquisition of knowledge to the development of competencies, which will ensure the learner to possess not only knowledge, skill but also appropriate attitude, communication skills with empathy. Teaching /learning methods, need to be shifted from teacher centered to learner as well as patient care centered. These approaches can be further validated by POL/ PBL, SGT. Learners must be made to have self directed learning, should take the ownership of learning process, this can be done by introducing innovative teaching learning techniques. Assessment has to be changed from the acquisition of basic knowledge, to assessment of competencies & work based activities with suitable check list. Learner has to be given the feedback, to modify his attitude & skills, for further progress.This can be obtained by Multisource feedback (MSF) from faculty, peers & patients. This can be maintained by the log book, which will help in the evaluation of the learner. Page 37

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The teaching & learning methods should focus on effective health care delivery to the community. This can be achieved through a multidisciplinary approach, community orientation, with demonstration of learning objectives in rural health care set up. This approach is to increase relevance, quantity, quality which will definitely strengthen the health profession education. For all these to happen, there are two important factors: (1) learner & (2) teacher. The learner need to be channeled in the proper path, by the trained faculty,which requires, the periodical Faculty development program.which aids in the pursuit of change in T/L methods for student centered approach, facilitating innovative methods, making learner to take ownership of the learning.

These trained faculties, make it feasible for the students to shift their attention from disease identification & treatment, TO disease prevention & health promotion. This is possible only when emphasis is laid on the concept of “HOLISTIC MEDICINE”. Which makes the spectrum get shifted from patient care to patient safety. This requires the effective participation of the learner too, who should be motivated, committed to the learning process, willing to take the role of being team worker, along with leadership qualities. There should be a fair selection of the students into the medical college, at the time of admission. They should be subjected for getting adequate exposure to other allied activities like Yoga & Musical therapy which also reduces the stress & helps in the modification of life style precipitated illness

REFERENCES 1. Ann.C.Greiner,Elisa Knebel.Editors, Committee on the health professions education summit.Health profession education : A bridge to quality.ISBN:0-309-51678-1,2003. 2. Prof.Juliofrank MD, Dr.Lincoln chen et al,Health Professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet. Volume 376, No. 9756,P1923 – 1958.4 Dec 2010.

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Review How Big A Sample Do I Require? Dr.G.Ezhumalai, Sr. Statistician & Research Consultant Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India.

Abstract  The objective of this article is to create awareness on the importance of sample

size which decides the validity and quality of the research outcome. It also provides ideas on what information is needed when consulting a statistician for sample size determination. Sample size calculation is scientific, should be reported with relevant formula and justification in every proposal/report of a research project.

INTRODUCTION When planning a research, the investigator is worried about “how many samples should I include in my study” and the statistician is also very particular about it. One should never compromise in fixing the sample size for any research activity. Why does it is important? Usually, sample data will be collected from a population to answer a question or to test a hypothesis. Hence, by doing sampling, one wants to be able to generalize the findings to the whole population, if possible. The sample estimates will be generalisable to the population values only when the sample represents the population. The question is to get a reliable estimate of the population, how many sample does the researcher need to have?

THEORY Sample size depends upon the aims, nature and scope of the research. All these need to be carefully addressed1. The quote “you need 30 samples for statistical significance” may hit millions of hits in whatsApp or similar applications. First, the 30-sample rule-ofthumb was originated by William Gosset, a statistician after being bamboozled by a correlation coefficient experiment for 750 times. Student t distribution was his own concept and it follows normal distribution as the sample size nears thirty2. The second point is “law of large number”. It says that when we take more samples, the more likely the estimates will be reliable Ann. SBV, Jan-Jun 2017;6(1 )

to the population value. In view of these two rules, are we now comfortable with a sample size of thirty? By law of large number, we may think that 30 samples will give a good result; but 40 samples will give better estimate than 30 samples: 50 samples would yield results better than 40 ….. What is the limit, then?

