ATCOM = the new MCI Attitudes & Communications Module for MBBS students

EXTRACT FROM MCI DOCUMENT REGARDING ATCOM MODULE FOR MBBS STUDENTS

Annexure III

Attitude and

Communication (AT-COM) Competencies for the Indian Medical Graduate

Prepared for the Academic Committee of Medical Council of India

by

Reconciliation Board

July 2015

Medical Council of India

Foreword

            The Medical Council of India has prepared revised Regulations on Graduate Medical Education and curriculum, accompanied by guidance for its implementation. In response to this, every medical college needs to develop the capacity to adapt to the requirements of the new guidelines. Earlier experience with implementation of curricular changes suggests that a carefully managed, sustainable approach is necessary to ensure that every college has access to these new skills and knowledge. Faculty development has been seen to play a key role in implementation and sustenance of any curricular reform.

The Medical Council of India has decided to implement Attitude and Communication module (ATCOM) in all medical schools across the country over the next two years. It is against this backdrop that the ATCOM module is prepared along with facilitators guide. This activity has been supported wholeheartedly by the President of Medical Council of India, Dr. Jayshree Mehta.  There are many new key areas recommended in the ATCOM module that were identified for implementation across the entire duration of the course. It is hoped that the successful implementation of the ATCOM modules will be forerunner of the transition to competency based medical education program envisaged by the Medical Council of India.

This booklet and other electronic resources provide background concept, session guidelines and other resources for these sessions. These will be useful for all faculty involved in conducting these sessions. These are conceptual frameworks only and institutions and faculty are at liberty to make modifications while implementing the same at their own settings.

It is proposed that the existing network of MCI Nodal/Regional Centers and Medical Education Units of all medical colleges will be the torchbearers of this transformational change. We hope that such a change will significantly impact the quality of community health and patient care in our country.

CONTENTS

Preamble /concept                                                                         5

How to use this document                                                   6

Definitions                                                                              7

Section I: Extract from the revised Regulations                          11

on Graduate Medical Education, 2012

Section II: Learning modules for Professional year 1-4           18

Section III: Competency acquisition                                        75

Section IV: Formative elements to be marked by tutor           80

Appendix 1: List of ATCOM competencies approved by                82

                   the Academic Committee, MCI

Appendix 2: Communication skills to rating tool                             86

Attitudinal and Communication (ATCOM) Competencies for the Indian Medical Graduate

Preamble / Concept

The overall goal of undergraduate medical education programme as envisaged in the revised Regulations on Graduate Medical Education - 2012 (GMR 2012) is to create an “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a physician of first contact of the community while being globally relevant. In order to fulfill this goal, the IMG must be able to function appropriately and effectively in her/his roles as clinician, leader and member of the health care team and system, communicator, lifelong learner and a professional. In order to effectively fulfill the above mentioned roles, the IMG must obtain a set of competencies at the time of graduation. In order to ensure that training is in alignment with the goals and competencies, MCI has proposed new teaching learning approaches including a structured longitudinal programme on attitude, communication and ethics. 

Role modeling and mentoring associated with classical approach to professional apprenticeship has long been a powerful tool. This approach alone is no longer sufficient for the development of a medical professional. The domains of attitude, communication and ethics therefore need to be taught directly and explicitly throughout the undergraduate curriculum. The two major aspects of teaching professionalism include explicit teaching of cognitive base and stage appropriate opportunities for experiential learning and reflection throughout the curriculum.

The ATCOM module has been prepared as a guide to facilitate institutions and faculty in implementing a longitudinal program that will help students acquire necessary competence in the attitudinal and communication domains. It offers framework of competencies that students must achieve. It also offers approaches to teaching learning methods. However it is a suggested format and institutions can develop their own approaches to impart these competencies.   

How to use this document

This document is a guide to facilitate institutions and faculty in implementing a longitudinal program that will help students acquire necessary competence in the attitudinal and communication domains. The purpose of this program is to allow the graduate to function in roles envisaged in the revised Regulations on Graduate Medical Education – 2012 or the Indian Medical Graduate (IMG) document. The IMG document creates roles for the graduate that goes beyond the traditional knowledge and skill components. In particular, it adds four roles including – leader and member of the health care team, communicator, life-long learner and professional, which call for learning and skills not addressed by the traditional syllabi.

The document is divided in to the following:

1.       Section I: contains an extract of the goals, roles and universal competencies as envisaged by the Indian Medical Graduate document. This is the base document upon which all learning in the undergraduate years must be based and lists the final competencies that all students must achieve.

2.       Section II: contains suggested teaching modules for each professional year including resources cases and method to teach.

3.       Section III: is a competency log that contains a list of skills that may be acquired prior to graduation. These skills are best imparted in a simulated setting (usually involving standardized patients). They are also best done progressing in complexity over time. For example a skill on communicating treatment options may be acquired at different level of complexities spread over phases before finally being certified.

4.       Section IV:  contains formative elements that are observable by tutors / mentors / guides and marked over time with appropriate feed back in a non punitive fashion

5.       Appendix 1: consists of the entire set of competencies as approved by the Academic Committee of the Medical Council of India

6.       Appendix 2: provides a modified communication skill rating tool adapted from the Kalamazoo consensus

It must be reiterated that this is only a suggested format to impart these competencies. Institutions may evolve their own innovative methods to suit local needs as long as they conform to the competencies identified in section I and appendix 1

Definitions

1.     Goal: A projected state of affairs that a person or system plans to achieve

     

In other words: Where do you want to go? or What do you want to become?

2.     Competency: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served

     

In other words: What should you have? or What should have changed?

3.     Objective: Statement of what a learner should be able to do at the end of a specific learning experience

     

In other words: What the Indian Medical Graduate should know, do, or behave

Action Verbs (Behaviour - Used in this document)  

Knowledge	Skill	Attitude/communicate
Enumerate	Identify	Counsel
List	Demonstrate	Inform
Describe	Perform under supervision	Demonstrate understanding of
Discuss	Perform independently
Differentiate	Document
Define	Present
Classify	Record
Choose	Interpret
Elicit
Report

 
 1.      Note that specified essential competencies only will be required to be performed independently at the end of the final year MBBS

2.      The word perform or do is used ONLY if the task has to be done on patients or in laboratory practicals in the pre/para- clinical phases

3.      Most tasks that require performance during undergraduate years will be performed under supervision

4.      If a certification to perform independently has been done - then the number of times the task has to be performed under supervision will be indicated in the last column

Explanation of terms used in this document

Lecture	Any instructional large group method including traditional lecture and interactive lecture
Small group discussion	Any instructional method involving small groups of students in an appropriate learning context
DOAP (Demonstration-Observation - Assistance - Performance)	A practical session that allows the student to observe a demonstration, assist the performer, perform in a simulated environment, perform under supervision or perform independently
Skill assessment	A session that assesses the skill of the student including the practical laboratory, skills lab, skill station that uses mannequins/ paper case/simulated patients/real patients as the context demands
Core	A competency that is necessary in order to complete the requirements of the subject (traditional must know)
Non Core	A competency that is optional in order to complete the requirements of the subject. (traditional nice know/ desirable to know)
National guidelines	Health programs as relevant to the competency that are part of the national health program

Domains of learning

K	Knowledge
S	Skill
A	Attitude
C	Communication

Levels of competency

K	Knows	A knowledge attribute - Usually enumerates or describes
KH	Knows how	A higher level of knowledge - is able to discuss or analyse
S	Shows	A skill attribute: is able to identify or demonstrate the steps
SH	Shows how	A skill attribute: is able to interpret/ demonstrate a complex procedure requiring thought, knowledge and behaviour
P	Performs (under supervision or independently)	Mastery for the level of competence - When done independently under supervision a pre specified number of times - certification or capacity to perform independently results

Note:

For the purposes of this document, a competency will be defined as a combination of one or more objectives addressing one or more domains of learning.

