Some articles on Medical Education

ARTICLES on

1. 360 degree assessment : 
2. Curriculum Development 
3. Evaluation - an introductory note 
4. Objective questions - MCQs 
5. Making your Powerpoint 
6. Teaching Learning Principles 
7. Performance appraisal for doctor - teachers 
8. Of Gold Medals & Castor plants 
9. Tackling absenteeism in class 
10. Systems Approach  
11. Pharmacovigilance 
12. Lesson Plan 
13. Reflection in Medical Education 

(published in our in-house bulletin on medical education)

360 degree Assessment

                                                                                                 Dr.Ravi Venkatachelam

            Assessment is a vital component of any educational process. In fact, it has been rightly said that ‘Assessment drives learning’ (George E Miller). Several evaluation methods are used in medical education today such as the Essay Question, MCQ, Practical Exam, Viva Voce, etc. Each has its own advantages and drawbacks but they complement each other. One major disadvantage of most of them is that they are one-time evaluation methods and test ‘task performance’ usually in a controlled situation – given a ‘case’, can the student elicit the history of fever, make out a palpable spleen and diagnose malaria and answer that he will prescribe chloroquine. But we do not test ‘contextual performance’ – will he, on a busy OP day, ask his 40^th patient with fever, whether he has chills and then diligently look for a spleen, prescribe chloroquine and answer all his doubts patiently? Secondly, conventional tests assess the student on that particular day – something like a One Day Cricket; even Sachin can get out for a duck and it would be unfair to devalue his batting prowess. The third drawback of most of the tests used commonly is that they do not assess the affective domain adequately – the student’s attitude, communication skills, interpersonal relations, handling stress and so on. This is where we need other evaluation methods and 360 degree assessment is one such tool in our armamentarium.

360 degree feedback, also known as multisource assessment or multirater feedback is a process whereby an individual (recipient) is rated on their performance by multiple people (raters) who are closely associated with them and know something about their work – these persons can be peers, managers, clients, etc. 360 here refers to the 360 degrees of a circle and hence means an all-round view.

This method was first used by the US Armed Forces in the 1940s to help in their staff development programs. Though analysis and feedback was difficult in the initial days when scores of sheets had to be studied and summarized, the advent of computers has made this process simpler and faster. Today, multisource feedback is used in many organisations to provide detailed information about the employees’ current performance so that recommendations may be made for further improvement.

Multisource feedback helps the individual know his strengths and weaknesses (areas where he can improve), potential areas where he can excel further, and, encourages teamwork. Consequently, the organization gets the necessary support to achieve its goals. Does it have a role in medical education? In fact, the Toolbox of Assessment Methods published by the American Board of Medical Specialities and Accreditation Council for Graduate Medical Education has 360 degree feedback listed as the first method for evaluating residents.

Evaluators of medical residents can include superiors, subordinates, nurses, peers, patients and their families. The evaluation is usually done by giving the raters a questionnaire or survey to elicit their opinions on the resident’s performance with reference to skills, teamwork, communication, decision making, management skills, patient care, professional behavior, etc. The responses are mostly given on a rating scale of e.g. 1 to 5, where 1 would mean ‘never’ or ‘worst’ and 5 ‘always’ or ‘best’. The ratings are summarized for all raters, topic-wise and a summary feedback is provided to the resident.

360 degree evaluation is used mostly for formative but can be used for summative assessment as well. In the former situation, evaluators tend to be lenient and also provide comments and suggestions for better performance. Confidentiality of the rater must however be strictly maintained, otherwise, raters will either decline to participate or give ‘safe’ and ‘uncontroversial’ reports. My own opinion is that multirater feedback would be most useful to us in evaluating attitudes of students, interns, postgraduates and staff members. We have quite robust tools to assess knowledge and practical skills. Attitudes however are seldom assessed in existing medical curricula and the teacher can get some informal assessment only through interaction during the viva voce or practical examination. Using 360 degree feedback here would give valuable information besides being useful to the student too.

There are several studies demonstrating the utility of multisource feedback in evaluation of medical professionals. These have shown that patients usually tend to be more critical when they are sick; patients who are better or recovering tend to overrate the doctors. Moreover, at least 50 patients need to be interviewed to get valid and reliable reports. Similarly, doctors / peers too do not fare very well in 360 degree feedback. Nurses, on the other hand, have proved to be more reliable and valid evaluators and just 5 – 10 nurses are enough to provide strong statistical data. Hence most multirater feedback programs rely heavily on nurses to fill the questionnaires.

How to conduct a 360 feedback then? First, discuss the issue with the authorities and students / doctors who are going to be evaluated. They must be willing to try / accept this. Then, lay down the objectives of the exercise. Lay down guidelines and rules how it will be done. Prepare a draft questionnaire covering the various areas to be assessed. The survey form is usually in the form of statements with a Likert or other rating scale. For example, some statements could be –

Deals with  patients with respect / courtesy

Explains and clarifies to patient

Gets on very well with other staff members

Gives a good clinical opinion

Punctual and attends in time

Works well under pressure

Very good at the job

Patient in dealing with others

Inspires others

Each of these will be rated on a 1 to 5 scale (1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = always). The rater can leave it unanswered or ‘unable to assess’. Other areas one would like to assess are behavior, competence, teamwork, communication skills, decision making abilities, collaboration, referral / transfer behavior, literature search, etc. The evaluator may also be asked to give narrative answers and more detailed suggestions / comments. The raters must have a briefing session, their opinion and consent obtained and assurance of confidentiality given. Evaluators can be nurses (5 to 10), peers (10 or more), superiors and patients / patient attendants (20 to 50).

Once the questionnaire has been prepared, it can be field tested in a small sample and then modified if necessary. Finally, the forms are distributed to at least 10 or more raters who are chosen by the recipient himself. Confidentiality of the rater and trust in the process are important for the exercise to be successful. After collecting back all the forms, they are analysed and the average score in each of the various areas is provided to the recipient in a private feedback session. This feedback session must be conducted with care and diplomacy without hurting sensitivities. One good way is to start first with the chief’s own 360 assessment by others. It is also helpful to include a facilitator if possible in the feedback session and also have some sort of mentoring / counseling and follow up sessions to help the student improve his affective skills. The entire 360 feedback program itself should be periodically evaluated for its efficiency and acceptability so that suitable changes may be made if necessary. Try out a 360 feedback in your department and see it work wonders.

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Curriculum  Development

                                                                                                Dr.Ravi Venkatachelam

(curriculum = the subjects that are studied or prescribed for study in a school;  any programme of activities. From Latin = course, race chariot ; from currere = run.

syllabus = the programme or outline of a course of study, teaching, etc.                                       Modified from Latin sittybas – from sittuba = title-slip or label.)

A curriculum is the backbone of any educational activity, be it at the elementary level or the highest academic level. The term curriculum is often used synonymously with the term syllabus, but, in fact, it is much more than just that.
A syllabus is basically an outline of the course and the topics that are included in it.
On the other hand, a curriculum is more comprehensive – it includes not just the outline of the course for study, but also, suggests the methods to impart the training, a time-frame for its implementation and methods to evaluate the course.

A curriculum has been aptly defined as a ‘planned educational experience’.  The structure and content of a curriculum can vary depending on whether it is formulated at the national, state, institutional, departmental or teacher level. At any level, the curriculum helps to plan the educational programme, coordinate activities and implement it; it also provides both the teacher and student a framework to work together to achieve the goal. Although a curriculum is essential for every educational course, it is a sad fact that most medical colleges do not have a prescribed curriculum for each course / subject though they may have a sketchy syllabus. This article tries to provide an outline of the steps involved in the development of a curriculum.

1. First a curriculum must contain the training to be imparted i.e. the subject and skills (cognitive, psychomotor, affective) that the student should learn – this is akin to the syllabus.

2. Next the curriculum must contain the training methodology to be used and infrastructure needed. This includes the Teaching / Learning methods to be used – e.g. lectures, demonstrations, field work, etc. and the T/L media and equipment required – e.g. Overhead Projector, specimens, laboratory equipment, etc.  It should also mention the faculty to be involved in the training.

3. The curriculum should also provide a time framework – i.e. a sort of time-table suggesting which topics must be covered at which stage of the course.

4. The curriculum must mention the course material and suggest reference books to be used.

5. Lastly the curriculum should include a method for evaluation of the students as well as the curriculum itself. This will help in assessing the effectiveness of the curriculum in achieving its objectives; moreover, evaluation helps in making any changes in the curriculum if necessary.

PREREQUISITES:

Important issues to consider while framing the curriculum are the learner background, the time allotted, integration of the course content, interdepartmental coordination and ‘process continuity’ with the previous learning experiences. The other issues to consider while formulating the course content are

-          the health-care needs of the society (so as to decide the topics to be taught)

-          test of survival (i.e. if a part of the existing curriculum has been going on successfully for the past several years, it must be good enough to continue)

-          inherent structure of the subject (meaning some topics are inherently essential for the subject – they will be automatically included in similar curricula in any medical college)

-          utility to the students and public

-          student interest which is necessary to make the curriculum successful

Educationists today should also consider the emerging generic demands in medical education while constructing a curriculum (David Kern) some of which are:

-          integration with clinical epidemiology, evidence based medicine, etc.

-          emphasis on preventive medicine and a  population/community based approach

-          a patient centred and problem oriented  rather than a disease oriented approach

-          emphasis on decision making skills, problem solving skills, cost-effective therapy

-          management techniques, team work, communication skills, etc.

-          stress on a biopsychosocial approach and behavioural medicine

-          emphasis on emerging areas like geriatrics, disaster medicine

-          promotion of creative capabilities and problem solving skills

CURRICULUM PREPARATION

 When a new curriculum is being prepared, a  6-step approach has been advocated by David.E.Kern and others:

1: Problem Identification and General Needs Assessment

2: Needs Assessment of Targeted Learners

3: Goals and Objectives

4: Educational Strategies

5: Organization & Implementation

6: Evaluation and Feedback

The first step includes an analysis of the health care needs and identification of the problem areas so as to devise the curriculum. e.g. for a curriculum in geriatrics, we must identify the common problems of the elderly that need to be covered. The second step is a needs assessment of the target student group involved; e.g. if a geriatrics course is being offered at, say, the 6^th semester in MBBS, it is useful to know what aspects of geriatrics the students might have already learnt earlier – in physiology, community medicine, etc. Once the requirements in the subject have been finalised and the background of the students analysed, the third step can be undertaken – defining the goals and objectives of the course.  These must be clear, precise and complete. The next step is a crucial one – formulating the Teaching / Learning methods and T/L aids to be used, mention of the reference books, the faculty to provide the training and a time-table. The fifth step  which includes implementation should address the issues of how to execute the curriculum, possible obstacles, resource mobilisation, etc. The last step offers methods to evaluate the student (which test to administer and when) as well as methods of evaluation of the programme itself i.e. is it achieving its objectives?