WHY IT SHOULD BE SCIENTIFIC? Estimation of sample size is one of the important aspects in conducting a research study. An excessive sample size may result in waste of materials, time and money because equally accurate estimates can be obtained from a smaller sample size. On the other hand, a lower sample size is also wasteful, since an insufficient sample size has a low probability of detecting a statistically significant difference even when a difference is really present3. Further, when an investigator does not find a significant result, he can’t say whether the intervention doesn’t work or the insufficient sample size has not able to find the difference. Finally, population parameters are represented by a confidence interval rather than point estimate from a sample. The confidence interval has a component called “standard error” which determines the narrowness of the interval. This error tends to a minimum with higher sample size and we get a reliable, estimate of the population. Hence, estimation of sample size requires a scientific approach to get better estimates of the population parameter. Page 39

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KEY COMPONENTS REQUIRED TO ESTIAMATE SAMPLE SIZE? It is neither feasible nor practical to study the entire population for any research problem. The aim of calculating an adequate sample size is to estimate the population values with a good precision. It can be estimated by using a simple formula with relevant inputs. Thus, the sample size obtained by calculation will adequately represent the population, provided, an appropriate sampling technique is also used. The results obtained from this sampling procedure will signify the true value of the population and the inferences are quite likely to be realistic4. The parameter required for calculating sample size are, 1. Variable of interest 2. Type I error (α) 3. Type II error (β) 4. Whether one tailed or two tailed 5. Study design 6. Effect size 7. Precision 8. Prevalence 1. Variable of interest The scale of measurement of variables is mainly grouped into three as categorical, ordinal and continuous. Description of these variables are distinct (percentage and mean) and hence the formulae for calculation of sample size also differ. Generally, categorical outcome variables require a higher sample size compared to continuous variable for the same precision5. 2. Type I error (α) Type I error known as α-error occurs when we “reject the null hypothesis when it is actually true”. When we fix significance level of α as 0.05, and obtain a probability value of 0.04 in two tailed, there are two ways to explain. First, really there exists a difference between the two groups and the second due to chance alone; but it is only 4%. When the p value is close to zero, the difference found in the study will be very low. Level of significance is set at 0.05 in many of the studies by convention. Lower the set alpha level, larger the sample size5. 3. Type II error (β) Type II error is defined as “we do not reject the null hypothesis when it is false”. Type II error is related Page 40

to power of the study. In many occasions, the power (1-β) of the study is set at 80% and increasing the power will give a higher sample size6. 4. One tailed or two tailed The direction of effect between two groups is important since the corresponding standard normal Z values are used in sample size calculation formula. Generaly, two tailed test of hypothesis is used in inferential analysis, unless the direction of effect is known. For example, when the claim is a superiority trial, single tail can be used and when the direction of change is not known two tailed is the choice. The sample size calculated using two tailed is always higher than that of one tailed. One tailed tests are more powerful, but two tailed have a stronger justification7. 5. Study design Study design controls the power of a study. Based on whether the study uses one group or many, whether it is observational or experimental, the sample size formula will vary. Descriptive studies need a larger sample to give acceptable confidence intervals. 6. Effect size Effect size is defined as the ratio of difference between means to the standard deviation. Higher effect size yields a higher power of the study. 7. Precision How precisely, the sample statistic is estimated is called precision. Standard error is a measure of precision and when it is small, estimates from the sample will be nearing the population values. While estimating the sample size, the researcher is free to allow some percent of error. Based on the situation, it can be fixed to 5% or 10% with justification. For example, suppose an anticipated population proportion is 20% and a 5% precision level is fixed, the expected population proportion will lie between 15-25%. 8. Prevalence The proportion (prevalence) of outcome variable related to the objective may be collected from review of literature. If one has several proportions from literatures, the value with similar study design, study population and the most recent values will be used. Ann. SBV, Jan-Jun 2017;6(1)

How Big A Sample Do I Require?

In case, it is not available, an assumed prevalence of fifty percent (p=0.5) can be used in the formula or estimated by doing a pilot study. There is not a single formula to calculate sample size but several according to the situation many. The investigator can choose some of the above requirements, the rest by doing review of literature or by doing a pilot study. A number of online/downloadable softwares are available to estimate sample size. After collecting the required inputs, and substituting the values in the formula, the minimum sample size can be calculated. Sample size will also be determined by negotiation based on the availability, cost involved, duration of research, risk involved and ethical issues in the study. Attrition, withdrawal, drop-out or death

of animals is also kept in mind while finalizing the sample size.

CONCLUSION The sample size must be adequate to answer a research question; but too large is waste of resources while too small inadequately represent the population parameters. Sample size calculation with relevant input and utilization of correct formula is more scientific and reasonable. It has its own merits in deciding the accuracy and precision of the estimates. The relevant precision must be decided by the researcher with up-to-date knowledge by doing a review related to their objectives. The researcher should always mention the process of sample size calculation in her/his proposal/report with justification.

REFERENCES

1. 2. 3. 4. 5. 6. 7.

