Using the health humanities to impart disability competencies to undergraduate medical students.

BACKGROUND: Disability competencies were included, for the first time, in India's new undergraduate competency-based curriculum as a result of physician-led advocacy in 2019; the regulatory body also recommended the use of the humanities in medicine. OBJECTIVE: To use tools from the health humanities to impart disability competencies and help students appreciate the social and human rights issues associated with disability. METHODS: A module was developed and piloted in the foundation course on the new cohort of students. The tools included storytelling, visual art, poetry, narratives, and Forum Theatre; many facilitators were doctors and patients with disabilities. Learners were introduced to the concept of universal design through a field visit. Quantitative and open-ended feedback was taken from learners after module delivery; reflections were sought after four months. RESULTS: The data revealed that the humanities tools used in the module had the potential to help learners explore struggle and oppression and to expose discriminatory attitudes. Learners were able to think beyond the hegemony of normalcy, and show an understanding of diversity, dignity, autonomy, disableism, social inclusion, equity, and universal design. They admitted to the misconceptions they carried and showed keenness to advocate for change. CONCLUSION: This study piloted a novel disability competencies module using tools from the health humanities and found that learners were able to engage with and show an understanding of the social and human rights issues associated with disability. Conversations by, for, and with people with disabilities must be part of such interventions in developing and delivering disability courses.

Developing Humanistic Competencies Within the Competency-Based Curriculum.

We herein, describe the rationale, content, methodology and evaluation of a health humanities module in the new competency-based curriculum, and share our experience of the same. Providing training in health humanities to the healthcare trainees will definitely go a long way in having a professional and responsive Indian medical graduate, who is able to provide empathetic and holistic healthcare to all sections of the society.

Evaluation of a faculty development workshop aimed at development and implementation of a competency-based curriculum for medical undergraduates.

INTRODUCTION: Faculty development to implement competency-based medical education (CBME) is urgently needed as the Medical Council of India has implemented the competency-based curriculum this year onwards. OBJECTIVES: To evaluate a 2-day faculty development workshop in terms of: (a) increase in knowledge about CBME terminology and concepts, (b) self-reported capacity to develop and implement a competency-based module in their respective disciplines, and (c) satisfaction of the participants. METHODOLOGY: A single arm interventional study using mixed methods was carried out in which faculty members were purposively identified and requested to volunteer for a two-day faculty development workshop on the development and implementation of CBME. The workshop was evaluated (open-ended and Likert scored items) by the participants for self-reported gain in knowledge, gain in their confidence to develop and implement CBME, and level of satisfaction with respect to the components of the workshop. Quantitative data was analyzed by Wilcoxon signed rank test and Kruskal-Wallis test. Qualitative data was analyzed by doing content analysis and emerging themes have been presented. RESULTS: Eleven faculty members attended a capacity building workshop for developing and implementing a competency-based curriculum for medical undergraduates. There was a significant improvement in their self-reported knowledge and attitude regarding the competency-based curriculum. New concepts learned fell into four domains: modification of the existing curriculum toward competency-based curriculum, knowledge of CBME, teaching-learning and assessment methods, and beneficial to the students. The participants were highly satisfied with the workshop in its current form. CONCLUSION: A two-day faculty development workshop can increase the knowledge and understanding of competency-based medical education and can be an important first step in the journey to more specialized training.

Disability-inclusive compassionate care: Disability competencies for an Indian Medical Graduate.

The new curriculum of the Medical Council of India (MCI) lacks disability-related competencies. This further involves the risk of perpetuating the medicalization of diverse human experiences and many medical students may graduate with little to no exposure to the principles of disability-inclusive compassionate care. Taking into consideration the UN Convention, the Rights of Persons with Disabilities, Act 2016, and by involving the three key stakeholders - disability rights activists, doctors with disabilities, and health profession educators - in the focus group discussions, 52 disability competencies were framed under the five roles of an Indian Medical Graduate (IMG) as prescribed by the MCI. Based on feedback from other stakeholders all over India, the competencies were further refined into 27 disability competencies (clinician: 9; leader: 4; communicator: 5; lifelong learner: 5; and professional: 4) which the stakeholders felt should be demonstrated by health professionals while they care for patients with disabilities. The competencies are based on the human rights approach to disability and are also aligned with the competencies defined by accreditation boards in the US and in Canada. The paper describes the approach used in the framing of these competencies, and how parts of these were ultimately included in the new competency-based medical education curriculum in India.

Perceptions of specialist doctors of the ability of doctors with colour vision deficiency to practise their specialty safely.