One or more objectives contribute to a competency. Many competencies contribute to fulfilling the attributes of a role. Many roles help fulfill the goal of the Indian Medical Graduate

In the table of competency - the highest level of competency acquired is specified and implies that the lower levels have been acquired. Therefore when a student is able to SH - Show how an informed consent is obtained - it is presumed that the preceding steps - the knowledge, the analytical skills, the skill of communicating have all been obtained.

It may also be noted that attainment of the highest level of competency may be obtained through steps spread over several subjects or phases and not necessarily in the subject or the phase in which the competency has been identified.

The competencies defined in this document benchmark student achievement of the knowledge skills attitudes communications and behavior at the end of the final year of medical college. By its very nature, the majority of the performance aspect of these competencies will only be fulfilled in the internship year (which these competencies do not address). Hence the highest level of achievement for the majority of the competencies will be a show how in the Dreyfuss model.

Section I

Extract from the revised Regulations on Graduate Medical Education, 2012

The undergraduate medical education program is designed with a goal to create an  “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a doctor of first contact of the community while being globally relevant.

2.   In order to fulfill this goal, the IMG must be able to function in the following ROLES appropriately and effectively:

2.1.       Clinician who understands and provides preventive, promotive, curative, palliative and holistic care with compassion.

2.2.       Leader and member of the health care team and system with capabilities to collect analyze, synthesize and communicate  health data appropriately.

2.3.       Communicator with patients, families, colleagues and community.

2.4.       Lifelong learner committed to continuous improvement of skills and knowledge.

2.5.       Professional, who is committed to excellence, is ethical, responsive and accountable       to patients, community and profession.

Global Attitudinal and Communication Competencies addressed in the Roles of an Indian Medical Graduate

3.   Competencies: Competency based learning would include designing and implementing medical education curriculum that focuses on the desired and observable ability in real life situations. In order to effectively fulfill the roles as listed in item 2 above, the Indian Medical Graduate would have obtained the following set of competencies at the time of graduation:

3.1.       Clinician, who understands and provides preventive, promotive, curative, palliative and holistic care with compassion        

3.1.1.   Demonstrate knowledge of normal human structure, function and development from a molecular, cellular, biologic, clinical, behavioral and social perspective.

3.1.2.   Demonstrate knowledge of abnormal human structure, function and development from a molecular, cellular, biological, clinical,  behavioural and social perspective.

3.1.3.   Demonstrate knowledge of medico-legal, societal, ethical and humanitarian principles that influence health care.

3.1.4.   Demonstrate knowledge of national and regional health care policies including the National Rural Health Mission (NRHM), frameworks, economics and systems that influence health promotion, health care delivery, disease prevention, effectiveness, responsiveness, quality and patient safety.

3.1.5.   Demonstrate ability to elicit and record from the patient, and other relevant sources including relatives and caregivers, a history that is complete and relevant to disease identification, disease prevention and health promotion.

3.1.6.   Demonstrate ability to elicit and record from the patient, and other relevant sources including relatives and caregivers, a history that is contextual to gender, age, vulnerability, social and economic status, patient preferences, beliefs and values.

3.1.7.   Demonstrate ability to perform a physical examination that is complete and relevant to  disease identification, disease prevention and health promotion.

3.1.8.  Demonstrate ability to perform a physical examination that is contextual to gender, social and economic status, patient preferences and values.

3.1.9.   Demonstrate effective clinical problem solving, judgment and ability to interpret and integrate available data in order to address patient problems, generate differential diagnoses and develop individualized management plans that include preventive, promotive and therapeutic goals.

3.1.10. Maintain accurate clear and appropriate record of the patient in conformation with  legal and administrative frame works.

3.1.11. Demonstrate ability to choose the appropriate diagnostic tests and interpret these tests based on scientific validity, cost effectiveness and clinical context.

3.1.12. Demonstrate ability to prescribe and safely administer appropriate therapies including nutritional interventions, pharmacotherapy and interventions based on the principles of rational drug therapy, scientific validity, evidence and cost that conform to established national and regional health programs and policies for the following:

a.  Disease prevention,

b.  Health promotion and cure,

c.  Pain and distress alleviation, and

d.  Rehabilitation and palliation.        

3.1.13  Demonstrate ability to provide a continuum of care at the primary and/or secondary           level that addresses chronicity, mental and physical disability.

3.1.14  Demonstrate ability to appropriately identify and refer patients who may require    specialized or advanced  tertiary  care.

3.1.15  Demonstrate familiarity with basic, clinical and translational research as it applies to          the care of the patient.

3.2.    Leader and member of the health care team and system

3.2.1    Work effectively and appropriately with colleagues in an inter-professional health care team respecting diversity of roles, responsibilities and competencies of other             professionals.

3.2.2    Recognize and function effectively, responsibly and appropriately as a health care             team leader in  primary and secondary health care settings.

3.2.3    Educate and motivate other members of the team and work in a collaborative and collegial fashion that will help maximize the health care delivery potential of the             team.

3.2.4    Access and utilize components of the health care system and health delivery in a    manner that is appropriate, cost effective, fair and in compliance with the national       health care priorities and policies, as well as be able to collect, analyze and utilize   health data.

3.2.5    Participate appropriately and effectively in measures that will advance quality of   health care and patient safety within the health care system

3.2.6    Recognise and advocate health promotion, disease prevention and health care        quality improvement through prevention and early recognition: in a) life style   diseases and b) cancer in collaboration with other members of the health care        team.

3.3.    Communicator with patients, families, colleagues and community

3.3.1    Demonstrate ability to communicate adequately, sensitively, effectively and           respectfully with patients in a language that the patient understands and in a        manner that will improve patient satisfaction and health care outcomes

3.3.2    Demonstrate ability to establish professional relationships with patients and families          that are positive,  understanding, humane, ethical, empathetic, and trustworthy.

3.3.3    Demonstrate ability to communicate with patients in a manner respectful of            patient’s preferences, values, prior experience, beliefs, confidentiality and privacy.

3.3.4    Demonstrate ability to communicate with patients, colleagues and families in a       manner that encourages participation and shared decision-making.