S.K.Lwanga and S.Lemeshow. Sample size determination in health studies â&#x20AC;&#x201C; A practical manual. World Health Organization, 1991 Student. Probable error of a correlation coefficient., Biometrika, 6(2-3),302-310, 1908 Jayakaran charan, N.D.Kantharia. How to Calculate Sample Size in animal studirs? Journal of pharmacology and pharmacotherapeutics, l4(4), 303-306, 2013 Baoliang Zhong, MD. How to Calculate Sample Size in Randomized Controlled Trial? Journal of thoracic disease 1:51-51 2009 KP Suresh, S Chandrashekara. Top of Form Sample size estimation and power analysis for clinical research studies. J Hum Reprod Sci. 2012 Jan-Apr; 5(1): 7-13. Prashanth Kadam, Supriya Bhalerao, Sample size calculation, International journal of Ayurvedha research vol 1(1), p55-57, 2010 Stata power and sample size reference manual release 13, A stata press publicaiotn, Stata corporation Ltd., College station, Texas, 2013

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Review Status of Radiology Teaching at Undergraduate Level Singh C. S. Ph D Scholar Adkoli B. V. Professor & Head, Ezhumalai G. Senior Statistical Consultant Sethuraman K.R. Vice Chancellor Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India.

Department of Health Professions Education, Sri Balaji Vidyapeeth, Mahatma Gandhi Medical College & Research Institute, Campus, Pillaiyarkuppam, Pondicherry 607403, India Radiology is one of the fastest growing specialties in medicine. Thanks to the phenomenal growth in imaging techniques and emergence of diagnostics, clinical practitioners have become more and more reliant on these modalities to arrive at the diagnosis accurately. Most specialists refer patients for radiological investigations with a provisional diagnosis. Their interest lies in either validating the diagnosis or ruling out the possibility. Ultimately, radiology helps in clinching the final diagnosis.1 In some cases radiological findings help in monitoring the treatment. Health experts therefore trust radiology more than any other discipline in patient care. It has been acknowledged that medical students with interpretative skills in radiology have enhanced their skills of clinical examination and self-confidence in arriving at diagnosis2. There is no doubt that basics in radiology are crucial for comprehension of images. As a result of the prestige attached to this specialty, there is a craving amongst the MBBS graduates for securing postgraduate seats in Radiology, either to set up a high-tech hospital or a diagnostic facility, or to become specialist in this field to remain in the forefront of medical profession. In this paper, we examine the various facets of undergraduate training in radiology globally and extrapolate the same to Indian context.

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Radiology teaching â&#x20AC;&#x201C; Global Scenario Though radiology as a specialty is advancing by leaps and bounds, the teaching and training in radiology have not received due attention. Even in the U.S., training has been found to be inadequate. 3 While the training in medicine, surgery and obstetrics has made significant strides globally, radiology training has been lacking. A review has shown that less than 25% of medical graduates are confident in interpretation of chest x-rays, which is considered as a basic skill for a radiologist.4 Another study has indicated that students did not master basic skills of radiology even during their clinical clerkship. 5. Nevertheless, the studies have led to the increased awareness about the importance of promoting training in radiology. Progressive medical colleges in the U.S. have started exploring new pathways of integrating radiology in the main stream of medical education. 6 D mytriw et al, conducted a survey at Dalhousie University, Mc-Gill University, and University of Toronto. Most of the respondents (91%) were of the opinion that radiology is essential for better care of the patients. While 98% conveyed significance of radiology in efficiency of treatment, 83% opined the shortfall of radiology education in medical college curriculum. The authors believe that it is essential for any medical graduate to know the view of the x-ray taken, basic densities, few normal anatomic structures, and findings of common pathologies to improve the skills of physicians.7

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Status of Radiology Teaching at Undergraduate Level

