Reflective student narratives: honing professionalism and empathy

The affective domain is not explicitly targeted during medical studies and poor skills in this domain may lead to conflict when dealing with patients. Reflective narratives are said to promote humanitarianism and professional development. We aimed to examine reflective narratives written by medical students in our institution for content relating to ethical and professional Attitude and Behaviour, Communication, respect for Diversity and Disability, and Empathy (the ABCDE paradigm). We were also interested in understanding how far the students enjoyed learning through the writing of narratives and in determining their perceived learning from the exercise. Volunteer medical students were introduced to Gibbs’ reflective cycle during a half-day workshop. After giving written informed consent, they submitted anonymous reflective narratives (online), based on an interaction that they witnessed between a patient and a doctor/student. The authors performed directed content analysis of the submissions, using predetermined codes pertaining to ABCDE. At the end of the study, the participants sent in their feedback through a questionnaire on the process and the learning acquired, if any. Twenty-six students volunteered and 15 narratives were submitted. The issues that had been identified were discussed with the students. Feedback was submitted by 12 students, who strongly felt that the writing of narratives enhanced learning about ethics, professionalism, communication, diversity and empathy. We conclude that reflective student narratives are a useful and enjoyable way of teaching students about issues in the affective domain that are not conventionally taught

Burden and depression in primary caregivers of persons with visual impairment.

Context: Caregivers who assist persons with visual impairment often neglect their needs, resulting in burden and depression. Rehabilitation efforts, directed to the disabled, seldom target the caregiver. Aim: To assess burden and depression in persons caring for blind individuals. Settings and Design: This was a cross-sectional study carried out in the outpatient department of a tertiary‑level teaching hospital in New Delhi. Materials and Methods: Institutional Ethical Board approval was obtained and written informed consent too was obtained from the participants involved in this study. Persons with best‑corrected vision <20/200 in the better eye, and their primary caregivers, were recruited. We recorded demography, other illness/disability, household income, relationship with disabled person, and caregiver burden (Caregiver Burden Scale) and depression (Centre for Epidemiologic Studies Depression Scale). Statistical Analysis: Statistical analysis was carried out using SPSS version 20 (Released 2011. Armonk, NY: IBM Corp.); range, average, and standard deviation were determined for age, burden, and depression. The association between burden and depression was determined using Pearson’s correlation; the relationship between degree of disability and caregiver burden and depression was determined using unpaired t‑test; using multiple linear regression, factors were found to be statistically significant; significance was taken at P < 0.05. Results: Twenty‑seven (53.0%) men and 24 (47.0%) women had visual impairment. Most caregivers (n = 40; 81.6%) were first‑degree relatives or a spouse; 32 (65%) had schooling <5 years; and 29 (59%) were unemployed. Depression ranged from 21 to 52 (average 43.2 ± 5.71); it correlated with degree of disability (P = 0.012), household income (r = −0.320; P = 0.025), and burden (r = 0.616; P < 0.001). Burden ranged from 30 to 73 (average 54.5 ± 6.73) and correlated with degree of disability (P = 0.006). On multiple linear regression, burden predicted depression (r = 0.557; P < 0.001). Conclusions: Caregivers merit community support, financial benefit, interventions to diagnose and treat depression, and training in coping. Centers that provide disability certification could offer counseling.

Entrustable Professional Activities: Teaching and Assessing Clinical Competence.

Entrustable Professional Activities are gaining acceptance as tools to demonstrate acquisition of competencies in a competency-based curriculum. The main advantage of Entrustable Professional Activities are that they are observable activities (thus assessable), are related to day-to-day functioning as a health care provider (thus relevant), and are awarded once the learner can be trusted to perform the activity effectively and safely, without supervision, and by integrating across different competency domains. In this article, we describe how Entrustable Professional Activities can serve as a useful learning and assessment tool. We have described the steps in formulation, the pitfalls to avoid, and the possible role of the Medical Council of India and the Indian Academy of Pediatrics in encouraging the use of Entrustable Professional Activities for executing competency-based modules.

Use of subjective and objective criteria to categorise visual disability.