Once the curriculum has been constructed, a field trial may be conducted to make any required changes. The course materials, etc. are prepared and the curriculum put into operation. Even after it is implemented, continuous evaluation of the curriculum and   feedback  are necessary to constantly update the curriculum and make it more effective and successful.  Flexibility  is an important property of a curriculum – otherwise it tends to become obsolete and ineffective and may succumb to diseases like curriculosclerosis (hardening or extreme departmentalisation), curriculoarthritis (lack of proper articulation or communication between departments), carcinoma of the curriculum (overgrowth of one department at the expense of the others), etc. (Stephen Abrahamson).

Keeping these guidelines in mind, it should be possible for any department to develop a curriculum for the MBBS graduate or PG student in that subject. The faculty must work together in close cooperation in this regard because construction of the curriculum for the first time can be an arduous task but that should not deter anyone. A curriculum committee can be formed and given the task of collecting background information from the students, other staff, those who have already passed out and practitioners; next, the needs can be assessed and curricula already existing in other institutions studied. The committee can formulate a draft curriculum and circulate it among colleagues and experts for any suggestions. Finally a comprehensive curriculum may be developed for implementation.

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EVALUATION   –   AN  INTRODUCTORY   NOTE

                                                            Dr. Ravi Venkatachelam (ravichitrapu@rediffmail.com)

‘Assessment drives learning’. (George E Miller)

Evaluation has rightly been considered to have the (most if I may use this adverb) central role in education. Among the triad of Educational Objectives, Learning experience (supplemented by T/L aids) and Evaluation, it is the last that drives the students’ learning process.

Evaluation is a systematic process of determining the extent to which the (predetermined) objectives have been achieved by the student.

            Some educationalists separate ‘assessment’ and ‘evaluation’. Assessment, they feel refers to measurement of learner achievement brought about by the educational program. Evaluation, they maintain, is broader and includes a judgement of the result of the test and refers to measurement of the effectiveness of the educational program itself or a part thereof. (i.e. assessment is student assessment, evaluation is program evaluation). Here, however we will not maintain any such difference.

An assessment scheme must satisfy 3 principles –

-          Educational – it must help students learn

-          Ethical – it must be fair

-          Regulatory – it must be within the University rules

Evaluation method must be  REAL  FAVOUR

Feasible – in reference to resources, etc. (Practicable)              

Acceptable (to faculty and students)                                        Relevant (to the syllabus/ level)

Valid (test what it is supposed to)                                            Easy to understand – simple and clear

Objective as possible                                                               Adequate coverage – of syllabus

Unambiguous                                                                          Legal – as per University rules etc.

Reliable (gives same result on repeat testing)

Assessment in medical education can be used to

-          Certify / judge competency (pass/ fail etc)                   - Help students learn (formative)

-          Determine if learning objectives have been met                      - Select students for a course (EAMCET)

-          Evaluate the educational program

We, as medical teachers, (and responsible citizens) must also remember always that, an important reason for having assessment methods is as a public safeguard – for us to ensure that only competent doctors are allowed to ‘go out’ and practise this science.

The USA lays stress on 6 domains of competence – Medical knowledge           Practice based learning

Professionalism       Communication & interpersonal skills     Patient care      Systems based practice

Assessment can be classified in different ways –

Descriptive evaluation – uses words to describe and summarize a student’s competence level.

Quantitative assessment – yields a score / number to grade the competence.

Formative & Summative –

Formative evaluation refers to tests to guide the student in their future learning, to reassure, to identify areas that need attention, etc. These tests do  not certify pass or fail.

Summative assessment judges about competence, qualification in exam, etc. (determines pass or fail, etc)

Subjective & Objective –

Depending on the objectivity of the test. For example, Essay question is subjective while an MCQ is objective.

Internal & External –

When the examiner was /is involved in the teaching of the student, they would be internal examiners. This is also known as Tutor assessment. The external examiner was not  invovled in the teaching.

Closed ended or Open ended –

In the closed ended question, the options are limited – e.g. True or false for statements, MCQs, choosing one out of 4 or more options.

Supply type & Selection type –

In supply type, student must supply answer – e.g. fill in the blanks; in selection, he chooses one of some alternatives – e.g. MCQs, true / false etc.

Continuous & Terminal –

Continuous assessment is an ongoing evaluation while the students are working in a course; it may include periodic tests, practical assessment or situational assessment.

Terminal assessment is done at the end of the course / unit. It is usually for certification (summative) purpose.

Written and Oral and Situational –

Written assessment is written such as essay, MCQs etc. Oral assessment is the viva voce examination.

Situational assessment is assessing the ability of the learner to cope with a real life situation.

Process or Product evaluation -

In process evaluation, we determine ‘how’ student arrived at the answer and give importance to this; in product evaluation we are more interested in the outcome – did they get the ‘correct answer’ is more important than how they arrived at the answer.

Norm referenced & Criterion referenced –

In Criterion referenced evaluation, the student is tested against an absolute standard – e.g. 50% marks to declare pass, etc. In norm referenced evaluation, the students are compared against each other and one of them used as a reference against which to assess the student’s performance.

Peer assessment (by other students) and Self assessment are other types of assessment.

So also evaluation can be Closed-book examinations or Open-book assessment (as in the Accounts Test for Govt. employees).

Assessment can also be Manual or Computer assisted assessment.

Ipsative assessment – here, the student’s performance is compared with their own earlier performance, to determine any improvement, etc. e.g. pre-test and post-test in a workshop / course.

Standard methods of evaluation include – COGNITIVE ASSESSMENT -

Essay question, Modified Essay Question, Structured Essay Question , Short answer questions –

Objective questions – MCQs, Fill in the blanks, matching, Assertion – Reasoning, True / False, etc.

Clinical & Practical questions (Bedside examination & Tableside exams) – PSYCHOMOTOR -

OSCE & OSPE Objective Structured Clinical / Practical Examination  - assesses psychomotor skills in an objective manner and can also assess AFFECTIVE.

Orals (viva voce) – This helps in cognitive assessment but also can be used to gauge the student’s affective domain to some extent.

Role plays & Simulated patient in OSCE format –  can be used to study affective domain

Panel discussion – helps in assessing interpersonal & cognitive skills & to some extent affective domain.

Patient Management Problems  & Computer Assisted Evaluation

Other methods of evaluation –

Project / Thesis –

Observation – (in department) – for overall assessment, especially affective can be assessed.

Reflective Portfolio – Student documents his/her course work, learning, work done, experiences, reflections & thoughts, etc.

360 degree evaluation - It is used to assess affective (and other domains) like interpersonal skills, behavior, etc. and is done by a questionnaire by those people around the student – peers, faculty,  paramedical staff, patients, etc.

Points to remember in evaluation –

-          Put the evaluation exercises in the curriculum with date, syllabus, mode of exam etc.

-          Have adequate (but not excessive) formative evaluation throughout the program

-          Time the exams appropriately (avoid too many exams at one time – so discuss with other depts.)

-          Give feedback /results to students quickly – give positive, encouraging comments & suggestions

-          Conduct exams fairly, without bias and strictly

-          Allow for students to clarify doubts on the marks / grades

‘Assessment expands professional horizons’ – M. Friedman, 2000. This stresses the important role of assessment in developing multiple dimensions of the medical profession.

Another important quality of test (besides validity, reliability, acceptability, feasibility, etc.) -

Educational effect of a test -  effect of test to motivate students to do well & directs their study efforts.

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Objective Questions - Multiple Choice Questions

                                                                                                Ravi Venkatachelam C.

            Multiple Choice Questions or MCQs are commonly used tests to evaluate the students’ knowledge. They are almost universally used in Entrance Examinations today for their objectivity and efficiency in selecting the best students for a course. A variety of objective questions exist, some of which include :

1. Multiple Choice Question – single correct answer type - traditional and commonly used form with one single response. An MCQ can also be of the best answer variety.
2. True / False questions – where the student has to decide if a statement is true or false.
3. Multiple Response Questions – wherein 2 or more options are correct answers.
4. Assertion Reasoning variety – where 2 statements are given and the student has to decide on the veracity of each statement, and, if one statement logically explains the other.
5. Combined Response question – where 4 statements are given and the student has to decide if statements 1&3, 2&4, 1,2,3 or only 4 is/are correct.
6. Graphical hotspot questions – e.g. labeling of diagrams
7. Matching questions –
8. Sore finger questions – choosing the odd man out of a set of options
9. Sequencing questions – wherein the student has to position text matter or diagrams in a logical order

Here, we deal with the classical MCQ – multiple choice question with single correct answer.