Bhogal et al in their comprehensive review came out with the following observations: a) Knowledge of clinical radiology, is presently vital to the management of patients. b) Radiology teaching helps the newly graduated doctors to have the knowledge, skills and attitudes for better competence. c) It also aids in building on this knowledge in their post-graduation years. d) A good groundwork in radiology is critical to clinical medicine. e) It will result in added efficiency in healthcare. f) All these will help in saving time, reducing redundant tests, decreasing harm to patients, and effective sharing of resources 8 European Society of Radiology (ESR) conducted a survey of teaching staff and heads of teaching hospitals of 430 European education centers to assess undergraduate teaching in Europe. Based on the survey, ESR has brought a white paper. It has been suggested that radiology training should start early and the syllabus should be integrated with the general program. While teaching may be embedded in the Department of Radiology, it has been emphasized that a close communication between radiology and clinical subspecialty must be maintained for an effective teaching to occur in a clinical context. This helps the students to establish clinical correlation which is vital for perceiving the relevance of training.9 Another survey was conducted in the U.S. by the Alliance of Medical Student Educators in Radiology (AMSER) who reiterated that imaging was pivotal for practice of modern medicine.10 Lee et al., of University of British Columbia reported that students were benefitted from radiology training during a first curriculum year 11 Therefore a case is made for early introduction of radiology. However, a curriculum with integrated teaching in radiology is considered academically valuable. 12 Assessment in radiology is essential as it motivates students to take training earnestly13. Assessment can be done during the clinical years by interconnecting the x-ray images and the diseases. 14 Drawing conclusions from a national survey of medical schools and radiology department leadership in the U.S., Straus et al offer three solutions, viz., a) to expose students to interdisciplinary meetings, b) to make digital sources of images extensively available for the training and c) to develop a common standardized curriculum15.

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Indian Scenario India witnessed a rapid expansion in the number of medical colleges as well as the enrolment of students for undergraduate (MBBS) and postgraduate (MD/MS) courses. Presently we have more than 412 recognized medical colleges, admitting 52,965 for MBBS and 22,850 for MD/MS every year.16 There is perceived shortage of teachers for the MBBS programs in many departments, including Radio-diagnosis in which adequate number of PG trainers are not available. A study has reported that the ratio of radiologists to population in India is 1: 100,000 in comparison with 1: 10,000 found in the US. This points to the need for more number of specialists in radiology. Presently the top-level students with MBBS prefer to pursue MD in radiology. 17 The curriculum in undergraduate radiology, like many other subjects has followed the conventional mode of â&#x20AC;&#x2DC;disciplinary approachâ&#x20AC;&#x2122;. The Medical Council of India (MCI) is the regulatory body that prescribes curricula of medical colleges. The teaching and assessment in radiodiagnosis are therefore, largely generally governed by the MCI Regulations of 1997.18 However, Universities being examining bodies have other sets of regulations for the assessment and examination for their affiliated medical schools. Hence there is no uniformity in the standard of medical education across the country 19. This holds good for radiology. The problem is further vitiated by the fact that the pattern of teaching varies from teacher to teacher depending upon his/her training background. It is well known fact that assessment drives student learning. Students and faculty invest more time and effort where assessment weigtage is high. Unfortunately, radio-diagnosis is a small part of surgical training and is assessed under Paper II of General Surgery which includes general surgery, anesthesiology, dentistry in addition to radio-diagnosis. According to MCI Regulations, training in radio-diagnosis consists of 20 hours of didactic lectures besides 2 weeks posting (each posting is of 3 hours duration) during 7th semester. Radiology can also be offered as one of the electives during clinical phase. However, since no detailed guidelines are available for teaching these electives, the training appears to be unstructured and variable in quality. The weightage given to radiology in assessment is not in commensurate with the current emphasis given to this subject. The examiners in Surgery and

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Medicine usually throw a few questions asking the students to interpret a given X-Ray, as a part of viva examination. The assessment system in general has followed traditional approach of written examination, practical, long/short case with viva exam. However, a recent development is the introduction of OSCEs as either formative or in some cases summative examination. OSCE approach has been considered as an objective and fair way of examining clinical, procedural and interpretive skills. This has enabled the assessment of radiology competencies, especially interpretation of X-Ray, ECG and other image data to assess the candidates’ skills in interpretation and problem solving. Future efforts to improve radiology training should revolve around the use of problem solving approaches and case based learning. The availability of digital technology and Picture Archival Communicating System (PACS) can help in a big way. Integrated teaching of radiology is another important way forward. This requires a concerted effort, vibrant leadership and team work amongst faculty. Some of the progressive

medical colleges including MGMCRI, Pondicherry have taken up keen initiative in this direction thanks to the support from top leadership and management. While a broad outline of the curriculum is already in place, the investment on faculty development can make a huge difference in the successful implementation of the curriculum. In conclusion, we observe that a lot more efforts are needed for revitalizing the teaching of radiology. While an integrated approach to the teaching with participation from clinical disciplines is a value addition to the training, the use of interactive teaching utilizing problem solving exercises drawn from a pool of real cases and their images would be a minimum requirement. This also calls for more research evidence to show that the new methodologies are feasible, student-friendly and helpful in achieving better learning outcomes. The first author is currently involved in conducting a longitudinal study focusing on the UG Department of Radiology MGMCRI and some of the initial outcomes are positive. There is no wonder if radiology teaching soon occupies the main stream of undergraduate teaching.

