Knowledge, attitude, and practice of virtual consultation among outpatients at a teaching hospital in Malaysia.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the use of virtual consultations has accelerated to ensure continued access to healthcare despite lockdowns and physical distancing measures. We aimed to determine the knowledge (awareness) of, attitude (acceptability) to, and practice (exposure) [KAP] of virtual consultations (VC), the demographic factors associated with poor KAP, and the correlation between the three KAP domains. METHODS: A cross-sectional study, using a convenience sampling technique, was conducted from 13 September, 2021 to 28 November, 2021. We designed a 45-item VC KAP questionnaire. This was distributed to outpatient users attending cardiovascular, dermatology, geriatrics, haematology, endocrine, respiratory, gastroenterology, rheumatology, or neurology clinics at the University Malaya Medical Centre. It was completed during face-to-face, online, or telephone interviews. The data were analysed using SPSS version 24.0. Binary logistic regression was used to determine the demographic factors associated with KAP. Correlation between KAP domains was determined using Spearman's rho (r). A p-value of <0.05 was considered statistically significant. RESULTS: A total of 366 questionnaires were completed. Knowledge (awareness), attitude (acceptability), and practice (exposure) were considered good in 69.7%, 80.9%, and 24.6% of participants, respectively. There were no significant relationships between age, gender, ethnicity, and duration of hospital attendance (years) with knowledge (awareness), attitude (acceptability), and practice (exposure). A moderate positive correlation was seen between knowledge (awareness) and attitude (acceptability) (Attitude total [Atotal]) (r = 0.48, p<0.001), with no significant correlation between knowledge (awareness) and practice (exposure) (r = 0.04, p = 0.45), and attitude (acceptability) (Atotal) and practice (r = 0.01, p = 0.82). CONCLUSION: Overall, outpatient clinic users had good knowledge (awareness) of and were receptive towards VC but had poor practice (exposure). More opportunities for VC use in healthcare can increase exposure and subsequent utilisation. Interventions to increase the effectiveness of VC use should be explored in future studies.

"Tell me what is 'better'!" How medical students experience feedback, through the lens of self-regulatory learning.

INTRODUCTION: While feedback aims to support learning, students frequently struggle to use it. In studying feedback responses there is a gap in explaining them in relation to learning theory. This study explores how feedback experiences influence medical students' self-regulation of learning. METHODS: Final-year medical students across three campuses (Ireland, Bahrain and Malaysia) were invited to share experiences of feedback in individual semi-structured interviews. The data were thematically analysed and explored through the lens of self-regulatory learning theory (SRL). RESULTS: Feedback interacts with learners' knowledge and beliefs about themselves and about learning. They use feedback to change both their cognitive and behavioural learning strategies, but how they choose which feedback to implement is complex. They struggle to generate learning strategies and expect teachers to make sense of the "how" in addition to the "what"" in planning future learning. Even when not actioned, learners spend time with feedback and it influences future learning. CONCLUSION: By exploring our findings through the lens of self-regulation learning, we advance conceptual understanding of feedback responses. Learners' ability to generate "next steps" may be overestimated. When feedback causes negative emotions, energy is diverted from learning to processing distress. Perceived non-implementation of feedback should not be confused with ignoring it; feedback that is not actioned often impacts learning.

Microlearning and online simulation-based virtual consultation training module for the undergraduate medical curriculum - a preliminary evaluation.

BACKGROUND: Virtual consultation is a synchronous mode of telemedicine provided remotely via information and communication technology. The projected growth of digitalization in healthcare delivery, however, necessitates medical student training in virtual consultation (VC) to ensure safe and effective patient care. This study describes the implementation and preliminary evaluation of a competency-based VC training module for undergraduate medical students. METHODS: A newly developed six-week VC module was implemented online through asynchronous microlearning and synchronous simulation-based experiential learning modalities. Clinical students in years 4 and 5 and fresh graduates, who had not started pre-registration house officer or residency programmes, were invited to participate. Training outcomes using checklist-based video-recorded assessments of VC encounters between medical students and simulated patients were compared. Each video was independently assessed by two facilitators trained in VC teaching and assessment, using a direct observed virtual consultation skills checklist derived from established VC competencies. The participants completed course evaluations electronically as additional outcome measures. RESULTS: Fifty-two clinical phase medical students and alumni completed both the instructional and practical phases of this module. Altogether, 45 (95.7%) students found the module beneficial, and 46 (95.9%) reported increased self-efficacy for conducting VC. In total, 46 (95.9%) students would recommend the course to others. Post-test results showed a significant increase in the students' abilities to conduct a VC (t-test = 16.33, p < 0.05). CONCLUSION: Microlearning and simulation-based sessions were effective instructional delivery modalities for undergraduate medical students in their attainment of VC competencies.

