Investigating the internal structure of multiple mini interviews-A perspective from Pakistan.

BACKGROUND: Healthcare professionals require many personal attributes in addition to cognitive abilities and psychomotor skills for competent practice. Multiple Mini- Interviews are being employed globally to assess personality attributes of candidates for selection in health professions education at all level of entry; these attributes are namely, communication skills, critical thinking, honesty, responsibility, health advocacy, empathy and sanctity of life. Considering the high stakes involved for students, faculty, institutions and the society, rigorous quality assurance mechanisms similar to those used for student assessment must be employed for student selection, throughout the continuum of medical education. It is a difficult undertaking as these psychological constructs are difficult to define and measure. Though considered to yield reliable and valid scores, studies providing multiple evidences of internal structure especially dimensionality of Multiple Mini-Interviews are sparse giving rise to questions if they are measuring a single or multiple constructs and even if they are measuring what they are purported to be measuring. OBJECTIVE: The main objective is to provide statistical support of the multi-dimensional nature of our Multiple Mini Interviews, hypothesized a-priori, through CFA. Another objective is to provide multiple evidences for the internal structure. Our study highlights the link between content and internal structure evidences of the constructs, thus establishing that our Multiple Mini Interviews measure what they were intended to measure. METHOD: After securing permission from the Institutional review board, an a-priori seven factor-model was hypothesized based on the attributes considered most essential for the graduating student of the institution. After operationally defining the attributes through extensive literature search, scenarios were constructed to assess them. A 5-point rating scale was used to rate each item on the station. A total 259 students participated in the multiple mini interviews over a period of three days. A training workshop had been arranged for the participating faculty. RESULTS: The reliability coefficient using Cronbach's alpha were calculated (range from 0.73 to 0.94), Standard Error of Measurement (ranged from 0.80 to1.64), and item to station-total correlation ranged from 0.43-0.50 to 0.75-0.83. Inter-station correlation was also determined. Confirmatory factor analysis endorsed the results of Exploratory factor analysis in the study revealing a seven model fit with multiple indices of Goodness-of-fit statistics such as Root mean square error of approximation (RMSEA) value 0.05, Standardized root mean square residual (SRMR) value with less than 0.08. All these indices showed that model fit is good. The Confirmatory factor analysis confirmed the multi-dimensional nature of our MMIs and also confirmed that our stations measured the attributes that they were supposed to measure. CONCLUSION: This study adds to the validity evidence of Multiple Mini-Interviews, in selection of candidates, with required personality traits for healthcare profession. It provides the evidence for the multi-dimensional structure of Multiple Mini interviews administered with multiple evidences for its internal structure and demonstrates the independence of different constructs being measured.

Transforming professional identity of medical teachers in Pakistan by a certificate program in health professions education: a thematic analysis of reflective essays.

Introduction: A teacher's professional identity development is a dynamic and continuous process that requires rigorous, longitudinal, faculty development initiatives which are designed to work on individual professional growth. Impact of such programs must be evaluated by qualitative means to identify the process of change; The purpose of our study was to investigate whether and how our thoughtfully designed 6-month certificate program has transformed the professional identity of medical teachers. Methods: The study was conducted in National University of Medical Sciences, Pakistan using thematic analysis, wherein a weekly task of guided reflective writing, on Moodle, was given. Data was analyzed in six phases to achieve credibility and transferability. Results: By analyzing 202 reflective writings, seven subthemes were identified which manifest transformation in certain aspects of identity of participants and grouped under three major themes. The seven subthemes represent transformative journey of participants and include recognizing millennial learners' dilemma, identifying learning gaps and overcoming barriers, discovering a newer version of self, alternative frame of thinking, transforming traditional classroom, conducive learning environment and Community of Practice. Three major themes identified were Awareness, Modeling and Socialization which represent three processes bringing transformation in participants. Conclusion: Our faculty development program has transformed certain aspects of professional identities of medical teachers by incorporating informal teaching strategies of experiential learning, professional socialization, reflections, and role modeling. Participants' beliefs and practices on teaching were challenged by giving a disorienting dilemma of millennial learners and learning theories. They underwent critical discourse with professional peers and mentors in community of practice, reflected on their traditional teaching practices, acquired new insight, underwent self-discovery, and introduced digitalization and interactive learning strategies within their classrooms.

Evaluating the impact of faculty development programme initiative: Are we really improving skills in MCQ writing?