Some doctors with severe congenital colour vision deficiency (CCVD) may experience difficulty in colour discrimination that can affect their decision-making. In the absence of evidence-based guidelines, learners with CCVD are arbitrarily debarred from specialising in some disciplines. This cross-sectional, anonymous, questionnaire-based study asked specialists from all over the country if doctors with CCVD should avoid specialising in their respective disciplines. Of 218 responses, 80 (36.7%) said they should avoid it, citing colour discrimination as critical. The 32 (14.7%) participants who were unsure and 106 (48.6%) who said that CCVD would not be a problem gave reasons that mirrored those in the literature: the degree of deficiency is variable; experience helps; automation, history-taking, close observation, good illumination, contrast, touch, and peer-corroboration can reduce dependency on colour. Awareness of the deficiency and finding ways to compensate for it during training may mitigate errors and safeguard patients. Instead of blocking people with CCVD from admission to some specialties, specialists should consider these findings and support learners who are aware of their deficiency and still wish to specialise in a particular discipline.

Forging an ethical pathway: Disability accommodation, diverse voices, and standards of care.

The opening quote by Alexandra Adams, the first deaf-blind medical student in the United Kingdom, is a response to naysayers on her decision to join medicine. The cover page of this issue of IJME also highlights the underrepresented in medicine: portraying a healthcare professional with an acquired visual impairment who works with full professional rigour and dedication.

Transformational learning for health professionals through a Theatre of the Oppressed workshop.

Theatre of the Oppressed (TO) is a powerful participatory tool for communities to examine their struggles against oppression. The healthcare community has problems inherent to complex, unequal power equations, and TO may be a useful means to understand and respond to their struggle. A 3-day workshop on TO was facilitated by the authors in the Himalayan Institute of Medical Sciences (HIMS) in Dehradun, India, in August 2017. The workshop culminated in the 'Forum Theatre', which included five short plays, each depicting a struggle due to real-life oppression faced by one or the other participant. The audience (about 200 invited members of the HIMS community) chose one play depending on the struggle with which they identified most. That play was 'forumed': spectators were invited to replace the struggling person and demonstrate how they would handle the oppression. Over the next week, participants reflected on the workshop through a structured online questionnaire. The feedback (n=16/27 participants; response rate 59.3%) was subjected to descriptive statistics and to qualitative analysis. The highest average Likert score (out of a maximum of 5) was given to the following items: TO engages senses and emotions (4.6±0.50), can help inculcate ethical behaviour (4.4±0.81), identifies conflict (4.4±0.51), and resolves issues of attitude, behaviour, communication, diversity and empathy (4.4±0.73). The Forum Theatre was reported to be a means to "express emotions and opinions and to simultaneously gather the same from others"; "make people push their own limits"; "bring out social problems in public"; "examine the root causes behind lived experience"; "provide context for understanding and for exploring alternatives"; and "convert thoughts to action." In conclusion, TO is an engaging activity that identifies conflict; participants' initial reactions suggest that it may initiate change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Coping strategy in persons with low vision or blindness - an exploratory study.

Purpose: Coping strategies employed by people with visual disability can influence their quality of life (QoL). We aimed to assess coping in patients with low vision or blindness. Methods: In this descriptive cross sectional study, 60 patients (25-65 years) with <6/18 best-corrected vision (BCVA) in the better eye and vision loss since ≥6 months were recruited after the institutional ethics clearance and written informed consent. Age, gender, presence of other chronic illness, BCVA, coping strategies (Proactive Coping Inventory, Hindi version), and vision-related quality of life (VRQoL; Hindi version of IND-VFQ33) were recorded. Range, mean (standard deviation) for continuous and proportion for categorical variables. Pearson correlation looked at how coping varied with age and with VRQoL. The analysis of variance (ANOVA) and t-test compared coping scores across categorical variables. Statistical significance was taken at P < 0.05. Results: Sixty patients fulfilled inclusion criteria. There were 33 (55%) women; 25 (41.7%) had low vision, 5 (8.3%) had economic blindness, and 30 (50.0%) had social blindness; 27 (45.0%) had a co-morbid chronic illness. Total coping score was 142 ± 26.43 (maximum 217). VRQoL score (maximum 100) was 41.9 ± 15.98 for general functioning; 32.1 ± 12.15 for psychosocial impact, and 41.1 ± 17.30 for visual symptoms. Proactive coping, reflective coping, strategic planning, and preventive coping scores correlated positively with VRQoL in general functioning and psychosocial impact. Conclusion: Positive coping strategies are associated with a better QoL. Ophthalmologists who evaluate visual disability should consider coping mechanisms that their patients employ and should refer them for counseling and training in more positive ways of coping.

Outcomes of preoperative intrapterygial injection of mitomycin C for pterygium excision with and without inferior conjunctival flap.