In someone else's shoes, are all wearers the same? Empathy in multi-ethnic Asian medical students.

Objectives: Considerable research interest has been observed in ascertaining the actual pattern of empathy skill acquisition, but this aspect remains largely unexplored in Asian medical students. This study explored the empathy trait in Asian medical students from different levels of seniority and investigated the association between students' empathy traits and their socio-demographic and socio-economic backgrounds. Methods: To explore the empathy trait, the Year 1 to Year 5 medical students completed the students' socio-demographic/economic and validated Interpersonal Reactivity Index (IRI) questionnaires. Results: The participants scored highest in the empathetic concerns (EC) and lowest in the personal distress (PD) subscale. Female participants scored significantly higher on the EC, PD, and fantasy subscales. Participants who went to government high schools scored higher on the PD and EC subscales. Participants who stated a preference for specialisation that required more communication with patients scored higher on the EC and Perspective Taking subscales. Conclusions: The empathy traits of Asian medical students may have cultural influences that are determined by their geographical background. Consistent observations regarding the inclination toward cognitive empathy traits in females were observed. This study also found that empathy traits are predictive of choices for postgraduate speciality training and that there is a difference in medical students' empathy traits during the different phases of study in medical school.

Anonymous Audience Response Technology in Image-Based Quiz (IBQ) Neuropathology Lecture for Undergraduate Pre-clinical Medical Students: a Comparison with Traditional Lectures.

Pathology teaching, an intensively image loaded discipline, poses a significant challenge in its delivery. A lot of effort has been placed into sourcing teaching methods that could effectively enhance students' understanding and knowledge retention in this discipline. We describe for the first time in the literature the use of an image-based quiz (IBQ) to deliver a neuropathology lecture. The participating medical students were randomised into either the study group (IBQ) or the control group (traditional lecture, TL). The students were asked to complete the pre- and post-multiple choice question (MCQ) test before and after attending either of the allocated interventions. In the IBQ group, the students were presented with image-based quizzes, and answers to the quizzes were projected in real-time on screen. The students in the TL group were given the usual, traditional lecture. A total of 75 third-year medical students participated in this study. The participants were recruited from third-year medical students representing two different academic years. There was no significant difference in the pre- and post-MCQ scores between the IBQ and TL groups. However, a significant improvement in the mean scores for the pre- and post-MCQ results in both the study (p = 0.001; 95% CI 0.572-1.954) and control (p < 0.001; 95% CI 0.561-1.763) groups was observed. We found that the IBQ was a simple, personalised, and cost-effective digitalised tool which our study suggests it to be as effective as the traditional lecture in the delivery of pathology knowledge in undergraduate medical students.

Sleep deprivation and its association with diseases- a review.

Sleep deprivation, a consequence of multiple health problems or a cause of many major health risks, is a significant public health concern in this era. In the recent years, numerous reports have been added to the literature to provide explanation and to answer previously unanswered questions on this important topic but comprehensive updates and reviews in this aspect remain scarce. The present study identified 135 papers that investigated the association between sleep deprivation and health risks, including cardiovascular, respiratory, neurological, gastrointestinal, immunology, dermatology, endocrine, and reproductive health. In this review, we aimed to provide insight into the association between sleep deprivation and the development of diseases. We reviewed the latest updates available in the literature and particular attention was paid to reports that detailed all possible causal relationships involving both extrinsic and intrinsic factors that may be relevant to this topic. Various mechanisms by which sleep deprivation may affect health were presented and discussed, and this review hopes to serve as a platform for ideas generation for future research.

Folic acid and diseases - supplement it or not?

INTRODUCTION: folic acid is a water soluble vitamin, which is synthetically-produced and found in fortified foods and supplements. Folate is found naturally in plants, such as the dark green leafy vegetables. Folate is not synthesized de novo by humans, therefore the daily requirements are met from the dietary intake of folic acid supplements or food rich in this vitamin. Folate deficiency could lead to numerous common health problems. Hyperhomocysteinemia and the possibility of malignancy developments are the long term consequences of this deficit albeit contradictory findings on these claims. METHODS: the articles included in this review focused on recent updated evidence-based reports and meta-analyses on the associations of the serum folate/folic acid and the various diseases found globally. RESULTS: the benefit of folic acid supplementation in the pre-conception period for the prevention of neural tube defects (NTDs) was well established and it was suggested that counseling sessions should be given to women with previous pregnancies affected by NTDs. However, supplementation of folic acid and its medicinal effects in the treatment of other diseases were contradictory and unclear. CONCLUSION: more detailed investigations into the health benefits of folic acid are needed before it could be recommended for supplementation, treatment or prevention of some of the diseases discussed in this review.

Folic acid and diseases - supplement it or not? / Ácido fólico e doenças - suplementá-lo ou não?