Parts of an MCQ  -

• item = entire unit
• stem = question or statement or lead-in to the question
• alternative / options /choices = possible answers
• keyed response = correct option
• foils or distractors = incorrect options

Advantages of MCQs :

• objective
• easy to correct - machine can do it
• less time for student to answer – so can cover more range of syllabus in given time 
• student friendly
• improve retention
• increase motivation
• versatile
• can do item analysis and modify questions

Drawbacks of MCQs :

• difficult and time consuming to construct
• 'easy' compared to essay etc
• do not test writing skills, organizational abilities, concept building,
• mostly knowledge based
• difficult to test higher levels of learning
• test 'recognition' (choose answer) rather than 'recall' (construct ans)
• scores seem to be unrealistically high (essay q. usually have a 'glass ceiling' at 70% or so)
• guessing answers (lucky monkey) - try negative mark to discourage
• or try mathematical strategy to normalise marks
• or use more options etc

Badly constructed MCQs can lead to several problems :

- give clues to the answer

- fail to test the skills needed by the intended learning outcomes

- have implausible distractors

- encourage rote learning

- confuse /frustrate students

- interfere with proper interpretation of scores

- negatively impact student pass rates

Constructing an MCQ with single best response -

Stem :

write as a sentence or question (sometimes a direct question is easier to understand)

stem can have graph, diagram, map, x-ray   

ideally item should be answerable without reading all options

stem should have only relevant info. and all of it  

keep stem as short as possible and have only necessary info.

stem can be longer where needed - e.g. in testing application rather than recall -

case vignettes - avoid verbiosity, extraneous material, redherrings

if a phrase can be stated in stem, do not repeat in the options

stem should not be tricky /misleading to deceive student

keep low reading difficulty - i.e. simple language (dont test their English)

usual speed of students is 1- 1 ½ MCQs/minute (if item is taking more time - recheck )

if more than one option has some truth, ask to select best answer rather than correct answer

in general make questions to ask for correct answer and not a wrong answer -

negative questions (not true, all except) are less effective and also more difficult  to understand

underline /bold/ caps, etc. negatives in stem - e.g NOT, except

avoid absolute terms like - always, never, all, none - in stem or distractors

avoid abbreviations, etc

Distractors :

the ability to discriminate depends on quality and attractiveness of option

each incorrect option must be plausible but incorrect

best distractors are accurate statements but are incorrect for the question and seem correct!

avoid implausible, trivial, nonsense distractors

ideal wrong options in mcq are common mistakes done by students

to conceive distractor ask question - what will student usually confuse this with? what is a common error in interpretation of this? what are the common misconceptions in this area.

3 option or 4 option are similarly effective

distractors must be related /somewhat linked to each other (e.g all some doses, or some tests, etc)

distractors should be similar in grammar, length, complexity

avoid none of the above, all of the above

put options in logical order where possible - e.g. numbers

avoid 'cueing' - one item revealing answer to another item

avoid 'hinging' - student know answer to one item to be able to answer another item

We will construct some MCQs and discuss them.

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Examples :

Select one best response for each question and darken the appropriate circle in the OMR sheet with a black ball point pen.

1. The drug of choice in cerebral malaria is

a. Quinine        b. Chloroquine            c. Mefloquine              d. Fansidar

(clear; basic recall level; Fansidar is trade name)

2. A 25 CSW has come with a two month history of diarrhea, on and off fever and has lost 4 kgs. weight. Which test would you like to order?

a. TC, DC, ESR          b. Stool microscopy               

c. Mantoux test           d. Blood for HIV ELISA

(clear; interpretation level; difficulty level?)

3. The Infant Mortality Rate in India presently is about

a. 100              b. 50                c. 150              d. 170

(clear; recall level; order of alternatives not  in numerical order) 

 4. A patient was admitted for congestive heart failure and put on frusemide 40mg IV bid and digoxin 1/2 tab daily. and enlapril 5mg bid. Two days later he developed altered sensorium. Bilateral pedal edema+. BP=120/80. Pt in AF - ventricular rate = 100. creatinine 1.5mg%. ser. Na= 128meq/L. K=3.5meq/L. 

Which of the following is an approprite treatment option? 

a. Increase dose of frusemide to 40mg qid.

b. Judicious water restriction 

c. IV hypertonic saline 200ml 

d. Pot. klor syru. 5 tsp 5id

(problem solving)

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MAKING YOUR POWERPOINT – some points for beginners

Ravi Venkatachelam –Andhra Medical College – mecell@rediffmail.com 

            Beginning –  Right click where you want to open your ppt presentation – on desktop or in the desired folder /drive – move to ‘New’ and the arrow leads you to various types of files – click on Power Point Presentation.  (or you can go to programs in Start menu – go to MS Office and thence to Power Point and open a new file).

            What I do next is to click the Office Button on Top Left – (the one with red, yellow, green, blue squares) and in the drop down menu click ‘Save as’ – I save PPT files in 97-2003 presentation format so that there would be no problem in opening this file in older versions of Windows. (if you are taking your own system /laptop – no problem and no need to save in Compatible formats)

You can click to start your first  slide – by default it is Title slide.

Change layout of slide – right click on or beside the slide and click on the desired style – the same can be done on the menu on the top of the screen by clicking on ‘Layout’.

            Colors –  Use white or light background and dark letters – blue or green usually. (Avoid red or use it for occasional use to draw audience attention).

The second option is dark background (blue) with white /yellow /light letters.

For images, prefer a white background.

Use fancy backgrounds cautiously.

            Adding text –  I usually give a border to the text boxes – this is in the top menu – on the rightish side – as ‘Shape Outline’ – choose any color you want.

Add text in clearly visible format – you can prefer Bold letters if you wish or use Bold /Underline to emphasize points. (italics is not very helpful for emphasis)

Prefer sans serif fonts (i.e. those which do not have tags at the ends of  letters – this article is in Times New Roman which has the serif marks or tags).

Sans serif fonts are – This is Comic Sans.  This is Calibri.  This is Arial . this is verdana.

They do not have the tiny serif marks at the ends of their letters.

Use one color for the text or at most 2 or 3 – to highlight points.

Write in sentence case- avoid only capital letters.

Keep Saving (Ctrl S) in between.

Use abridged language-  Do not cut & paste from text straightaway –

Instead of sentences  - use phrases.     Instead of phrases – use words.

Prefer a maximum of 5 or at most 7 lines per slide and equal words (or at most 10 per line).

You can use a variety of bullets for the lines.

Use letters in big size – easy to read – at least 28 -32 or so font size. Title can be 40 or 44 size.

Keep the design simple and neat – not cluttered with a lot of text and images.

Prefer one slide for one or a few key points. Use another slide – it doesn’t cost anything.

            Animation –  Do not use too much of animation – either for the text /lines /images etc. Use it only if needed – to show movement, to highlight, etc.

Animation can be done for Entrance or Emphasis or Exit – all can be programmed at specific times, for specific durations – for this – click on the text box or image – and use the Animation button on top which has some options – or click the Custom Animation button below – and use the various options available there.

The animation can be effected with a mouse click or on its own – along with the slide or after a tiny time gap. (I prefer the ‘with previous’ and give a small  time of 1 second or so – it saves me from again clicking the mouse)

You can also customize motion pathways for your object /image in the animation menu.

Do not use complex slide transitions – they consume a lot of time.

            Picture /shapes etc can be Inserted – click on the ‘Insert’ button on top leftish.

If you are using pictures from the Net be aware of copyright issues. Acknowledge source. Or use sites like FlickR which give free images.

The shapes come as solid – if you want only outline – click on the shape – and click on the top rightish button of ‘shape fill’ in the Home menu format.

Click slide show or F5 to start slide show.

If you want a Blank screen – press B while in slide show format.

If you want a white /lighted screen – press W in slide show format.

In slide show format – you can write /highlight on the screen – right click and choose the option in Pen – ballpoint pen or felt pen or highlighter.

(more during the presentation) ****

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Teaching – Learning Principles

 Dr.Ravi Venkatachelam

Outline –

Why T /  L principles ?

Learning – definition, what it encompasses, factors enhancing learning

Some characteristics of adult learners

Teaching – what it entails, how to facilitate learning

As a teacher, it is our prime duty to teach – or rather to help the student learn. Though we have been doing it since ages (without any formal training as such), it helps to know the science behind learning (teaching) so that we can achieve our duty better.

Definition & the process of learning -

Learning is a process that leads to a modification in one’s behaviour; this modification is relatively permanent and could be in the domain of knowledge /skills /attitude. Learning is an active process that occurs from active interaction by the student. Teaching is the process carried out by the teacher to facilitate this learning process; it need not be a didactic, one-way process.

The Learning process includes several phases –

Motivation (to learn) à          Acquisition (of knowledge) à           Short term memory à

(Long term memory à)          Recalling & performing

Why learning theory & principles –

-          Helps us to have a terminology & conceptual framework for what we do /observe in teaching & learning

-          Helps us find /evolve solutions to problems in teaching /learning

3 main philosophical frameworks for learning theory -

Behaviourism (Skinner, Thorndike, etc)

-           objectively observable aspects – learning is acquisition of new behavior through conditioning (reinforcement) – reflex associations – environment has a role.

Cognitivism (Bode, gestalt psychologists)

-           memory system is an active organization of information (short & long term memory) - prior knowledge has a crucial role in learning (instructional design uses these concepts)

Constructivism

-           learner actively constructs new learning based on current & past knowledge /experience (active learning, discovery learning)

Edward Thorndike first enunciated 3 laws of learning; 4 more were added later –

-          Law of Readiness – to learn

-          Law of Exercise – repeating things helps to remember well

-          Law of Effect -  Positive reinforcement strengthens learning

-          Law of Primacy – first impression makes a strong impact

-          Law of Recency – things recently learned are best remembered

-          Law of Intensity – the more intense, the more likely it is to be retained

-          Law of Freedom – things freely learned are best remembered

factors affecting learning -

Several points about learning/ learner must be kept in mind –

-          Learning is active and not just a passive transfer of information

-          Motivation is important and depends on the usefulness & interest of the knowledge

-          Learning is guided by the student’s experience – past and present

-          Learning is influenced by the student’s current physiological /psychological state

-          Application of knowledge and repetition facilitate retention

-           

The best options to (teach/ ) learn a new skill /knowledge /attitude are –

-          Real life experience

-          Simulated experience

-          Observing a live /simulated educational activity

-          Learning a description of the educational activity

(e.g. performing a lumbar puncture, doing it on a manikin, seeing a video of LP, reading or listening to a description of the procedure)

Features of adult learners -

Andragogy (the science of teaching adults) was proposed by Malcolm Knowles.

5 principles underlie adult learning –

-          Adults are independent and self directed learners

-          Adults have much experience which is a rich source of learning

-          Adults prefer learning that is relevant and meets their daily needs

-          Adults prefer immediate problem centred learning methods

-          Adults are motivated to learn by internal factors

Knowles observed that adults learn best when –

-          They understand WHY something is important to know or do

-          They have the FREEDOM to learn in their OWN WAY

-          Learning is EXPERIENTIAL

-          The TIME IS RIGHT for them to learn

-          The PROCESS is POSITIVE & ENCOURAGING

A teacher cannot ‘treat’ adult learners like schoolchildren. Adults expect some respect for their age and experience, like to be treated on par, may not appreciate criticism and sermonizing in the class and like to have some independence.