References 1. Gunderman, R.B. Educating Medical Students about Radiologists’ Contributions to Patient Care:Acad Radiol 2012; 19:908-909 2. Butter J, Grant TH, Egan M, Kaye M,Wayne DB, Carrion-Carire V, et al. Does ultrasound training boost year 1 medical student competence and confidence when learning abdominal examination? Med Educ. 2007;41(9):843-?? 3. Gunderman R.B., Siddiqui AR, Heitkamp DE, Kipfer HD. The vital role of radiology in the medical school curriculum. Am J Roentgenol. 2003;180(5):1239-42. 4. Jeffrey DR, Goddard PR, Callaway MP, Greenwood R.; Chest radiograph interpretation by medical students. Clin Radiol. 2003;58(6):478-81 5. Scheiner JD, Novelline RA; Radiology clerkships are necessary for teaching medical students appropriate imaging work-ups ;Acad Radiol. 2000;7(1):40-5. 6. Dienstag JL; Evolution of the new pathway curriculum at Harvard medical school the new integrated curriculum; Perspect Biol Med. 2011;54(1):36-54. 7. D mytriw A. et al Radiology in the Undergraduate Medical Curriculum: Too Little, Too Late?-; Short Communication; Med Sci. Educ. 2015(25):233-227 doi:10.1007/ s40670-015-0130-x 8. Bhogal P. et al. Radiology in the undergraduate medical curriculum – Who, how, what, when, and where? Clinical Radiology 2012 (67): 1146-1152 9. Éamann Breatnachl. Undergraduate education in radiology. A white paper by the European Society of Radiology; Insights Imaging;2011(2):363-374 ; DOI 10.1007/ s13244-011-0104-5 10. Phillips AW, Smith SG, Straus CM. The role of radiology in pre-clinical anatomy: a critical review of the past, present and future. Acad Radiol 2013(20):297-305. 11. Lee JS, Aldrich JE, Eftekhari A, Nicolaou S, Muller NL. Implementation of a new undergraduate radiology curriculum: experience at the University of British Columbia. Canadian Association of Radiologists Journal 2007;58(5):272-8. 12. Mirsadraee S, Mankad K, McCoubrie P, Roberts T, Kessel D. Radiology curriculum for undergraduate medical studies – a consensus survey. Clin Radiol 2012 (67):1155-61. 13. Dobre MC, Maley J. Medical student radiology externs: increasing exposure to radiology, improving education, and influencing career choices. J Am Coll Radiol 2012;9:506-9. 14. Kourdioukova E.V. et al; Analysis of radiology education in undergraduate medical doctors training in Europe:-European Journal of Radiology 2011;78:309-318 15. Medical Student Radiology Education: Summary and Recommendations From a National Survey of Medical School and Radiology Department Leadership -Christopher M. Straus et al; J Am Coll Radiol 2014;11:6:606-610. http://dx.doi.org/10.1016/j.jacr.2014.01.012 16. Total Number of Medical Seats in India – State-wise https://admission.aglasem.com/total-number-medical-seats-india-state-wise/ accessed on 26/5/2017 17. Arora R. The training and practice of radiology in India: current trends: Quant. Imaging Med Surg. 2014; 4(6): 449–450. doi: 10.3978/j.issn.2223-4292.2014.11.04: PMCID: PMC4256238 18. Medical Council of India Regulations on Graduate Medical Education, 1997. Medical Council of India. http://www.mciindia.org/RulesandRegulations/ GraduateMedicalEducationRegulations1997.aspx Accessed on 26/5/2017 19. Sood R. Medical education in India. Med Teach 2008; 30(6):DOI: 10.1080/01421590802139823

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Review Students Needing Additional Curricular Support and Psychological Support (SNACS, SNAPS) – A perspective Shift Shivasakthy Manivasakan1, K. R. Sethuraman2

Reader, Dept. of Prosthodontics, Indira Gandhi Institute of Dental Sciences 2 Vice Chancellor, Sri Balaji Vidyapeeth 1

Sri Balaji Vidyapeeth - Mahatma Gandhi Medical College and Research Institute Campus Pillaiyarkuppam, Puducherry - 607403, India.