PURPOSE: This study aimed to report the comparison of recurrence rate and complications of intrapterygial injection of mitomycin C (MMC) 1 month before bare sclera excision of pterygium with and without conjunctival flap from the inferior bulbar conjunctiva. METHODS: This prospective interventional study enrolled 60 patients of pterygia from November 2010 to June 2012. All eyes received 0.1 ml (0.02%) of intrapterygial MMC injection 1 month preoperatively. Patients were divided into two groups of 30 each: Group 1 - bare scleral excision (BSE) and Group 2 - BSE with conjunctival flap from the inferior bulbar conjunctiva to cover the bare sclera. Chi-square test, Fisher's exact test, and unpaired t-test were used for statistical analysis. RESULTS: The mean age was 40.6 ± 12.8 years and 36.9 ± 10.9 years in Group 1 and 2, respectively, (P = 0.2329). There were 11 (36.7%) males and 19 (63.3%) females in Group 1 and 7 (23.3%) males and 23 (76.7%) females in Group 2 (P = 0.101). The recurrence rate was 0% in Group 1 and 3.3% (1 eye) in Group 2 (P = 1.00). Postoperatively, scleral whitening occurred in 6 (20%) eyes in Group 1 and none in Group 2 (P = 0.015). CONCLUSION: Both techniques, BSE alone or with conjunctival flap from the inferior bulbar conjunctiva 1 month after intrapterygial MMC, resulted in negligible (0%-3.3%) recurrence of pterygium. Conjunctival flap significantly reduced (0%) the postoperative complication of scleral whitening. This is the first report of efficacy of conjunctival flap in reducing scleral whitening after intrapterygial MMC.

Development and validation of simulated virtual patients to impart early clinical exposure in endocrine physiology.

In the country presently, preclinical medical students are not routinely exposed to real patients. Thus, when they start clinical postings, they are found to have poor clinical reasoning skills. Simulated virtual patients (SVPs) can improve clinical skills without endangering real patients. This pilot study describes the development of two SVPs in endocrine physiology and their validation in terms of acquisition of clinical knowledge and student engagement. Two SVPs, Nandini Sharma (unintentional weight gain) and Sunil Yadav (polyuria), were created and published on the i-Human Patients platform through an iterative, interdisciplinary, and transdisciplinary collaborative process using the conceptual framework of Kim et al. (Kim S, Phillips WR, Pinsky L, Brock D, Phillips K, Keary J. Med Educ 40: 867-876, 2006). After internal and external peer validation, the SVPs were piloted on 40 students (20 students per virtual patient) over 2 wk. A cognitive pretest was conducted before exposure, and a posttest soon after. Faculty and student feedback were collected. Faculty found SVPs authentic, helpful as teaching-learning tools, and useful for giving feedback and for assessment. Students found SVPs more engaging than paper cases and helpful in developing clinical reasoning and in imparting clinical exposure. Pretest and posttest scores indicated knowledge gain ( P < 0.01). Although challenging to create, SVPs created on the i-Human Patients platform improved learning in endocrine physiology and were well accepted by students and faculty as a means to provide early clinical exposure. More SVPs can be developed through collaboration between stakeholder departments and integrated into the curriculum for greater benefit.

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.

Preparing medical students with congenital colour vision deficiency for safe practice.

BACKGROUND: Colour vision of candidates is tested in many medical colleges in India at the time of admission to undergraduate courses; however, there are no guidelines, and therefore no counselling, on how students with congenital colour vision deficiency (CCVD) should negotiate the medical course, and how best they can practise safely after graduation. Problems in interpreting coloured signs may lead to misdiagnosis. This study aimed to explore difficulties during clinical work that requires colour discrimination, and to offer suggestions on safe practice based on the findings and a review of the literature. METHODS: We did a cross-sectional study after obtaining institutional ethical clearance and written informed consent. Thirty volunteer medical students with CCVD (≥3 errors on Ishihara chart) were matched with 30 volunteers from their own batch who made no errors. All participants interpreted colour-dependent clinical and laboratory photographs. RESULTS: Students with CCVD made more errors (range 5-26; mean [SD] 13.17 [5.873] out of 75 items in 35 colour-dependent photographs) than colour-normal students (range 2-13; mean [SD] 5.53 [3.037], p<0.001). The nature of the errors suggested that medical students with CCVD could have problems in learning histology, pathology, haematology, microbiology, dermatology, paediatrics, medicine, biochemistry and during ophthalmoscopy. CONCLUSIONS: Screening at the time of admission will make students aware of their CCVD status and, through conscious practice thereafter, they may understand their limitations. Faculty could guide and prepare such students for safe practice.

Adjustment to acquired vision loss in adults presenting for visual disability certification.

