Mini-CEX: feasibility, acceptability and effectiveness of its use in the learning of post graduate residents

Objective: To assess feasibility, acceptability and effectiveness of launching mini-CEX as a Work Place Based Assessment tool in Obs/Gynae post-graduate residency program. Study Design: Mixed method approach. Place and Duration of Study: Obs/Gynae dept of Islamic International Medical College Rawalpindi Pakistan, from Aug 2016 to Feb 2017

Patients and Methods: Twenty one post graduate residents from first to final year MCPS/FCPS and available faculty members [10] were invited to participate. Non-probability convenience sampling was used. We adopted an amended mini-CEX tool. The residents were assessed in history taking, physical examination, clinical judgment, communication skills and professionalism. Copies of the mini-CEX forms were collected and analyzed. Results of the first and last Mini CEX scores were compared to determine the efficiency of mini-CEX. These results were analyzed using SPSS version 21. Perceptions of faculty and PG residents are expressed as average scale frequencies +/- 2 standard deviation. To assess the feasibility; time taken for each encounter was noted. Mean time was calculated. The total time taken for mini-CEX encounters during the study period was extrapolated over a year. For further assessing the feasibility; considerable practical difficulties were identified

Results: Almost all the residents [18/21] and faculty members [8/10] were satisfied with the mini-CEX as a learning tool. More than 75% of the residents showed gradual improvement in scores from the first to the fourth mini-CEX. The average duration of mini-CEX was 19.51 minutes. Average time taken for the feedback was 13.08 minutes. Seventeen residents were contented with feedback of each session of mini-CEX. Majority of comments indicated that feedback was the strongest characteristic of mini-CEX. Most participants [17 residents; 8 faculty members] never or occasionally experienced trouble organizing the mini-CEX. About 27% residents felt anxious being observed

Conclusions: This study concluded that Mini-CEX is highly acceptable and feasible educational tool. Its effectiveness was established by statistically significant improvement in results of post graduate residents over a period of time. It was also useful in helping faculty to assess and to give formative feedback to residents on their clinical performance in real workplace based environment

Learning the pelvic examination by clerkship medical students: evaluating skills by standardized patient model

To compare the effectiveness of training of pelvic examination [PE] of medical students on standardized patients [SPs] with the training on regular patients [RPs] during clinical rotations. A prospective controlled study. Obs/Gynae Unit I and II, Pakistan Railway Teaching Hospital, Islamic International Medical College - Rawalpindi; from April 1[st], 2013 to December 31[st], 2013. The fifth year MBBS students, doing their clerkship in Obs/Gynae department were included in the study through simple random sampling [probabilistic sampling]. Sixty seven medical students participated in the study. Group I comprised of 35 students who were trained on RPs. However 3 students of this group did not appear for assessment by OSCE so finally 32 students were left for OSCE assessment and data collection. Group II comprised of 35 students who were trained on SPs. After the completion of training, PE skills of both the groups were assessed through OSCE. The average assessment scores, technical skill scores, and communication skill scores of both the groups were calculated and standard deviation was obtained. After applying t-test, p-value was calculated, p-value less than 0.05 was considered to be statistically significant. The OSCE based average assessment scores of combined modular examination of Group I and Group II was 6.0 and 7.7 respectively. The p-value was <0.001, which was statistically significant. Similarly the average assessment score for group I and II for Technical skills in combined modular examination was 6.0 and 7.75 respectively. The average assessment scores of group I and II for communication skills was 6.25 and 8.0 respectively. Statistically significant p-value of <0.001 was calculated. It was significantly found that the students trained on SPs were more competent in technical as well as communication skills of pelvic examination as compared with the students trained on RPs. To conclude, SPs are a much more useful and efficient alternative to RPs for the clinical training of medical students of PE

Emergency Peripartum Hysterectomy in Pakistan Railway Teaching Hospital Rawalpindi: Eleven Years Review