3.4.    Life long learner committed to continuous improvement of skills and knowledge

3.4.1    Demonstrate ability to perform an objective self-assessment of knowledge and  skills, continue learning, refine existing skills and acquire new skills.

3.4.2    Demonstrate ability to apply newly gained knowledge or skills to the care of the    patient.

3.4.3    Demonstrate ability to introspect and utilize experiences, to enhance personal and professional growth and learning.

3.4.4    Demonstrate ability to search (including through electronic means), and critically   evaluate the medical literature and apply the information in the care of the patient.

3.4.5    Be able to identify and select an appropriate career pathway that is professionally rewarding and personally fulfilling.

3.5.    Professional who is committed to excellence, is ethical, responsive and accountable to patients community and the profession

3.5.1    Practice selflessness, integrity  responsibility, accountability and respect.

3.5.2    Respect and maintain professional boundaries between patients, colleagues and    society.

3.5.3    Demonstrate ability to recognize and manage ethical and professional conflicts.

3.5.4    Abide by prescribed ethical and legal codes of conduct and practice.

3.5.5    Demonstrate a commitment to the growth of the medical profession as a whole.

Assessment of Attitudinal and Communication Skills

      Assessment is a vital component of competency based education. In addition to make the pass/fail decisions, a very important role of assessment is to provide feedback to the learner and help him/her to improve learning. The assessment in ATCOM nodule has been designed with this purpose. The teachers should use this opportunity to observe the performance and provide feedback based on their observations.  In case a student has demonstrated a performance, which is considered below expectation, corrective action including counseling should be initiated. Many of the tools in this module may appear subjective but coupled with the experience of the assessor, they will serve a very useful purpose.

Section II

Learning modules for Professional year I

Number of Modules: 5

Number of hours: 34

1.          What does it mean to be a doctor?

Background

It is important for new entrants to get a holistic view of their profession, its ups and downs, its responsibilities and its privileges. It is important to start this discussion early in their careers when their minds are still fresh with the thrill of joining medical school. Such a discussion will help them remember the big picture through the program and remind them why they have chosen to be doctors.

       Competencies addressed

1. Enumerate and describe professional qualities and roles of a physician	KH
2. Describe and discuss the commitment to lifelong learning as an important part of physician growth	KH
3. Describe and discuss the role of a physician in health care system	KH
4. Identify ,discuss physician’s role and responsibility to society and the community that she/ he serves	KH

Learning Experience

When: Professional year 1

Hours: 8 (6 hours + 2 hours self directed learning)

This session can be delivered by 4 inter-dependent learning experiences

1.     An exploratory session with the students enquiring from them why they chose to become doctors and what do they think are the privileges and the responsibilities of the profession. What do they expect from society and what do they think society expects from them? What will they have to do and give up in order to meet their own and society’s expectations. This is preferably done in a small group discussion.

2.     A facilitated panel discussion involving doctors who are at various stages of their careers (senior, midlevel, young) where doctors share their experiences and also answer questions from students.

3.     Self directed learning where students write a report from reflection based on sessions 1 & 2 and on other readings, TV series movies etc that they have chosen from the lay press about doctor experiences.

4.     Introductory visit to the hospital / community medical centres

5.     A closure session with students to share their reflections based on 1, 2, 3 and 4 that includes what they plan to do in the next 5 years in order to fulfill their professional and personal roles as doctors.

6.     A coat ceremony in the Foundation Course may be considered

Assessment

1.     Formative: not required

2.     Summative: not required

Resources

1.     Whitcomb ME.  Academic Medicine 2007 82: 917

2.     A white coat ceremony is a symbolic transition of the medical student in many institutions done prior to their first clinical day in order to emphasize importance of their new role as budding doctors.

3.     Eisenberg C. It is still a privilege to be a doctor

4.     Ofri D. Neuron overload and the juggling doctor. The Lancet 2010. 376: 1820 - 21

2.          What does it mean to be a patient?

Background

Doctors deal with human suffering throughout their professional careers. A balanced approach to the patient care experience requires an understanding of patients, illnesses, their concepts of suffering, coping mechanisms, the role of the doctor, an exploration of empathy vs equanimity and the difference between healing and curing. In the first professional year, an introduction to this fundamental but complex field is important. An introductory experience will allow students to keep the patient experience in perspective during their learning.

         CompetencIES addressed

1..Enumerate and describe professional qualities and roles of a physician	KH
2. Demonstrate empathy in patient encounters	SH

Learning Experience

When: Professional year 1

Hours: 8 (6 hours + 2 hours self directed learning)

This session can be delivered by 2 interdependent learning experiences

1.     An exploratory session with the students enquiring from them about their views on health disease and suffering. Discussion could involve their personal ill health or involving someone they know among their families and friends. How did that experience affect them? What do they believe patients feel and go through? How does it affect patient’s behaviour, outlook and expectations.

2.     Students are assigned to patients in the hospital, interview them about their experiences, reactions, emotions, outlook and expectations

3.     Self directed learning where students write a report from reflections based on sessions 1 & 2 and on other readings, TV series movies etc

4.     A closure session with students to share their reflections based on 1, 2 and 3 in order that includes how they intend to incorporate the lessons learnt in their learning and patient

Assessment

1.     Formative: The student may be assessed based on their active participation and presentation (written and oral)

2.     Summative: SAQ

Resources

Student narrative

The student narrative is a learning method that focuses on the following skills:

1.     elicit observe and record data

2.     reflect on the data at a higher level of thinking and derive opinions and conclusions

3.     communicate the observations and conclusions in a written and verbal form and expand on an defend the conclusions with colleagues and teachers

4.     Form new experiences and conclusions based on this discussion

3.      The doctor patient relationship

BACKGROUND

The doctor patient relationship is the cornerstone to effective patient care. This session builds on the previous two sessions which address doctors and patients and attempts to explore the fundamental basis of the doctor patient contract, its rules, boundaries and duties. It provides an introduction to the nature of relationship, importance of communication, honesty, transparency, shared responsibility, equality and vulnerability. While complex this introductory session will provide an overview for the student to provide them with a perspective on the doctor patient relationship through their years of study.

COMPETENCies addressed

1. Enumerate and describe professional qualities and roles of a physician	KH
2.. Demonstrate empathy in patient encounters	SH

Learning Experience

When: Professional year 1

Hours: 7 hours (5 hours + 2 hours of self directed learning)

This session has several interdependent sessions

1.     An anchoring large group session emphasising the fundamentals of the doctor patient relationship (1 hour)

2.     Self directed/Guided learning by students on the doctor patient relationship that includes learning from resources, lay press, movies and media (2 hours)

3.     An interactive discussion in a small group based on session 1 with illustrative cases. Examples of cases that can used are provided in the resources section (2 hours)

(Or) a patient doctor encounter observation with checklist may be used

4.     A closure session with reflection by the students based on items 1,2 and 3

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions. A written critique of the situations discussed in item 2 may be used for formative assessment

2.     Summative: Short questions  for example a) rights of patients b) responsibilities of patients c) duties of doctors d) boundaries of the doctor patient relationship

Resources

1.     http://www.cpso.on.ca/policies-publications/the-practice-guide-medical-professionalism-and-col/principles-of-practice-and-duties-of-physicians

2.  Cases for discussion:

1.     A 53 year old man is seen by a cardiologist for chest pain lasting for a few minutes on accustomed exercise for the past 3 weeks. After a detailed history and physical examination the doctor orders an ECG which was normal. He further orders an exercise stress test which showed reversible ischemia. The doctor orders an angiogram. At the time the patient requests that he would like to have a second opinion. The cardiologist explains that he has done everything correctly and that the patient indeed requires an angiogram. The patient tells him that he cannot make a decision unless he talks to his family doctor of 20 years. The cardiologist is offended and tells the patient that he does not any longer wishes to see the patient

Points for discussion

Trust in the doctor patient relationship

      Rights of a patient

      Duties of a doctor

         Is the request for a second opinion grounds to terminate the doctor patient relationship

      Resources for case 1: a. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8041.page?

