Writing Articles on Continuing Medical Education for Medical Journals

@#Sharing of knowledge through Continuing Medical Education (CME) contribute immensely to professional development of skills in clinical medical practice. Thus, the writing of CME articles should adopt an approach that addresses the needs of the readers by attempting to fill gaps in their knowledge, skills, and ethics about clinical care. As such CME articles should be comprehensive and focused on specific areas. The specific learning outcomes should be well defined. In designing and development of such articles, pedagogic principles are to be borne in mind. In this article we outline a guide to writing a CME article, incorporating both the principles of instructional design and directed selflearning. The ideal CME articles will transit through multimedia-enhanced interactive online learning, with greater use of connectivity through the internet. Synchronous and asynchronous learning is in greater need, as distance and online learning are increasingly popular. Authors of CME articles will need to eventually design CME articles to be interactive, enriched with multimedia to engage their readers. Lesson plans employing instructional design principles should aim to promote both instructions for learning and formative assessment ensuring learning have taken place, and outcomes have been achieved. This article describes on how to write effective CME articles for medical journals.

Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review

The aim of this systematic review is to compare the vaginalerosion rates in different synthetic materials used insuburethral slings in Tension Free Vaginal Tape (TVT-O/TOT) procedures in management of female stress urinaryincontinence.Methods: PRISMA 2009 framework was adopted for studydesign. Scholarly literature search was done usingMEDLINE, EMBASE, the Cochrane Library and ClinicalTrials.gov using selected keywords. Five articles fulfilled theinclusion and exclusion criteria. Our main outcome ofinterest is to review the ideal properties of the suburethralsling, procedure of insertion and post-surgical complicationfollowing the sling insertion primarily vaginal erosion.Results were compared using one way-ANOVA test andindependent T- test.Results: Total of 1725 subjects were available for analysisin the five studies. Monofilament polypropylene constituted92.5% of the total sample size from one study alone.Polyester (n= 16/51) causes higher incidence rate of vaginalerosion compared to monofilament polypropylene (31.4 vs.,4.7; p = 0.01). There was no difference in the vaginal erosionrate between monofilament polypropylene and multifilamentpolypropylene (4.7 vs, 14.1; p=0.055) as well as betweenmultifilament polypropylene and polyester (14.1 vs, 31.4;p=0.068). Although there was a marginally lower rate ofvaginal erosion in TVT-O over TVT, the difference was notsignificant. (5.6 vs., 6.4, p=0.468). Common presentations ofvaginal erosion were vaginal discharge, perineal pain anddyspareunia. Conclusion: Given the limited sample size, polyester slingmaterial appears to cause higher rates of vaginal erosion.No difference in erosion rate was seen between TVT andTVT-O.

Online formative assessments: exploring their educational value

Introduction: online formative assessments [OFA's] have been increasingly recognised in medical education as resources that promote self-directed learning. Formative assessments are used to support the self-directed learning of students. Online formative assessments have been identified to be less time consuming with automated feedback. This pilot study aimed to determine whether participation and performance in online formative assessments [OFA's] had measurable effects on learning and evaluate the students' experience of using the OFA's in the department of Obstetrics and Gynaecology

Methods: this is a cross-sectional study conducted among fourth year medical students [n=92] during their seven week postings in Obstetrics and Gynaecology. Five sets of online formative assessments in the format of one best answers [OBA], Objective structured practical examination [OSPE] and Short answer question [SAQ] with feedback were delivered over five weeks through the online portal. The mean scores of the end of posting summative exam [EOP] of those who participated in the assessments [OFA users] and of those who did not [non-OFA users] were compared, using Students t-test. The frequency of tool usage was analysed and satisfaction surveys were utilized at the end of the course by survey questionnaire using the five point Likert scale

Results: the mean scores of the students in end of posting summative examination marks for students who had participated in the online formative assessment [OFA users] and for those who had not [non OFA users] showed no significant difference in all the three components OBA, SAQ and OSPE [p=0.902, 0.633, 0.248]. Majority of the students perceived that OFAs fulfilled the stated aims and objectives and so they would persuade their peers to participate in the OFAs

Conclusions: online formative assessments are perceived as tools that promote self-directed learning, improved knowledge and tailor learning for individual learning needs and style