A series of seven workshops were conducted in 2018, at the National University of Medical Sciences and its affiliated institutes, to evaluate the effectiveness of a three-hour workshop in improving faculty competence in developing high quality test items. Participants' satisfaction was evaluated with a post-workshop feedback questionnaire. A self-made structured questionnaire was required to be filled as a pre-test and post-test assessment. Paired t-test was applied and difference in mean scores of responses was evaluated. A total of 141 faculty members were trained. The training session led to high satisfaction in all elements of workshop, significant improvements in boosting confidence in item writing skills (p=0.001), recognising parts of MCQs (p=0.001), identifying item writing flaws (p=0.001), and levels of Millers pyramid and blooms taxonomy (p=0.001). Training sessions of short duration are effective in improving faculty competence in writing high quality test items, if hands-on experience is built-in and effective feedback is provided.

Point-of-care testing facilitates screening and treatment for anaemia in women and children in rural Pakistan.

OBJECTIVE: To use point-of-care testing to screen and facilitate treatment for anaemia and to establish an estimate of the prevalence of anaemia in the local population. DESIGN: An uncontrolled before and after study design was used to evaluate the effectiveness of the intervention on the anaemia status of participants. SETTING: This study took place in a rural mountain community (population approximately 1000) in the Haripur district in northern Pakistan. PARTICIPANTS: Women of child-bearing age (15-49 years) and children (12-14 years) were included in this study. INTERVENTIONS: The intervention included point-of-care testing for haemoglobin, treatment with mebendazole and oral iron supplementation, and an education campaign about anaemia delivered by community health workers and medical students. MAIN OUTCOME MEASURES: The main outcome measure was an increase in blood haemoglobin over the study period. A secondary outcome measure was a positive change in anaemia status or classification post-intervention. RESULTS: Anaemia was initially detected in 64 (53%) women and 15 (47%) children. The mean haemoglobin concentration increased significantly (P < 0.001) from 118 to 130 g L-1 (women) and 120 to 130 g L-1 (children) post-intervention. Overall prevalence of anaemia in women (P < 0.001) and children (P < 0.001) decreased significantly (by 30% and 34%, respectively) post-intervention. CONCLUSIONS: Point-of-care testing used for the detection of anaemia in this rural community helped to identify the burden of disease and to reduce this significantly by way of rapid diagnosis, education and immediate medical intervention.

Multiple mini interviews as a measure of non-cognitive skills for admissions into undergraduate medical education programme in Pakistan: A validity study.

Student selection for Undergraduate Medical Education Programmes (UGME) is a highly selective process globally. Health care practice requires many attributes like communication skills, professionalism, critical thinking and problem solving in addition to cognitive abilities. This study reports the development and administration of Multiple Mini Interviews (MMI), the descriptive and psychometric properties of the MMI station scores and assesses the validity of MMI stations to ascertain if the stations measured the intended attributes. Nine attributes considered most essential for a successful health care professional were selected. A 5 point rating scale was used to rate each item on the station. The scores were then converted into percentage scores. The mean scores on each MMI station ranged from 27.4% to 80.0%. The reliability of stations using Cronbach's alpha ranged from 0.64 to 0.98. MMI can be used to make reliable and valid decisions to select students with desired non cognitive attributes.

Improving health literacy of women about iron deficiency anemia and civic responsibility of students through service learning.

BACKGROUND: Service-learning (S-L) is an educational approach that integrates community service with academic learning. S-L helps educate youth about their civic role and responsibility in society, and empowers them to tackle societal problems, strengthening communities through civic engagement. The objectives of this study were to demonstrate the effectiveness of S-L in fostering civic responsibility and communication skills in college students and to increase health literacy regarding iron-deficiency anemia (IDA) among both students and community women. METHODS: This interventional exploratory study used a mixed methods approach. Thirteen first-year students from a women's college participated in the project. The authors held small interactive group sessions to teach the students about IDA and communication skills. A questionnaire measured the students' perceived knowledge about civic responsibility, communication skills, and IDA. The students then developed and delivered a health education campaign for sixty five community women and measured changes in the women's health literacy about IDA. A focus group discussion was conducted to collect students' reflections after the S-L experience. The changes in the civic responsibility and communication skills were determined by Wilcoxon rank test, while health literacy in women by a McNemar test. RESULTS: Students showed significant improvement in all three constructs of civic responsibility and in perceptions of their communication skills. Increases in civic responsibility and in acquisition of knowledge emerged as the main themes of the focus group discussion with students. The community women showed substantial improvement in health literacy of IDA. DISCUSSION: In this study, S-L achieves two purposes: (a) Increases students' knowledge of health topics, their sense of civic responsibility and improves their communication skills, and (b) educates women in the community about common and preventable health issues.