2.   A young doctor has been taking care of a 86 year old woman for the past 2 years. She had a fall 2 years ago and has been mostly bed ridden. She lives alone with just  a care taker and her children are abroad. She mostly requires preventive care and the doctor makes house visits once a week. The doctor spends time talking to her each visit and makes here feel comfortable. One day during such a visit the patient expresses the view that her children have been ungrateful to her and that she intends to call her lawyer today and divide her assets between the doctor and the caretaker after her death. What should the doctor do?

Points for discussion

      Boundaries in the doctor patient relationship

      Trust and vulnerability in doctor patient relationships

Resources for case 2 : https://www.dovepress.com/getfile.php?fileID=1351

4.      The foundations of communication 1

Background

Communication is a fundamental prerequisite of the medical profession and bedside clinical skills is crucial in ensuring professional success for doctors. This module  provides students with an introduction to doctor patient communication. The Kalamazoo consensus statement provides a working model of teaching communication skills and may be used to impart communication skills. The five As elements of behaviour change model may also be used. Skills that will be introduced should include effective listening, verbal and non verbal communication and creating respect in patient encounters.

competency addressed

1. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non- judgemental  and empathetic manner

SH

Learning experience

When: Professional Year 1

Hours: 7 hours (5 hours + 2 hours self directed learning)

What?:

This module includes 2 interdependent learning sessions

1.     Introductory large group sessions on the principles of communication

2.     Self directed/ Guided learning by students on the importance and techniques of effective communication

3.     Small group sessions on improving communication. These sessions can include either videos or role play highlighting common mistakes in patient doctor communication and allowing students to identify these mistakes and discussing how to correct them. Situations that can be used include a) a noisy ambience with a distracted doctor who is multitasking b) lack of eye contact c) doctor who keeps on interrupting patients and not listening  d) doctor who talks down to patients etc.

4.     Closure session with reflection by students in a small group based on sessions 1,2 and 3 with emphasis on learning done and future directions

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions. A written critique of the situations discussed in item 3 may be used for formative assessment

2.     Summative: may be deferred for later phases

RESOURCES

1.  Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.

5.    The cadaver as our first teacher

Background

Medical students enter college and their first and lasting encounter is with the cadaver. Respect for tissue as a teacher translates later into respect for human beings as teachers and a lifelong respect for learning. Throughout the world the emphasis on “humanizing” the cadaver with respect as first patient or first teacher has gained momentum.

COMPETENCY ADDRESSED

1.Demonstrate respect and follows the correct procedure when handling cadavers and other biologic tissue

SH

Learning experience

When: Beginning and End of Professional year 1

Hours: 4 (2+2) hours

What

4.     An initial introductory session (large or small group) on the importance of biologic tissue and cadavers in their learning. The discussion should focus on the fact that some of these cadavers were unclaimed but also many of them are an anatomic gift by families and how respect for them is importance and also on how tissue must be respected. The session should include safe and clean handling and disposal of biologic tissue (2 hours).

5.     A session at the end of phase is a small group or large group discussion with reflective presentations by students on how the cadaver helped them learn, their experience with dissection etc. These sessions should allow students to display their creativity and may include prose, poetry and sketches etc. An example of such a project is found in the resources section (2 hours).

ASSESSMENT

1.     Formative: The student may be assessed based on their active participation in the sessions. The respect and the manner in which students handle biologic tissue throughout the phase may be part of the overall formative assessment of the student.

2.     Summative: may not be required

RESOURCES An example of the project is found here: http://medicine.yale.edu/education/donation/reflections/

Learning modules for Professional Year 2

Number of modules: 8

Number of hours: 35

1.    The foundations of communication 2

Background

Communication is a fundamental prerequisite of the medical profession and beside skills is crucial in ensuring professional success for doctors. This module  continues to provide an emphasis on effective communication skills. During professional year two the emphasis is on active listening and data gathering

COMPETENCY ADDRESSED

1. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non- judgemental  and empathetic manner

SH

Learning experience

When: Professional year 2

Hours: 5 (1 + 2 +2)

What?:

This module includes 2 interdependent learning sessions

1.     Introductory small group session on the principles of communication with focus on opening the discussion listening and gathering data

2.     Focused small group session with role play or videos where students have an opportunity to observe critique and discuss common mistakes in opening the discussion, listening and data gathering

3.     Skills lab sessions where students can perform tasks on standardised or regular patients with opportunity for self critique, critique by patient and by the facilitator

Assessment

1.     Formative:  Participation in session 2 and  Performance in session 3 may be used as part of formative assessment

2.     Summative: may be deferred

RESOURCES

1.     Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.

2.     Hausberg M Enhancing medical students' communication skills: development and evaluation of an undergraduate training program. BMC Medical Education 2012, 12:16 

 

2.    The foundations of bioethics

Background

An introductory session in a large group that provides an overview of the evolution and the fundamental principles of bioethics including the cardinal pillars of ethics including (autonomy, beneficence, non maleficence and justice)

COMPETENCies ADDRESSED

1. Describe and discuss the role of non maleficence  as a guiding principle in patient care	KH
2. Describe and discuss the role of autonomy and shared responsibility  as a guiding principle in patient care	KH
3. Describe and discuss the role of beneficence of a guiding principle in patient care	KH
4. Describe and discuss the role of a physician in health care system	KH
5. Describe and discuss the role of justice as a guiding principle in patient care	KH

Learning experience

When: Professional year 2

Hours: 2

What?:

This module is a large group learning session that can be made interactive by illustrative examples

Assessment

1.     Formative:

2.     Summative: Short notes on a) Autonomy b) Beneficence c) Non maleficence

RESOURCES

      A review of the four principles of bioethics is found here: http://archive.journalchirohumanities.com/Vol%2014/JChiroprHumanit2007v14_34-40.pdf

3.    Health care as a right

       Background

                 This session is aimed at introducing students to health care systems, their access, equity in access the impact of socio economic situations in determining health care access and the role of doctors as key players in the health care system

Competency addressed

1.Describe and discuss the role of justice as a guiding principle in patient care

KH

       Learning experience

When: Professional year 2

Hours: 2

What?:

         This module may be done as a participatory student seminar with debates on the more controversial issues to increase a reflective process.

