ASPIRE #37

CONTENTS Foreword Editorial Board Contributors Executive Committee AMSA Intl Activities Meet The Expert Health Issues Clinical Challenge Creative Corner Feedback Survey Media Partners

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Greetings, People of Tomorrow!

AMSA International eNewsletter proudly presents to you ASPIRE #37: Medical Education, Beyond The Public Eye! As medical students, we felt that it is only right for us to talk about our study environment, and explore the diversity within our beloved organisation.

In this edition, you will discover an array of amazing articles, as well as creative work by our lovely contributors. Hence, this eNewsletter would be the perfect read to entertain you during your downtime.

We hope you love this edition as much as we loved making it!

Virtus et Doctrina, Viva AMSA!

Best Regards,

Kassie Gracella Putri Chief Editor of eNewsletter AMSA International

EDITO BOA AMSA INTERNA AUSTRALIA

BANGLADESH

ENGLAND

Kirsten Tsan

Nashita Nowshin

Macy Au

MALAYSIA

MONGOLIA

Hasanah N

Byambasuren

HONG KONG

INDIA

INDONESIA

KYRGYZSTAN

Tania Chan

Samneet Singh

Priscilla Sayogo

Rahul Gautam

NEPAL Susmita K

PAKISTAN Bisma Arif

PHILLIPINES

SCOTLAND

TAIWAN

Lloyd Anicier B

Samantha Goh

Wendy Liu

ORIAL ARD ATIONAL 2021/2022

INDONESIA

PHILLIPINES

Shafira Meutia

Celestina Salvador

AUSTRALIA

INDONESIA

INDONESIA

Justin Lee

Garry Soloan

Gifta Hamiseno

INDONESIA

INDONESIA

INDONESIA

Charlotte Lintang

Florentia Amanda

Jauda Hanoon

INDONESIA

INDIA

M Raihan Ramdhan

Disha Suresh

Bhumika Raisinghani

Jibin Chacko

Kulisara Singsriwao

AMSA Indonesia

AMSA Phillipines

AMSA Thailand

CONTRIBUTORS.

Vittavat Tungdumrongvong

Thammakan Nampacharoen

AMSA Thailand

AMSA Thailand

Simran Rauniyar AMSA Nepal

Nadhira Tsurraya R.

Natthima Suwan

Pimsiri Siribunrit

AMSA Indonesia

AMSA Thailand

AMSA Thailand

Purevsod Lkhagvasuren

Yash Sanjaykumar Patel

Praveen Bharath S

AMSA Mongolia

AMSA India

Siena Placino

Rachita Reddy

Prayash Paudel

AMSA Phillipines

AMSA India

AMSA Nepal

AMSA India

With the theme of “High Yield Meeting to Bring Sponsors to Your Chapter”, the AMSA International Marketing & Sponsorship Masterclass was conducted on the 8 April 2022. As per its title, the event discussed strategies for and approaches to soliciting sponsors for an event organisation and invited two speakers to share their knowledge regarding this topic. Following the presentations, the participants were able to delve deeper into the subject and apply their new knowledge through a focus group discussion.

Our f irst esteemed speaker was Dr. Jack Yang who is currently a General Physician at National Taiwan University Hospital Hsinchu br. and was the Director-General of the 2017 Taiwan World Health Organisation (WHO) Simulation. He is also a fundraising instructor for workshops that are held by the International Federation of Medical Student Association in Egypt, Tanzania, Thailand, Mexico and Taiwan.

“No Projects would be Successful Jack Yang, MD

Dr. Yang’s talk about “Sponsorship Strategies 101” started by sharing his vast experiences in Rakuten and the 2017 Taiwan World Health Organisation Simulation, where he developed the conf idence in communicating with different nationals and the character of attentiveness in particular details.

It was imparted that in order to attract a sponsor, it is essential to know the event extremely well with a specif ic goal, exuding a professionally positive and grateful attitude with an emphasis on the other person’s shoes. Moreover, after citing the four categories of sponsors such as the Government, Private, Schools and Foundations, the pre-meeting weapons, meeting etiquette and post-meeting must-knows were also discussed.

“

without Sustainable Finances

Pre-meeting weapons are the materials meticulously prepared for the target sponsor/s containing all the information about the proposed event.

Meeting etiquette is basically about the f irst impression displayed- such as the professional appearance, proper hand-shake and the concise slides having a minimum of 1 minute to a maximum of 30 minutes. Most importantly, the post-meeting wherein the follow-up schedule should be established and the gesture of gratitude through a ‘Thank You Letter’ which also welcomes a possible network in the future.

Following the f irst speech was a second f rom Annisa Nur Insani, who served as the Treasurer of AMSA Indonesia in the tenure of 2020/2021.

Titled ‘The complete guide to write sponsorship prospectus”, Annisa’s presentation went over the basics and key elements of a sponsorship prospectus, the dos and don’ts of writing one, as well as the steps following the completion of a prospectus.

A sponsorship prospectus is a document targeted at potential investors of an event or organisation. This document would contain information on the event or organisation itself, as well as the opportunities and benef its the investors would gain. These opportunities may involve increased brand awareness, novel exposure and thus engagement, as well as presenting a positive reputation for the sponsor.

In a typical sponsorship prospectus, its information and contents would be structured into various sections that make up the anatomy of the document. These sections include a cover, table of contents, foreword, description of the organisation, an overview of the event, the sponsorship packages, testimonials, and contact details. Annisa then went on to elaborate on the different sections and the components they entail, as well as how they can contribute to making your event/organisation more attractive to potential sponsors.

During the Dos and Donts part of her presentation, Annisa shared tips on what to aim for when trying to market an event/organisation, including utilising branding and making the prospectus aesthetically pleasing, using data and statistics, making estimates using reports f rom the previous year, and being open to negotiating with interested sponsors. The ‘Donts’ included exaggerating numbers and statistics, assuming that your readers will already know about your company, and excessive explanations.

The presentation was concluded with an explanation of what comes after f inishing a sponsorship prospectus, and how to actually get the prospectus to target sponsors. These steps included contacting prospective sponsors, communicating the next steps to interested parties, being ready to further market your event/organisation, and following up on initially uninterested sponsors.

Following the two speeches, Dr. Yang and Annisa were invited to answer questions posed by the participants regarding the previously shared material. During this session, they provided advice on how to contribute to a marketing and sponsorship team with a lack of connections, including past and current sponsors in a sponsorship prospectus, as well as maintaining relationships with external organisations and parties.

After this f ruitful question and answer portion armed with all the pertinent basic knowledge shared by our adept speakers, attendees were grouped to discuss a given scenario and were tasked to present their concluded approach towards it. Everyone undeniably performed as a team producing different ways to handle a realistic situation when inviting a sponsor.

After each group presented their discussion results, the masterclass speakers provided feedback on the participant’s answers, adding further insights f rom their own experiences and knowledge. They highlighted that there was no one right answer to the case, and elaborated on the nuances of the possible approaches when applied in a practical and real-world context.

The event was concluded with a certif icate-awarding session for Dr. Wang and Annisa as a form of appreciation, as well as a closing statement f rom Eric Hsuan Cho as the Director of Marketing and Sponsorship. Upon the closure of the event, the participants were able to leave with enhanced knowledge and know-how regarding approaching and acquiring sponsors. Overall, this year’s marketing and sponsorship masterclass was a success.

Jauda Hanoon eNewsletter Editorial Board 2020/2021

MARKETING & SPONSORSHIP

Nur Hasanah eNewsletter Editorial Board 2021/2022

Bisma Arif eNewsletter Editorial Board 2021/2022

MEDICAL EDUCATION FROM AN EXPERT POINT OF VIEW

This edition of Meet the Expert session saw us meeting with Dr Ardi Findyartini (nicknamed Dr Titin). She is the Head of the Medical Education Unit & Head of Cluster of Medical Education Center of Indonesia Medical Education and Research Institute (IMERI). When talking about Medical Education from an Expert’s Point of View, there is no panelist more fitting than Dr Titin. Together with Bisma, we managed to cover quite a vast range of questions regarding medical education and how it has evolved over the years.

Question 1 Should students be involved in improving the current medical education?

Dr Titin: It is an obligation for medical institutions to uphold a student-centred learning philosophy by including the students’ feedback to improve the syllabus.

Since students are the ones going through the syllabus, it is only fair that they too have say in how improvements can be made. Moreover, it is crucial that the medical curriculum is designed in a way where it can meet the needs of the society in the 15-20 years to come, be it in urban or rural areas.

Question 2 Some medical institutions required an undergraduate degree before entering medical schools such as in the USA, Canada and a few more countries. How much difference do you see in terms of performance between graduate entries and high school entries?

Dr Titin: Currently, there is no report that specifically confirms that graduate entries are better than high school entries. However, certain reports do suggest a slight increase in performance amongst graduate entries.

Generally, mature students do have better emotional intelligence and maturity compared to younger students.

However, they do have their own challenges such as juggling between work life, their own families and study life. Meanwhile, high school graduates tend to be more indecisive and lack emotional maturity. It is the job of the medical curriculum to accommodate the differences between the two categories. Medical school does not only recognise one’s cognitive abilities, but also their emotional intelligence, communication skills and resilience can be made. Moreover, it is crucial that the medical curriculum is designed in a way where it can meet the needs of the society in the 15-20 years to come, be it in urban or rural areas.

Question 3 The pandemic has caused a major shift towards online learning in medical schools. How can we balance the use of technology and real-life teaching in medicine?