Parenteral iron therapy in the treatment of iron deficiency anemia during pregnancy: a randomized controlled trial.

OBJECTIVE: To compare the efficacy and safety profile of total dose infusion of low molecular weight iron dextran with divided doses of intravenous iron sucrose for the treatment of iron deficiency anemia during pregnancy. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, over a period of two years from January 2008 to December 2009. METHODOLOGY: Pregnant women at gestational age more than 12 weeks with the confirmed diagnosis of Iron Deficiency Anemia (IDA) were divided into two groups. In the group-A, intravenous iron sucrose was given in divided doses while in the group-B, total daily intake of Low Molecular Weight (LMW) of iron dextran was given. Post-infusion Hemoglobin (Hb) was checked at 4 weeks and at the time of delivery for both groups. Paired sample t-test is applied and comparison (in terms of rise in hemoglobin from pre to post) of both groups was not found to be significant. RESULTS: In the group-A (iron sucrose group), mean pre-infusion Hb levels was 9.09 ± 0.83 gm/dl. Mean increase in Hemoglobin (Hb) was 10.75 ± 1.097 gm/dl after 4 weeks of infusion and 11.06 ± 0.866 gm/dl at delivery (p < 0.001). In group-B (iron dextran group) pre-infusion haemoglobin was 8.735 ± 0.956 gm/dl and the mean increase in hemoglobin was 10.613 ± 1.22 gm/dl at 4-week while mean increase of 10.859 ± 1.11 gm/dl at the time of delivery (p < 0.001). CONCLUSION: Both LMW iron dextran, as well as iron sucrose are equally effective in treatment of IDA during pregnancy, however, LMW iron dextran has the advantage of single visit treatment.

Efficacy of levonorgestrel intrauterine system (LNG-IUS) for abnormal uterine bleeding and contraception.

OBJECTIVE: To find out clinical response, side effects and patients' acceptability of levonorgestrel-releasing intrauterine system (LNG-IUS). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Gynaecology Department of Shifa International Hospital, Islamabad, from June 2005 to May 2008. METHODOLOGY: Adult women were enrolled in the study. In group-A, 57 married women were enrolled presented with abnormal uterine bleeding while in group-B, 16 married women attended for contraception. All women in group-A had thyroid stimulating hormone, pelvic ultrasound and outpatient endometrial biopsy. Detailed counselling was done before insertion. Outcome variables were improvement in bleeding pattern, safety profile, spontaneous expulsion rate and continuation at the end of one year. RESULTS: In group-A (abnormal bleeding) menstrual cycle became normal in 40.4% women in the first 3 months. At the end of one year, 50.9% women experienced normal cycle, 8.8% were oligomenorrhic and 12.3% were amenorrhic. In group-B (contraceptive group) all women started with normal cycles. At the end of 3 months 42% complained of vaginal spotting which reduced to 10% at the end of one year. Menstrual pattern at the end of one year showed normal cycles in 52%, oligomenorrhea in 19% and amenorrhea in 10% women. Vaginal spotting was experienced by 42% women at 3 months as main complaint which reduced to 10% at the end of one year, however, 7% women requested for removal of device at one year. CONCLUSION: LNG-IUS is an effective and acceptable treatment for abnormal uterine bleeding as well as for contraception. Vaginal spotting was the most frequent side effect experienced by both groups.

Low haemoglobin levels, its determinants and associated features among pregnant women in Islamabad and surrounding region.