Context: Visual disability is categorised using objective criteria. Subjective measures are not considered. Aim: To use subjective criteria along with objective ones to categorise visual disability. Settings and Design: Ophthalmology out‑patient department; teaching hospital; observational study. Material and Methods: Consecutive persons aged >25 years, with vision <20/20 (in one or both eyes) due to chronic conditions, like cataract and refractive errors, were categorized into 11 groups of increasing disability; group‑zero: normal range of vision, to group‑X: no perception of light, bilaterally. Snellen’s vision; binocular contrast sensitivity (Pelli‑Robson chart); automated binocular visual field (Humphrey; Esterman test); and vision‑related quality of life (Indian Visual Function Questionnaire‑33; IND‑VFQ33) were recorded. Statistical Analysis: SPSS version‑17; Kruskal‑wallis test was used to compare contrast sensitivity and visual fields across groups, and Mann‑Whitney U test for pair‑wise comparison (Bonferroni adjustment; P < 0.01). One‑way ANOVA compared quality of life data across groups; for pairwise significance, Dunnett T3 test was applied. Results: In 226 patients, contrast sensitivity and visual fields were comparable for differing disability grades except when disability was severe (P < 0.001), or moderately severe (P < 0.01). Individual scales of IND‑VFQ33 were also mostly comparable; however, global scores showed a distinct pattern, being different for some disability grades but comparable for groups III (78.51 ± 6.86) and IV (82.64 ± 5.80), and groups IV and V (77.23 ± 3.22); these were merged to generate group 345; similarly, global scores were comparable for adjacent groups V and VI (72.53 ± 6.77), VI and VII (74.46 ± 4.32), and VII and VIII (69.12 ± 5.97); these were merged to generate group 5678; thereafter, contrast sensitivity and global and individual IND‑VFQ33 scores could differentiate between different grades of disability in the five new groups. Conclusions: Subjective criteria made it possible to objectively reclassify visual disability. Visual disability grades could be redefined to accommodate all from zero‑100%.

Motivation and preparedness of first semester medical students for a career in medicine.

Purpose : To determine motivation of medical students towards a medical career, and their knowledge of and preparation for it. Methods : After ethical committee approval, students admitted in 2009, who volunteered, were administered an anonymous questionnaire. Descriptive analysis was done. Results : Of 150 students admitted, 103 (68.7%) submitted completed questionnaires. Fifty-seven students (55%) got admission after ≥2 attempts; 65 (63%) decided on a medical career before class ten. Accurate knowledge about the curriculum was poor even though many had a family member in the health field and were encouraged to take up medicine. Only half had sought guidance from a medical person; most had never undergone career preparation activity. Conclusion : Students are early deciders and highly motivated to join medicine. Family is a strong motivator and could encourage career preparation activities. Policy makers could design interventions to inform school students before they make the critical decision to join medicine.

Student performance during the medical course: Role of pre-admission eligibility and selection criteria.

Background. Marks scored in class XII determine the eligibility to apply to a medical course in India; selection is through an entrance test. Some students do poorly in the medical course. We assessed the eligibility and selection criteria as predictors of in-course performance. Methods. This cross-sectional study included marks in class XII and in each professional examination, and the Delhi University Medical–Dental Entrance Test (DUMET) rank for five batches of medical students. Students were grouped as those who passed professionals in the first attempt and those who did not. Unpaired t-test and Mann–Whitney U test compared class XII marks and mean DUMET scores between the two groups; ROC analysis determined class XII cut-off marks above which no student failed a professional. Results. Students who passed a professional in the first attempt had higher marks in class XII (p0.001). DUMET rank, however, was comparable for the two groups (p>0.05 each). Above a cut-off of 77.8% (in physics, chemistry and biology) students were significantly likely to never fail any professional. Conclusions. Prior academic achievement is a useful measure of in-course performance; however, the current eligibility cut-off results in poor in-course performance by some students. The DUMET is a poor predictor of performance. There is need to reform eligibility and selection criteria to admit students who will do well in the medical course.

Mentoring for first year medical students: humanising medical education.

New entrants are vulnerable to the challenges of the medical course; mentoring programmes are known to offer support. This paper evaluated the experiences of students and faculty enrolled in a new mentoring programme. After needs analysis of students and faculty, a small-group mentoring programme for new medical students was initiated.