Guidelines while teaching students who are independent and self directed (BMJ & Knowles)–

-          Ensure a ‘safe & comfortable’ learning atmosphere for learners to express freely

-          Involve learners to be active in the planning of curriculum and t/l methods

-          Help learners to diagnose their needs and build up an inner motivation

-          Permit learners to formulate their objectives themselves and thus control their learning

-          Encourage learners to identify resources and utilize them to learn

-          Extend support to learners to achieve their learning & encourage self directed learning

-          Let learners evaluate their learning – this will develop critical reflection among them

-          Relate learning to real life situations & past experiences

-          Allow for practice, constructive feedback and self reflection

-          Be role models to learners

Self efficiency -

Promote Self efficiency – learner’s judgement /opinion of their own ability to deal with a task – develops from 4 inputs – their performance ability, peer performance, verbal encouragement, physiological state.

Teacher can use these factors to encourage student learning – by giving clear goals, good t/l experience, corrective & encouraging feedback, demonstration & support.

TEACHING PRINCIPLES for the teachers -

-          First acquire knowledge & be competent /proficient in your subject matter

-          Acquire relevant knowledge about students & background – cultural, generational, prior knowledge,  - this will help planning curriculum

-          Keep in mind & align the 3 components – learning objectives, instructional activities, assessments upfront while planning curriculum

-          Clearly communicate your expectations to students – about objectives, policies, assessment methods, what is permitted what not, etc.

-          Prioritise the knowledge and skills to focus on – you may not be able to cover all the syllabus in the given time

-          Recognize & overcome your ‘expert blind spots’ – as teachers /experts, we use knowledge automatically making connections, inferences & choices unconsciously) – the learner may not be able to do this as yet – so be explicit & explain the component steps and connections

-          Adopt appropriate teaching roles to meet the learning goals & learner needs – e.g. synthesizer, moderator, challenger, commentator

-          Adapt & refine the course based on feedback & reflection

Suggestions to facilitate learning -

Chickering’s 7 principles – Good practice involves the following -

1. (frequent) contacts between students and faculty
2. Reciprocity & cooperation between students (not isolated or competitive)
3. Active learning techniques
4. Prompt feedback
5. Emphasizes time on tax (allot realistic time to education)
6. Communicate high expectations – expect more and you will get it
7. Respects diverse talents & ways of learning

Past learning – if accurate, adequate and activated appropriately – helps learning now

                        if incorrect, inadequate or inert – can impede new learning

organization of learning –       if meaningful and organized connections – helps learning

                                                if random or inaccurate connections – retrieval difficult

students must learn component skills & also integrating them & applying the knowledge /skills

goal directed practice and targeted feedback help learning

(goal directed + repeated practice + focused feedback)

Teach them metacognition – how to monitor & control /guide their learning so as to develop appropriate intellectual & learning strategies

Recognize and accept the importance of informal learning (out of class etc)

Learning environment must be supportive & productive

& promote independence, interdependence and self motivation. (Take care of the physical, emotional & social climate in classroom also)

Student needs, backgrounds, perspectives & interests must be reflected in the learning program. Learner types can be visual, auditory or kinesthetic /tactile.

Challenge and support the students to develop deep levels of thinking, learning, application

Maintain discipline

Use Strategies to encourage desirable behavior & discourage undesirable behavior

Goals & content must be clear & comprehensible

Meet needs of diverse students

Build professional relation with parents, colleagues etc – communicate with parents

Keep track of trends and research in education methods

Be aware of dynamics of interpersonal relations

Appropriate teacher response to situations etc

Nonverbal communication skills

Be a role model

Develop good and appropriate Questioning techniques

Be clear of Rules & regulations and ensure they are followed

Use appropriate Motivational strategies

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PERFORMANCE  APPRAISAL  FOR   DOCTOR - TEACHERS

Dr.Ravi Venkatachelam

Performance appraisal is a time tested tool used in organisations to assess the work performance of the staff and offer suggestions so as to improve efficiency and productivity. It is being used in more and more institutions and has been mooted for use in medical colleges and hospitals. This article presents a brief account of performance appraisal, its methodology and process, its uses and drawbacks and how it can be effectively used in our setting for better work performance.

Performance appraisal basically comprises

-  assessment of the employee’s performance in terms of work output (quality and quantity) work

    relations, attendance, etc. 

-  judgement on the worker’s performance based on the above rating,  and  

-  counseling to offer suggestions to improve work performance in next year.

Performance appraisal is usually done by a superior officer or employer; however, the appraisal can also be done by the employee himself (self appraisal). While a superior officer is expected to be mature and senior in judging the worker and thus be able to offer constructive suggestions, there is also the possibility for bias and favoritism towards some subordinates. On the other hand, self appraisal by the worker should be ideal and democratic, but, it may lead to only positive comments in the report, lethargy and indiscipline. Subordinates can also be asked to assess their superior officers and submit their views and opinions – this again is a good, democratic move but subordinates may be hesitant to assess their boss and pronounce judgement; on the same count, they may be unfairly critical of the boss. Thus a judicious mix of the various appraisal methods is the best option. Participatory appraisal consists of both appraisal by the superior and by the worker himself.

What are the uses and benefits of performance appraisal?

- An appraisal system has been used for promotion, hike in salary, bonus, etc. (this however does not apply in the AP Medical & Health System as of now).

- Performance appraisal satisfies the inherent desire of every human being to know how well  (s)he is performing.

- It helps the worker’s morale to know that the boss/employee is interested in the worker’s progress and performance.

- It, of course, helps in career growth and development.

- The appraisal process also offers suggestions and means to improve work efficiency.

How may the method of performance appraisal be misused?

When used improperly, a performance appraisal report can dampen the enthusiasm and efficiency of the workers especially when the boss shows bias and favoritism. Subjectivity and the human factor are the Achilles heel in a performance appraisal system. Unfair criticism can make the worker defensive, frustrated and complacent; bias towards some staff members can have similar consequences. Further, most appraisers maintain excessive secrecy, do not discuss the appraisal report with the worker, nor do they give appropriate feedback. This hampers the very purpose of appraisal.

How can these drawbacks be overcome?

The employer / appraiser must be fair and unbiased in evaluation and judgement of the subordinate. Criticism must be constructive and definite suggestions must be given to correct mistakes rather than just pointing them out. Targets set for the workers must be realistic and achievable giving due weightage to new recruits, etc. Assessment methods must be made as objective as possible and must be discussed with the employee. The report must be discussed with the appraisee and her / his views incorporated into it.  This sort of participatory appraisal by both superior and subordinate is more acceptable.

For any employee to perform his duties well and give his/her best, (s)he should

- know what work is expected from him/her

- have an opportunity to perform

- know how well (s)he is doing

- receive training/assistance as needed

- be rewarded for performance

The steps involved in performance appraisal include:

Defining targets and ‘effective performance’

Observing the performance

Periodic review of the performance

Making an assessment (diagnosis) and offering counselling / suggestions

Final overall review and report.

First, the appraiser and appraisee sit together and set up duties / responsibilites and targets for the ensuing period – e.g. for a clinical teacher, this may be examining patients, taking classes for students, preparing a report of the work done such as surgeries, mortality, doing research, publishing papers, etc. All these must be clearly stated. After the said period, the employee makes a self-assessment report and submits it. The boss then makes a performance appraisal report. The boss and worker sit together and discuss the reports before a final performance appraisal report is prepared with new targets for the next year and concrete suggestions for further improvement. It is advisable for the appraisee to discuss the performance appraisal report with his higher-up or the head of the institution for review and advice.

Before instituting a performance appraisal system for the first time in an organisation it is advisable to have several discussions with the staff and take their suggestions. The teachers may be advised to maintain a record of the work done by them – classes, patient care, laboratory work, research activities, other co-curricular activities, etc. They can be asked to write down their feelings/ideas in a diary and do a sort of self-appraisal of their work. Colleagues, superior officers, heads of departments and the principal can be requested to visit the classroom, hospital ward or workplace to assess and give suggestions.

The performance appraisal report should contain

- The name and other identification data of the individual

- His/her work output, achievements and contributions

- Improvements over past performance

- Suggestions/changes for improvement in next appraisal period

- Goals & targets for next appraisal period

- Training/counseling as necessary

The overall performance of the individual may be marked as

- Unsatisfactory – Does not meet minimum requirements

- Average – sometimes acceptable but not consistent

- Satisfactory – consistently meets all requirements

- Excellent – clearly and consistently above what is required

- Outstanding – unique and exceptional achievement

Rating is done on the basis of the following characteristics:

job knowledge – academic/technical/administrative/managerial skills as are required for the job;

                        efforts to learn new skills and update his/her knowledge

work output – quality (accuracy, thoroughness, reliability, completion of work) and

                      quantity (volume of work, speed in completion, consistency of output)

initiative and resourcefulness – creativity, instituting changes, developing new ideas at the workplace

communication – conveying information and ideas, clarity of communication, seeking clarification,

                        gaining an understanding of unfamiliar or vague terms/concepts

attendance – punctuality, dependability in fulfilling work requirements in time,

                    communicating changes in schedule

interpersonal relations – building and maintaining proper and cordial work relations,

        support to organisational goals

management skills - leadership skills, resolving conflicts, personnel and resource management,

       judgement (analysis, counseling), staff development, responsibility and planning,

       assertiveness and motivation, team work, problem solving, cost effective strategies

planning & organisation – task planning & implementation, proper use of time & resources,

      prioritising, meeting deadlines

Staff members in general tend to resent an appraisal system and this is especially so in medical colleges and hospitals. Why is it so? Doctor-teachers are likely to feel that they know their duties, perform them exceptionally well, they are above any appraisal method and do not need such systems to adjudge them. They are also likely to feel insecure with a new appraisal system in force. And of course, there is always reason to suspect that an appraisal system will not be implemented fairly and unbiasedly. However, if there is a thorough discussion of the pros and cons of a performance appraisal system and a good, objective and acceptable method is devised, it will be welcomed by all the staff and lead to improved performance, productivity and realisation of the institutional goals.

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Of Gold Medals and Castor Plants

                                                                                                                        Ravi Venkatachelam

            Ei chettu leinappudu, aamudam chettei mahaa vruksham. (When there is no tree around, the castor plant is the biggest / greatest tree.) - this is a familiar Telugu saying; I don’t know of a close English alternative but how does this sound – In the land of the blind, the one-eyed man is the king. Yet it does not convey the full meaning of the Telugu metaphor, nor as well. Before I go into my main thesis, here is more information on the castor oil plant, from the net.