Narrative Medicine: An unexplored perspective in the medical curriculum to enhance patient-centredness and empathy in medical students

A medical narrative is a physician-patient dialogue, where the physician listens carefully to fragments of the patient’s story, while interpreting their hidden messages and word sequences, as well as observing their gestures and body language. This aspect of the therapeutic relationship contributes to deciphering symptoms which are not apparent in the conventional interview and contributes to a much broader perspective of illness and health. The arts and the humanities have always been inseparable from each other in medical education. In this biomedical revolution, the humanities are needed now more than ever before to bridge the divides that separate the physician from the patient, from self, from colleagues, and society. Narrative Medicine (NM) which aims to treat the whole person, and not just the illness, is an emerging patient-centred discipline in medical schools that can humanise medical care and promote empathy. NM helps medical students cope with the suffering of their patients as well as their own emotions by reducing the anxiety and threat that come with illness, thereby providing a psychologically-sound foundation for the development of self-reflection and empathy. NM facilitates medical students’ adoption of patients’ perspectives with the hope of ultimately leading to more humane, ethical and empathetic healthcare for their patients. The discipline of NM is critically examined in this review paper from the perspective of external and internal stakeholders.

Neuroendocrine carcinoma of the cervix: Review of classification and current developments in diagnosis and management

Neuroendocrine carcinoma of the female reproductive tract are a heterogeneous group of rare neoplasms posing both diagnostic and therapeutic challenges. The recent classification by WHO includes neuroendocrine carcinomas (NECs) and neuroendocrine tumours (NETs). NECs are the poorly differentiated small cell carcinoma (SCNEC) and large cell neuroendocrine carcinoma (LCNEC), while well-differentiated NETs include typical carcinoids (TC) and atypical carcinoids (AC). Majority of these tumours have an aggressive clinical course and published data is supportive of multi-modal therapeutic strategies. Etoposide/platinum based chemotherapy is commonly advocated. Histopathological categorisation and diagnosis are paramount to guide therapy. Well-differentiated carcinoid and atypical carcinoid tumours should be managed similar to gastroenteropancreatic neuroendocrine tumours. This review discusses the current classification, clinicpathologic characteristics and advances in the diagnostic evaluation and the treatment options of neuroendocrine carcinoma of the cervix.

Strategic Interventions in the Management of Gestational Diabetes to Reduce Type 2 Diabetes Mellitus in Women in Malaysia

According to the Global status report on non-communicable diseases 2010, the prevalence of high blood sugars among adults exceeds 11 % in both males and females in Malaysia. This is the highest among ASEAN countries. This ties up closely with the prevalence of overweight adults in both sexes in the same report, again Malaysians rank highest among ASEAN countries. The burden of diabetes mellitus in Malaysia is estimated to be 12% of the population with a projected figure exceeding 15 % in 2020. 1 This enormous rise in both obesity and hyperglycaemia in adults is alarming and clear strategies to combat this noncommunicable disease is urgently warranted. One such strategy is to relook at the focussed approach of gestational diabetes mellitus (GDM) management currently in vogue in Malaysia, and suggest more effective preventive measures in view of information currently coming to light on both short and long term implications of GDM on both mother and offspring. Although information on actual prevalence of GDM in Malaysia is lacking, available crude data from hospital births obtained from the National Obstetric Register in 2010 involving 14 major government hospitals was 9.9% with Indians ranking highest followed by Malays and Chinese. Incidence of macrosomia in GDM mothers was double that of non-GDM mothers. A higher caesarean section rate with a threefold increase in shoulder dystocia was also recorded in those with GDM.

Is Google search a useful medical diagnostic tool for third year medical students?