Abstract  Labelling the students as problem learners or slow learners remains pejorative and

has detrimental effects on both the students’ as well as the teacher’s attitude. Even though labelling is bad, a term is needed for identifying the students to enable specific support strategies that exhibit positivity. Hence better terminology of addressing the students as Students Needing Additional Curricular Support and Students Needing Additional Psychological Support are introduced. The theories behind the labelling effect on students are explained. The frameworks for identifying the student with problem, the rationale for support and the support strategies are reviewed.

SNACS, SNAPS – The terminology The students who learn slow and achieve low are termed as Students Needing Additional Curricular Support (SNACS) and Students Needing Additional Psychological Support (SNAPS) to avoid using a pejorative term like slow learners, underachievers or problem learners.1What is the need for concern in terminology? For the reason that, the terminology here becomes a label. The classic labelling theory by Howard Becker, states that both the concerned individual and the society are affected by the Label. The individual starts reflecting the labelled behaviour and the labeller and the society becomes prejudiced about their deeds. Often the labelled group are considered to be unacceptable.2,3 Nevertheless, to offer extra support and guidance, the group needs to be identified. Kaufmann in the context of special education had acknowledged few advantages of labelling such as easy communication between the teachers on their need, to initiate research Ann. SBV, Jan-Jun 2017;6(1 )

on best practices targeting that group and to apply the evidence at a later stage for their progress.4 To gain the benefits and to avoid the detrimental effects of labelling and to develop a positive interpersonal connection between the teachers and the students5,6 based on the motivation model by Cornell, the group should be addressed in a better term. Hence the terms Students Needing Additional Curricular Support (SNACS) and Students Needing Additional Psychological Support (SNAPS) serves the purpose better.

Whom to Support? – The identification Students belonging to this group have multi-faceted aetiology. Often the problem is not restricted to direct learning problem for SNACS or frank psychiatric problem for SNAPS. Vaughn et al have classified the problem learners based on the cause into four classes namely cognitive, structural, affective and interpersonal. The students in cognitive class found Page 45

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to have less knowledge, problem in written and verbal communication, spatial perception problems and lack of integration. The students in the structural class have problem in organization, time management and study habits. The affective class students have problem in memory and motivation. Many of them would have some personal life issues or health problems that lead to depression. The interpersonal class have problem in interacting with others including the teachers. The background reason might range from ethnicity issues to personal habits like substance abuse. Some may be of shy nature.7 David C. Yao et al reported insufficient clinical skills, medical knowledge and time management as problem of the medical residents, often the cause being underlying depression.8Evans et al also reported that the students with learning difficulty exhibited deficiency in attendance, clinical skills, knowledge, communication skills and presence of anxiety.9 The identification of the students who need support plays a key role in planning effective management strategies. Moreover since learning alone is not a problem, Rachel et al stressed on differential diagnosis of the students based on the cause into three categories namely the knowledge base deficits, problems with synthesis and professionalism issues.10 Steinert proposed a framework to identify the learner’s problem. The framework reflects the problems in all three domains namely the knowledge, attitude and skills. It also helps to identify whether the problem is due to the student or the teacher or the system itself. Whenever the teacher gets an intuition of something is wrong with a student, the framework can be used to identify the problem and act accordingly.11

Why to Support? – The rationale Before heading on to further management, there should be a decision on to whom the problem belongs to. Apart from the learners issues discussed before, the other issues also can predispose them to fall in that group. The contributing factor could be the teacher themselves when there is a personality conflict with the student or when the expectations are far high or being judgemental. The contributing factor could be the system when the teaching is not standardized, ineffective feedback mechanism, excessive workload or unclear standards. Factors associated with the teachers and system should also be corrected respectively.12 Page 46