Dr Titin: The use of technology is inevitable these days, regardless of course you are in or whether you are studying or working.

Technology should not be the sole substitute for real-life experience, but it should be something that complements the students’ education in attaining competence. There is no doubt that students must undergo the real setting at work in hospitals, clinics and so on, but the use of technology may still be

implemented where suitable such as during theoretical lectures, seminars, and problem-based learning sessions just to name a few. The internet is a useful and resourceful place, but it can bring the dangers of cognitive overload. Hence, the dialogue between students and lecturers should be maintained always, despite the increasing use of technology in the medical education.

Question 4

Question 5

Apart from our own curriculum, we see some great websites like Coursera offering diplomas and short courses.

Do you see the importance of them for a medical student in their career.

Are they valid for their CVs? Should we really invest in them?

Research no doubt stands a lot of importance in a career of a doctor.

Would you suggest emphasising on conducting research before graduation, during our years in university?

Dr Titin: The courses are of great help when you want more information regarding the topic. If students get time apart from their own curriculum, these courses are a great investment. Their certificates can be added in CV but more importantly these courses are for personal growth and knowledge for students.

Dr Titin: Research is always exciting and challenging for medical students.

It should be brought into practice in medical school so that students can become familiar and when they have to do major researches in their professional field as doctors, they can have the confidence and knowledge

It was a pleasure meeting Dr Titin. We have been enlightened with her words. I hope they would help alot of us with our confusions and decisions ahead.

HEALTH ISSUES

Below mentioned are some of the ways in which a positive outlook on mental health can be maintained.

CHALLENGING BURNOUT & ITS EFFECTS ON MENTAL HEALTH. T H E MEDICAL YO U T H T O RIS E WIT H MOR E V IGOR...

Written by: Jibin Chacko AMSA Philippines Gullas College of Medicine University of The Visayas

Burnouts are no exception with the rising pressure in any field. Its also much common in the field of medical sector especially to medical students. There are several instances wherein due to extreme academic pressure , medical students get overloaded with the sessions that they are handling. This has a bigger impact to play on their mental health as well. The mental health of an individual can get aggravated through many ways as with the anxiety, stress & depression

that can creep in either through their study or work atmosphere. In fact, these factors in total can be of both external & internal.

The people in the medical education along with family, friends & co students are essential pathways the same could be determined.

Even though its much usual to see with burnout in this field, its even more essential in some or the other way to curb this issue & do the necessary steps to rejuvenate the youth from this degrading scenario.

1

Maintain a schedule that can balance work & interests Its much essential to understand that apart from the core interest that could be shared in the study sector , we must also find an angle where we could also exercise our time for people , family , friends & other interests that could help a lot in balancing or in combating the stress that one could experience from heavy loads of work.

2

A platform for consistent & regular exercise On medical & physiological basis speaking , exercise without fail is one of the key ways to fight stress.

The physical activity is with no doubt , a way to pump up the production of the brains feel- good neurotransmitters. By the strenuous activity, blood

circulation also facilitates a key role in having a push.

3

Well balanced diet Food is something that really cannot be compromised in any way.

It’s the main fuel to the body for the energy production.

When we talk about food, its on a prior importance also to depend if possible more on to the organic content. Water intake is also a salient feature in keeping the body cool, composed & more safer. Balanced diet with all composition of food varieties along with fruits & vegetables would enhance a better maintenance. Its also to be noted along with this that use of cigarettes & alcohol consumption which are adapted by some people are only temporary means to avoid stress & do also have a long term impact of negative effects.

4

A very supportive team The environment & people around us matter very much in terms of the mental health & stability that should be maintained.

Learn to be with positive people who can spread inspirational & motivational messages.

Avoiding a crowd with negativity can also go a long way in building self confidence & improving on stress

5

Keeping hobbies in list

One must always have an eye on a bucket list of hobbies where your real fun, joy & enjoyment comes.

This provides the slot to replenish yourself from all the other areas of the work that you are engaged with.

6

Techniques as to meditation Meditation has proved to be a very efficient practice in providing a space to know ourselves more & to have a self contemplation. This self contemplation can bring in many acts of self realisation that can help understand one’s own value & beliefs &

can find ways in improving in areas that are supposed to be & thereby mind based reduction of stress.

7

Sleep Sleep is the time during which the body can help a lot in removing the waste products. It is thus of higher importance to maintain proper & needed timings with sleep as this duration also helps to regain back energy for work & also in leaving out stress. It’s a perfect time to regain with judgement , improving concentration & better decisions in the making.

8

Pets A pet/ pets can from a very lively circle with humans.

Especially for those who are staying alone, having a pet can also keep you amused, friendly & in a positive vibe.

This prevents you from feeling lonely & also helps to reduce stress by staying active.

9

Vacation/break A break from one’s occupation will help a lot

in renewing the strength itself. This would help provide time to be exposed to the nature itself & feel the positive energy that can help reset our template of work & flush out toxic means of stress

10

Therapy/counselling If all the remedies that could be tried haven’t worked with one’s own innate efforts, then it’s the right time to seek for psychological assistance through means of proper counselling & therapies which could pave way for better directions in life for stress reduction.

A positive & strong mind can help any individual to soar higher. For any medical student to achieve the same & to stay confident , its necessary to achieve ways by which the same could be exercised.

This long term mission to fight burnouts will surely lay better goals for a more colourful life to dwell.

REFERENCES Stoll M. 10 simple ways to cope with

stress [Internet]. Place

unknown : Sutter Health; Date unknown . Available from: https:// www.sutterhealth.org/health/ mind-body/10-simple-ways-tocope-with-stress

In order to be a successful medical student, the passion is required. Students in any field, especially in medical field which requires a lot of patience to understand complex mechanisms of our bodies and good memorising skills, are not considered a successful one if they get good GPAs and are actually unhappy with their studying life due to the lack of passion for their future careers, the overloading tasks and lessons, the competition as well as the work/life balance. Sometimes, the problem is not solely the student but also the system itself or the social belief.

“ Passion happens when we like what we do and experience. ”

Written by: Kulisara Singsriwao AMSA Thailand Medicine, Phramongkutklao College of Medicine

Vittavat Tungdumrongvong AMSA Thailand Medicine, Phramongkutklao College of Medicine

Pimsiri Siribunrit AMSA Thailand Medicine, Phramongkutklao College of Medicine

A sophisticated medical student once gave a metaphor of growth mindset as an arrow, people can change their directions of their own arrows to go forward or backward; this can actually be fixed mindset if we don’t know the reason of having that particular growth mindset.

We have to find the long terms of our growths which are not work-related, we have to focus on life experiences and our indeed happiness not just the work productivity.

Medical students have to handle multiple commitments including teaching, clinical attachments, exams, extra-curricular activities and social life. Massive academic workload and clinical tasks can affect

medical students work-life balance and wellbeing. The term work-life balance includes selfcare. If not addressed properly, physical and mental health problems can follow in students. The key is to adjust effective work-life balance.

Universities should support students in overcoming these challenges. They may provide multiple interventions at different phases of time such as studying skill lessons and time management.

Extroverted people seem more helpful for the society in the terms of good communicating and may steal all the lights from the introverted; Yet they can happily be together in the society. Some societies lowkey force students to be more extroverted when it’s not their ways of expressing themselves.

Many medical students have an idea to drop off from college because of the lack of interest to medical lessons, their families, the economy, the pressured environment or the ones that doesn’t fit them, some students gave up on this toxicity and actually dropped off, some couldn’t do it because of stigma; they’re scared of being seen as “losers” when they deeply just want to start their new chapters with new studying paths or even in another medical colleges. No matter which reasons are why they have the idea of dropping off, they should be heard and supported since staying in the area that can’t make your attention and spirits bloom like white blossom won’t let them make it to the end which is being decent doctors.

Written by: Natthima Suwan AMSA Thailand Faculty of Medicine, Srinakharinwirot University

PROBLEM-BASED LEARNING: Online Problems and Adaptations for Asians Problem-based Learning (PBL) was implemented in many Asian medical schools1, with the expectation of archiving a better learning method. Moreover, it is a promising tool to develop 21st-century skills such as creativity, communication, collaboration, and critical thinking.2 Due to the different cultural learning perspectives of Asians, the outcomes do not match the expectation. Nevertheless, abandoning PBL is neither a better option as the world progresses into a knowledge-based economy. The need for practitioners who have 21st-century skills will never diminish. Therefore, the PBL adaptation in Asian countries is essential.

What is PBL? PBL lies in lifelong learning and Bloom’s Taxonomy. The taxonomy classifies the level of learning into six levels; Remember, Understand, Apply, Analyse, Synthesise, Evaluate, and Create.3 The higher the thinking level, the better the brain learns the information and the higher its ability to perform tasks.3,4 The processes of PBL start with a presentation of a problem which is a trigger for students to find relevant information.

The self-directed learning session already archives a higher thinking order than the traditional lecture-

based learning because the students must at least select and determine the relevant information.

Discussion and argument sessions enhance even higher thinking levels such as analysis, synthesis, integration, and application of the newly acquired knowledge.5 Moreover, during the discussion session, students also develop communication and socialisation skills6, which will be beneficial in the clinical years. In other words, the processes of PBL are designed to enhance the thinking levels and ability to learn.

Different Cultural Perspectives on Learning It may be a shared Asian culture where younger people respect authority and people with seniority and status. This culture embeds deep in the Asian learning perspectives. The teachers and mentors are highly respected morally and intellectually.