OBJECTIVE: To estimate the haemoglobin levels in pregnant women and to determine the socio-demographic factors associated with anaemia in pregnancy. PATIENTS AND METHODS: In this cross-sectional survey, a total of 200 patients visiting prenatal clinic of Shifa International Hospital/Shifa Foundation Community Health Centres, Islamabad over the period of six months, both booked and non-booked were included. A detailed questionnaire was filled and complete blood count, peripheral smear and absolute values were performed in all cases. Haemoglobin levels (Hb) of women below 10.5g/dl were considered to be low (anaemia) and were further subjected to urine/stool routine examination. Cases of thalasaemia trait were excluded from the study. All the data was entered in SPSS v 10.0. Descriptive analysis was done obtaining frequencies for socio-demographic factors. Mean haemoglobin levels along with standard deviation and confidence interval were reported. Frequency of helminthic infestation of suspected cases was also reported. Analysis included any significant differences in mean haemoglobin levels of booked versus non-booked cases. RESULTS: Mean haemoglobin of our study population was 11.0 +/- 1.64 g/dl. Frequency of decreased haemoglobin was found to be in 42.5%. Mean haemoglobin of patients having income less than Rs5000 was 10.5 +/- 1.24 g/dl and those with income more than Rs5000/month had a mean Haemoglobin of 11.5 +/- 1.44g/dl. Mean haemoglobin of patients with history with or without pica eating was 10.1 +/- 1.31g/dl and 11.9 +/- 1.56g/dl respectively. CONCLUSION: Low haemoglobin was commonly seen in our population among pregnant women irrespective of their socioeconomic status. The severity of anaemia was significantly associated with lower socioeconomic status and odd eating habits.

Efficacy and safety of total dose infusion of low molecular weight iron dextran in the treatment of iron deficiency anemia during pregnancy.

OBJECTIVE: To determine the efficacy and safety of Total Dose Infusion (TDI) of low molecular weight iron dextran for the treatment of iron deficiency anemia compared to oral iron replacement during pregnancy through improvement in hemoglobin (Hb) after intervention. STUDY DESIGN: Non-randomized control trial. PLACE AND DURATION OF STUDY: Section of Gynaecology and Obstetrics, Shifa International Hospital and Shifa Community Health Centre, Islamabad during January 2005 to January 2006. PATIENTS AND METHODS: A group of 100 pregnant women with gestational age greater than 12 weeks with confirmed diagnosis of iron deficiency anemia attending the antenatal clinics were enrolled in this study. Total dose iron infusion of low molecular iron dextran was given to these patients after calculating iron deficit, in a monitored in-patient setting. Control comprised of a second group of 50 pregnant females matched for age, parity and baseline hemoglobin, tolerant to oral iron supplementation (ferrous sulphate 200 mg three times a day) attending the antenatal clinics during the same period. Post-treatment hemoglobin levels of study group as well as the oral control group were determined between 3 to 4 weeks. RESULTS: In the intervention group, mean pre-infusion hemoglobin level was 8.57 +/- 0.9 gm/dl (range 5-10.5 gm/dl) and mean post-infusion Hb was 11.0 +/- 1.1 (range 8.4-14.3 gm/dl). In control group, mean pre-oral intake Hb level was 9.5 +/- 0.9 gm/dl (range 7-10.5 gm/dl) and mean post-oral intake Hb was 10.2 +/- 1.2 gm/dl (range 6.4-12.8 gm/dl). Mean increase of Hb in intervention group was 2.43 gm/dl (95% CI 2.4 - 3.8) and for controls it was 0.7 gm/dl (95% CI 0.6-2.3). Flushing and palpitations were observed in 4% of interventional group patients and none in the control group. No significant adverse reactions were observed in either group. CONCLUSION: We conclude that the total parenteral iron replacement with low molecular weight iron dextran is an effective and safe method for the treatment of iron deficiency anemia in a selected group of pregnant women.

Clinical diagnosis of polycystic ovarian syndrome and response to metformin therapy.

OBJECTIVE: To determine the accuracy of diagnosing polycystic ovarian syndrome (PCOS) predominantly on clinical features and the response to metformin therapy. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Shifa College of medicine and Shifa International Hospital, Islamabad from January 2003 to July 2006. PATIENTS AND METHODS: Women fulfilling the inclusion criteria (oligo/hypomenorrhea, infertility, weight gain, hyperandrogenism) were enrolled. Ultrasound pelvis was obtained in all women. Presence of eight or more multiple follicles in both or one ovary without presence of mature follicle was the cutoff number for positive ultrasound. Thyroid stimulating hormone levels were performed in all patients, and patients with abnormal levels were excluded from the study. Metformin was adjusted to 500 mg thrice daily. Six months later patients were again evaluated for response to metformin therapy and those who failed to conceive were given clomiphene citrate along with metformin. Fertility was re-evaluated at the end of one year. RESULTS: At the start of the study, 81% women had menstrual irregularity and 84% had infertility. Hirsutism was seen in 72% while history of weight gain was present in 62% of patients. Ultrasound evidence of polycystic ovaries was seen in 93% of women. After 6 months of metformin therapy, 80% patients had achieved correction in their menstrual irregularity. After 6 months on metformin alone, 51% patients conceived while an additional 20% conceived on both metformin and clomiphene citrate during next 6 months. Overall fertility rate was 71% at the end of one year. There was statistically significant change in pre-treatment and posttreatment BMI. CONCLUSION: Combination of three or more of the clinical features (irregular cycles, history of weight gain, infertility and hirsutism) provide an appropriate basis for the diagnosis of PCOS. Metformin alone was an effective treatment for PCOS in this series.