The castor oil plant known as Ricinus communis, grows to a height of about 10 feet (much more than what I thought before). In fact it is said to grow quite fast though it is classified as a shrub. It is said to grow to the height of a small tree but is not as hardy. Some trees however are said to grow to a height of 30 feet especially in tropics with a lot of sunlight – wow, that’s a lot tall. I was under the false assumption that it is a small plant; maybe we should revise our Telugu saying. And, as an afterthought, maybe I should also change the title of this article.

            Gold medals and academic prizes are major achievements in a medical student’s career. Students vie with one another to win at least one medal in MBBS; of course there are a fortunate few who are ‘multi-medalists. Gold medalists receive a lot of attention. Faculty often have a special corner for them while junior students gaze at them with awe and respect. While the medalists themselves feel immensely happy at their accomplishment, they are a source of pride, (sometimes envy?), to their friends and batchmates. There is always the occasional cynic who will question the knowledge and credentials of a medalist while a conceited braggart will claim that he doesn’t care for a medal but he is definitely better than the medalists themselves. To the medalist, that feeling of nostalgia and sense of fulfillment is always special when, decades later, (s)he returns to the alma mater for reunions and sees his/her name on the brown board above.

‘Academic excellence’ – ‘cut above the rest’

            Gold medal examinations / competitions are meant to select a student of an exceptionally high caliber, cut above the rest, one who displays academic excellence in that subject. The key words here are ‘excellence’, not just competency, and ‘exceptionally high’, not juts above average. Gold medals / prizes exist for almost all the major subjects in MBBS in our college, most of them since decades; some departments have prizes of academic excellence for PGs too but my focus here is on graduate gold medals. The rules governing the award of these prizes vary broadly between two methods – most of the medals are awarded based on a competitive examination (theory and / or practical exam) usually held before the University exams. All of these medal exams, I understand, are open only to the big batch of students (so called regular students), the lone exception being the recently instituted Cardiology Gold Medal. But I remember one occasion when a student of a big batch who had failed in two subjects in his Second MBBS appeared for the Medicine Medal exam; to be fair to him, he didn’t do too bad in the exam. But I have always felt uncomfortable with this rule (it exists in some PG entrance exams too) which bars a student forever just because he has failed in one exam, once, during his undergraduation. Anyway, the second method of awarding medals is to select the student who stands first in the University exam – a rather safe and often unbiased method because the theory papers nowadays are evaluated after coding.

Me for the Medal Exam – why take the pains?

            Gold medal examinations traditionally have followed the University examination pattern, be it theory or practical examination though the rules do not often give any specific instructions. Faculty and students too, I guess, are more comfortable with the University exam pattern; in fact, suggestions to modify exams or choose alternative modes which are modern or innovative, are not welcome. Some departments screen the contestants with an initial theory exam selecting only a few for the practicals, while, most allow all the students to take the practical exam too. Senior faculty members, many of whom I have spoken to, feel that the standards of the students have been declining over the years. Some departments have been quite strict about maintaining standards but the outcome hasn’t been very good – when medals were not awarded for some years, instead of taking it as a challenge and working harder, the students gave up and there was a precipitous fall in contestants and on occasions, none appeared for the medal exam. I guess a student would think why he should struggle so much - what is the material benefit of a gold medal – there is no gold in it (the interest from the principal amount deposited decades ago, being just a few hundreds). Of course, students are not money-minded to worry about this, but perhaps more important to them would be the query – ‘how would the medal or certificate help me later on? neither in the PG entrance exam nor to get a job; so why take the pains and struggle for months when anyway I know they won’t give me the medal?’ (As an aside, a GO MS 30 for recruiting faculty in government medical colleges in 2000 allotted 5 marks for a gold medal (out of 100; the other weightages were 85 for MBBS marks and upto 10 for years since passing MBBS). Anyway, it is sad that students nowadays are losing the passion to learn for learning’s sake. The fallout of their behavior has been the professor’s dilemma – should the prof. continue to apply a ‘high calibre’ criterion (criterion based evaluation in educational terminology) and cancel the medal if no one is up to the mark or lower the bar, if needed, and select the best of the lot (the aamudam plant I was referring to in the beginning of the article). Sad to say, some professors have been forced to give a medal to the best of the lot (norm based evaluation).

In Olympics – they don’t cancel gold medals

            I had an interesting conversation on this issue with a professor. To my argument that if no student was up to the mark, let us not award the gold medal but, instead, present a merit certificate or a cash prize, if we wish to, his response flummoxed me for a while - ‘In the Olympics they give the gold medal to the fastest runner even if (s)he clocked less than the previous year’s bronzer; in the Asiad, the best weight lifter gets the gold irrespective of his record vis-à-vis the world record.’ Agreed, sir, but the Olympics and Asiad get the best athletes, never average or below average performers. Okay, golds may not be cancelled in sports but they are sometimes cancelled in arts – in cinema awards, for example, national or state award gold medals are sometimes not awarded in a particular category because no entry is up to the mark.

            Prize examinations and gold medals have, now and then, had their share of controversy, some of them, quite shamefully being allegations of corruption!! These are fortunately only an occasional blip but why should we tolerate even these. Secondly, eyebrows are sometimes raised when a professor’s son or daughter gets a medal. Usually these are unfounded doubts and quite uncharitable, I would say, but it would be prudent on the part of the examiners to ensure full transparency in the examinations.

            How has the students’ trend been over the years? Students in older times took medal exams very very seriously. Plans were made months or sometimes years ahead and they would passionately pursue that subject, attend as many classes as possible from various lecturers, read up as many books and so on. And if they had the faintest doubt that they were not good enough, they were terrified of facing the professor and  would give up midway, some even on the day of examination – and, remember, giving up after a long gruelling preparation. Nowadays too, some students do train well enough and well ahead. But there are many who take the examination with inadequate preparation and it is quite painful to see their ignorance and mediocrity in the medal exam. I am glad though that students are not as timid as before and they brave the examination, but they do need some guidance. Unfortunately, here again, we do not have any mechanism whatsoever to give them an opportunity to train for a medal exam. We want them to excel in the medal exam and perform better than a PG but leave them to fend for themselves and learn on their own arguing that they’re medal students, aren’t they? My personal opinion, though, is that they should be given some training. Lastly,

Some suggestions –

Have a schedule for the medal exam. Announce the dates well in advance.

The medal exam should preferably be at least one month before the final exams.

Adjust the dates such that they do not clash with other medal exams or internal assessment exams.

Try out new formats for the exam (e.g. MCQs or OSCE / OSPE) but announce the methodology in advance and don’t keep changing it every year.

Set some minimum standards which the student must reach to be eligible for the medal.

If none of the students attain this standard and you don’t want to disappoint them, give a merit certificate, not the gold medal, to the best of the lot.

See if you can present a real gold medal, at least a gold coated silver medal; ask the principal for funds – it costs about 1200 rupees now.

Encourage more students to take the medal exam; some are capable but need a small push.

Call the top performers (in the internal exams, etc.) and encourage them to appear for the exam.

Ensure total transparency in the medal exam.

Try having an ‘externals examiner’ or two in the medal exam – for example from outside or another college if possible.

* * * * * *

Tackling absenteeism in class

(should we, should we not??? !!!) (why / how should we??? !!!)

                                                                                                            Dr.Ravi Venkatachelam

            Absenteeism among students in schools and colleges has been emerging as a noticeable problem in recent years. As ‘elders’ recall, gone are the ‘good old days’ when students pursued their studies and viewed their institutions / faculty with steadfast devotion, ingrained discipline and unquestioned obedience. Bunking classes has become common – also in professional (read medical) colleges which were once considered to be a step above other colleges. In an online poll on rediff.com, 90% students confessed to bunking classes! The situation in medical colleges, especially our own college, may not be as dismal but it is definitely not negligible. Figures vary but many students and teachers agree that attendance is rarely if ever 100% in a class and no student has 100% attendance in any subject. My own guesstimate is that the average attendance in a subject could vary anywhere between 50% to 75% (- of classes conducted, not necessarily the number of classes as prescribed by UHS / MCI). Leaving aside rules and regulations, is absenteeism really so bad or is it acceptable? Does it have any serious adverse fallout on the medical education or health care system? Do we need to be more stringent about it? Having had informal conversations with some students and faculty I myself felt a wee bit hesitant and insecure in answering a number of questions they raised (hence the byline to the title above). But of course, at the end, we all consensually did reason out that attendance in classes is essential and cannot be totally done away with but there are some nuts and bolts to tighten up.

First the rules : What does the University Handbook for students say about attendance –

75% of attendance is compulsory inclusive of attendance in non-lecture teaching i.e. seminars, group discussions, tutorials, demonstrations, practicals, hospital postings and bedside clinics, failing which the student will not be permitted to appear for the University exam. . . .  

Attendance shall be calculated from the total number of hours prescribed by UHS / MCI and not the number of classes conducted.

Theoretically speaking, why should students attend classes? Primarily to acquire knowledge of course, and, to pass the examination, or, if planning to pursue that particular speciality (e.g. gynaecology), and, lastly, because attendance is mandatory.

What some educationists have said about absenteeism and its classification -

Ken Reid speaks of various types of school absenteeism – specific lesson absenteeism, parentally condoned absence, psychological absence, school phobia, etc.

Malcolm et al (2003) describe 3 types of students’ nonattendance –

Truancy – absences which students themselves agree are unacceptable to teachers

Unacceptable absences – absences which are unacceptable to teachers / administration but not recognized so by the students

Parentally condoned absences – parents keep students away from college

We could also add Acceptable / unavoidable absences – due to illness, participation in sports, etc. Stoll (1990) defines truancy as ‘absence without any legitimate reason’ while Atkinson (2000) likes to include time as a qualifying criterion, arguing that skipping a single class or two is different from absence for days or weeks or more.

A study published in Academic Medicine October 2007, by Billings Gagliardi et al., which surveyed about 200 medical students of the University of Massachusetts Medical School, after their First Year, found that only 17% routinely attended all classes while the majority deliberated before attending classes and attended only if they wanted to.  

Of the latter, most (82%) said they relied on past experience about the lecturer – clear, understandable explanations, active / interactive classes being positive factors while simple projection of points and lack of clarity were deterrents

40% answered they would consider if attending the class would help them learn and then decide - e.g some students said they would not attend a particular class if they felt they would get the same knowledge equally or better from the textbook. 10% confessed that their personal lives / issues affected attendance. 60% rated lectures slides as a positive factor.