Career choices of undergraduate medical students.

Background. Many factors influence the career choices of undergraduate medical students. We sought to identify the career choices of medical students in an Indian medical college and what influenced these choices. Methods. We conducted a questionnaire-based cross-sectional survey. We included medical students of all semesters at a medical college. The sociodemographic data, first choice of career on the day of the questionnaire and rating of 34 factors influencing choices were recorded. Results. Two hundred and eighty-two questionnaires were analysed. The most preferred career choices were medicine and surgery, followed by orthopaedics; 3 students each chose obstetrics and gynaecology, and anaesthesia; none chose community medicine. Second-semester students made choices before and the rest after joining medical college. Significantly, senior students were disinclined to take up surgery (p=0.003), preferring orthopaedics instead (p=0.017). ‘Personal interest’ was rated by 80% of students as important in influencing their choice, followed by stability (58%), reputation of the specialty (56%) and lifestyle (55%). Conclusion. The career choices of medical students at our institution were biased against some subjects. Often, choices develop during the course. Role modelling by faculty during departmental postings could be a factor influencing choice.

Masters theses from a university medical college: Publication in indexed scientific journals.

Background: The thesis is an integral part of postgraduate medical education in India. Publication of the results of the thesis in an indexed journal is desirable; it validates the research and makes results available to researchers worldwide. Aims: To determine publication rates in indexed journals, of works derived from theses, and factors affecting publication. Settings and Design: Postgraduate theses submitted over a five-year period (2001-05) in a university medical college were analyzed in a retrospective, observational study. Materials and Methods: Data retrieved included name and gender of postgraduate student, names, department and hierarchy of supervisor and co-supervisor(s), year submitted, study design, sample size, and statistically significant difference between groups. To determine subsequent publication in an indexed journal, Medline search was performed up to December 2007. Statistical Analysis: Chi square test was used to compare publication rates based on categorical variables; Student's t-test was used to compare differences based on continuous variables. Results: One hundred and sixty theses were retrieved, forty-eight (30%) were published. Papers were published 8-74 (33.7 ± 17.33) months after thesis submission; the postgraduate student was first author in papers from 26 (54%) of the published theses. Gender of the student, department of origin, year of thesis submission, hierarchy of the supervisor, number and department of co-supervisors, and thesis characteristics did not influence publication rates. Conclusions: Rate of publication in indexed journals, of papers derived from postgraduate theses is 30%. In this study we were unable to identify factors that promote publication.

Are current guidelines for categorization of visual impairment in India appropriate.

Context: Visual disability in India is categorized based on severity. Sometimes the disabled person does not fit unambiguously into any of the categories. Aims: To identify and quantify disability that does not fit in the current classification, and propose a new classification that includes all levels of vision. Settings and Design: Retrospective chart review of visual disability awarded in a teaching hospital. Materials and Methods: The last hundred records of patients who had been classified as visually disabled were screened for vision in both eyes and percentage disability awarded. Data were handled in accordance with the Helsinki Declaration. Results: Twenty-one patients had been classified as having 30% disability, seven each had 40% and 75%, and 65 had 100% disability. Eleven of them did not fall into any of the current categories, forcing the disability board to use its own judgment. There was a tendency to over-grade the disability (seven of 11; 63.6%). The classification proposed by us is based on the national program for control of blindness' definition of normal vision (20/20 to 20/60), low vision (<20/60 to 20/200), economic blindness (<20/200 to 20/400) and social blindness (<20/400). It ranges from the mildest disability (normal vision in one eye, low vision in the other) up to the most severe grade (social blindness in both eyes). Conclusions: The current classification of visual disabilities does not include all combinations of vision; some disabled patients cannot be categorized. The classification proposed by us is comprehensive, progresses logically, and follows the definitions of the national program.

Paradoxical reaction in tubercular meningitis resulting in involvement of optic radiation.