Therefore, learning is heavily on a teacher-based centre, in which teachers provide students with knowledge and more. The knowledge evaluation is mainly a searching process for academic performance excellence, resulting in

students focussing on obtaining information instead of sharing opinions.6 As the education system aims for academic performance excellence, competition is inevitable.

The attitude of viewing peers as opponents is typical. Furthermore, fear of showing ignorance, irrational questions, and comments on academic performance, students develop discomfort and unwillingness to share knowledge and participate in the group discussion.

Another hindrance that makes PBL not as effective in Asian countries is the unfamiliarity with self8 learning . As mentioned, Asian learning is dependent on teachers.

The students develop a

mindset that teachers should provide them with sufficient resources, and their responsibility is to gather the most of them.

However, in PBL, the students must develop higher thinking processes than understanding and applying information.

Therefore, the discussion session may be only a sharing instead of evaluating and synthesising knowledge.

The different cultural learning perspective of Asians affects the outcomes of PBL. Methods in PBL such as face-toface interaction, sharing opinions, and self-learning are unconventional to an Asian learning culture.

Hence, the PBL outcomes are not as successful as the West.

PBL During Online Learning Since the Covid 19 outbreak, many medical schools use online learning systems.

Due to the restriction of social distancing, PBL designed for face-toface interaction cannot continue.

Instead, the schools use meeting platforms, for example, Zoom, Microsoft team, and others during the discussion sessions.

Using a digital platform can promote students’ participation and cognitive development.7 According to my personal experiences and interviewing a few first and second-year Thai medical students, the results contradict the expectation.

The participation is still low.

Dead air, tiredness, and disfavour are stated.

Despite the teacher’s encouragement, some students are still unwilling to discuss.

Inadequate knowledge seems to be the problem of the low interaction. Besides,

frequent group changes and large group sizes (more than ten people) are mutual.

The cultural learning perspectives are still the main factor of low contribution. Additionally, few in-person group activities due to social distancing, communication problems due to internet connection, and medium errors discourage students’ participation.

Consequently, the online PBL has an even more undesirable result.

ADAP T AT IO NS F OR ASIANS

Smaller Close PBL Group

Implementing PBL to be as successful as the West is challenging. It involves time-consuming, patiently changing the mindset of students about learning and encouraging them to discuss. However, the environment and some activities might improve PBL outcomes.

1

Creating a Supportive Environment

Even though the cultural perspectives on learning are an aggregation of beliefs and experiences, they can be changed. For example, Asian students who study abroad typically have more confidence to speak up and share their opinions. The Asians have a karaoke culture, a conductive environment encouraging people to sing and have fun.1 Therefore, creating a supportive and entertaining environment contributes greatly to student participation.

Role of Teachers as the Moderator

2

Asian students seldom ask questions or share their opinions unless they are asked.6 In Asian countries, the teachers might have to be more than a facilitator to the student learning process but a moderator who initiates the question and creates a supportive environment.

3

4

The studies show that the productivity of a group performing a task decreases compared to individual performance.8 To engage the student effort, the size of the team should be small as it can increase the motivation and involvement of students.

Increase Group Activities The sudden change of the learning style from individual to teamwork may cause unfamiliarity and an inability to adapt. Therefore, group activities gradually teach what a team is and develop interpersonal skills. Also, the activities may change the competitive mindset to welcome group study.

Asian culture values relationships in workplaces. Trust and cooperation develop during work. The students may find it difficult and uncomfortable to work with new peers. To increase the feeling of belonging to the group and promote interrelationships among students, the change of group members should not be frequent at first.

5

Evaluation Changes to Team Performances and Individual The competition among students in Asian culture is difficult to devalue.

However, an alteration of scoring to have a team performance and individual score may direct students’ mindset to value teamwork.

Using E-learning to Promote Self-Learning

6

The customary teacher-based learning was one of the hindrances to PBL’s success. Due to a short adaptation time, the students may not accustom themselves to the new learning style. The inability to adapt can cause other problems, for example, stress. So, students should have access to supportive resources, for instance, online lecture videos and quizzes. The availability of E-learning also promotes self-learning: an important skill for future physicians.5,9

7

Student Understanding of the Theories and Benefits of PBL Despite all PBL engaging factors, the failure to comprehend PBL theories and benefits leads to incorporation among students. They might view the PBL process as unavailing, therefore, having no attempts to change their study methods and participate in the discussion.

Therefore, before doing PBL, the schools should provide students with basic principles and potential benefits of the activities.

REFERENCES: 1. Gwee MCE. Globalization of problem-based learning (PBL): crosscultural implications. Kaohsiung J Med Sci. 2008; 24(3 Suppl): S14-22.

2. Wartman SA. The empirical challenge of 21st-century medical education. Acad Med. 2019; 94(10):1412–5.

3. Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med Libr Assoc. 2015;103(3):152.

4. The Learning Center. Higher order thinking: Bloom’s taxonomy [Internet]. Chapel Hill: University of North Carolina: 2022 [cited 2022 Apr 15]. Available from: https://learningcenter.unc.edu/tips-and-tools/ higher-order-thinking/ 5. Gwee MCE. Problem-based learning: a strategic learning system design for the education of healthcare professionals in the 21st century.

PBL is student-centred learning which promises higher thinking levels and 21st-century skills. Despite its promising outcomes, the learning differences of the Asians, for example, seniority respect and teacher-centred learning are the cultural barriers, resulting in PBL being unsatisfactory. The Online PBL reports are neither more successful. The developing PBL processes require time and commitment from all involved parties. Nevertheless, promoting discussion involvement of students through group activities, changing the role of teachers as moderators, a small group in PBL, changing evaluation criteria, E-learning to support self-learning, and students having a clear understanding of the theory and processes may improve the PBL outcomes.

Kaohsiung J Med Sci. 2009; 25(5):231–9.

6. Raymond CY. Understanding Asian students learning styles, cultural influence and learning strategies. J Educ Soc Policy. 2017;7(1).

7. Aslan A. Problem- based learning in live online classes: Learning achievement,

problem-solving

skill,

communication

skill,

and

interaction. Comput Educ. 2021; 171:104237.

8. Amichai-Hamburger Y. Understanding social loafing. In: Sagie A, Stashevsky S, Koslowsky M, editors. Misbehaviour and dysfunctional attitudes in organizations [Internet]. London: Palgrave Macmillan; 2003 [cited 2022 Apr 17]. 79–102p. Available from: https://link.springer. com/chapter/10.1057/9780230288829_5 9. Shimizu I, Nakazawa H, Sato Y, Wolfhagen IHAP, Könings KD. Does blended problem-based learning make Asian medical students active learners?: A prospective comparative study. BMC Med Educ.

2019:19(1):147.

MEDICAL SYS T EMS: Mongolia

MEDICINE AND MENTAL HEALTH ALONG SILK ROAD The Silk Road was a 4000-mile route that helped connect Asia and Europe during ancient times. Along the route, precious goods were exchanged from both ends of the continent, medicine and diseases included. Presently, this route covers a few countries in Asia. We have collaborated to provide you with salient features of medical systems along with hot spots on the road: Mongolia, China and India.

■ MBBS - 6 years including basic sciences and para-clinical subjects.

■ Each year has 120 hours of study of these subjects ■ In recent years, medical practice has been cancelled due to the COVID 19 pandemic ■ Daily exams are outdated tests that are used every year.

■ Final exams to graduate contain stations similar to OSPE/OSCE ■ A Bachelor’s degree programme in Medicine has been accredited by ASIIN in 2016 ■ Implements many training programmes for student researchers ■ As experienced by the Mongolian National University of Medical Sciences MNUMS

China ■ MBBS 6 Years incl. basic science; para-clinical and clinical subjects ■ Exams are conducted at the end of each semester. Each year consists of two semesters.

■ Internship of one year included.

■ Exam Pattern includes MCQs, Terms, and long and short question answers.

■ Research is not mandatory for undergraduate students.

■ As experienced by JIANGSU UNIVERSITY

India ■ MBBS – 5.5 Years including basic sciences, para-clinical and clinical Subjects ■ Exams are conducted annually. A new system was introduced in 2019.

■ Newly introduced AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy) education promotion during the internship ■ During the pandemic, classes were shifted to online leading to little to zero clinical exposure.

■ Internship of 1 year included within the course ■ New “Adoption of a Rural Family” programme to be executed ■ Research is not mandatory for undergraduates ■ Used to be only subjective answers with long essays as exams. Included MCQ components recently in the new system.

■ As experienced from KAP Viswanatham Government Medical College

MEN T AL DIS T R ESS AMO NG MEDICAL S T UD EN T S We’ve come up with a few reasons from the medical systems that have contributed to increasing the burden on their mental health.

Mongolia ■ Manifold academic stress in all courses.

■ College is situated far from home. For example, the distance between Ulaanbaatar and Bayan Olgii is 1277.3 km. This distance is equal to 793.68 miles. Medical schools are located in Ulaanbaatar, the capital of Mongolia, which is a two-day bus ride away from the farthest aimag, BayanUlgii. (Aimag, a provincial equivalent in Mongolia).

■ Being away from home leads to psychological problems, such as loneliness and stress.

■ The Common Mongolian branch that is widely spoken in Mongolia is made up of roughly 6 languages, which makes interactions among medical students and studentpatient interactions difficult.

■ Different writing systems cause confusion. There are 4 different types of systems: Traditional Mongolian (in China and Mongolia), Mongolian Cyrillic (in Mongolia and Russia), Mongolian Braille and Phags-pa.

■ There are a lot of negative socio-economic issues surrounding Mongolia.