Introduction: In recent years, the internet has become an increasingly popular tool for people to obtain information due to the overwhelming availability of material. As internet access becomes more readily available, the newer generation of patients, medical students and doctors are starting to prefer the internet as a source of reference to acquire medical knowledge. The main objectives of this study were to determine the accuracy of using Google search in establishing a clinical diagnosis based on information provided from the New England Journal of Medicine (NEJM) and to determine the concordance rate of Google diagnosis with the actual diagnosis from NEJM. Method: The research design was a cross sectional study of 200 NEJM cases. The research team comprised of four 3rd year medical students and one senior supervisor. Google search engine was used to obtain a diagnosis. The time allocated for a Google search for each case was 20 minutes regardless of the number of websites used. The top two diagnoses were then compared to the actual diagnoses of the NEJM case and the accuracy of Google was then assessed. Results: The study achieved a congruence of 71.5%. This is considered acceptable and satisfactory as the cases presented in NEJM covered a wide variety of problems and encompassed rare diseases. Conclusion: From the final results obtained, it can be concluded that with the aid of Google, medical students in their 3rd year of their Bachelor of Medicine and Bachelor of Surgery programme are able to obtain a reasonable clinical diagnosis.

Applying the learning theories to medical education: A commentary

Medical education of today continues to evolve to meet the challenges of the stakeholders. Medical professionals today are expected to play multiple roles besides being experts. Thus, the curriculum has to be developed in a manner that facilitates learners to achieve the intended goal of becoming a medical professional with multiple competencies. The understanding of learning theories will be helpful in designing and delivering the curriculum to meet the demands of producing a medical professional who would meet the CanMEDS model. This commentary explores and reflects on the learning theories of behaviorism, cognitivism and constructivism as they have evolved over time and the application of these learning theories in medical education, particularly in the context of medical education in Malaysia. The authors are convinced that these three theories are not mutually exclusive but should be operationalized contextually and throughout the different stages of learning in the MBBS curriculum. Understanding these theories and their application will enhance the learning experience of students.

The ethical decision making model in obstetrics and gynaecology practice

This paper attempts to utilise clinical scenarios where ethical issues are embedded and requires appropriate application of the steps of the framework mentioned. A step by step sequential approach is adopted to illustrate how the ‘ethical decision model ‘can be used to resolve ethical problems to arrive at a reasonable conclusion. The UNESCO ethical method of reasoning is used as the framework for decision making. Physicianeducators should be competent to use ethical decision models as well as best available scientific evidence to be able to arrive at the best decision for patient care as well as teach health professional trainees how reasonable treatment decisions can be made within the perimeter of medical law and social justice.

Uncomplicated hyperemesis gravidarum does not alter the course of cardiovascular changes during pregnancy

The purpose of this prospective longitudinal study was to investigate the maternal cardiac haemodynamic and structural changes that occur in pregnancies with uncomplicated hyperemesis gravidarum in a selected Malaysian population. Nine women underwent serial echocardiography beginning at 12 weeks of gestation and throughout pregnancy at monthly intervals. Their echocardiograms were repeated at 6 and 12 weeks following delivery to reflect the pre-pregnancy haemodynamic state. Cardiac output was measured by continuous wave Doppler at the aortic valve. Interventricular septum thickness was determined by M- mode echocardiography and ventricular diastolic function by assessing flow at the mitral valve with Doppler recording. Cardiac output showed an increase of 32.9% at 36 weeks and maintained till 40 weeks of gestation. Heart rate increased from 79 ± 6 to 96 ± 8 beats/ min at 36 weeks. Stroke volume increased by 16.4 % at 40 weeks of gestation when compared to the baseline value. Systolic and diastolic blood pressure did not appreciably change but showed a lower reading during the mid-trimester period. Early inflow velocity of left ventricle did not show a rise while peak atrial velocity showed an increasing trend; thus the ratio of early inflow to peak atrial transport showed a declining trend from early pregnancy to term. End diastolic dimension of left ventricle and interventricular septum thickness showed an increased value at term. Uncomplicated hyperemesis gravidarum did not alter the haemodynamic changes throughout pregnancy and concur with established data for normal pregnancy.