         Focus may be on 1. Is health care a right? 2. What are the implications of health care as a right? 3. What are the social and economic implications of health care as a right 4. What are the missing links (see resource 2 for a brief overview) and 5. What are the implications for doctors

       Assessment

1.     Formative:

2.     Summative: Short note on a) barriers to implementation of health care as a universal right

RESOURCES

1.     The universal declaration of human rights . http://www.un.org/en/documents/udhr/

2.    Missing links in universal health care http://www.thehindu.com/opinion/lead/missing-links-in-universal-health-care/article6618667.ece

4.    Working in a health care team

       Background

            This session is aimed at introducing students to health care systems and their functioning. It allows students to “tag along” members of health care teams observe their work and gain experience about their perspectives. It is hoped that this experience will help students understand the need for collaborative work in health care, how each member of the health care team is important and also develop respect

COMPETENCIES ADDRESSED

1 Demonstrate ability to work in a team of peers and superiors	SH
2. Demonstrate respect in relationship with patients, fellow team members, superiors and other health care workers	SH

       Learning experience

            When: Professional year 2

            Hours: 6 hours ( 4 hours tag along + 2 hours discussion)

            What?:

      This module may be done as two interdependent sessions

1.     A “tag along” session where students spend time with other health care workers including nurses  technicians and others, observe their work, their interactions conduct a small interview with them and write a narrative based on this interview

2.     A small group discussion which is based on the students observation experiences reflections and inferences and what must be done by them to work as an integral part of the health care team

       Assessment

3.     Formative:  Student participation in session 2 with assessment of submitted narrative

4.     Summative:

Resources

5.   Bioethics continued - Case studies on patient autonomy and decision making

         BACKGROUND

         The important parts of ethical care of the patient are best learnt in a hybrid problem based format with additional lectures and other sessions that allow students to learn collaboratively with different learning styles. A guide for case discussion is provided in the resources section of this module and may be used as a guide for other modules. The key element is that students remain in the same group with the same facilitator since groups mature in their learning over time.

         The first module has a discussion on patient autonomy right to know and disclosure

         Hours : 6

         Introduction and group formation : 1 hour

         Case 1 Case introduction: 1 hour

         Self Directed learning : 2 hours

         Anchoring lecture: 1 hour

         Case Resolution : 1 hour

Case 1. The cover up

         You evaluate Mrs Lakshmi Srinivasan who is a 48 year old woman presenting with lymphadenopathy. She had been complaining of mild fever and weight loss for the past 4 -5 months. Examination of the neck shows large rubbery lymph nodes that are present also in the axilla and the groin. There is a palpable spleen. She is accompanied by her caring husband.

         Lakshmi undergoes a lymphnode biopsy and the pathologist calls you and tells you that she has a lymphoma. That evening Mr Srinivasan comes in first into your office and leaves the report on your table. As you read the description you realise that the final diagnosis has been altered to Tuberculosis by whitening out the pathologist’s report. When you look up he tells you - Sir I googled lymphoma - it is almost like a cancer. My wife can’t handle that diagnosis. She has always been a worried frightened person.  I want you to tell my wife that she had TB. She is waiting outside doctor. I thought I will call her in after I have a chat about this with you.

       Competency addressed

      

         Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to patient autonomy, patient rights and shared responsibility in health care

       Points for discussion

1.      Does the patient have a right to know their diagnosis

2.      What should the patient be told about their diagnosis  therapy and prognosis

3.      How much should be told to a patient about their illness?

4.      Are there exceptions to full disclosure? Can family members request withholding of information from patient?

       Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) Define patient autonomy 2) Contrast autonomy and paternalism 3) What are the responsibilities of patients and doctors in shared decision making 4) What is full and reasonable disclosure?

       Resources

Guidelines for Case Discussion

A hybrid problem oriented approach is one of the most effective ways for students to explore the various facets of “real life issues” that will confront them in their careers. In addition to problem solving skills case discussions promote collaborative learning, team work, reflection and self directed learning. The cases presented in this booklet represent competencies that lend themselves best to this form of learning.

The figure provided below explains the suggested format of the hybrid problem solving method:

1.      Two or more learning sessions are recommended for each session with ample time for self directed learning and other learning activities between each session

2.      A case is introduced into a small group and the facilitator facilitates a small group discussion where,

a.          initial reactions of the group to the case obtained

b.         the underlying ethical legal and societal principles of the case are elicited

c.          learning objectives for the case are developed

d.         Learning tasks are assigned for members of the learning groups

e.          Learning resources are identified

THE HYBRID PBL MODEL SUGGESTED FOR ATCOM CASES -

WEEK 1 - INTRODUCTION OF CASE 1. DEVELOPING LEARNING OBJECTIVES; ASSIGNMENTS FOR TEAM MEMBERS.
INTRODUCTION & GROUP FORMING
WEEK 2 - SELF DIRECTED / COLLABORATIVE LEARNING. ANCHORING LECTURE OR OTHER LEARNING ACTIVITY
WEEK 3 - INTRODUCTION OF CASE 2. DEVELOPMENT OF LEARNING OBJECTIVES; ASSIGNMENTS FOR TEAM MEMBERS . DISCUSSION AND CLOSURE OF CASE 1.

The suggested location for such a session is a small group discussion area which requires a small table with seating for 8 - 10 students

  Suggested duration for such a session is 1 hour

A board with chalk or marker is also required

3.            Learning occurs in between sessions by the learners through following:

1.      Self directed learning by study of identified learning resources

2.      Self directed learning through study of online learning resources

3.      Identification of legal ethical and social precedents for the given settings

4.      Obtaining opinions from seniors in the profession on their impressions on the setting

4.      Reinforcement of the fundamental concepts underlying the case can be done through a large group learning session (lecture or equivalent) in between the small group sessions

5.      In the second session the small group discussion is focussed on closure of the case (or the part of the case) for which learning objectives were identified for in the first session. The facilitators may guide the discussion based on the ethical legal and societal and communication aspects of the case. The group discusses the case based on the learning done in between the session and provides suggestions and alternatives on the approach for doctors to follow. It must be reiterated that there may be not be one correct way to resolve a case. The approach will be to allow students to reflect, make a choice and defend their choice based on their values and learning.

          The suggested location duration and requirements are as in item 2

6.      Once the case (or part of the case) is resolved as in item 5, the next case (or the next part of the case) is introduced as in item 2.

6.    Bioethics continued: Case studies on autonomy and decision making

BACKGROUND

Also see module 4. This introduces the student to further issues in autonomy including competence and capacity to make decisions.