Frequency and antimicrobial susceptibility of aerobic bacterial vaginal isolates.

OBJECTIVE: To determine the frequency and antimicrobial susceptibility of aerobic bacterial isolates from high vaginal swab cultures. DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, from January 2003 to February 2004. PATIENTS AND METHODS: The subjects included 136 symptomatic women attending Obstetrics and Gynecology Out-Patient Department. A proforma was filled to document the demographic details, presenting complaint and examination findings. High vaginal swabs were taken for gram staining, culture and antimicrobial sensitivity testing using standard microbiologic techniques. RESULTS: Normal flora was isolated in 30% of the cases, followed by Candida spp. (21.3%), Enterococcus spp. (14.7%), E.coli (10.2%), Beta hemolytic Streptococcus spp. (7.3%), Staphylococcus spp. (4.4%), Enterobacter spp. (4.4%), while Streptococcus pyogenes, Staphylococcus epidermidis and Klebsiella spp. were isolated 1.5% each. Enterococcus, Staphylococcus and Streptococcus were mostly sensitive to penicillin and amoxicillin while E.coli and Klebsiella were sensitive to (piperacillin-Tazobactum, Imipenem and vancomycin. Enterococci species showed significant resistance to aminoglycoside antibiotics (68.8% to 81.3%) resistance to vancomycin was 5%. CONCLUSION: Thirty percent of symptomatic patients had normal flora on culture. Candida spp was the most frequent pathogen isolated. Co-amoxiclav should be used as empiric therapy until culture-sensitivity report is available.

Frequency of hepatitis C in pregnancy and pregnancy outcome.

OBJECTIVE: To determine the frequency of HCV infections in pregnant women, to find out the risk factors for HCV infection in pregnant women and to compare pregnancy outcome of the sero-positive women with sero-negative women. DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, from June 2001 to May 2002. PATIENTS AND METHODS: Study was conducted on 947 booked pregnant women who were screened for HCV antibodies during antenatal consultation and were admitted for delivery in labour room. At the time of admission in labour ward, medical records of all patients were reviewed for anti HCV antibody testing and the presence of risk factors for HCV infection. Previous vaginal deliveries with episiotomy, previous surgeries, blood transfusions, and D&C for abortion or dysfunctional uterine bleeding were taken as independent variables. The obstetric outcome variables studied were: completed weeks of gestation by mother, birth weight and apgar score of newborns. The risk factors under study and the outcome variables were compared among HCV positive and negative women through a case-control study and measures of association calculated. RESULTS: The proportion of HCV sero-positivity among pregnant woman in our study was 3.27%. Among all the risk factors under study, previous surgery was found to have a significant association with HCV positive status of women (p=0.001). Other variables did not have significant association with HCV positive status in our study. There was no statistical difference in the mean birth weight of newborns (p= 0.94), mean Apgar score of newborns (p= 0.73) and mean gestational period among HCV positive cases and controls (p= 0.47). CONCLUSION: Prevalence of hepatitis C in pregnant women was 3.27%. Past history of surgical procedures was the most important factor for transmission of hepatitis C virus infection. No adverse effect on pregnancy outcome was observed in terms of gestational age, Apgar score and baby weight when compared with the controls.

Neoadjuvant chemotherapy in stage IV ovarian malignancy.

A 57 years old woman was diagnosed to have stage IV ovarian malignancy on the basis of ascitic fluid cytology, tumor marker and imaging. Neoadjuvant chemotherapy was administered before surgery. Four months after surgery no evidence of malignancy was found on laparotomy and histopathology. She is under surveillance for any signs of recurrence.