Emergency Peripartum Hysterectomy [EPH] is a major surgical procedure. There appears to be a rise in the rate of emergency peripartum hysterectomy [EPH] in the developed world. Peripartum hysterectomy is high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the complications, as early intervention and proper management results in optimal outcome. To determine the incidence, indications, risk factors, complications and management of EPH over the last eleven years. A descriptive study. All cases of EPH performed in the period between January 2001 and December 2011 were included in the study. Study was conducted at Railway Teaching Hospital, Rawalpindi [in northern Pakistan]. Data of all the cases of EPH cases operated during the study period was collected from the hospital obstetric record. Data of basic demographics, mode of delivery, maternal and fetal outcome along with associated complications was collected and entered into the Statistical Package for Social Sciences version 14.0 [SPSS Inc., Chicago, IL, USA] for further analysis. Indications, pre-op planning, type of operation, emergency decision, blood loss, transfusion, complications, were compared and cross-tabulated. Statistical analysis included: Chi-square and Fisher exact tests, where appropriate, and two-sample t test. Total deliveries were 13560 in 11 years. Twenty Six EPH cases were performed among deliveries, giving an incidence of 1.8 per 1000 deliveries i.e. one in 566 deliveries. The indications were uterine atony [34.61%], ruptured uterus [23.07%] and cervical/vaginal tears [11.53%], placenta praevia [11.53%], invasive placental adhesion [accreta, increta, percreta [11.53%]]. A significant association between previous uterine surgery and abnormal placentation was shown [p=0.02], especially those with previous caesarean [p=0.003]. One maternal and six perinatal mortalities were recorded. Four perinatal deaths were of non-booked patients, handled by traditional birth attendants/private clinics. Out of two perinatal deaths of booked patients, one was pre-term and other was delivered by forceps. Maternal morbidity was prevalent, including twenty three intensive care admissions, three disseminated intravascular coagulopathies, three bladder injuries, three re-explorations, multiple blood, FFPs and platelet transfusions, two pulmonary embolism and one cardio- respiratory failure. Maternal death was of non-booked patient with previous scar, home delivery, uterine rupture and brought to hospital with un-recordable BP and very weak pulse. Incidence of peri-partum hysterectomy is increasing. It is a major operation, and almost always an emergency with significant blood loss. An early decision should be made to save life of the patient and prevent complications. The most important risk factor for peripartum hysterectomy in our patients is hemorrhage, most notably caused by uterine atony, uterine rupture, placenta previa and abnormally adherent placenta

Patients' Attitude towards Medical Students in a Teaching Hospital of Pakistan

To study patient's attitude towards medical students on clinical clerkship rotation in a hospital Descriptive Cross Sectional Study. Medical, Surgery and Gynae/Obs Departments of Pakistan Railway Teaching Hospital, Rawalpindi from March 30, to May 30, 2013. Two hundred and seventy five patients were included in the study through non probability purposive convenient sampling. A questionnaire was prepared to interview the patients participating in the study. Data collected was entered into Statistical Package for Social Sciences [SPSS Version 17]. Descriptive statistics were applied for all the variables to present the frequencies and percentages. For history taking, a larger preference was shown by the patients to the students' involvement irrespective of the gender; 55% patients recommended the presence of both male and female students, 50% patients were willing to allow medical students of either gender to take their medical history in the doctor's presence and 43% patients were willing to permit without a doctor's supervision. For medical examination by the medical students, patients were more inclined to the presence of a doctor but much more patients became gender conscious. 36% preferred the presence of both male and female students, 31% patients were willing to allow medical students of either gender in the doctor's presence and only 22% to permit medical students to carry out their examination without a doctor's supervision. Patients' preference to students' involvement while a medical procedure is carried out on them, in general, around 50% of the patients were reluctant; 48% patients would not allow medical students to be present as observers, 57% were reluctant to allow the students to carry out a procedure on them in the presence of a doctor and 68% patients were unwilling to let medical students to carry out a procedure on them in the absence of doctors. For gender conscious patients, a significantly larger preference was shown towards female students over male in all the three situations. It is concluded that the attitude of patients' towards the involvement of medical students in their clinical health care is related to the extent of students' involvement, the presence of a doctor[s] and the gender of the students and the patients