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

Case 2.          Life on a machine

You are taking care of 78 year old Mrs. Mythili who was living all alone in an apartment  with only a live in caretaker 3 streets away from your clinic. She is a widow and her only son emigrated to the US 32 years ago. He visits her once a year. One year ago she had a fall with a hip fracture that healed badly. She has hypertension which is reasonably controlled on medications. She continues to come to your clinic once a month. Four months ago she spent some time talking about her sister who recently died following metastatic breast cancer. “My sister suffered a lot Doctor - they put a tube down her throat to breathe. Even when her heart stopped they kept thumping her chest - it was awful. If I ever fall sick I don't want to go through all this. Promise me doctor that you won’t do all of this to me. I have lived all alone since my husband died but i have lived independently - now i don't want to depend on a machine to live”. You had reassured her that she would be ok and this was just the recent death of her sister affecting her. On subsequent visits she would still bring up this issue and state that there was no use of her living as a burden to anyone and that no one should endure what her sister had undergone.

         One day you get a call from the Emergency Room of the local hospital stating that Mrs. Mythili has been admitted by the caretaker. She had developed fever and shortness of breath. She was brought hypoxic to the emergency room and they had intubated her. Chest X ray revealed a large pneumonic patch. Laboratory testing revealed hyponatremia.

When you visit her she is somewhat drowsy, intubated and restrained. The nurse tells you that she is sometimes lucid at other times not even able to recognise her son who was there since this morning. She points out at the ET and makes a pleading gesture to remove it. Her son accosts you in the hall way. He tells you that he got a call while he was traveling in Singapore and took the first flight out to be with his mom. He was very distressed at his mother’s health and that he wants “everything” possible done for her. You ask him if she had ever indicated what she wanted to be done if she were to require hospitalization and intubation - he says that he used to speak her every month on the phone and she was always cheerful and enquiring about her grandchildren but did not talk about her health.

       Competency addressed

Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to refusal of care including do not resuscitate and withdrawal of life support.

       Points to be discussed

1.      Extent of patient autonomy

2.      Elements in decision making : Competency Vs Capacity

3.      Surrogacy in decision making

4.      Autonomy vs beneficence

5.      How much do family wishes count

6.      Legal ethical and social aspects of Do not resuscitate

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) What determines decision making capacity and competency,  2) Who has the right to make decisions for a patient who cannot determine for himself

       Resources

1.   See Module 4

7.    Bioethics continued: Case studies on autonomy and decision making

BACKGROUND

Also see module 4. This introduces the student to further issues in autonomy including informed consent and refusal.

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

Case 3.         Who is the doctor?

         A 54 year old man Mr Surendra Patel is admitted for acute chest pain in a medical centre. His father had died of a myocardial infarction at the aged of 60. Two years ago his brother had been admitted to a hospital with a myocardial infarction and had died after complications following an angioplasty. Mr. Patel is a diabetic and is on multiple oral hypoglycemic agents with moderate control. He is a businessman with his own small industry. After initial stabilization. the patient is comfortable and pain free after analgesics nitrates and statins. Preliminary blood work and ECG confirm an acute coronary event. The next morning the senior cardiologist makes rounds and reviews the patient. “You have unstable angina Mr. Patel and require an angiogram. You may also require either a stent or coronary bypass after the procedure. The nurse will provide you with the necessary paperwork. Please sign it and I will plan the procedure for 4.35 AM tomorrow morning.”.“Doctor saheb“asked Mr. Patel, “I am not comfortable with the idea of an angiogram; my brother died on the table when an angioplasty was being done. Aren’t there other tests that you can do? I am not happy with this option.”“Your brother would have had it with someone else Mr. Patel - I have the best hands in town; nothing will happen when I do it” retorted the cardiologist. “But aren’t there any other options to see what I have? Is this is the only test? I have read somewhere that you can do a CT angiogram, persisted Mr Patel. “Are you the doctor or am I the doctor?” retorted the cardiologist angrily. “If you are ready to do as I say sign the papers and I will see you in the cath lab tomorrow. Otherwise you are free to get discharged” He stomped out. 

       Competency addressed

         Identify discuss and defend medico-legal socio-cultural and ethical issues as it pertains to consent for surgical procedures

       Points to be discussed

7.     Extent of patient autonomy

8.     Informed consent and informed refusal

9.     Conflict between autonomy and beneficence

10. What should the patient be told about a procedure

11. What must the informed consent include?

       Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1)What is informed consent? 2) What is informed refusal

       Resources

            See module 4

8.    What does it mean to be family member of a sick patient

           

Background

Doctors deal with human suffering throughout their professional careers. A balanced approach to the patient care experience requires an understanding of support systems of patients, priorities coping and emotions of families, the role of the doctor, an exploration of empathy vs equanimity and the difference between healing and curing and support.

Learning Experience

When: Professional year 2

Hours: 6 (includes 2 hours of SDL)

This session can be achieved by 2 interdependent learning experiences

1.     Option A: Students are assigned to patients in the hospital, interview their family about their illnesses, experience, reactions, emotions, outlook and expectations (or can be done in a controlled environment with standardised patients

      Option B: Family members of patients with different illnesses may with permission be brought to a large group discussion and an interactive discussion (based on the items outlined in option A. Can use standardised patients)

2.     Self directed learning where students write a report from reflection based on sessions 1 & 2 and on other readings, TV series movies etc

3.     A closure session with students to share their reflections based on 1, 2 and 3 in order that includes how they intend to incorporate the lessons learnt in their learning and patient

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions and submission of the written narrative

2.     Summative: Short questions on the role of doctors in the community and expectations of society form doctors

      eg. 1. What is empathy? What is the role of empathy in the care of patients?

RESOURCES

Student Narrative

The student narrative is a learning method that focuses on the following skills:

1)     elicit observe and record data

2)     reflect on the data at a higher level of thinking and derive opinions and conclusions

3)     communicate the observations and conclusions in a written and verbal form and expand on an defend the conclusions with colleagues and teachers

4)     Form new experiences and conclusions based on this discussion

Learning modules for Professional Year 3

Number of modules: 5

Number of hours: 25

1.    The foundations of communication 3

Background

Communication is a fundamental prerequisite of the medical profession and beside skills is crucial in ensuring professional success for doctors. This module builds on the listening skills developed in year 2. The Kalamazoo consensus statement provides a working model of teaching communication skills and may be used to impart communication skills. Skills that will be introduced should include “dealing with emotion”.

COMPETENCY ADDRESSED

Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non judgemental  and empathetic manner

SH

When: Professional year 2

Hours: 5 (1 + 2 +2)

What?:

This module includes 2 interdependent learning sessions

1.     Introductory small group session on the principles of communication with focus on dealing with emotions

2.     Focused small group session with role play or video where students have an opportunity to observe critique and discuss common mistakes when dealing with emotion

3.     Skills lab sessions where students can perform tasks on standardised or regular patients with opportunity for self critique, critique by patient and by facilitator

Assessment

1.     Formative: Participation in session 2 and Performance in session 3 may be used as part of formative assessment

2.     Summative: may be deferred

RESOURCES

1.     Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.