The Self-fulfilling prophecy termed as “Pygmalion effect” by Rosenthal and Jacobson states that the students lived upto their teacher’s expectations. It is further explained by a vicious cycle where a person’s expectation on some other person’s behaviour serves as a self-fulfilling prophecy that reinforces their self- beliefs and modify their actions accordingly which in turn increases positive expectation from the previous one.13 Therefore, additional support to the students based on their need as either towards curriculum or psychology would have a positive effect on those students. Since the millennial generation students always desire to have positive feedback, mutual trust is needed between the student and the teacher for the feedback to be effective. Deficiency of faculty development programs and inappropriate measures of students’ success often lead to teacher centred feedback which turns out to be ineffective. Unconscious incompetency is more damaging to medical students. More damaging is a direct negative feedback to these students who perceive it as personality damage. The ego block the feedback approaching the concerned in right way and hence the feedback should always be constructive.14 Hunt et al studied the frequency of occurrence of problem medical students in clinics. The students were discussed in four groups based on the frequency of occurrence and the difficulty in managing them. More frequent and difficult to manage (type1) were the students who were shy and had interpersonal problems rather than cognitive. The next frequent but not difficult to manage (type2) were those with poor knowledge and skills and inefficient time management. The less frequent and difficult to handle (type 3) were students under substance/ alcohol abuse, psychological problems and manipulative students. Infrequent and not so difficult (type 4) were those students who show hostility or unavailable at all.15,16 To reduce the stress for the students in all these categories and to prevent attrition in medical and dental schools, sufficient and constant support from the teachers is mandatory.

How to support? – The methods The support strategies begin with proper identification, defining of the problem, differentiating the contributing factor as student themselves, teacher or the system followed by the supporting strategies.17,12 Documentation needs to be done at each step. Discussion with the students on how they perceive the issue will give a detailed input for the appropriate intervention. Though certain compromise are needed Ann. SBV, Jan-Jun 2017;6(1)

Students Needing Additional Curricular Support and Psychological Support (SNACS, SNAPS) – A perspective Shift

as a part of the supporting mechanism, compromise need not be done in vital areas like the clinical posting schedule or basic expected competency required of a health profession graduate.17Multiple interventions were discussed by Steinert et al that includes decreasing the workload of the students, change of posting batch / supervisor, availability of teachers other than class hours that facilitate individual discussions, support from mentors and peers, academic guidance, counselling and structured remedial programs.12 Vaughn et al proposed a modified S-T-P model originally given by Schmuck and Runkel’s for problem solving. This model was proposed since it had similarities with the doctor patient relationship from diagnosis to treatment and could be easy for them to implement in handling the student problems too. The S-T-P model stands for Specify the problem – Target state – Procedure plan. The first step (Specify the problem) is an information gathering stage which involves not only identifying the problem learner but also specifying them in which class they belong to like cognitive, interpersonal etc. The second stage (Target) involves a brainstorming session by the concerned student and the teacher on setting goals together to improve the situation. The identification does not stop with the teacher but also includes the self-assessment by the student and mutual feedback between the both. The third stage (Procedure/Plan/Path) involves decision making by the teacher on the steps to be taken. If the situation cannot be handled by the teacher’s supporting strategies, then decision should be made for referral to consultants in adult learning or psychologists based on the need. Irrespective of the modality a definite follow up protocol with feedbacks is mandatory.7 The key to success of the supporting mechanisms lies in the degree of motivation experienced by the students. There is no scope for motivation unless the basic needs of the students are taken care as per the Maslow’s Hierarchy of needs.18,19 Working through the steps in hierarchical needs helps to target the internal motivation and self-actualisation itself since extrinsic motivation can wean off anytime unless internalised. Setting reasonable goals in consensus with the student is one of the best supporting mechanism, as the

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achievement serves as a major motivation factor. The achievement motivation theory by McClelland supports the above said factors as reflectors of high achievement need.20 Motivation could be incorporated into the course by defining the course goals to the students, make them realize the relevance of the course, teaching them independent learning skills along with frequent feedback.21As per McGregor theory of assumptions22, theory Y where the teachers require an optimistic attitude on student’s progress and trust is required for the supporting mechanisms to be beneficiary. Mayer et al described the emotional intelligence as an ability to perceive the emotions in correct sense which enhances the emotional growth and intellectual growth as well.23 The concept of Social and Emotional Learning (SEL) would be of benefit to the students needing the support in general to modify their thought process and inculcate positive wellbeing. The CASEL (Collaborative for Academic, Social and Emotional Learning) describes five core competencies for SEL. This includes Self-awareness, Self-management, Social awareness, Relationship skills and Responsible decision making. These skills support the students to regulate their emotions effectively that enhances their quality of interpersonal skills. The emotional and social wellbeing leads to better performance.24

Summary Shifting of the perspective towards the Students Needing Additional curricular and Psychological support (SNACS, SNAPS) is a need of the hour. Labelling them as a problematic student will further damage the situation and needs to be avoided. The identification of the problem and classifying them based on the underlying cause and determining the contributing factors are essential before starting the supporting strategies. Not only a perspective shift but a paradigm shift in the thought process and actions of the teachers are necessary for the program to be successful. The system should also make sure that there are adequate faculty development programs for the teachers in this regard and availability of multiple supporting strategies to the students’ progress.