SUMMARY Introduction: folic acid is a water soluble vitamin, which is synthetically-produced and found in fortified foods and supplements. Folate is found naturally in plants, such as the dark green leafy vegetables. Folate is not synthesizedde novo by humans, therefore the daily requirements are met from the dietary intake of folic acid supplements or food rich in this vitamin. Folate deficiency could lead to numerous common health problems. Hyperhomocysteinemia and the possibility of malignancy developments are the long term consequences of this deficit albeit contradictory findings on these claims. Methods: the articles included in this review focused on recent updated evidence-based reports and meta-analyses on the associations of the serum folate/folic acid and the various diseases found globally. Results: the benefit of folic acid supplementation in the pre-conception period for the prevention of neural tube defects (NTDs) was well established and it was suggested that counseling sessions should be given to women with previous pregnancies affected by NTDs. However, supplementation of folic acid and its medicinal effects in the treatment of other diseases were contradictory and unclear. Conclusion: more detailed investigations into the health benefits of folic acid are needed before it could be recommended for supplementation, treatment or prevention of some of the diseases discussed in this review.

RESUMO Introdução: ácido fólico é uma vitamina solúvel em água produzida sinteticamente e encontrada em alimentos e suplementos enriquecidos. O folato é encontrado naturalmente em plantas, como vegetais folhosos verde-escuros. O folato não é sintetizado de novo por seres humanos; portanto, as necessidades diárias são satisfeitas a partir da ingestão de suplementos de ácido fólico ou alimentos ricos nessa vitamina. A deficiência de folato pode levar a inúmeros problemas de saúde comuns. Hiper-homocisteinemia e a possibilidade de desenvolver malignidades são as consequências a longo prazo desse déficit, ainda que os resultados sejam contraditórios sobre essas afirmações. Métodos: os artigos incluídos nesta revisão tratam de relatórios recentes atualizados com base em provas e metanálises sobre a associação entre o folato/ácido fólico e várias doenças encontradas globalmente. Resultados: o benefício da suplementação de ácido fólico no período de pré-concepção para a prevenção de defeitos do tubo neural (DTN) foi bem estabelecido e foi sugerido que sessões de aconselhamento devem ser providas às mulheres com gravidezes anteriores afetadas por DTN. No entanto, os benefícios da suplementação de ácido fólico e os efeitos medicinais no tratamento de outras doenças são contraditórios e pouco claros. Conclusão: investigações mais detalhadas sobre os benefícios do ácido fólico são necessárias antes que a suplementação seja recomendada para tratamento ou prevenção de algumas das doenças discutidas nesta revisão.

The near-peer tutoring programme: embracing the 'doctors-to-teach' philosophy--a comparison of the effects of participation between the senior and junior near-peer tutors.

BACKGROUND: While there is an increasing pool of literature documenting the benefits of near-peer tutoring programme, little is known about the benefits for junior and senior peer tutors. Knowledge of the peer tutors' perceived benefits at different levels of seniority will aid in the development of a near-peer tutoring programme that will better fulfil both curricula and personal aspirations of near-peer tutors. We, therefore, investigated the perceived benefits of participation in a near-peer tutoring programme for junior as well as senior near-peer tutors. METHODS: Pre- and post-participation questionnaires were distributed to near-peer tutors after their clinical skills teaching sessions with Phase I undergraduate medical students. The Peer Tutor Assessment Instrument questionnaires were distributed to the 1) students, and to the 2) near-peer tutors (junior and senior) after each teaching and learning session for self-evaluation. RESULTS: The senior near-peer tutors felt that their participation in the programme had enhanced their skills (p=0.03). As a whole, the near-peer tutors were more motivated (Pre 5.32±0.46; Post 5.47±0.50; p=0.210) to participate in future teaching sessions but did not expect that having teaching experiences would make teaching as their major career path in the future (Pre 4.63±1.07; Post 4.54±0.98; p=0.701). The senior near-peer tutors were evaluated significantly higher by the students (p=0.0001). Students' evaluations of near-peer tutors on the domain of critical analysis was higher than self-evaluations (p=0.003). CONCLUSIONS: Generally, the near-peer tutors perceived that they have benefited most in their skills enhancement and these near-peer tutors were scored highly by the students. However, senior near-peer tutors do not perceive that the programme has a lasting impact on their choice of career path.

The relationship between learning preferences (styles and approaches) and learning outcomes among pre-clinical undergraduate medical students.