2.     Hausberg M Enhancing medical students' communication skills: development and evaluation of an undergraduate training program. BMC Medical Education 2012, 12:16 

2.    Case studies in bioethics - Disclosure of medical errors

BACKGROUND

Also see module 4 in year w. This introduces the student to further issues in autonomy including full disclosure of mistakes

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

Case 3.      Seeking immunity

     

It was a busy clinic day and getting worse. Patients were getting impatient. Time was marching and details were becoming a casualty. 5 year old Madhumita comes in with her mother. She has asthma and under your care. You examine her and adjust your prescriptions and start your good byes. At that time her mother reminds you that she is due for her booster shots Oh that you frown - and tell her to wait for a few minutes and that you will have the nurse load the injection and come to the adjoining room and give the injection. You ask the nurse to load the injection and keep it for you over the intercom

 You continue to see patients. After a couple of patients the mother  knocks indicating that she is getting late. You get up and go to the next room. The nurse is not there but you find a loaded syringe. You quickly administer the injection to the child and get back to seeing patients.

A few minutes later the nurse calls back saying that she has loaded Madhumita’s injections. You drop everything and go into the injection room and confront the nurse “But doctor that was gentamicin I had loaded for Mrs Asif” she says

Competency addressed

Demonstrates an understanding of the implications and the appropriate procedure and response to be followed in the event of medical errors

Points to be discussed

1.      Medical errors in clinical care

2.      The correct approach to disclosure of medical errors

3.      Consequence of failure to disclosure of medical errors including medico legal social and loss of trust

Assessment

1.      Formative: The student may be assessed based on their active participation in the sessions including role play on disclosure of errors

2.      Summative: Short questions on 1)What is the ethical standard in dealing with medical errors

Resources

3.    The foundations of communication 4

Background

Communication is a fundamental prerequisite of the medical profession and beside skills is crucial in ensuring professional success for doctors. This module continues to provide an emphasis on effective communication skills. During professional year three the emphasis is on administering informed consent.

Competencies addressed

23. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non judgemental  and empathetic manner	SH
18. Identify, discuss and defend, medico-legal, socio-cultural and ethical issues  as they pertain to consent for surgical procedures	KH
33. Administer informed consent and appropriately address patient queries to a patient undergoing a surgical procedure in a simulated environment	SH

Learning experience

When: Professional year 3

Hours: 5 (1 + 2 +2)

What?:

This module includes 2 interdependent learning sessions

4.      Introductory small group session on  on the principles of communication with focus on administering informed consent

5.      Focused small group session with role play or video where students have an opportunity to observe critique and discuss common mistakes in administering informed consent

6.      Skills lab sessions where students can perform tasks on standardised or regular patients with opportunity for self critique, critique by patient and by facilitator

Assessment

1.      Formative: Participation in session 2 and  Performance in session 3 may be used as part of formative assessment

2.      Summative: A skill station in which the student may administer informed consent to a standardized patient

RESOURCES

1.      Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.

2.      Hausberg M Enhancing medical students' communication skills: development and evaluation of an undergraduate training program. BMC Medical Education 2012, 12:16 

4.    Case studies in bioethics - Confidentiality

BACKGROUND

Also see module 4 in year 2. This introduces the student to confidentiality and its limits

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

 

Case 5.       Do not tell my wife

Ramratan was in tears. “How is it possible doctor? We are expecting our son soon. He will not have a father.”Ramratan had seen you with vague aches, fever, weight loss and cough with expectoration not responsive to antibiotics for the past three months. He had a right mid zone lung shadow on X ray and the sputum was positive for AFB. On questioned he had revealed that he had unprotected sexual intercourse with multiple partners 3 years ago. “But I stopped after I married Danno doctor - i am faithful to her”. An informed consent was obtained and HIV screening test was ordered and it was positive. A confirmatory test was subsequently obtained and it was also positive. A CDC count was < 100. Ramratan had come to discuss the results of his HIV test. After consoling him and writing out prescriptions for TB and HIV you mention to him that he must bring his wife for testing. “This is important Ramratan“you add - “especially since she is pregnant.”

“Absolutely not sir!” he explosively retorts. That is not possible. I will be humiliated. Danno will leave me and go. I will never be able to see my son. I will become an outcast in our community. I can’t live without my wife doctor. I urge you doctor - don't do this. I forbid you…

Competency addressed

Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to confidentiality in patient care

Points to be discussed

1.      The primacy of confidentiality in patient care

2.      What does confidentiality entail

3.      When can confidence be breached with who and how

4.      Confidentiality and diseases that may engender patients and society

Assessment

1.      Formative: The student may be assessed based on their active participation in the sessions

2.      Summative: Short questions on 1) What are instances in which confidentiality of patient information may be breached

5.    Case studies in bioethics - Fiduciary duty

BACKGROUND

Also see module 4 in year w. This module discusses doctor’duty including fiduciary duty (Fiduciary)

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

Case 6. Is he a human being or a machine?

It was a long day and the surgeon has finished four surgeries. Two of these were complicated surgeries requiring all his experience and skills. But it was gratifying. After that he had seen 40 outpatients. He was the most successful doctor in that small community and had provided service for the past 25 years. He had finished his outpatient, ate his meal and went to bed. The night duty doctor who usually comes around 10 pm to sit in the clinic and answer calls from inpatients had taken the night off - he had entrance exams next day. Praying it would be a quiet night he told his wife - I am very very tired; make sure that I am not disturbed.

He woke up at 1AM with the sounds of commotion downstairs. He could hear signs of arguing - Call the doctor he must come down. He could hear his wife - “please take her to the nearest government hospital. This is a surgical nursing home and doctor is very tired - I cannot wake him up.”He could hear irate patient attendents - but your board says open 24 hours for emergency. The town hospital is 15 kms. away I don't know if my daughter will make it. By the time the venom will reach the brain. Call your husband now madam. This is not correct”. His wife retorted “He has worked from 4 AM this morning - he has gone to sleep very tired asking me not to wake him up. Is he the only doctor in town. Is he a human being or a machine. Why are you being unreasonable?”. The surgeon reached out for his clothes…

Competencies addressed

1.     Identify, discuss and defend medico-legal socio-cultural professional and ethical issues as it pertains to the doctor patient relationship (including fiduciary duty)

2.     Identify, discuss doctor’s role and responsibility to society and the community that she/ he serves

Points to be discussed

1.     Duty of a doctor

2.     The concept of fiduciary duty

3.     Balancing personal and professional life

4.     Where to draw the line

Assessment

1.     Formative:  The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on What is fiduciary duty?

Learning modules for Professional Year 4

Number of modules: 9

Number of hours: 45

1. The foundations of communication 4

Background

Communication is a fundamental prerequisite of the medical profession and beside skills is crucial in ensuring professional success for doctors. This module continues to provide an emphasis on effective communication skills. During professional year three the emphasis is on communicating diagnosis prognosis and therapy effectively.

COMPETENCies ADDRESSED

23. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non judgemental  and empathetic manner	SH
34. Communicate diagnostic and therapeutic options to patient and family in a simulated environment	SH

Learning experience

When: Professional year 3

Hours: 7 (1 + 2 + 4)

What? :

This module includes 3 inter-dependent learning sessions

1.     Introductory small group session on   the principles of communication with focus on administering communication of diagnosis prognosis and therapy

2.     Focused small group session with role play or video where students have an opportunity to observe critique and discuss common mistakes in communicating diagnosis prognosis and therapy

3.     Skills lab sessions where students can perform tasks on standardised or regular patients with opportunity for self critique, critique by patient and by facilitator

Assessment

1.     Formative: Participation in session 2 and  Performance in session 3 may be used as part of formative assessment

2.     Summative: A skill station in which the student may communicate a diagnosis management plan and prognosis to a patient

RESOURCES

1.     Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.