The students who attended all classes said they did so because they felt they were beneficial as they could know areas to focus upon and interact with teachers / peers which facilitated learning.

Why are students absent from classes?

The commonest reason is lack of any action on a student who is absent. Action which may be as simple as summoning the student to the office or calling up his parents or as severe as not allowing the student to sit for the examination can be a strong deterrent to potential ‘bunkers’. It is a well known fact that in our own college, attendance in SPM and Biochemistry is always above 75-80% for every student; next come the other nonclinical subjects. Final year clinical subjects come a distant last!

Below are the reasons cited for absenteeism – mainly by authors like Reid, Kinder and Malcolm – (I have divided them into three groups) -

Student dependent

 Simple laziness

Too much of socialization

Irresponsible pursuit of leisure

Taking part in culturals, sports, etc.

Inferiority complex

Lack of interest in subject / studies

Apathy 

Avoidance on encountering difficulty

Lack of aptitude to medicine

Preparing for some exams / assignment

Fear / Lack of confidence

(especially in clinicals to present cases)

Learning difficulties

Fear of class / questions / examinations

Substance abuse

Fatigue due to excessive socialization

Negative perception of the teacher and course

Dislike to a teacher

 Faculty / college dependent

 Lack of action if student is absent

(no disincentive like detention) 

Poor teaching

Monotonous lectures

Teacher not examiner

Faculty frequently cancelling classes or

Combining 2 – 3 semesters

(likely in clinical postings)

Lengthy classes

Teacher insulting / rebuking students

Irrelevant / restrictive curriculum

Content and delivery of curriculum

Poor infrastructure in class / college

College far off – no proper transport

Classroom ambience

Lack of proper canteen, food

 External factors (incl. family etc.)

 Availability of lessons elsewhere – internet, books, guides, etc.

Too much pampering by family

Availability of excess pocket money, bike, mobile, home theatre, etc

Influence of friends and peers

Illness

Working elsewhere - job / income

Opportunity to go to entertainment – cinema, mall, net browsing, etc

Ragging / bullying / teasing by seniors

Family problems, responsibilities, etc

Disadvantaged home background

Inadequate peer relations

What can be done to prevent absenteeism?

First this needs a strong, strict and firm administration (HOD or Principal) which should make it clear to the students that attendance is mandatory. Students who bunk classes must be summoned, counseled and mentored, and, if necessary their parents called for discussions. Attendance particulars of students must be periodically displayed on the board or put up in the net. The benefits of attending classes must be emphasized and periodic consultations held with students to give a better learning platform. Faculty must be trained properly and motivated to deliver better classes. Some other measures are listed below.

Measures to ensure attendance in classes –

 Strict attendance calls (biometric system if needed)

Maintain statistics and display attendance periodically

Communicate with parents (avoid sermonizing)

Consistent & transparent attendance policy &

Consistence policy to tackle absence

(no influence by recommendations, bribe, etc.)

Have a clear policy on absence monitoring and action

Take feedback from students about classes

Mentoring, counseling

Supportive college culture

Friendly teacher / student relationship

Follow up

Involve students while planning teaching schedule

Have network groups

External review of classes

Options for practical / applied knowledge

Promote importance of attendance and education

Conduct interviews when they return after sickness

 Flexible time table, home-working,

Creative teaching methods / classes

(videos, problem solving)  

 Glenn Bond writing on behalf of a committee on the effects of absenteeism mentions missing critical stages of interaction with peers, low self esteem and dissatisfaction among the students and faulty academic progress as consequences of absenting from classes. We could add others – inadequate knowledge, lack of a practical approach, and, lack of emphasis on important areas in the subject. I must add that I cannot think of any adverse effects of attending classes! Even if a lecture is ‘bad’, I wouldn’t say that going to it is a waste of time – you could learn some points still, and, think how to present that topic in a better way!

Coming back to my earlier question, should we be so strict about attendance or can we give the students more freedom (like the IITs perhaps?). Assuming that the primary reason to attend classes is to gain knowledge, if a student can get it by other means like books or the net, can we let him miss classes? Theoretically yes, perhaps, but we must ensure that he has acquired the knowledge he is supposed to, for which, we need a strong, fair and accurate exam system. The ground reality is that to learn without attending classes (the theory part only – practicals & clinicals cannot be learnt without attending labs & wards) needs a high degree of internal motivation and commitment; moreover our present system of examination is too lenient to fail an undeserving candidate; and to be honest, we (students) still need something to goad us to acquire knowledge and skills – be they examinations or compulsory attendance. And teachers must be more sensitive to this issue and make their classes more interactive and innovative. To conclude, we must all perforce agree that attending classes is mandatory in medical colleges and there is no alternative. So go to classes and enjoy learning.

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SYSTEMS  APPPROACH  IN  MEDICAL  EDUCATION 

Systems Approach – Medical Education

                                                Ravi Venkatachelam (ravichitrapu@rediffmail.com)

(Greek – Synistanai = to combine or bring together)

Systems approach is a way of looking at /approaching an organization or workplace etc.This approach is supposed to yield better results and help in successful running of the organization /workplace to achieve its goals.

SYSTEM (definition) = A system is a Functional Entity with a number of interrelated components (subsystems) all of which function to achieve a common goal.

Thus a system =

-          Has several parts

-          Has a common goal to achieve

-          The parts are influenced by one another

-          Has a process which changes an input into an output

A system can be considered in two ways –

Anatomical (physical parts)

Physiological (functional or working elements)

e.g. – the circulatory system comprises anatomically the heart, arteries, capillaries and veins, etc.and physiologically has the systemic circulation and pulmonary circulation – its function is circulation of blood – carrying blood for oxygenation to the lungs and carrying the oxygenated blood to the body, etc. So also, a car is a system, a college is a system.

A system can have subsystems and it itself can be part of a larger (supra) system.

The college has physically its buildings, equipment, etc. while functionally it may have different departments which train in different subjects – the common goal is to bring out a student with the requisite competencies.

A system has 3 broad functional aspects –

Input                à        Process            à        Output

A medical college for instance, gets the Plus 2 student, trains them for 5 ½ years and brings out a doctor who can offer primary medical care.

A system has different properties –

-          Specialisation = a particular component has a particular specialization – e.g. Anatomy dept, Psychiatry dept, Casuality dept

-          Grouping = related components can be grouped together – e.g. the basic sciences group, the paraclinical group, medical superspecialities group

-          Coordination = the components must work in coordination

-          SYNERGY / Emergent properties = the system as a whole is greater than the simple sum of the individual parts because they are all functioning together.

A system can be a closed system – more often seen in physics etc. where it is self regulated and constant with little exchange with the environment.

Most biological and social systems are Open systems which interact continuously with the environment and are influenced by it, which receive an input from environment, process it and give an output to the environment.

There are 3 other important features of a SYSTEM –

-          Purposiveness = goal which may be Single (Unitary) or sometimes Multiple (pluralistic)

-          Hierarchy = levels in a system – can be natural (e.g. by seniority or age) or arbitrary – an arbitrary hierarchy needs more energy to maintain compared to a natural hierarchy

-          Homeostasis = self regulation through feedback – the larger the system, the greater the energy it needs to maintain its balance

Concept of ‘White Box’ & ‘Black Box’ –

-          White box – refers to the visible or known components or parts

-          Black box – refers to the invisible components or parts that we may not be considering or which we may be ignoring

Medical College as a system –

Input = Students, Faculty, Infrastructure, T/L resources

Process = Objectives,  T/L process, Assessment

Output = Qualified & competent doctor (Cost effectiveness)

Systems approach would be helpful in a medical college –

-          In designing the time table / curriculum

-          In solving problems / mishaps

-          During assessment

-          In evaluation of the teaching program

6 stages of systems approach to medical education –

-          Student characteristics & subject components

-          Existing skills & knowledge

-          Objectives /learning outcomes

-          Appropriate instructional material

-          Implement the curriculum

-          Assessment

A good system must be

-          Effective & efficient

-          Flexible & acceptable

-          Reliable

System error vs. Individual error =

Individual error is Active error or ‘Sharp end’ of the injury  = mistake done by the actual person on the field

System error is Latent error or ‘Blunt end’ of the injury = mistake is failure of the whole system or organization that led to the mistake (e.g. workload, inadequate workforce or equipment, no checklist, improper communication systems, improper working environment, etc.)

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PHARMACOVIGILANCE - Some Points

(compiled from the net by Dr.Ravi Venkatachelam)

Pharmacogivilance (PhV) –  the science dealing with Drug Safety -

 Understanding & detection & assessment & prevention of adverse effects and drug related problems. (so includes collection & analysis of data & monitoring towards this end).

(Pharmakon in Greek = Drug;  Vigilare in Latin = keep a watch on)

Sources of Information / Reports of such adverse events include

- clinical trials & the research studies

- post marketing surveillance

- information from doctors by PhV agreements

- information from other healthcare professionals by PhV agreements

Thus PhV mainly focuses on collecting data on ADRs (Adverse Drug Reaction).

PHARMACOVIGILANCE  - concerned with

Not only drugs – but also devices, vaccines, blood products, biologicals, herbal / traditional /complementary medicines, etc.

Also concern about – substandard drugs, medication errors, off-label use for not-proven conditions, reports of poisoning, abuse/misuse of drugs, drug interactions, lack of efficacy reports, etc.

And also about environmental burden of medicines, effect of ‘inactive’ ingredients (excipients), effects of drug residues in animals

Communicating drug safety information in a transparent and equitable manner

Risk & crisis management 

The main aim of PV therefore is to

- Improve patient care & safety in relation to use of drugs / devices etc

- Contribute to the assessment of benefit /risks of drugs, etc. and promote rational, safe, effective use

- Promote awareness, education, training in PV

National Pharmacovigilance Centres will –

Collect & analyse case reports of ADRs

Distinguish Signal from background ‘noise’

Make regulatory decisions based on strengthened signals

Alert prescribers, manufacturers & public to new risks of adverse reactions

Who can report ADR – theoretically - anyone could report an ADR - could be -

Doctor                                                             Pharmacist

Patients                                                           Other hospital personnel – nurses, etc.

?? public / 3^rd party / advocacy group/ lawyer ????