BACKGROUND: Learning styles and approaches of individual undergraduate medical students vary considerably and as a consequence, their learning needs also differ from one student to another. This study was conducted to identify different learning styles and approaches of pre-clinical, undergraduate medical students and also to determine the relationships of learning preferences with performances in the summative examinations. METHODS: A cross-sectional study was conducted among randomly selected 419 pre-clinical, undergraduate medical students of the International Medical University (IMU) in Kuala Lumpur. The number of students from Year 2 was 217 while that from Year 3 was 202. The Visual, Auditory, Read/Write, Kinesthetic (VARK) and the Approaches and Study Skills Inventory for Students (ASSIST) questionnaires were used for data collection. RESULTS: This study revealed that 343 students (81.9%) had unimodal learning style, while the remaining 76 (18.1%) used a multimodal learning style. Among the unimodal learners, a majority (30.1%) were of Kinesthetic (K) type. Among the middle and high achievers in summative examinations, a majority had unimodal (Kinaesthetic) learning style (30.5%) and were also strategic/deep learners (79.4%). However, the learning styles and approaches did not contribute significantly towards the learning outcomes in summative examinations. CONCLUSIONS: A majority of the students in this study had Unimodal (Kinesthetic) learning style. The learning preferences (styles and approaches) did not contribute significantly to the learning outcomes. Future work to re-assess the viability of these learning preferences (styles and approaches) after the incorporation of teaching-learning instructions tailored specifically to the students will be beneficial to help medical teachers in facilitating students to become more capable learners.

Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism: epidemiology, metabolism and the associated diseases.

The Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism is associated with various diseases (vascular, cancers, neurology, diabetes, psoriasis, etc) with the epidemiology of the polymorphism of the C677T that varies dependent on the geography and ethnicity. The 5,10-Methylenetetrahydrofolate reductase (MTHFR) locus is mapped on chromosome 1 at the end of the short arm (1p36.6). This enzyme is important for the folate metabolism which is an integral process for cell metabolism in the DNA, RNA and protein methylation. The mutation of the MTHFR gene which causes the C677T polymorphism is located at exon 4 which results in the conversion of valine to alanine at codon 222, a common polymorphism that reduces the activity of this enzyme. The homozygous mutated subjects have higher homocysteine levels while the heterozygous mutated subjects have mildly raised homocysteine levels compared with the normal, non-mutated controls. Hyperhomocysteinemia is an emerging risk factor for various cardiovascular diseases and with the increasing significance of this polymorphism in view of the morbidity and mortality impact on the patients, further prevention strategies and nutritional recommendations with the supplementation of vitamin B12 and folic acid which reduces plasma homocysteine level would be necessary as part of future health education. This literature review therefore focuses on the recent evidence-based reports on the associations of the MTHFR C677T polymorphism and the various diseases globally.

Assessors for communication skills: SPs or healthcare professionals?

INTRODUCTION: The complexity of modern medicine creates more challenges for teaching and assessment of communication skills in undergraduate medical programme. This research was conducted to study the level of communication skills among undergraduate medical students and to determine the difference between simulated patients and clinical instructors' assessment of communication skills. METHODS: This comparative study was conducted for three months at the Clinical Skills and Simulation Centre of the International Medical University in Malaysia. The modified Calgary-Cambridge checklist was used to assess the communication skills of 50 first year and 50 second year medical students (five-minutes pre-recorded interview videos on the scenario of sore throat). These videos were reviewed and scored by simulated patients (SPs), communication skills instructors (CSIs) and non-communication skills instructors (non-CSIs). RESULTS: Better performance was observed among the undergraduate medical students, who had formal training in communication skills with a significant difference in overall scores detected among the first and second year medical students (p = 0.0008). A non-significant difference existed between the scores of SPs and CSIs for Year 1 (p = 0.151). CONCLUSIONS: The SPs could be trained and involved in assessment of communication skills. Formal training in communication skills is necessary in the undergraduate medical programme.

Differential expression of the angiogenesis growth factors in psoriasis vulgaris.

BACKGROUND: Angiogenesis has been reported to be one of the contributory factors to the pathogenesis of psoriasis vulgaris. This study aims to compare the expression of different angiogenesis growth factors namely (1) the vascular endothelial growth factor (VEGF) subfamily: A, B, C, D and placenta growth factor (PlGF); (2) nerve growth factor (NGF) and (3) von Willebrand factor (vWFr) in the skins of patients with psoriasis vulgaris and non-psoriatic volunteers. RESULTS: Comparative immunohistochemistry study was performed on the paraffin-sectioned psoriatic and healthy skins with the abovementioned markers. VEGF-C (p = 0.016) and NGF (p = 0.027) were expressed intensely in the cases when compared with the controls. The NGF was the only marker that was solely expressed in the cases and absent in all the controls. CONCLUSION: The NGF (angiogenesis) and VEGF-C (lymphangiogenesis) might play a crucial role in the pathogenesis of psoriasis vulgaris and could be researched further as potential new targeted therapies for psoriasis vulgaris.