■ Stress-induced smoking is common among university students. (ELECTRONIC CIGARETTES are more famous than TOBACCO).

■ Lack of libraries and other facilities for individual and group study.

■ Information on events such as scholarships and student exchanges is not easily available to all students.

China ■ The Determinants of depression and anxiety included individual factors, social and economic factors, and environmental factors.

■ It has been reported that academic pressure and study loads, financial difficulty, being away from home or unstable family, and campus bully can all increase the risk of mental health disorders.

■ Obsessive compulsion, interpersonal sensitivity and depression are the top three reported problems in university studied students.

■ The COVID-19 pandemic has a negative impact not only on physical health but also on psychological well-being, particularly when the outbreak lasts longer and is still developing.

■ During the lockdown period, students did not get permission to go outside the campus. Most of the people, except for those involved in epidemic prevention and control, the police, and a few workers

of necessary industries, were required to stay at home. This played a massive role in the mental breakdown of students especially.

■ Higher depressive symptoms were reported in students with smoking and drinking habits, poor adaptability, and sleep deprivation and in those who had been hospitalised or received medication for 1 week or more in the last 4 weeks, were at a lower academic grade level.

■ Those who had a low monthly family income per capita, parents with a poor educational background, a strained relationship with classmates, a broken family, financial debts, and a family medical history.

■ Many overseas students are struggling with their mental health over the past few years because of online classes as China is still not ready to open its borders and is worried about their degree and practical knowledge.

India ■ Medical students’ lifestyle have integral components like skipping meals and having financial responsibility.

■ The location of the college in a vast country is mostly far from home and having different languages, cultures, and habits to be acculturated by the student within a short time span while balancing academics with it is stress-inducing.

■ Using more years in preparing for medical entrance examinations leads to a higher age average within medical colleges and was found to have a direct proportion to the stress level.

■ Vastness of academic curriculum.

■ Fear of failure in exams due to unfair reasons not pertaining to academics.

■ Single annual examinations and not based on semesters or blocks.

■ Small group clinical discussions often clash with afternoon lectures in content and end up burdening readers and rather promote procrastination.

■ Using internationally renowned books in the initial part of the year and ending up relearning from Indian authors before the exam as they have a more relatable approach and patients for demonstration.

■ Not a lot of students make notes during reading and end up buying commercial notes from other students/seniors.

■ Rampant substance abuse involving alcoholism and smoking leads to downgraded health among students.

■ The existence of an authoritarian hierarchy may promote an unsupportive and low-nurturing flow of education to underlings.

■ High parental expectations and loneliness as a result of parental support during pre-medicine and post-medicine infer guilt to children if underperform than peers.

IN F ER EN C E Common issues: ■ Colleges being far from home and miss their warmth during difficult times.

■ Stay-at-home during the pandemic led to decreased clinical skills.

■ Family and Peer relationships if strained had a negative impact with regard to intimacy and socioeconomic levels.

■ Dependence on local languages for patient interactions ■ Outdated testing systems and vast syllabus leading to cramping of details.

■ Campus bullying and substance abuse

Written by: Purevsod Lkhagvasuren AMSA Mongolia Mongolian National University of Medical Sciences-MNUMS, Mongolia Yash Sanjaykumar Patel AMSA India-AISEP Jiangsu University, People’s Republic of China

REFERENCES: ■ Aoki A, Togoobaatar G, Tseveenjav A, Nyam N,

org/10.1186/s12909-019-1744-2

randomized

Zuunnast K, Lkhagvasuren G, Shagdar BE, Mori R,

■ 6.

Community Medicine. 2021;46(4):735.

Kikuchi A, Soya H, Kasai K, Takehara K. Socioeconomic

college students and associated factors in Hubei

■ 10. 2. Anuradha R, Dutta R, Raja J, Sivaprakasam

and

of China. PLoS ONE 16(7): e0254183. https://doi.

P, Patil A. Stress and stressors among medical

health problems among Mongolian students. Soc

org/10.1371/journal.pone.0254183

undergraduate students: A cross-sectional study

Psychiatry Psychiatr Epidemiol. 2022 Apr;57(4):791-

■ 7.

in a private medical college in Tamil Nadu. Indian

803. doi: 10.1007/s00127-021-02178-7. Epub 2021 Sep

and Yi Xu.Psychological Outcomes and Associated

Journal of Community Medicine. 2017;42(4):222.

30. PMID: 34595562; PMCID: PMC8483169.

Factors Among the International Students Living

■ 11.

■ 2.

in China During the COVID-19 Pandemic https://

Gnanadurai T, Ayyavoo S, Manickam T. Perceived

Eshita, Peng Qin, Lifu Chen, Juan Sun.The impact

doi.org/10.3389/fpsyt.2021.707342

stress and sources of stress among first-year

of academic stress on medical students attending

■ 8.

Peng Xiong, Wai-kit Ming, Caiyun Zhang,

medical undergraduate students in a private

college in the Inner Mongolia Area of China. Open

Jian Bai, Chaohua , Wenyuan, Fan Zhang and Qian

medical college - Tamil Nadu. National Journal

Journal of Preventive Medicine 03(02):149-154

Tao.Factors Influencing Mental Health Among

of Physiology, Pharmacy and Pharmacology.

■ 3.

Chinese Medical and Non-medical Students in the

2016;6(1):9.

Early Stage of the COVID-19 Pandemichttps://doi.

■ 12. 4. Brahmbhatt K, P N, S P, S J. Perceived

org/10.3389/fpubh.2021.603331

stress and sources of stress among medical

with UNICEF in tackling mental health issues in

■ 9.

George N, Priyadharshini K, Britto D, Nirmal

undergraduates in a private medical college

teenagers. 255489

S, Tamilarasan M, Kulothungan K. Assessment of

in Mangalore, India. International Journal of

■ 5.

stress, resilience, and coping style among medical

Biomedical and Advance Research. 2013;4(2).

factors

associated

with

mental

Jie Chen, Yanyan Wu, He Yi, Zhijun Li, Yuki

World Health Organization. The Global Youth

Tobacco Survey (GYTS). MONGOLIA 2019 ■ 4.

Praveen Bharath S AMSA India KAP Viswanatham Government Medical College, India

lifestyle

Munkhzul

A.

Montsame.

Partnering

Mao, Y., Zhang, N., Liu, J. et al. A systematic

Lei X, Liu C, Jiang H (2021) Mental health of

Md. Dhedharul Alam , Jing , Li Ni, Shaohua Hu

review of depression and anxiety in medical students

students

and

effectiveness

of

intervention

in China. BMC Med Educ 19, 327 (2019). https://doi.

programs on stress level in South India: A non-

3.

control

trial.

Swaminathan

Indian

A,

Journal

Viswanathan

of

S,

Written by

Prayash Paudel AMSA Nepal MBBS, Maharajgunj Medical Campus

If you resonate with the sounds of burn out!

“As we are done with all bones, we are going to take viva coming Thursday, be ready!”

Ok, ma’am!

“The general portion of integrated basic medical science is completed and we will have a general examination very soon; if you fail, you will not be allowed to stay for the board examination, do you understand?”

Yes, sir!

“This weekend on Tuberculosis Day, we are collaborating with the Department of Pulmonology and Communicable Diseases to organise a grand programme where we will be keeping stalls, visiting an old age home to collect samples, and so on. Are you all good to volunteer?”

Why not, sir!

“April is World Autism Awareness Month and we are collaborating to organise awareness stalls and continue the ‘Light it Up, Blue’ programme as well. Are you in?”

Yes, I am in!

“I will be a bit busy today, will you please help me in taking practical classes for your juniors?”

How wonderful were those days?

But today, you wake up not wanting to do anything from among the same set of activities you loved to get engaged in anytime anywhere then. Today, you fantasise about not having to see Bailey and Loves’ in front and want to take a break. You fail to find a purpose in the field you were previously so interested, good at, and wanted to be wholehearted.

You have gradually lost interest; felt you are not good at it anymore and found a long-lasting lag, incompetence, exhaustion, isolation, cynicism, and helplessness. If it’s not you, it’s 59% of millennials, 58% of Gen Z, 50% of medical students, 42% of physicians, and 40% to 70% of healthcare workers (1). Is it not a terrifying statistic if I say this much percentage of people experience burnout and medical burnout has

Good To Know!

Malachi Burnout Inventory, the gold standard for measuring burnout captures emotional exhaustion, depersonalisation, and reduced personal accomplishment as three parameters!

Reality check – for a lot of us today, life is a rat race. Race to study the whole night to become the one to cover the syllabus earliest, race to participate in as many extracurriculars to stand out, race to collaborate and volunteer in every health-related day celebrations to include something extra in your CV, race to help in both personal and professionals of professors to please them. We have already ingrained the wrong definition of sincerity early on in the medical fraternity. Sincerity and resilience considered good benchmarks for medical students today are in ‘never say no or never and do whatever you have been told without any complains and contraindications.’ This culture makes medical students forget there is indeed a limit to human endurance and we must respect it.

Though chronic stress due to student debt resulting in burnout is not prominent in Nepal, it is prominent in many countries.