A 25-year-old woman was diagnosed to have tubercular meningitis (TBM) with a right parietal infarct. She responded well to four-drug anti-tubercular treatment (ATT), systemic steroids and pyridoxine. Steroids were tapered off in one and a half months; she was put on two-drug ATT after two months. Six months after initial diagnosis she presented with sudden, bilateral visual loss. Vision was 3/200 with afferent pupillary defect and un-recordable field in the right eye; vision was 20/60 in the left eye, pupillary reaction was sluggish and the field showed a temporal hemianopia. On reintroduction of systemic corticosteroids vision improved (20/120 in right eye and 20/30 in left eye) within three days; the field defects improved sequentially to a left homonymous hemianopia, then a left homonymous inferior quadrantonopia. A diagnosis of TBM, on treatment, with bilateral optic neuritis, and right optic radiation involvement was made. Since the patient had been off ethambutol for four months, the optic neuritis and optic radiation lesion were attributed to a paradoxical reaction to tubercular allergen, corroborated by prompt recovery in response to corticosteroids. This is the first report of optic radiation involvement in a paradoxical reaction in neuro-tuberculosis in a young adult.

An observational study of the proceedings of the All India Ophthalmological Conference, 2000 and subsequent publication in indexed journals.

AIMS: To determine the quality of reporting in the proceedings of the All India Ophthalmological Conference (AIOC) 2000, subsequent rate of publication in an indexed journal and differences between the proceedings and the journal version of these papers. DESIGN: Observational study. MATERIALS AND METHODS: All papers presented at the AIOC 2000 were retrieved from the proceedings and assessed for completeness of reporting. To determine the subsequent full publication, a Medline search was performed as of January 2007; consistency between the proceedings paper and the final publication was evaluated. Statistical analysis: Chi square and Fisher's exact tests were used to compare publication rates based on geographical location, subspecialty and study design; Student's t -test was used to compare differences based on the number of authors and sample size. RESULTS: Two hundred papers were retrieved; many failed to include study dates, design or statistical methods employed. Thirty-three (16.5%) papers were subsequently published in indexed journals by January 2007. The published version differed from the proceedings paper in 27 (81.8%) instances, mostly relating to changes in author name, number or sequence. CONCLUSIONS: The overall quality of reporting of scientific papers in the proceedings of the AIOC 2000 was inadequate and many did not result in publication in an indexed journal. Differences between the published paper in journals and in proceedings were seen in several instances. Ophthalmologists should be cautious about using the information provided in conference proceedings in their ophthalmic practice.

A prospective study of medical students' perspective of teaching-learning media: reiterating the importance of feedback.

To enhance successful communication, medical teachers are increasingly using teaching-learning media. To determine medical students' perception of three such media (blackboard, overhead projector, and slides), and to generate recommendations for their optimal use, a prospective questionnaire-based study was carried out among 7th semester medical students of the University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. Students made a forced choice between: (1) The three media on 8 questions regarding their advantages and disadvantages and (2) four aspects of a lecture (teaching-learning media, topic, teacher and time of day) regarding which made the lecture most engaging. Resulting data was analysed by Chi-square and Fisher's exact tests. Chalk and blackboard was rated as best in allowing interaction and helping recall (p<0.001 each). The overhead projector was best in providing information pointwise (p<0.001; 67 students, 89.3%, considered this an advantage). More subject matter could be covered per lecture (p=0.001; 58 students, 77.3%, considered this a disadvantage). Slides were best in imparting clinical details (p=0.004), but were sleep inducing (p<0.001). The teacher's style of instruction was most important in making the lecture engaging (p<0.001). The teacher's role in the learning process is important. Students enjoy the slow pace and interaction allowed by blackboard, pointwise information presented by the overhead projector, and the clinical details a slide can provide. The results suggest that the lecture could best be a combination of two or more teaching-learning media. Students' interaction should be encouraged whatever the media used.

Barriers to the uptake of cataract surgery in patients presenting to a hospital.