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Reference 1. Shivasakthy M, Sethuraman KR, Usha C. Learn slow, achieve low – Students Needing Additional Curricular Support and Psychological Support (SNACS, SNAPS). IERJ 2016;2(9):9-10. 2. Howard S. Becker. Outsiders. Studies in the sociology of deviance. The Free Press. Newyork. 1963. 3. Moniqueka E. Gold, Heraldo Richards. Label or Not to Label: The Special Education Question for African Americans. Educational Foundations, Winter-Spring 2012. 143-156. 4. Hallahan, D. P, & Kauffman, J. M. Exceptional children: Introduction to special education. Englewood Cliffs, NJ: Prentice Hall.1982 5. Jonathan Muema Mwania, James Matee Muola. Teachers’ Labeling of students and its effect on Students’ Self– concept: A Case of Mwala District, Machakos County, Kenya. International Journal of Education and Research 2013;1(10):1-7. 6. Ercole, Jacqueline, “Labeling in the Classroom: Teacher Expectations and their Effects on Students’ Academic Potential” (2009). Honors Scholar Theses. 98. http://digitalcommons.uconn.edu/srhonors_theses/98 7. Lisa M. Vaughn, Raymond C. Baker, and Thomas G. DeWitt. The Problem Learner. Teaching and Learning in Medicine 2015;10(4):217-222. 8. David C Yao, Scott M Wright. National survey of internal medicine residency program directors regarding problem residents. JAMA 2000;284(9):1099-1104. 9. Evans DE, Alstead EM, Brown J. 2010. Applying your clinical skills to students and trainees in academic difficulty. Clin Teach 7(4):230-235. 10. Rachel Bonnema, Abby Spencer, Mary Brown, Reed VanDeusen, Melissa McNeil. Dealing with the Problem Learner: learning is not always the problem! SGIM 2008, Annual Meeting April, 2008. 11. Steinert Y. The ‘problem’ junior: Whose problem is it? BMJ 2008;336(7636):150-153. 12. Yvonne Steinert. The “problem” learner: Whose problem is it? AMEE Guide No. 76 Medical Teacher 2013;35(4): e1035-e1045, DOI: 10.3109/0142159X.2013.774082. 13. Robert Rosenthal and Lenore Jacobson. Pygmalion in the classroom. The Urban Review 1968;16-20. 14. Robert G. Bing-You, Robert L. Trowbridge. Why Medical Educators May Be Failing at Feedback. JAMA 2009;302(12):1330-1. 15. Hunt DD, Carline JD, Tonesk X, Yergan J, Siever M, Loebel JP. Types of Problem Students Encountered by Clinical Teachers on Clerkships. Med Edu 1989;23:14-18. 16. Hunt DD, Khalid BA, ShahabudinSH, Rogayah J. The problem student on clinical rotations: A comparison of Malaysian and North American views. Med J Malaysia 1994;49(3):275-81. 17. William Edward Osmun, Jennifer Parr. The occasional teacher. Part 5: the learner in difficulty. Can J Rural Med 2011;16(4):131-2. 18. Nyameh Jerome. Application of the Maslow’s hierarchy of need theory; impacts and implications on organizational culture, human resource and employee’s performance. International Journal of Business and Management Invention 2013;2(3):39-45. 19. Avneet Kaur. Maslow’s Need Hierarchy Theory: Applications and Criticisms. Global Journal of Management and Business Studies 2013;3(10):1061-64. 20. Pardee, Ronald L. Motivation theories of Maslow, Herzberg, McGregor and McClelland. A literature review of selected theories dealing with job satisfaction and motivation. 1990. Educational Resources Information Center (ERIC). 21. Capturing and Directing the Motivation to Learn. Speaking of Teaching Fall 1998;10(1):1-4. 22. Matthew Stewart. Theories X and Y revisited. Oxford Leadership Journal. Shifting the trajectory of civilization 2010;1(3):1-5. 23. Mayer D John, Peter Salovey. What is Emotional Intelligence? Emotional Development and Emotional Intelligence. Chapter 1;1-30. 24. Marc A. Brackett, Susan E. Rivers. Transforming students’ lives with social and emotional learning. Handbook of emotions in education. Yale Centre for Emotional Intelligence. Yale University.

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Annals of SBV Sri Balaji Vidyapeeth

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