How do you know if anyone around you in your classroom or medical fraternity is experiencing burnout? ▶▶ Does not enjoy his daily to-do’s ▶▶ Detachment: fails to identify and sync with the true purpose of joining medicine then ▶▶ Lacks competence, confidence, and compassion: the feeling of being incapable or not good at studies and clinical doings’ anymore ▶▶ Reduced performance and productivity ▶▶ Physical signs like sleeplessness, headache, fatigue, nausea, joint pains ▶▶ Anxious, hopeless, sad, and depressed ▶▶ Annoyed with people around ▶▶ Has lately started misbehaving with colleagues and professors ▶▶ Has started fantasising to drop out! ▶▶ To get rid of anxiety and stress, one starts drinking alcohol, using drugs, and smoking. In the study to correlate burnout and alcoholism among medical students, one-third of students were found to meet diagnostic criteria for alcohol abuse/ dependence and burnout was the prominent reason(4).

How normal is burnout then and how are you supposed to get rid of it?

Burnout is normal and has nothing to do with your capability to cope with stress. To handle burnout, you should start normalising self-care, a good complete sleep, mental health vacations, no whole night study to cover the entire syllabus or prepare for papers/viva, stay in a close circle of supportive friends and very importantly understand burnout.

MailOnline featured life coach Niki Plus who shared to her audience on TikTok that burnout recovery can take 3 to 5 years. See, it does take time! Why not opt for team effort among students, professors, coordinators, and management of medical schools to help cope with burnout and remain competent, and productive throughout, shall we?

References:

1.

Kaushik C. Medical burnout: Breaking bad. AAMC. 2021 Jun 4; 2.

Mian A, Kim D, Chen D, Ward WL. Medical student and resident burnout: a review of causes, effects, and prevention. J Fam Med Dis Prev. 2018;4(4):1–8.

3.

Bayes A, Tavella G, Parker G. The biology of burnout: Causes and consequences. The World Journal of Biological Psychiatry. 2021;22(9):686–98.

4.

Dyrbyne LN. Study: Around 1 in 3 Med Students Abuse Alcohol. Physician’s Weekly. 2017 Mar 6;

Written by Rachita Reddy AMSA India 2nd Year MBBS, Vydehi Institute of Medical Sciences

M

edicine is a demanding profession that requires both physical and mental effort.

In 2021,15,44,275 candidates took the Indian medical school entrance test; 8,70,075 passed, but only 75,000 were chosen. The training is academically and personally challenging, lasting over 5 years. Many people pursue medical courses because of family pressure instead of genuine interest which can lead to dissatisfaction and hinder access to treatment.

Suicide is the top cause of mortality in India, which has the world’s largest population of people aged 10–24 years.

In a news report about nearly 10,000 students attempting suicide in one year, ‘academic trauma’ was identified as a

“

[...] ‘academic trauma’ was identified as a cause of student suicide.

”

Students must deal with academic as well as social demands. Over the past few years, there has been a steady rise in anxiety, depression, and frustration.

To deal with stress, students succumbed to substance abuse, which has led to psychiatric problems. The repercussions of substance abuse are violent conduct, mental instability, and memory and cognition loss.

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MENTAL HEALTH ISSUES AND BURNOUT IN MEDICAL STUDENTS

Increased number of exams, high competition, reduced time, external pressure, and high level of difficulty contributes to mental health problems.

An unhealthy mind can cause increased levels of cortisol and adrenaline, which shall result in burnout of the student. The student tends to give up on their career, attain emotional exhaustion due to low marks, and lose a sense of personal accomplishment.

Mental health has gained increased attention in recent years. Many people strive for a balanced lifestyle to achieve mental stability. We are taught as medical students the importance of having a healthy mind and how it might affect our physical health. Even though we are studying the subject, we are nevertheless under pressure to be on time, financially self-sufficient, academically excellent, and socially active. All of these variables contribute to feelings of weariness, incompetence, and emotional incapacity.

Among an age with high mental health issues, studies have proved that medical students are the most vulnerable group. This has far-reaching ramifications for medical education institutions and the general public because we already know that psychological discomfort and mental illness in medical trainees and physicians have negative consequences for their present and future patients. Medical students are also at a higher risk of acquiring eating disorders.

“

An unhealthy mind can cause increased levels of cortisol and adrenaline, which shall result in burnout of the student.

”

Mental health issues can worsen and lead to despair, anxiety, and, eventually, student burnout. Chronic exertion and work overload cause burnout. People lose motivation and become tired. There is a loss of motivation, exhaustion, lack of leisure time, sleep deprivation, and emotional drain from sick and dying patients. Students who are burned out find it difficult to put forth effort in whatever they are pursuing, their emotions are blunted, and they feel hopeless.

Burnout has the potential to harm medical students’ professional growth, as well as their personal and professional traits. Decreased patient satisfaction and increased medical errors are consequences of burnout.

One of the key stress-inducing factors is a lack of social support.

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X

X

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Discussing possible doctors’ performance regarding healthcare conditions and overall quality of treatment, the purpose is to avoid medical students’ susceptibility to job burnout from manifesting itself largely during their studies. To achieve this, techniques for increasing students’ social protection, supporting their adaptive defence strategies, reducing overall distress and dysfunctional coping strategies, and addressing fatigue and dropout intention must be developed.

“

The importance of mental well being must be highlighted [...]

”

The importance of mental well being must be highlighted along with improving the quality of treatment. Maintaining a sleep schedule will have a positive impact on overall health. During rest, the body rejuvenates, and all hormone levels reach equilibrium, this, in turn, helps in improving mental health and stabilising one’s thoughts. Developing an encouraging social circle prevents burnout due to stress. To cope with stress students can go to a therapist or practise yoga and meditation. However, due to fear of jeopardising professional advancement medical students may not seek help for mental health disorders and suffer greatly.

The first step in improving one’s mental health is to identify it or receive help from a qualified professional.

X X

Written by

Siena Kathleen V. Placino AMSA Philippines St. Luke’s Medical Center College of Medicine William H Quasha Memorial.

introduction

&

MENTAL ISSUES BURNOUT

in medical students

M

edical education on its own is already a grueling, exhaustive experience often consuming half of students’ early 20s with endless exam preparation, cramped schedules, and unavoidable stressful situations in a highly competitive environment. With “normal” medical student stressors aggregated on to universally distressing experiences caused by the COVID-19 pandemic, it comes as no surprise that the mental wellbeing of medical students are suffering. Academic stressors on top of multifactorial stressors from the ongoing pandemic involving health concerns and socioeconomic pressures are at a threatening level and increasingly predisposes medical students to mental health issues such as anxiety and depression, excessive stress and burnout. (Halperin et al., 2021)

mental health issues in medical students Stress, Anxiety and Depression: The Cost of Medicine Anxiety and depression are common in medical students given their highly competitive environment and constant high stress situations. One study conducted in a private medical school in the Philippines found that almost onefifth- of the first to third-year medical students have depression, with the highest prevalence among second-year medical students, males, 20-22 years old. (Paulina et al., 2019) Findings of anxiety and depression are found in several other local studies as well (Berlin & Singson, 2020) and one phenomenological studies even goes so far as to say Philippine medical students are living a “life on a tightrope,” considering the amount of academic stress they are burdened with. (Garan-Giller et al., 2019) Another study focused on health-related quality of life of medical students in the Philippines found that depression, stress and burnout were more significant than physical health issues, since these were limited to mostly physical functioning and bodily pain related to vitality and role limitations due to emotional and mental health problems. (Domantay, 2014) Similar findings in multiple studies in other countries imply that this is not an isolated experience for medical students universally. One such study assesses the potential stressors of medical students including but not limited to: academic demands (e.g., vast syllabus, frequent

exams, inadequate feedback, lack of time, transition (e.g., from undergraduate and early education, from preclinical to clinical phase, lack of communication skills, etc.).

(Rubaba Azim, 2021) These factors were also found in the Philippine study by Domantay (2014) which observed the same adjustment problems and experiences of academic overload. Personally, when I first read these two studies, I saw myself and my fellow peers reflected in the medical student participants and found incredibly similar stressors in my own environment.

Similar findings of mental health issues, most commonly anxiety and depression are found in other studies in different countries including China (Zeng et al., 2019), Indonesia (Ramadianto et al., 2022), Nepal (Pokhrel et al., 2020) (Kafle et al., 2021), Jordan (Seetan et al., 2021), Portugal (Oura et al., 2020), Spain (CapdevilaGaudens et al., 2021), Ireland (O’Byrne et al., 2021), the United States (Halperin et al., 2021), and throughout Asia (Cuttilan et al., 2016). High prevalence of depression, anxiety and burnout are seen not only in medical students, but residents as well although medical students were more prone to anxiety (Pokhrel et al., 2020) especially those in their early preclinical and clinical years. (Ramadianto, Adhitya Sigit et al., 2022)

“

High prevalence of depression, anxiety and burnout are seen not only in medical students, but residents as well .

”

Burnout secondary to psychological distress was found to be a multifactorial result of an overwhelming and consistent burden of stressors (Pokhrel et al., 2020) mainly involving academic-related pressure, overwork, lack of leisure and sleep time, and the coinciding of medical training years with major life events. (Mian, 2018) I find myself pondering at times, as an unmarried and financially dependent 24 year old female, when I would reach the milestones my non-medical peers seem to have already passed, a somewhat isolating feeling reserved for most medical students as they dedicate their time and efforts to academia and their future profession. Solely strung by the core concept of “delayed gratification,” that “our time” will eventually come for

those life milestones, can only do so much for us. In effect, Mian (2018) finds that the effects of burnout are equally disastrous.