Decision making in hyperglycaemia seen in pregnancy

Delay in childbearing, family history of type 2 diabetes mellitus and obesity in childbearing years increases a possibility of glucose intolerance or overt diabetes in pregnancy which may remain unrecognised unless an oral glucose tolerance test is done. The International Association of Diabetes and Pregnancy Study Group (IADPSG, 2010) recommended the detection and diagnosis of hyperglycaemic disorders in pregnancy at two stages of pregnancy, the first stage looking for ‘overt diabetes’ in early pregnancy based on risk factors like age, past history of gestational diabetes and obesity and the second stage where ‘gestational diabetes’ at 24-28 weeks with 75 g oral glucose tolerance test. Although the one step approach with 75 g of glucose offers operational convenience in diagnosing gestational diabetes, there are concerns raised by the National Institute of Health in the recent consensus statement, supporting the two step approach (50-g, 1-hour loading test screening 100-g, 3-hour oral glucose tolerance test) as the recommended approach for detecting gestational diabetes. Medical nutrition therapy (MNT) with well-designed meal plan and appropriate exercise achieves normoglycemia without inducing ketonemia and weight loss in most pregnant women with glucose intolerance. Rapidly acting insulin analogues, such as insulin lispro and aspart are safe in pregnancy and improve postprandial glycemic control in women with pre-gestational diabetes. The long acting analogues (Insulin detemir and glargine) though proven to be safe in pregnancy, do not confer added advantage if normoglycemia is achieved with intermediate insulin (NPH). Current evidence indicates the safe use of glyburide and metformin in the management of Type 2 diabetes and gestational diabetes as other options. However, it is prudent to communicate to the women that there is no data available on the long-term health of the offspring and the safety of these oral hypoglycemic drugs are limited to the prenatal period

Omega-6 and omega-3 fatty acid nutrition amongst Malaysians are far from desirable

This paper reviews available reports on the omega-6 (linoleic acid, LA) and omega-3 fatty acid [alpha-linolenic acid (ALA) + eicosapentaenoic acid (EPA) + docosahexaenoic acid) intakes amongst Malaysians against Malaysian Recommended Nutrient Intakes (RNI), focussing particularly on pregnant and lactating women because of the availability of data for these latter vulnerable groups. Overall, the omega-6 and omega-3 fatty acid nutrition amongst Malaysians are poor and far from desirable. The nutritional situation regarding these long-chain polyunsaturated fatty acids (LCPUFA) amongst Malaysian pregnant and lactating women is alarming and warrants urgent attention in nutrition promotion activities/counselling. Daily consumption of LA by these women and other Malaysians studied ranged from 3.69 - 5.61 % kcal with 38-60% of individuals not meeting their RNIs. Daily intakes of omega-3 fatty acids faired worse, averaging 0.21- 0.33 % kcal with as high as 92% of subjects in one study not meeting their RNIs. The omega-6 to omega-3 fatty acid ratios obtained in the studies reviewed are about 20:1, which is way above the World Health Organisationrecommended ratio of 5-10:1. Dietary sources of these omega- fatty acids in the subjects studied are chicken, fish and milk. Since local foods are not particularly rich in LCPUFA such as EPA and DHA, the options to improve EPA/DHA nutrition amongst Malaysians are the greater consumption of omega-3 enriched foods and in the case of pregnant and lactating women, LCPUFA supplementation may warrant serious consideration.

The influence of working memory capacity on academic achievement of final year medical students

This is a cross sectional study conducted in July 2010 at the International Medical University, Seremban, Malaysia. The objective of this study was to ascertain the relationship between working memory capacity of final MBBS medical students using the digit span backward test and their academic achievement based on the total score at the modified essay questions (MEQ) which was the principal component of the theory examination. Seventy eight final year medical students were recruited, 41 (52.6%) were females and remaining 37 (47.4%) were males. Working memory capacity was measured by digit span backward test (DSBT) which ranged from 3 to 8 digits. The mean digit score was 6.6 ± 1.1 falling under the category of ‘above average’ score. There was no significant difference between working memory capacity and gender (p>0.05). There was no significant difference in the MEQ mean score and the different categories of working memory capacity (p>0.05). The DBST shows uniformity in working memory adequate to pass the modified essay questions. Medical students appear to use encoding and retrieval process in problem solving based on functionality and pattern recognition in tackling the problems in the MEQ.

Reflective writing in case summary assignments

Outcome and competency-based undergraduate and graduate medical education is the desired standard embraced by many medical educationists worldwide. Reflective capacity is an integral component of that strategy and reflective writing has shown tremendous potential as a delivery tool. But there are various challenges in the implementation of the initiative. Efficacy as a delivery tool, achievement of pedagogical outcomes, reliability issues, challenges in assessment outcomes/tools, and whether it can be taught and learnt, need to be addressed. Many questions are still not satisfactorily answered, and this review attempts to offer some perspective on the issues.