Some terms used in PhV -

Side effect – Any unintended effect of a pharmaceutical product occurring at normal dose, and, which is related to the pharmacological properties of the drug

Adverse event –  Any untoward medical occurrence during treatment with a pharmacological product – need not necessarily have a causal relation proved.

Adverse (Drug) Reaction – A noxious and unintended response to a drug / medicinal product at any dose.

(previously – a causal relation was to be present or suspected, and, it was at the normal dose of the drug)

Depending on the frequency of ADRs,  the following terms are used,

Very Common is > 10%                                               Common (Frequent) is >1% & <10%

Uncommon (Infequent) is >0.1% & <1%         Rare is >0.01% & <0.1%

Very Rare is < 0.01%

The two main types of Drug Reactions are -

Type A adverse reactions (“Drug Actions”) – (Augmented effect / Anticipated)

-          Pharmacological – common (>1%); dose related; reproducible; low mortality

-          These can be

-          undesirable exaggeration of the desired effect - e.g. orthostatic hypotension after antihypertensive or hypoglycemia with insulin OR

-          undesired pharmacological effect (lateral or parallel effect) - constipation with morphine; hair loss with chemotherapy.

-          AEs In special situations –  in risk situations (liver / kidney disease); in elderly; in pregnancy / lactation

Type B adverse reactions (“Patient Reactions”)- (Bizarre / Idiosyncratic)

-          Idiosyncratic; metabolic intolerance; etc. – rare (<1%); causality uncertain; no dose relation; not reproducible expt.ally; higher mortality

-          e.g. drug induced hemolysis in patients with G6PD deficiency

(other types of adverse reactions include - C,D,E (these terms not often used - )

C= Continuous / Chronic use - e.g analgesic nephropathy; 

D = delayed appearance - e.g. teratogenic & carcinogenic effects - phocomelia with thalidomide, vaginal carcinoma with diethylstilbestrol; 

E = End of use - e.g withdrawal effects on stopping beta blockers / steroids; malignancy after chemotherapy)

Unexpected Adverse Reaction –  An Adverse Reaction that is unexpected from drug characteristics or whose nature / severity is not consistent with the drug labeling

Serious Adverse Event / Reaction –  Any untoward medical occurrence at any dose that causes

-          Death

-          Patient in-hospitalisation or prologongs  hospitalization

-          Is life threatening

-          Persistent or significant disability / incapacity

-          Congenital anomaly

-          Required medical or surgical intervention to prevent permanent damage

SUSAR - Suspected Unexpected Serious Adverse Reaction

Outcome - (of the adverse event) - can be any one of the following

Fatal                Continuing (symptoms continuing)     Recovering      Recovered       Unknown

Causality / Causal Association –  A medicine causing an adverse reaction

Causality Assessment –  Evaluation of the likelihood of Causality between a Drug & an Adverse event

(a challenging process that determines the causality – and gives an estimate of the causality as Certain / Probable or Likely / Possible / Unlikely / Conditional or Unclassified / Unclassifiable or Unassessable

Side Effect –  An unintended effect of a drug at usual doses, and related to the pharmacological properties of the drug

Medical Error –  An unintended act of omission or commission or an act that does not achieve its intended outcome

Prescription-Event or Cohort-Event Monitoring  -  System to monitor adverse drug events in a population. Prescribers report all events, irrespective of whether they are suspected adverse events or not, for identified patients using a drug

Signal –  Reported information on a possible causal relation between and Adverse Event and a Drug, the relation being unknown or incompletely documented before.

(after one or several individual reports of an event, a Signal will be generated which  calls for some action or review)

Spontaneous Reporting –   Voluntary submission of case reports of Adverse Drug Events by health professionals & pharma manufacturers to the national regulatory authority

Notifier – anyone who suspects to have experienced / observed and ADR and informs any PhV centre about it

Reporter – a healthcare professional reporting ADR on an ADR form

CDSCO (Central Drugs Standard Control Organisation) - drug regulatory authority under MoHFW in India.

ICSR –   Individual Case Safety Report – a report containing the information which describes the suspected Adverse Reaction to a Drug in an individual patient

Vigi Base = the WHO Global ICSR Database

(it uses VigiFlow, VigiMine, Vigimed, VigiSearch for the ICSR Management System, statistical data and communication facilties to member countries of WHO and Search service)

Uppsala Monitoring Centre –  WHO collaborating centre for International Drug Monitoring, in Uppsala,Sweden

WHO –ART & MedDRA –   WHO – Adverse Reaction Terminology is replaced by Medical Dictionary for Drug Regulatory Activities

1968 – WHO started the International Program for Drug Monitoring

1984 – International Society of Pharmacoepidemiology set up

1992 – (European – later International) Society of Pharmacovigilance set up

1998 – India joined the Uppsala centre for adverse event monitoring

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National Pharmacovigilance Program in India –

            The NPPI was planned to be launched over 5 years from 2010 to 2015. It works in collaboration with the global ADR Monitoring Centre in Uppsala and receives reports of ADRs from centres in India. It helps the regulatory authority in India - CDSCO - to take decisions regarding safe use of medicines.  The National Coordinating Centre (NCC) is currently at Indian Pharmacopoeia Commission in Ghaziabad.  

5 Regional PhV centres –

Peripheral PhV centres – (PPC) – each PPC to record at least 30 AE per month (i.e. would be about 30 AEs in about 1500 patients)

As on 2014 - there are 150 ADR Monitoring Centres - 90 connected to Vigiflow

In 2013, out of 117 countries, India stood 7th contributing 2% of global ADRs (first is USA with 55% of ADRs; next come Japan, Germany, Italy, Korea & Canada with 6,5,5,4,3%).

The Indian ICSR reports have an average score of 0.88 out of 1 in the WHO-UMC Completeness Score.

A helpline number is provided - 1800 180 3024

website is  www.ipc.gov.in  

The scope of the NPP is

- to create a nationwide system of patient safety reporting

- to identify and analyse new signals from reported cases

- to analyse the risk - benefit ratio of marketed drugs

- to generate evidence based information on drug safety

- to communicate the drug safety information to various stakeholders

- to provide training

- to promote rational use of medicines

Focus will be on collecting reports of AEs with new drugs & ‘Drugs of Current Interest’ (prepared by CDSCO) and also all suspected drug interactions and serious AEs.

Reports to be submitted by health care professionals – doctors, nurses & pharmacists but not by lay public.

Function of PvPI AMCs (ADR Monitoring Centres) in medical colleges –

-          Collect ADR reports

-          Do follow-up with complainant to check completeness as per SOP

-          Data entry into Vigiflow

-          Report to PvPI National Coordinating Centre through Vigiflow

-          Training / sensitization of physicians

The PvPI NCC will assess the ICSRs for quality and if okay, send report to Uppsala centre & CDSCO. Or it may send it back to the AMC for correction / completion.

The ICSR is checked for -

- Quality of documentation - completeness, integrity, quality of diagnosis, follow-up

- Coding - Drug names as per MedDRA

- Relevance  - i.e. New Drug (upto 4 years after introduction in Indian Pharmacopoeia), Unknown Reaction (not included in drug summary) or Serious Reaction

- Causality Assessment

- Duplication of reports

The data will be analysed and used -

- To generate  a Signal / strengthen previous such signals / reports

- Drug regulation

- Education of health personnel

 Some points to remember when filling the Suspected ADR Reporting Form to AMC in India.

Points 1,5,7,8,11,15,16.18 are compulsory to fill for the form to be accepted.

Patient information: initials, age at onset of reaction, gender. § Suspected adverse reaction: A reaction term(s), date of onset of reaction § Suspected medication: Drug(s) name, dose, date of therapy started, indication of use, seriousness, outcome, de-challenge and re-challenge details § Reporter: Name and address, causality assessment, date of report

Any health professional incl. Doctor, Dentist, Nurse, Pharmacist can submit an ADR reporting form.

The AMC will assess Causality using the WHO-UMC  scale. The analysed forms are sbmitted to the NCC through the ADR database and thence to the WHO-UMC. The reports are reviewed by the NCC and used to assess the risk-benefit of drugs. The information is submitted to the Steering Committee of the PhVPI which may suggest any interventions.

The patient's name is held in strict confidence. Only the initials are mentioned in the ADR reporting form.

The drug name, brand / generic, manufacturer, batch no., expiry date, dose given, route, frequency, date of starting & stopping treatment and indication must be entered.

The effect of De-challenge must be entered as Yes (abated) or No, Unknown, or NA (for single dose or anaphylaxis etc)  or if it occurred at Reduced Dose.

Similarly, any  Re-challenge information must  be entered as Yes (if reappeared) or No, Unknown, or NA and the dose of Re-introduced dose.

Concommitant drugs, other relevant tests & history must be included.

Submission of  a report does not constitute an admission that the medical personnel or manufacturer or the product caused or contributed to the reaction.

The reporter, if trained, can perform the causality assessment.

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Lesson Plan

                                                            Dr.Ravi Venkatachelam (ravichitrapu@rediffmail.com) 

Outline –

Lesson plan – why & what                                         Components of a lesson plan

How to make a lesson plan                                        Model lesson plan

Introduction -

            Providing professional (clinical care) services, doing medical research and teaching students are the three chief duties of a doctor. When teaching, a lecture or lesson is the most commonly used method we use to train students in medicine. When performing a medical procedure like a surgery we draw up a mental plan on how to do the operation; before undertaking a research project, we write a carefully detailed protocol or plan of the study. But, when it comes to our third duty of delivering a lecture or taking a class, why aren’t we making an equally rigorous plan?

Such planning for a lesson will help to organize the lesson in the given time and achieve our objectives (of the student learning a particular knowledge /skill) effectively.

            A lesson plan is a teacher’s detailed description of the course of instruction for an individual lesson.

            (Unit plan is for an entire unit which may cover days or weeks and has a set of objectives and time frame)

But it is better to view lesson plan as a sequence of lesson plans in relation to other lessons, rather than in isolation – planning the sequence will help to maintain linkages.

Structure of a lesson plan :

A lesson plan incorporates teacher’s philosophy of learning and students’ interests and needs.

Lesson plan must clearly COMMUNICATE the lesson plan – to – YOU.

It has an end to achieve (objective) and the means (what will happen incl. teacher & student activities) and an input (student background, resources); at the end, assessment will tell if objective is achieved. Thus the lesson comprise –

Input à Process à output

Input – refers to physical materials, resources, and other information needed for the Process. Input comprises Information about the following –

-        Students background and what they already know& what they want to learn

-        Time available

-        Materials needed & how you will get the materials

-        Any special preparations /permissions etc.