Several consequences mentioned include clinical signs of distress and depression, professional impairment, a considerably alarming effect given that this profession is sensitive to the life and death of patients, predisposition to dropping out, drug, alcohol and substance abuse, and suicidality. These alarming effects implicate how essential empathetic action and intervention is needed for medical students undergoing overwhelming psychological distress and prevent burnout from occurring or becoming too severe.

covid-19: exacerbating psychological distress and burnout It is difficult to imagine these already taxing pre-pandemic stressors medical students face in tandem with the onset and continuing strain of the COVID-19 pandemic. Feelings of uncertainty and isolation, financial and health concerns, and the sudden transition to online learning are a few of a multitude of factors that may add to the distressful experiences caused by the pandemic.

Couple these with the demanding degree of medical school work and it may very well sound like a nightmare come to life.

Anxiety and depressive symptoms have unsurprisingly increased to more than half when compared to pre-pandemic studies. (Imran et al., 2021) (Halperin et al., 2021) Seetan et. al. (2021) found that about half of their medical student participants

had a severe mental disorder and only a mind-boggling 13.2% were actually well during the COVID-19 pandemic. In some populations, psychological distress may be severe enough to manifest suicidal ideation (Zeng et al., 2019) with one study reporting that one in five medical students in all of their 11,000 medical student participants “thought that it would be better if they were dead, and 8% admitted to often think of committing suicide during the past 2 weeks.” (Imran et al., 2021) This is extremely alarming and warrants for both systemic institutional aid in allaying their stressors and demanding environment, psychological interventions, and effective self coping strategies.

“

About half of their medical student participants had a severe mental disorder and only a mindboggling 13.2% were actually well during the COVID-19 pandemic (Seetan et al.). 2021).

”

Aside from deleterious psychological effects of the pandemic, cognitive and learning difficulties (Aftab et al., 2021) and barriers to medical education secondary to the sudden transition to online learning were also observed. (Baticulon et al., 2021) Aftab et al. (2021) found at a drastic 96% of students faced problems including trouble memorising (54%), concentration problems (67%), more prone to making mistakes (55.5%), and overall 90% explicitly had greater difficulty in overall learning during the pandemic in comparison to pre-pandemic times. A similar study found that most students (74.7%) agreed that the pandemic significantly disrupted their medical education and 83.4% of participants wanted normal clinical rotations like in prepandemic times so much, in aversion the online learning means, so as to even accept the risk of COVID-19 infection if they returned to the clinical setting. (Harries et al., 2021) Baticulon et al. (2021) found that in the local Philippine setting, medical students were confronted with several barriers to online learning involving “difficulty adjusting to learning styles, having to perform responsibilities at home, and poor communication between educators and learners. Not only were medical students burdened with anxiety, depression and burnout, but these often occurred alongside a brutal detriment to the quality of their medical education during the COVID-19 pandemic.

“

A drastic 96%

of students faced problems [...] and overall 90% explicitly had greater difficulty in overall learning during the pandemic in comparison to prepandemic times.

”

“

Having a solid support system[...] to rely on, and a positive and encouraging learning condition [...] can be protective factors against burnout .

”

coping mechanisms and room for improvement Systemic Change and Coping Strategies: Surviving the Journey

Surviving the stress of medical school and COVID-19 pandemic does not come easy and for most it’s simply about finding a means to withstand the pressure and get through the week, take things day by day and find comfort and resilience where we can find it. Having a solid support system whether that be in the form of close family and friends to rely on, and a positive and encouraging learning condition involving their school and professors’ amount of empathy, support and flexibility with the unique and sudden changes brought upon by the COVID-19 pandemic can be protective factors against burnout (Mian, 2018). For some, effective prevention of burnout and excessive psychological distress may necessitate prevention programmes for teaching stress management strategies. Means for intentional, targeted prevention programmes teaching affecting coping skills and even going so far as to consider structural and systemic institutional change in training programmes and academia culture may be critical in reducing stressors for medical students during a global pandemic.

Mian (2018) also emphasises on the importance of finding meaning in their work, adequate time-management, maintenance of social connections and incorporating coping skills and reflection during the most stressful and vulnerable periods of this medical journey. Mentoring programms may be useful as well because these present individuals who have successfully become physicians themselves despite the challenges of medical school and training, albeit it was not

Capdevila-Gaudens et al. (2021) mentions the importance of creating an environment in which mental health is openly discussed and guidance is provided, subsequently implying that medical schools and universities should provide due support to their students in need through medical services available in their respective institutions.

Factors such as culturally destigmatising mental health issues are equally crucial so as to avoid shame and acknowledge and address mental and emotional problems early. One study attempts a “care pathway” provided to medical students who scored high on emotional distress, suicidality and mental illness. This involves intentional intervention with an initial review by a psychiatrist who triaged students to psychologists who then were able to deliver therapies such as Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Eye Movement Desensitisation Reprocessing Therapy or Cognitive Analytic Therapy, resulting in obvious benefit from timely specialist mental health input and vast improvement in their mental well-being and improved functioning. This design is unique and may serve as an example for other medical schools who like to provide psychosocial aid to their students. Likewise, preventive mental health services as part of routine clinical services provided to medical students especially in their transitional years, e.g. first year medical students and those going from their preclinical to clinical years, may be significantly beneficial.

(Abdulghani et al., 2011) Non-psychotherapeutic management such as academic engagement may also serve as a protective factor, which is shown as a protective factor against dropout secondary to burnout.

Medical schools who wish to preserve the sanity and well being of their students may fit well to develop similar interventions to alleviate some of their stressors and prevent burnout in their institution. (Abreu Alves et al., 2022)

More specific to the Philippine medical student populace, increased anxiety and depression were related to student status, low confidence in doctors, dissatisfaction with health information, long daily duration spent on health information, worries about family members contracting COVID-19, ostracisation, and unnecessary worries about COVID-19 were associated with adverse mental health. It is important to address these sociocultural factors that add on to the stresses of the medical student outside of academia.

Systemic change is a process and takes collective effort and time. Therefore, healthy and effective coping strategies must be developed in order to maintain a sound mental and emotional state. Neufield & Malin analysed both healthy and unhealthy coping methods.

Students use of problem-focussed (e.g., planning, active coping, seeking instrumental support) and active, emotion-focussed (e.g., seeking emotional support, positive reframing, humor) coping strategies were deemed healthy strategies whereas other less frequently used and relatively unhealthy coping strategies were passive and avoidant. Examples of these involve denial, substance use, behavioural disengagement.

There was another category that was not categorised as either

References

Abdulghani, H. M., AlKanhal, A. A., Mahmoud, E. S., Ponnamperuma, G. G., & Alfaris, E. A. (2011). Stress and Its Effects on Medical Students: A Cross-

because these were dependent on individual context such as self-blame, self-distraction or “escapism” and venting. One of these I relate to would be the escapist or venting coping strategies. Although these do not work to address the problems directly, I find solace in conversing with other peers who are experiencing similar obstacles as me. I feel however that self-blame and self-distraction should be a balanced amount.

Self-distraction provides temporary recovery from overwhelming stressors and self-blame, which may vary depending on the person, may actually motivate the student to become more productive secondary to the guilt they feel for perhaps, not being satisfied in their grades or academic standing. I emphasise on the problem-focused means of coping however, and feel that these are the most effective in alleviating anxiety and depression symptoms especially when under pressure.

sectional Study at a College of Medicine in Saudi Arabia. Journal of Health, Population and Nutrition, 29(5). https://doi.org/10.3329/jhpn.v29i5.8906 Abreu Alves, S., Sinval, J., Lucas Neto, L., Marôco, J., Gonçalves Ferreira, A., & Oliveira, P. (2022). Burnout and dropout intention in medical students: the protective role of academic engagement. BMC Medical Education, 22(1). https://doi.org/10.1186/s12909-021-03094-9 Aftab, M., Abadi, A. M., Nahar, S., Ahmed, R. A., Mahmood, S. E., Madaan, M., & Ahmad, A. (2021). COVID-19 Pandemic Affects the Medical Students’ Learning Process and Assaults Their Psychological Well Being.

International Journal of Environmental Research and Public Health, 18(11), 5792. https://doi.org/10.3390/ijerph18115792 Arif, N. M. N. A., Roslan, N. S., Ismail, S. B., Nayak, R. D., Jamian, M. R., Mohamad Ali Roshidi, A. S., Edward, T. C., Kamal, M. A., Mohd Amin, M. M., Shaari, S., & Shaharudin Basri, M. F. (2021). Prevalence and Associated Factors of Psychological Distress and Burnout among Medical Students: Findings from Two Campuses. International Journal of Environmental Research and Public Health, 18(16), 8446. https://doi.org/10.3390/ijerph18168446

A personal example of this is that my own medical school actually maintains a “meme page” on social media sites that serves to provide humorous content that our own student community can relate to and may help with positive reframing of our own collective struggles. At the end of the day, however, individual coping methods such as these may not be enough and professional mental health consultation may be warranted and it is crucial to have a sense of selfawareness of how you are doing, whether your current coping methods are effective, or whether they only serve to numb down distressful feelings. With this, I wish for my fellow peers and those medical students in other countries undergoing similar pressures of strength and good health as they tread through these tedious and trying times.