CONTEXT: Rehabilitation of the visually disabled depends on how they adjust to loss; understanding contributing factors may help in effective rehabilitation. AIM: The aim of this study is to assess adjustment to acquired vision loss in adults. SETTINGS AND DESIGN: This observational study, conducted in the Department of Ophthalmology at a tertiary-level teaching hospital, included thirty persons (25-65 years) with <6/60 in the better eye, and vision loss since ≥6-months. MATERIALS AND METHODS: Age, gender, rural/urban residence, education, current occupation, binocular distance vision, adjustment (Acceptance and Self-Worth Adjustment Scale), depression (Center for Epidemiologic Studies-Depression Scale), social support (Duke Social Support and Stress Scale), and personality (10-item Personality Inventory scale) was recorded. STATISTICAL ANALYSIS: To determine their effect on adjustment, Student's t-test was used for categorical variables, Pearson's correlation for age, and Spearman's correlation for depression, personality trait and social support and stress. RESULTS: Of 30 persons recruited, 24 were men (80%); 24 lived in urban areas (80%); 9 were employed (30%); and 14 (46.6%) had studied < Class 3. Adjustment was low (range: 33%-60%; mean: 43.6 ± 5.73). Reported support was low (median: 27.2; interquartile range [IQR]: 18.1-36.3); reported stress was low (median: 0.09; IQR: 0-18.1). Predominant personality traits (max score 14) were "Agreeableness" (average 12.0 ± 1.68) and "Conscientiousness" (average 11.3 ± 2.12). Emotional stability (average 9.2 ± 2.53) was less prominent. Depression score ranged from 17 to 50 (average 31.6 ± 6.01). The factors studied did not influence adjustment. CONCLUSIONS: Although adjustment did not vary with factors studied, all patients were depressed. Since perceived support and emotional stability was low, attention could be directed to support networks. Training patients in handling emotions, and training family members to respond to emotional needs of persons with visual disability, might contribute to reducing stress and depression.

Harnessing the medical humanities for experiential learning.

A month-long workshop on medical humanities was held in the Jorhat Medical College, Assam in September 2015. It employed experiential learning (both online and onsite) using humanities tools, such as the theatre of the oppressed, art, literature, reflective narratives, movies, the history of medicine, graphic medicine, poetry and diversity studies. As a result of the interactions, 28 volunteer participants, comprising students and faculty members, wrote reflective narratives on doctor​-patient relationships, produced a newsletter and a logo for their medical humanities group, and staged cultural performances and forum theatre. The narratives, participants' reflections and feedback received were subjected to qualitative analysis; the workshop was evaluated using Kirkpatrick's model. The participants learned to examine their attitudes and behaviour, communicate with their bodies, and experience respect for diversity. There was an improvement in their understanding of empathy, ethics and professionalism. The workshop achieved level-3 (behaviour) on Kirkpatrick's model, suggesting that such workshops can initiate a change in the ABCDE attributes (attitude, behaviour, communication, diversity, ethics and empathy) of medical professionals.

Producing Competent Doctors - The Art and Science of Teaching Clinical Skills.

For a doctor to provide medical care with competence, he must not only have knowledge but must also be able to translate that knowledge into action. It is his competence in clinical skills that will enable him to practice safely and effectively in the real world. To ensure acquisition of clinical skills, medical teachers must adopt teaching methods that prioritise observation, practice, feedback; and more practice. We try to elucidate the meaning of clinical skills, the challenges inherent in clinical skills training in India, training models that have shown success in practice and can be adopted in the Indian context, and various techniques to enhance skill-training, including the giving of feedback, which is a critically important component of skills development.

Admission to Undergraduate and Postgraduate Medical Courses: Looking Beyond Single Entrance Examinations.

In India, a single national level entrance examination for admission to undergraduate and postgraduate medical courses has been introduced. This is largely an effort towards alleviating financial corruption in admission process, improving logistics and ease of examination for students, and resource-efficacy in conduct of examination. Unfortunately, the possible educational impact of such single high-stakes examination has not been overtly discussed. A major handicap in doing so is the lack of documentation and analysis of our own experience with multiple entrance examinations over many years. One adverse aspect of a single high-stakes examination, especially the Postgraduate entrance examination, is that the students' learning priorities get redefined to being 'examination-oriented' rather than 'competency-development oriented'. Hence, we must draw lessons from admission processes in other countries that have gone through similar course. Two key effective practices in these countries include giving weightage to prior academic performance, and use of a combination of some form of cognitive testing, aptitude testing and non-cognitive assessment, for taking selection decisions. It is prudent to modify our existent examination processes utilizing the same principles. There is a need to improve the formative assessments and the end-of-training certification examinations, and possibly also include them as inputs for the admission process.

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.