PURPOSE: To assess the barriers for the acceptance of surgery among patients with cataract and visual disability. MATERIALS AND METHODS: A short-term descriptive study was conducted in patients with cataract presenting to a hospital. Socio-demographic data were entered in a proforma. An interviewer-assisted questionnaire, surveying knowledge about cataract and barriers to cataract surgery, was administered by one of the authors (SKG) in the local language (Hindi). RESULTS: There were 100 patients (53 men and 47 women); 14 were bilaterally blind (vision < 10/200 in the better eye). Attitudinal barriers included: could manage daily work (71%), cataract not mature (68%), could see clearly with the other eye (64%), too busy (57%), female gender (37%), fear of surgery (34%), fear of surgery causing blindness (33%) or death (13%), old age (33%), it is God's will (29%) and worry about cost of surgery (27%). The barriers relating to service delivery, cost and affordability included: insufficient family income (76%), not knowing another person who had undergone cataract surgery (26%), no one to accompany (20%), distance from hospital (20%) or from a main road (9%) and lack of transport (7%). CONCLUSIONS: Attitudinal barriers were reported more often, rather than issues of accessibility or cost. Eye care providers should address the identified barriers for increasing acceptance of surgery in the study area.

Retinopathy of prematurity--risk factors.

OBJECTIVE: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit. METHODS: Neonates with gestational age < or = 35 weeks and/or birth weight < or = 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0. RESULTS: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies < or = 32 weeks gestation and 36.4% in babies weighing < or = 1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age. CONCLUSION: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight < or = 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.

Absenteeism and under-achievement in final year medical students.

BACKGROUND: Absenteeism among medical students has received little attention in the literature. The aim of this study was to determine the causes of absenteeism from didactic lectures in ophthalmology and its correlation with performance in formative assessment. METHODS: The attendance of 101 final year medical students for lectures in ophthalmology was studied in three parts: terms 1, 2 and 3. Based on the attendance in all three terms, students were divided into groups I to V, where group I students had good attendance in all three terms down to group V, with very poor attendance in one or more terms. The marks scored in the first, second and third terminal theory tests were tabulated separately. Results of the second and final professional examinations were assessed for the five groups of students. Students were asked to list the causes of absenteeism in a proforma. Data were analysed by regression analysis and Chi-square test. Significance was obtained at 5% level. RESULTS: In each formative assessment, higher attendance was associated with better marks (p < 0.0001). Illness, family commitment, teacher/topic, or lecture period spent in an extended clinical posting were cited as causes of absenteeism in 62.6% of instances. Six of the 10 students who failed the ophthalmology professional examination were in groups IV and V and had failed the second professional examination as well. They were designated low achievers, as were 3 students who made several attempts to pass the second professional examination and failed in ophthalmology despite a fair-good attendance. CONCLUSION: Learner absenteeism may contribute to low achievement. However, absenteeism may be symptomatic of low achievers. Low achievers or students with learning handicaps must be identified before admission or early in the medical course and encouraged to improve their performance and thereby enhance their self-esteem. A support group of family, peers, faculty and psychologists could help.

Enhancing eye donation rates. Training students to be motivators.

PURPOSE: Medical professionals could enhance eye donation rates by reminding relatives during grief counseling at the time of patient's death. This study was designed to assess the knowledge and attitudes of final year medical students (future doctors) towards eye donation, prior to instruction in eye banking. METHODS: The responses of 49 final-year medical students to a questionnaire on eye donation were compared with 24 non-medical students (controls). The results were analysed statistically using the chi-square test. RESULTS: More than one-third of students and controls were unaware that eyes are removed within six hours of death. Eight (16.3%) students and 6 (25.0%) controls felt that a close relative's eyes could be donated after death only if he had indicated willingness (P = 0.05). Three (6.1%) students and 3 (12.5%) controls were undecided about donating their own eyes. Nineteen (38.8%) students and 6 (25%) controls did not know where to go in order to pledge/donate eyes. The controls had poorer knowledge of ocular and systemic contraindications, and they did not know that storage could be prolonged (P < 0.001). Only 27 (55.1%) students had knowledge of corneal storage. CONCLUSIONS: Controls were poorly informed about various aspects of eye donation suggesting inadequate dissemination of information by the media. Students and controls alike had misconceptions regarding donation of relatives' eyes and hesitation regarding their own. These aspects should be emphasized during undergraduate teaching to dispel misgivings regarding wastage of donor eyes and to encourage future doctors to promote eye donation.