Baticulon, R. E., Sy, J. J., Alberto, N. R. I., Baron, M. B. C., Mabulay, R. E. C., Rizada, L. G. T., Tiu, C. J. S., Clarion, C. A., & Reyes, J. C. B. (2021). Barriers to Online Learning in the Time of COVID-19: A National Survey of Medical Students in the Philippines. Medical Science Educator, 31(2), 615–626. https://doi.org/10.1007/s40670-021-01231-z Capdevila-Gaudens, P., García-Abajo, J. M., Flores-Funes, D., GarcíaBarbero, M., & García-Estañ, J. (2021). Depression, anxiety, burnout and empathy among Spanish medical students. PLOS ONE, 16(12), e0260359. https://doi.org/10.1371/journal.pone.0260359 Cuttilan, A. N., Sayampanathan, A. A., & Ho, R. C.-M. (2016). Mental health issues amongst medical students in Asia: a systematic review [20002015]. Annals of Translational Medicine, 4(4), 72. https://doi.org/10.3978/j. issn.2305-5839.2016.02.07 Domantay, J. A. A. (2014). Health-Related Quality of Life of Future Physicians at a Medical School in the Philippines. SAGE Open, 4(3), 215824401454545. https://doi.org/10.1177/2158244014545459 Franco, P. I. G., Palileo-Villanueva, L. M., Cuaño, P. M. G. M., Bayan, Ma. R. E., Ma. Rosario, B., & Mendoza, J. A. (2022). Burnout and Resilience of Internal Medicine Physician Trainees in a Tertiary Government Hospital in the Philippines during the COVID-19 Pandemic: A Mixed-method Study. Acta Medica Philippina, 56(6). https://doi.org/10.47895/amp.v56i6.3535

Garan-Giller, E. A., Dator, D. C. S., Juan, M. B. A. P., Querubin, G. A. R., Sevilla, T. P., &

Oura, M. J., Moreira, A. R., & Santos, P. (2020). Stress among Portuguese Medical Students: A

Calimag, M. M. P. (2019). Life on a Tightrope: An Interpretive Phenomenological

National Cross-Sectional Study. Journal of Environmental and Public Health, 2020, 1–7. https://doi.

Analysis of Narratives of Coping with Academic Stress among Filipino Medical

org/10.1155/2020/6183757

Students. Journal of Medicine, University of Santo Tomas, 3(1), 248–259. https://doi. org/10.35460/2546-1621.2019-0001

Paulina, N., Vitocruz, Ann, P., Vivar, Georgene, D., Whang, Wonglue, N., Wu, Y.-C., Larimel, R., Yadao, J., Melody, A., Yao, Y., Ybanez, J., Yu, A., Luisito, J., Zulueta, A., Ronilo, J., Juangco, G., Paz, M., &

Halperin, S. J., Henderson, M. N., Prenner, S., & Grauer, J. N. (2021). Prevalence of

Garcia, S. (2019). Prevalence of depression among medical students in a private medical school:

Anxiety and Depression Among Medical Students During the Covid-19 Pandemic: A

A

Cross-Sectional Study. Journal of Medical Education and Curricular Development, 8,

Sciences%20Journal/Vol8%20No2%20July-December%202019/HSJ%20vol.8no.2%202019-122-

238212052199115. https://doi.org/10.1177/2382120521991150

126.pdf

Harries, A. J., Lee, C., Jones, L., Rodriguez, R. M., Davis, J. A., Boysen-Osborn, M., Kashima,

Pokhrel, N. B., Khadayat, R., & Tulachan, P. (2020). Depression, anxiety, and burnout among medical

K. J., Krane, N. K., Rae, G., Kman, N., Langsfeld, J. M., & Juarez, M. (2021). Effects of the

students and residents of a medical school in Nepal: a cross-sectional study. BMC Psychiatry, 20(1).

COVID-19 pandemic on medical students: a multicenter quantitative study. BMC

https://doi.org/10.1186/s12888-020-02645-6

cross-sectional

study.

https://library.uerm.edu.ph/kohaimages/UERM/repository/Health%20

Medical Education, 21(1). https://doi.org/10.1186/s12909-020-02462-1 Ramadianto, A. S., Kusumadewi, I., Agiananda, F., & Raharjanti, N. W. (2022). Symptoms of depression Hill, M. R., Goicochea, S., & Merlo, L. J. (2018). In their own words: stressors facing

and anxiety in Indonesian medical students: association with coping strategy and resilience. BMC

medical students in the millennial generation. Medical Education Online, 23(1),

Psychiatry, 22(1). https://doi.org/10.1186/s12888-022-03745-1

1530558. https://doi.org/10.1080/10872981.2018.1530558 ‌Rubaba Azim, S. (2021). Mental Distress among Medical Students. Anxiety Disorders - the New Jacob, R., Li, T., Martin, Z., Burren, A., Watson, P., Kant, R., Davies, R., & Wood, D. F. (2020).

Achievements. https://doi.org/10.5772/intechopen.91864

Taking care of our future doctors: a service evaluation of a medical student mental health service. BMC Medical Education, 20(1). https://doi.org/10.1186/s12909-020-

Seetan, K., Al-Zubi, M., Rubbai, Y., Athamneh, M., Khamees, A., & Radaideh, T. (2021). Impact of

02075-8

COVID-19 on medical students’ mental wellbeing in Jordan. PLOS ONE, 16(6), e0253295. https://doi. org/10.1371/journal.pone.0253295

Kafle, B., Bagale, Y., Kadhum, M., & Molodynski, A. (2021). Mental health and burnout in Nepalese medical students: an observational study. Middle East Current Psychiatry,

Tee, M., Wang, C., Tee, C., Pan, R., Reyes, P. W., Wan, X., Anlacan, J., Tan, Y., Xu, L., Harijanto, C.,

28(1). https://doi.org/10.1186/s43045-021-00134-4

Kuruchittham, V., Ho, C., & Ho, R. (2021). Impact of the COVID-19 Pandemic on Physical and Mental Health in Lower and Upper Middle-Income Asian Countries: A Comparison Between the Philippines

Kostić, J., Žikić, O., Đorđević, V., & Krivokapić, Ž. (2021). Perceived stress among

and China. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.568929

university students in south-east Serbia during the COVID-19 outbreak. Annals of General Psychiatry, 20(1). https://doi.org/10.1186/s12991-021-00346-2

Tus, J. (2021). Amidst the New Normal of Education: The Resilience and Academic Burnout Among Filipino Tertiary Students. Figshare. https://doi.org/10.6084/m9.figshare.17707442.v4

Liu, H., Yansane, A. I., Zhang, Y., Fu, H., Hong, N., & Kalenderian, E. (2018). Burnout and study engagement among medical students at Sun Yat-sen University, China.

Xiong, P., Ming, W., Zhang, C., Bai, J., Luo, C., Cao, W., Zhang, F., & Tao, Q. (2021). Factors Influencing

Medicine, 97(15), e0326. https://doi.org/10.1097/md.0000000000010326

Mental Health Among Chinese Medical and Non-medical Students in the Early Stage of the COVID-19 Pandemic. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.603331

Mian, A. (2018). Medical Student and Resident Burnout: A Review of Causes, Effects, and Prevention. Clinmed Journals.org. https://doi.org/10.23937/2469-5793/1510094

Yin, Y., Yang, X., Gao, L., Zhang, S., Qi, M., Zhang, L., Tan, Y., & Chen, J. (2021). The Association Between Social Support, COVID-19 Exposure, and Medical Students’ Mental Health. Frontiers in Psychiatry,

Neufeld, A., & Malin, G. (2021). How medical students cope with stress: a cross-sectional

12. https://doi.org/10.3389/fpsyt.2021.555893

look at strategies and their sociodemographic antecedents. BMC Medical Education, 21(1). https://doi.org/10.1186/s12909-021-02734-4

‌Zeng, W., Chen, R., Wang, X., Zhang, Q., & Deng, W. (2019). Prevalence of mental health problems among medical students in China. Medicine, 98(18), e15337. https://doi.org/10.1097/

O’Byrne, L., Gavin, B., Adamis, D., Lim, Y. X., & McNicholas, F. (2021). Levels of stress in medical students due to COVID-19. Journal of Medical Ethics. https://doi.org/10.1136/

md.0000000000015337

Written by Simran Rauniya AMSA Nepal

Institute of Medicine, Tribhuvan University

G

PRECLINICAL EXPOSURE bridging gaps or burdening?

reetings from a third-year medical student from Nepal who recently got the dates of the final exams and is hurriedly trying to tick tasks off the non-existential to-do list before the exhaustive routine for finals starts (Please insert a cry emoji here as you read). Well, the third year’s coming to an end; it started in mid-July sometime after the second wave of COVID. The third wave hit a few months after the school started physically, so for all reasons and dignity, I declare my batch as the “Pandemic Batch” enduring all of its pros and cons. Of course, there is Zoom and google meets but not all the med school stuff can be taught online right? Imagine a bedside teaching class and not being able to practice the percussion taps on your friend! After two years of basic science, the jump to the clinicals can be quite perplexing; it was for me at least. ‘Lost’ is the word I use to describe myself towards the start of my clinical year and I still am halflost to be honest. Coming to the main query behind all my rantings- had we been exposed to this during our preclinical years, would it have been a little easier? Would I have been a little less lost?

The majority of medical schools over the world have curricula stretched over 4 or 4.5 years with clinical clerkship from the third year onwards. In Nepal too, the clinical exposure begins with postings in clinical departments from the third year and continues till the remaining 1.5 years; that counts to 2.5 years of clinicals. The curriculum does include Communication skills and pre-clinical exposure in the first two years of basic science during which rapport building, basics of history taking, clinical examinations and Community Health Diagnosis are introduced to the students. But the pandemic batch had it a little different. Amidst all the chaos, haste to complete the courses, and vain effort to stick to the academic calendar, the pre-clinical classes could not be consistent. And the COVID made us all a little indolent too, right? When I was first asked to take the history of a patient, all I could squeeze out were the patient particulars and the diagnosis, and yes, the ‘diagnosis’ as dictated by the patient and not the chief complaints. I could have used a little help here.

advantages Preclinical exposure or early clinical exposure (ECE) is not an entirely new concept and it has been practised by many medical schools worldwide.