Mentoring in the clinical setting: Process, issues and challenges

Abstract: Mentoring in academic medicine requires the trained mentor to commit time, purpose and dedication for the personal and professional development of three categories of protégés or mentees i.e. medical students, the clinician-trainee and the clinical-educator. Conventionally, assigned mentors monitor the progress of the first two categories of personnel as their career pathway is clearly defined. On the other hand the clinician–educator in academic medicine could be a scientist or a career clinician expected to contribute to medical education activities and research. The clinicianeducator has grown in complexity as he multitasks in providing clinical care, assists in delivering the medical curriculum and is expected to do research and publish. Although there is dearth of research in mentoring the clinician-educator, it is clear that mentored clinicaleducators are more productive by way of scientific publications. Trained mentors are expected to identify the needs of the mentee with regards to the level of his career development and his aptitude to move up the academic ladder, successfully nurturing the maturation process. Processes of mentoring in the clinical setting, attributes of the successful mentor and facilitating the mentee in overcoming challenges in academic medicine are discussed.

Simultaneous Presence of Pelvic Endometriosis and Polycystic Ovary Syndrome

The simultaneous presence of polycystic ovary syndrome with pelvic endometriosis presents compounded gynecological effects on women with subfertility and pelvic pain as the common symptoms. . We describe one such case. The molecular basis for etiology is discussed and the need for individualized treatment is suggested.

Clinical Research In The International Medical University

Clinical research refers to any field of research involving human subjects. Clinicians as researchers are well placed in contributing to research as they have access to human subjects and are able to apply research results for better patient outcome. The need for clinician-scientists as a dedicated breed is hence implied. Clinical research has low priority in the agenda of academic clinicians for various reasons. Strategies to overcome such a malady include training in research methodology and creating a permissive environment for the conduct of research. The IMU has introduced several measures to enhance clinical research and has a vibrant postgraduate program. The BMedSc programme has seen an increase in MBBS students taking this degree. Research is part of the curriculum before the Semester 7 examinations. Clinicians have been increasingly seen to be involved in research. The enhancement of clinical research through encouraging formal clinical research training and development of the MBBS-PhD programs could further enhance clinical research at the IMU. Attention to logistic constraints, improvement in collaboration with the CRC-MOH and other agencies and the close working relationship with scientists will propel clinical research to higher levels.

Understanding the Decision-Delivery Interval in Cesarean Births

Avoiding the adverse neonatal effects of perinatal asphyxia has been one of the common indications for cesarean deliveries in current obstetric practice. Expeditious delivery is dependent on decision to perform cesarean delivery and time lines achieved. A decision-delivery interval of 30 minutes, a concept initiated by the American College of Obstetricians and Gynecologists has open to debate as controversy reins about neonatal outcome when this time interval is considered in isolation. Time lines alone are probably not the only criteria to be employed, and may contribute to errors in interpretation by professional regulatory bodies and the society at large. Procedures prior to decision making like trial of labour, fetal scalp sampling and readily available resources for instituting emergent cesarean delivery invariably need to be considered. Though decision to delivery time is an integral component of critical conduct intervals in the acutely compromised fetus, a more pragmatic approach needs to be taken considering potential and known logistical and obstetric factors in line with good obstetric practice.

Urinary tract infections in pregnancy

Urinary tract infections frequently affect pregnant mothers. This problem causes significant morbidity and healthcare expenditure. Three common clinical manifestations of UTIs in pregnancy are: asymptomatic bacteriuria, acute cystitis and acute pyelonephritis. Escherichia coli remains the most frequent organism isolated in UTIs. All pregnant mothers should be screened for UTIs in pregnancy and antibiotics should be commenced without delay. Urine culture and sensitivity is the gold standard in diagnosing UTIs. Without treatment, asymptomatic bacteriuria in pregnancy is associated with preterm delivery, intrauterine growth retardation, low birth weight, maternal hypertension, pre-eclampsia and anaemia. Acute pyelonephritis can lead to maternal sepsis. Recurrent UTIs in pregnancy require prophylactic antibiotic treatment.