Maternal and fetal outcome of pregnancies with umbilical cord problems

To seek relationship between cord problems [like long cords, short cords, nuchal cord and cord knots] and its effects on fetus as well as mode of delivery. Descriptive [case series] Obs/Gynae wards Railway hospital, Rawalpindi from September 2006 to August 2007. It was a descriptive case series study. Hundred patients with umbilical cord problems, detected at delivery were included.Effects of these cord problems on mode of delivery and fetal outcome were observed. Twenty two percent patients had long cord, 14% had short cords.41% had single nuchal cord, 22% had double loop of cord around the neck, and 4% patients had triple loops of Nuchal cord. It was observed that 4% patients were having true kanots in umbilical cord and and only 26% patients had false knots in umbilical cord. In the patients with cord problems, rate of SVD was more than 70% and LSCS < 20%. These problems did not show significant effects on birth weight and Apgar scores when present alone.But multiple cord problems in a single pregnancy were associated with fetal complications. Long and short umbilical cords, umbilical cord knots and Nuchal cords had no significant effects on mode of delivery and Apgar score in 5 minutes. But multiple umbilical cord problems in same case may pose problems to the fetus and early diagnosis can prevent fetal harm

External cephalic version [ECV] for breech presentation at term -experience at railway hospital

To assess the effectiveness of ECV in singleton breech presentation at term and to determine its effect on maternal, delivery and perinatal outcomes in women to whom the procedure was offered. Aquasi experimental study. The study was carried out in the Department of Obstetrics and Gynaecology, Railway hospital, Rawalpindi, fromAugust2006 to December2008. Eligible women, presenting with uncomplicated breech, between 37-41 weeks gestation, underwent ECV on day care basis. Fifteen minutes before the procedure, injection salbutamol 0.5 mg was administered. Cases with contraindication to ECV or salbutamol injection were excluded from the study. Success rate of ECV [in terms of conversion from breech to cephalic presentation at the completion of procedure confirmed through ultrasound] along with maternal, delivery and perinatal outcomes were assessed. Maternal and fetal demographic characteristics were also recorded as secondary outcome measures. For statistical analysis, SPSS version 10 was used and Chi-square test applied with a p<0.05 taken as significant. Of the 42 ECV procedures, 25 [59.5%] were successful. None of the patient suffered from serious maternal complications. Seven [16.7%] parturients complained of severe palpitations and 4 [9.5%] of marked discomfort during the procedure. Reversible fetal bradycardia was seen in 1 [2.4%] patient. Reversion to a non cephalic presentation occurred in two cases. Vaginal delivery was carried out in 21 patients out of the 25 who successfully underwent external cephalic version while all the patients with failed ECV underwent caesarean delivery. The 5 minute Apgar score was more than 8 in all except one baby. Adverse maternal and fetal outcomes of breech presentation at term are rare and there was no increased risk of complications after external cephalic version. Findings provide important data to quantify the frequency of adverse outcomes that will help facilitate informed decision-making and ensure optimal management of breech presentation

Impact of labour and delivery simulation classes in undergraduate medical learning

To compare the impact on knowledge and learner's satisfaction of adding a labour and delivery simulator-based training module with a self-study session, to the pre-existing theoretical class, in the 5[th] year undergraduate medical curriculum. Descriptive. At Islamic International Medical College, Pakistan Railway Hospital Rawalpindi from September 2007 to December 2008. Ninety four students attending the 5-week Obstetrics and Gynecology rotation were enrolled, and 94 completed the study. After a 45-minute [labour and delivery] theoretical interactive class, students were randomized into two groups: the first [n=53] participated in a 30-minute supervised self-study session, while the second [n=41] attended a 20-30 minute delivery simulator session. Tests consisting of 10 multiple-choice questions were given before the theoretical class [pre-test], after the self-study or simulation session [1[st] post-test] and 12-15 days later [2[nd] post-test]. Paired rank sum test, T test, and z-statistic with continuity correction were employed for statistical analysis, setting significance at p<0.05. Pre-test scores were similar in both groups [p=0.9567], but in the first post-test they were significantly higher in the simulation group [p=0.0017]. In the 2[nd] post-test, however scores were again similar in both groups [p=0.2204]. Satisfaction was significantly higher in the simulation group [p<0.0001]. Adding a simulator-based training session for medical students in management of labour and delivery to the theoretical class led to a higher short-term increase in knowledge and student satisfaction than attending a self-study session. Significant differences in knowledge were no longer demonstrable at 12-15 days