It is the method of modifying the curricula to meet the need of 1 tomorrow . We all must have heard the Chinese proverb that goes, ‘I hear and I forget, I see and I remember and I do and I understand’. The major advantage of preclinical exposure is that it exposes students to real-life scenarios, provides a space to relate

their learnings, and helps in decision 2 making. It has been associated with better clinical knowledge of basic science, boosted motivation to study, and a better understanding of the doctor-patient relationship and 3 specialities. Group-based work helps develop good communication skills not only with the peers but also with the patient and fosters empathic relationships leading to better patient 4 cooperation and compliance.

“

Preclinical exposure [...] exposes students to real-life scenarios, provides a space to relate their learnings.

”

One may question how to harmonise this into the already hectic and brimming course of the basic science years. Basic science correlation, Clinical skills and Humanities in medicine are the three major components of the ECE and can be conducted in a classroom, hospital or community setting.4 Co-operative patients can be brought to the classroom for the discussion and examination or the students can be taken to the in-patient wards or in rounds by doctors for observation and learning about history taking and examinations.4 Students can also be taken to the community setting to understand about the livelihood, knowledge, attitude, and practice of people

disadvantages Preclinical exposure has been included in the curriculum but its effectiveness in the current scenario has not taken the full bloom due to mismanagement, lack of proper resources, time, and training for the educators.4 The shortfall is even on students who do not take these classes earnestly, essentially for the aforementioned reasons and the vicious cycle continues. It is also arguable that it can overburden students with advanced clinical information when they are still trying to grasp the basics and that too, of all basic subjects of all the systems.

4

and how it affects the health conditions.

Studies have shown that videos of clinical facts help students understand better and retain longer as this 3-D media stimulates Wernicke’s area through auditory as well as the visual pathway leading to better integration of the information.5 Pre-clinical exposure is effective in this regard as well.

A few decades back when the medical education system was almost new to Nepal and the number of medical schools and medical students, both were low,6 there were better student-teacher relationships, more opportunities for students, and good clinical exposure. With the advancement of time, there has been the “mushrooming of medical colleges”,6 and consequently, the rise in the number of medical students; reforms need to be made in medical education as well.

We have good community exposure right from the first year but it could be helped in hospital and classroom settings. work in the future. Early clinical exposure including problem-based learnings, case discussions, simulations, workshops, etc fosters critical thinking and analysis which helps in real-time decision making in the long run. Students also get a glimpse of how diligent and skilfully one needs to work in the future.

conclusion We very well understand that learning medicine requires a lot of patience and time and early clinical exposure is not shortening this time in any way, but providing a means for revision. The core idea is not to replace the traditional teaching-learning method, but to reinforce it to bridge the gap between the preclinical and clinical years. Even our educators are aware of the perks of the ECE and have been trying to include some elements in a way or the other like corelation seminars etc; we are thankful to them. And if not anything, maybe we could have perfected those percussions. Not talking about histories because they will always be lacking.

REFERENCES

1.

Verma M. Early clinical exposure: New paradigm in Medical and Dental Education. Contemp Clin Dent. 2016;7(3):287–8.

2.

Early Exposure of Medical Students to Types of ... | MedEdPublish [Internet]. [cited 2022 May 5]. Available from: https://mededpublish. org/articles/8-151 3.

Govindarajan S, Vasanth G, Kumar PA, Priyadarshini C, Radhakrishnan SS, Kanagaraj V, et al. Impact of a Comprehensive Early Clinical Exposure Program for Preclinical Year Medical Students.

Health Prof Educ. 2018 Jun 1;4(2):133–8.

4.

View of Early Clinical Exposure in Preclinical Years of Medical School [Internet]. [cited 2022 May 5]. Available from: https://www. jnma.com.np/jnma/index.php/jnma/article/view/5341/3832 5.

DAS P, BISWAS S, SINGH R, MUKHERJEE S, GHOSHAL S, PRAMANIK D. Effectiveness of early clinical exposure in learning respiratory physiology among the newly entrant MBBS students. J Adv Med Educ Prof. 2017 Jan;5(1):6–10.

6.

Dixit H, Marahatta SB. Medical education and training in Nepal: SWOT analysis. Kathmandu Univ Med J. 2008;6(3):412–20.

MEDICAL EDUCATION: Beyond the Public Eyes

C

ovid-19. The situation changes the education system in many faculties.

One of them is medical school.

Therefore, the purpose of this article is to analyse the consequences of Covid-19 in medical education.

Before the pandemic, medical students need to wake up to go to their medical schools and learn medicine. They learn medicine in many aspects like theories laboratories or clinical training.

Nevertheless, Covid-19 challenges the medical education system and online learning may either give us some chance to improve education or worsen it.

Access in lesson Owing to the pandemic, the medical system should change to online learning via conferencing programmes such as Zoom or Google Meet. It can help students access lessons from remote areas. However, In my opinion, on-site learning probably makes students focus on lessons more than online learning due to the environment in the classroom.

Technology Many new technologies were used in medical education during the Covid-19 era. Here are examples of technology:

1. Telemedicine It allows students to conduct lessons or clinical practice from remote areas. For example, medical students communicate with patients via video conferencing.

It can apply in many fields such as telesurgery and telerehabilitation.

However, it is important to let students learn from patients at hospitals, as they must develop their medical skills.

2. Metaverse Metaverse be can applied in medical education. For example, augmented reality lets medical students learn anatomy. Another example of the application of metaverse is digital laboratories such as using programmes to conduct laboratories in biochemistry.

Meanwhile, there are limitations to using it. To illustrate, It can make students don’t have laboratories or clinical skills like using medical instruments because they use only programmes or platforms.

Mental health Due to the situation, online learning may contribute to mental health problems in medical students such as depression because they lack interaction with their classmates or professors. In my opinion, there are still some advantages to social isolation. One of that is it makes some students have a lot of time to read and review lessons because they don’t expense time travelling between home and school.

In conclusion, there are advantages and disadvantages of Covid-19 that challenge medical education. Some aspects can develop or improve future medical education, such as using technology in medical education. Regardless, there are several disadvantages of Covid-19 as well. For instance, the Covid-19 situation causes medical students to easily lose their focus on the lesson and have mental health problems.

Written by Thammakan Nampacharoen AMSA Thailand Phramongkutklao College of Medicine

References

1. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and medical education in the age of COVID-19. Acad Med. 2020:95(12):1838-43.

2. Kye B, Han N, Kim E, Park Y, Jo S. Educational applications of metaverse: possibilities and limitations. J Educ Eval Health Prof.

2021; 18: 32.

3. Kaul V, Gallo de Moraes A, Khateeb D, Greenstein Y, Winter G, Chae, J, et al. Medical education during the COVID-19 pandemic.

Chest. 2021; 159(5): 1949-60.

Aspire #37

Clinical Challenge Medical Education

Across 2.

3.

6.

7.

8.

9.

Undergraduate (post-secondary) medical degree (1 word) Evidence-based technique exam to assess clinical skills and utilising a reliable checklist-based assessment (1 word) Postgraduate advanced medical training and education usually under a certain specialty (1 word) A process of employing a set of procedures and tools to provide useful information about medical education programs and their components to decision-makers (1 word) Degree received from osteopathic medical schools (1 word) Graduate (post-baccalaureate) medical degree (1 word)

Down 1.

4.

5.

International association for medical education (1 word) A sophisticated blend of educational strategies, course content, learning outcomes, educational experiences, and assessment (1 word) An approach to teaching or the theory/practice in learning (1 word)

Fill your answer on:

https://bit.ly/ClinChallAspire37

Winners of ASPIRE #36 Clinical Challenge 1. Jacqueline Angelica, AMSA Indonesia 2. Bunyawee Kasemsongkhram, AMSA Thailand 3. Tirza Mulia Simanjuntak, AMSA Indonesia

CREA CO

ATIVE ORNER

“The Royals, The Secret, and The Boy” was simply an adolescent with a responsibility to protect the land, the people, and the crown—they said. All of the trials and tribulations, the tears we shed, are for the sake of the future, and you. May the threads remain entwined and let the new chapter begin.

WRITTEN BY : Nadhira Tsurraya Ramadhani AMSA Indonesia Universitas Sriwijaya

Romeo & Mercutio

WRITTEN BY : Bhumika Raisinghani AMSA Indonesia Faculty of Medicine, Universitas Pelita Harapan

T’was a numbing furlough the ol’ think’r low, lower so, than lowest trench; the ol’ tink’r quench’d at sight of mirroring candor; dand’r rose to sland’r wholly, totally at me; mīn windeth bareth mīn lee!

Medicine, mine own loveth yet mine own challeng’r I knoweth thee needst patience, tanag’r!

Yet mine own heart, hardly fit to giveth m’re; “I am not restful”, mine own spirits roar.

Then, cameth thy gleeful beam.

Ch’rtles springs thy teeth to gleam, thy peepeth’rs peeps as crescent gems, \ thy mane twists, turns, as Thames.

Aid, through rocky Rockys, nev’r hadst to sayeth please.

We twirl’d to twinning tunes, days begin feeleth of summ’r of June.

At long last, this, to thanketh thy loving amity; thee, f’rev’r beest mine own trusty.

Eke, i thanketh me f’r exiting of this gloom, hopeful yond lief its timeth to bloom.

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