Process – is the actual activity plan. It comprises –

-        What are the inputs we have (info. about students, resources, time, etc)

-        What is output we want – what is student supposed to learn

-        What will teacher do  – description of instructional activity including introduction, instructional techniques, closure

-        What will students do – activity for them

-        How will learning be assessed -

Any follow up activities – homework, project, assignment etc.

Self assessment of your lesson – were objectives achieved?

The actual lesson process in the class occurs in five phases –

-        Preparation – a broad outline of the lesson objectives, drawing student interest

-        Presentation /modellling – of the lesson

-        Practice – student activity

-        Evaluation

-        Expansion – applying the knowledge to outside situations

For each of these, you must write the allotted time and what teacher will do and what student will do during that time.

How to Write a Lesson Plan

Madeline Hunter’s 8 step lesson design model –

1 - Anticipatory set (focus)                            2 - Purpose (objective)

3 - Input – concepts, terminology, skills       4 - Modeling (show)

5 - Guided practice                                         6  - Check for understanding

7 - Independent practice                                 8 - Closure

First do a needs assessment of the students and what they require in the class. Then write the lesson plan as follows.

Title of lesson

Name of Teacher                                                        Date

Semester /class of students                                        Subject

Time required by lesson

Brief description of lesson

Goals – (broad based)

Objectives – (specific for this class)

List of required materials / media – books, audio visual equipment, other specimens, etc.

Student characteristics & prerequisites

Learning strategies

Terminology if any

Procedure – detailed step by step description of the lesson

Welcome or warm up or Set or lead-in – to draw student interest – question or a problem

Can ask students to write their expectations from the lesson

State class objectives (any unmet expectations – tell why)

Instructional component – main activity - sequence of events in the lesson including instructional input – lecture /presentation - better not more than 20 min without a break

            How to relate lesson with expectations & past learning

            Choose appropriate method to teach – demo for practical skill, discussion, etc

Student Activity – small group activity better- any activity or discussion on the points learnt

& guided practice

Independent practice

Discussion & debriefing – discuss what was learnt in activity & bring back to class in 5 min

Thus complete all components in class

Summary /conclude /closure

Evaluation component – short evaluation & comments; did students learn what they wanted to

Analysis component – for the lesson itself for improving if needed

Continuity component – review & reflection from previous lesson

A lesson plan must be carefully prepared for successful implementation. Bob Kizlik mentions 6 mistakes that are commonly made while preparing a lesson plan –

1. Objective is not clear enough to specify what the student must be able to do that is observable

2. Assessment is not based on the same behavior as specified in the objective

3. Prerequisites that the student must possess are not mentioned

(upto 70% of what a student learns depends on their possessing the necessary prerequisites; we must know what they have learnt previously; we can also specify what they must know to learn this lesson)

4. Materials are too many & overkill and not in line with lesson plan

5. Instructional method used is not efficient for the level of the intended student group

6. Student activities do not contribute to the lesson objective

Example of a lesson plan – (a sample plan I have written – not field tested)

Title - Management of Acute Left Ventricular Failure

Dr.****           Date : 27^th Dec.           Semester – 5^th sem.    Sub : Medicine –Cardiology 

30 min.

Acute LVF, emergency – common causes are . . . , diagnosis by clinical exam and investigations like BNP, Echo and management with Frusemide, morphine, nigroglycerin and enalapril

Materials – Chalkboard & Chalk, Computer & LCD projector with screen, Prepared Powerpoint, Case study questions in PPT or as printout, Xray & Echo video in PPT, prepare case history

Goals : diagnosis and management of common cardiac disorders

Objectives – at the end of the class, the student should be able to

-        Describe acute LVF and its clinical features

-        Mention the investigations to be done in a pt. with acute LVF and the results of the tests

-        Write a treatment protocol for acute LVF

-        Interpret an xray chest and an echo of a pt. with LVF

-        Understand the emergency nature of LVF

Cognitive domain mainly with some affective domain –

Methods – lecture /discussion with students, demonstration of xray and echo

Student prerequisites – knowledge of cardiac function & determinants (pre, after load, contractility); attended Medicine wards /ICU and seen patients with LVF

No.	Content	Method	Teacher activity	Student activity	TL Media	Duration	Evaluation
1	Set in	Lecture	Tell a case story of LVF	Listens -		2 min	Questions in class
2	LVF def. & causes	Lecture	Narration	Listen	PPT (LCD)	2  min	Questions
3	Patho-genesis	Lecture	Derivation & diagram	Students tell	Chalk board	4 min	Students answer
4	Clinical features	Lecture	Narration	Listen	PPT	3 min	Questions & case
5	DD (asthma & noncardiogenic Pulm edema)	Lecture	Narration	Listen	PPT	3 min	Questions & Case
6	Investigations xray echo etc	Lecture	Narration & display	Listen & answer	Xray echo	3 min	Students answer
7	Case study – why is it LVF	Case history	Facilitate	Solve & answer	Handout or PPT	4 min	Students answer
8	Treatment O2 back rest, lasix, morphine etc	Lecture & derive	PPT	Listen & tell	PPT	3 min	Questions & case
9	Write treatment plan	Case history	Facilitate	Solve answer	Handout or PPT	4 min	Students answer
10	Summary & closure	Lecture & interaction	Interactive	Listen & answer	Chalk board	3 min	Students answer
11	Homework	Case history	Facilitate & assess	Submit answer	Handout	Home work	Written Answer

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Reflection in Medical Education

Ravi Venkatachelam C. (ravichitrapu@rediffmail.com)   

Mark Van Doren – ‘The art of teaching is the art of assisting discovery’.

John Dewey – ‘We don’t learn from experience. We learn from reflecting on experience’.

Darnell – learning process is Input à Process à Output à Reflect

1933 - Dewey is considered the modern world originator of Reflection. He thought of reflection as a problem solving chain that linked several ideas.

Reflection is thinking for an extended period by linking a recent experience with earlier ones in order to promote a more complex and interrelated mental schema. This is a higher order thinking skill.

Reflection is a metacognitive process that creates understanding of self and situations to inform future action.

Reflection helps us to constructing a meaning from an experience by encouraging insight and complex learning. Reflection can be done alone or in groups.

Scaffolding  = linking a current experience to a previous learning

In reflection – students obtain information from various sources (visual /auditory / tactile /kinesthetic and process the info. and evaluate the data to make a conclusion /decision.

They make meaning out of their experience and express it Orally or Written.

Reflective thinking usually starts with a dilemma – when faced with dilemma, we don’t make a decision – we gather information, study the problem, gain new knowledge, and come to a proper decision.

Grimmett proposed 4 modes of thinking – from Technological to Situational to Deliberate to Dialectical. They go up from lower levels of reflection (for routine decisions) to higher levels (for complex dilemnas)

Technological (Formulaic) thinking – based on proven practice / knowledge that we know will work. Done for routine decisions.

Situational thinking – focusing on information in a specific context /time and reflect quickly and take a quick decision to solve the problem.

Deliberate thinking – seeking more information than the immediate context provides, and understand the dilemma and taking a decision.

Dialectical thinking – builds on deliberate thinking to understand the situation and generate solutions and strategies.

Strategies to guide students through Reflection –

> Discussions – students share their problem solving processes, strategies, metacognitive proceses, how they arrive at a decision

> Interviews – teacher can interview student or student by student (each other). This also helps develop /practise skills of listening, thinking, communicating, empathy, questioning, etc.                                          (‘critical friend’ dyad)

> Questioning – how much are they aware of their learning from the experience, what strategies were analysed, what insights were gained, how it helps future decisions, etc.

> Logbooks / journals – students periodically read their journals, compare their notes and how they can use this for future situations.

> Using movies / stories -

> Sentence stems – ‘I chose this essay because .  . . .  .  ..’.            ‘I like this scene /movie because .  ..  . . . .  ..  .’

> PUNs & DENs approach (Eve 1994) – after a doctor –patient consult, first identify the PUN (Patient Unmet Need) and then the DEN (Doctor’s Educational Need). Then the DEN has to be met.

> structured reflection template – Describe (what happened)          feeling             evaluation (what was good / bad)                        analyse                        conclusion      action plan

Reflection is not giving a testimonial that the experience was good or fun or what was bad in it. Reflection is considering what was learnt from the experience. Students should describe what they saw in their own work /in themselves that has changed or that needs to change, or must be described for someone else to understand.

Surbeck, Han & Moyer (1991) – 3 levels of reflection –

-  Reacting – commenting on feelings toward the experience

- elaborating – comparing reactions with other experiences

- contemplating – focusing on problems, insights

Hatton & Smith identified 4 essential issues in reflection –

- learn to frame /reframe complex or ambiguous problems, test out various interpretations and modify our actions accordingly

- thoughts should be extended & systematic by looking back upon our actions some time after they have taken place

- certain reflective activities like use of journals /group discussions after an experience, are often not directed towards solution to a specific problem

- critical reflection – accounting for cultural / historic beliefs & values while arriving at a solution to a  problem

4 activites take place in Critical Reflection –

- Assumption analysis – thinking such that we challenge our beliefs /practices /values.

- contextual awareness – realizing our assumptions are created in a social /cultural context

- imaginative speculation – imagining alternative ways of thinking - & challenging our prevailing ways

- Reflective speculation – questioning all the claims and patterns of interaction to establish the truth or viability of a proposed action.

A Reflective Learner will continually reflect on what they are learning & how, their strengths & weaknesses, & gaps in knowledge /skills, how to work towards it,

Factors affecting ability of reflection – Student related, Environmental, reflection task

* Student /learner related – skill & experience in reflective thinking, knowledge of the content area, motivation to complete the task, mental preparation, degree of security /freedom felt when reporting actual reflection vs. perceived desired response.

* Environment related – physical environment (noise, TV, discomfort etc.) interpersonal environment,

* (reflction) task related – reacting or elaborating or contemplating level; written or oral; type of feedback, consequences of reflecting

Writing can be 4 types – 1^st is nonreflective 2^nd to 4^th are reflective

1. Descriptive writing – reports the events

2. Descriptive reflection – (I chose this book because..  ..   .)

3. dialogic reflection –

4. Critical reflection

AMEE Guide – 2009; 31: 685 – 695

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