Managing shoulder dystocia: perceptions of accoucheurs regarding their training

To assess the perceptions of labour ward staff at teaching hospitals regarding their theoretical and practical training for the management of shoulder dystocia as well as their opinion for further need of such trainings. Across sectional survey. At Islamic International Medical College, Railway Hospital Rawalpindi and College of Physicians and Surgeons Regional Centre Islamabad, from October to November 2008. The study was carried out by using a six item questionnaire. Four items were related to the respondent's training regarding the management of shoulder dystocia while two wete about their response to frequently performed actions which are known to increase the incidence of complications associated with the management of shoulder dystocia. Among sixty seven healthy personnel's involved in the management of parturient in the labour ward, 86.6% [n=58] were doctors and 1 3.4% [n=9] were midwives. The years of experience managing labouring patients ranged from 1 to 30 years. Although only 1 8% [n=1 2] thought that they did not have any theoretical training in shoulder dystocia and 40% [n=27] thought that they did not have any practical training, almost 72% [n=48] expressed a need for more theoretical and 91% [n=61] wanted more simulated training to manage shoulder dystocia. However, only 7.5% [n=5] of respondents involved in this survey said they would use fundal pressure and 1 0.4% [n=7] would apply strong traction to the fetal neck. In the opinion of labour ward attending physicians, the current level of their training for the management of shoulder dystocia is inadequate and there is a need for organizing regular practical training programs to improve their skills in managing this obstetric emergency

OSCE as an assessment tool: perceptions of undergraduate medical students

To describe the perceptions of undergraduate medical students regarding Objective Structured Clinical Examination [OSCE] and its comparison to Multiple Choice Questions [MCQ], essay questions and viva voce. This cross-sectional survey was carried out at Islamic International Medical College Rawalpindi [Pakistan], from 3 December 2008 to 2 January 2009. We used a questionnaire comprising of a total of 12 items, out of which 8 items were regarding the quality of exam [Liken scale], 3 regarding the difficulty, being educative and fairness of OSCE relative to other methods of assessment and last one regarding its acceptability as a method to assess clinical skills for undergraduate medical students. The questionnaire was distributed to students of 4th and 5th year medical students to be filled and returned for assessment of the responses. One twenty seven students completed the questionnaire. The results of the study showed that the exam was stressful for 51% of the respondents. About 81% thought that performance of tasks during OSCE was interesting and educative. OSCE, essay type, MCQ and oral viva examination were perceived easy by 44, 33, 18 and 5% students, educative by 32, 16, 23 and 30% and fair by 43, 13, 32 and 11% respectively. OSCE is well-received and acceptable to undergraduate medical students of Pakistan as a method to assess clinical skills

Low amniotic fluid index in high-risk pregnancy and poor apgar score at birth

To determine the accuracy of antepartum Amniotic Fluid Index [AFI] of 5 cm was labeled as predictor of good outcome at birth. The subjects in both the groups were demographically matched and fulfilled the inclusion and exclusion criteria. The Apgar score was calculated at 5 minutes of birth. The newborns, with Apgar score 6 were labeled as healthy. AFI was compared with Apgar score, using Chi-square and a p-value was calculated to determine the statistical significance. Sensitivity, specificity, efficiency and the predictive values of AFI at a cut off point of

Impact of new diagnostic criteria of diabetes mellitus

To compare the frequency of diabetic individuals diagnosed by fasting plasma glucose [FPG] >/= 7.0 mmol/L with previous value i.e. >/= 7.8 mmol/L and to determine the diagnostic accuracy of FPG >/= 7.0 mmol/L. A cross-sectional study. The Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from April to July 2003. FPG of 5250 subjects was checked to compare the frequency of diabetic subjects diagnosed by FPG >/= 7.0 mmoI/L with >/= 7.8 mmol/L. Of them, 301 symptom-free subjects were subjected to 75 g Oral Glucose Tolerance Test [OGTT] and their 2 hours post glucose [2-h PG] challenge level was taken as [gold standard] to determine the diagnostic accuracy of FPG at >/= 7.0 mmol/L. By lowering the cut off point of FPG from 7.8 mmol/L to 7.0 mmol/L, the percentage of diagnosed diabetic subjects increased from 35% to 42%. Statistical analysis revealed a significant increase [p< 0.0001]. FPG >/= 7.0 mmol/L had a diagnostic sensitivity of 70%, specificity 91%, the predictive value of positive and negative diagnosis was 84% and 80% respectively. FPG at cut off point of >/= 7.0 mmol/L, will greatly facilitate the early diagnosis of diabetes mellitus [DM]. An early diagnosis can be further facilitated by a combination of FPG and 2-h PG estimation