2.     Hausberg M Enhancing medical students' communication skills: development and evaluation of an undergraduate training program. BMC Medical Education 2012, 12:16 

 

2.    Case studies in medico-legal and ethical situations

BACKGROUND

Also see module 4 in year 2. This module discusses the medico legal and ethical conflicts in adolescents

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

 

The Child’s Child

You are the family doctor of Mr. Ravikiran for the past 10 years. One evening toward the end of a busy clinic Mr. Ravikiran, his wife and daughter come in. The usual smiles were absent. There was silence for a few minutes and when you asked what is the matter, Mr. Ravikiran points out to his wife and tells her that you tell him.

Reluctantly and with tears bursting in her eyes she tells you that her only daughter Sapna who is 16 years old had amenorrhea for 4 months. She had taken her to the gynaecologist who after examining her ordered an ultrasound scan of the abdomen which showed a 16 week fetus. After much argument and discussion, the family requested the gynaecologist to perform a medical termination of pregnancy (MTP). Sapna, however refuses to undergo a MTP - claiming that the child is her expression of love and that she believes that taking away her baby’s life will be tantamount to murder.

The parents are embarrassed to face society and feel that continuing the pregnancy will harm the daughter. As parents they feel that they have a right to determine if their daughter should undergo a medical termination or not. The daughter feels that she is old enough.

As their family doctor they would like you to help them through this nightmare.

compEtency addressed

Identify discuss and defend medico-legal socioeconomic and ethical issues  as it pertains to abortion / medical termination of pregnancy and reproductive rights

Points for discussion

1.     Who makes health care decisions for adolescents?

2.     What are the medical implication of the MTP act?

3.     Are there provisions for emancipated minors?

4.     Should adolescents be included in the decision making process?

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on the medical termination of pregnancy act

3.    Case studies in medico-legal and ethical situations

BACKGROUND

 Also see module 4 in year 2. This module discusses the medico legal and ethical conflicts in organ transplantation.

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

The angry brick kiln owner

68 year old Muthukumar is your patient for the past 8 years. You are his family doctor and he seldom does anything without consulting you first. A self made man with no formal education he is a successful brick kiln owner in the suburbs of the city. He has hypertension and diabetes even before the time he has been under your care.

Today he enters your office distraught and angry and unable to speak. You calm him down…

Muthukumar is a known diabetic and hypertensive for the past 23 years and has been on multiple medications in the past. Six years ago he was diagnosed chronic renal failure. For the past one year his renal function has been worsening. The nephrologist that you had recommended had suggested dialysis and he has been on hemodialysis thrice a week for the past 6 months. At the last visit he was suggested renal transplantation.

Muthukumar continues “I saw that kidney doctor today Doctor. He said that I can get a new kidney instead of my old one. He told me that I need someone to donate a kidney to me. I told him that I don't need anyone’s charity and I can buy one donor. That doctor laughed at me sir - he told me that i cannot buy any kidney and that one of my relatives must donate it to me - He even said that my younger brother is probably the best person to donate the kidney. How dare he sir - my younger brother who is more dear to me than a son. I have so many employees in my factory who will line up to give me a kidney. Why is this doctor talking like this?

competency addressed

Identify discuss medico-legal socioeconomic and ethical issues  as it pertains to organ donation

Points for discussion

1.     Can a kidney be bought?

2.     What are the health economic outcomes of selling a kidney

3.     What are the medical legal and ethical implications of the organ transplantation act?

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) the organ transplantation act

4.    Case studies in ethics empathy and the doctor-patient  relationship

BACKGROUND

Also see module 4 in year 2. This module discusses some nuances in the doctor patient relationship including - failure of therapy, termination of relationships etc.

COMPETENCIES ADDRESSED

40. Demonstrate empathy in patient encounters	SH
35. Communicate care options to patient and family with a terminal illness in a simulated environment	SH

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

 

A letter from the grave

Respected doctor:

I am writing this letter with extreme sadness. As you may know that it has been that three months have passed since my wife and your patient Mrs Alka Chaturvedi has passed away. I am writing this letter not with anger or with spite; i am writing this only with the intent that my wife’s death not be in vain and that the lessons that can be learned from the way you took care of her may be valuable to other patients in your care and that they will receive the compassion and care from you that Alka never received.

As you may recall Alka was diagnosed with breast cancer 5 years ago. We rushed to you knowing your reputation as a talented oncologist and we were not disappointed. Your aggressive approach to the disease made all the difference. Surgery and aggressive chemotherapy while distressing helped Alka beat the disease and live disease free for 2 years. We were very happy and were and still are very grateful to you. But fate had ordained that our joy will be short-lived.  The disease came back with a vengeance. Even at this time you did not give up hope and took on the disease like a warrior but then there came a time that it was clear that the disease had won. We were devastated.

Alka looked upto you as a doctor to provide her with support but it looked like that you were unable to confront the failure. While you did prescribe pain medications and your office helped us find a home nurse you were reluctant to meet Alka or talk to her. When we called for appointments your office would tell us to contact our family doctor for pain medications. When we did get to see you would not even look at Alka’s eyes. You would distractedly talk to her refill her pain medications and dismiss us quickly. It was as if we were seeing a different doctor than the one we had seen when all was well. And when Alka was admitted to the hospital where she breathed her last you would not even come and see her. We made so many requests for you to come and visit with her. I even called and told you that it would mean so much for her to see you before she departs but you did not.

Would it have been too much for you to come and hold her hand for a minute or say a kind word. Doctor - I am not as learned as you are but patients come to you and repose their faith in you to help them through their illness. We come to you not with the expectation that a cure is always possible but always with the expectation that you will support us in coping with the disease and the tremendous effects it has on our lives. We don't always expect you to succeed but we always expect you to show us care and compassion. I hate to point to out doctor that you abandoned Alka when it was clear that she will not be a trophy that you can parade as a success. You abandoned Alka and us at the time we needed you most. You sir, abandoned us that we were most vulnerable.

I write this to you not to fault your knowledge skill which is considerable. I bear you no ill will. I am grateful that you gave Alka and our family a few years of togetherness. I only write to remind you that knowledge and skill are not sufficient for a doctor. Compassion, empathy and non abandonment are superior virtues. I can only hope that Alka’s experience with you will help you take care of your other patients who may not all be successes as you seem to define it. If only you provided patients empathy all your patients will be your successes irrespective of outcome.

Sincerely

Points for discussion

1.     The role of a doctor as a healer

2.     Failure of treatment and its implications for the Doctor Patient Relationship

3.     Empathy and patient care

4.     Can the doctor patient relationship be terminated

5.     Hospice care

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) Empathy 2) Doctor responsibilities in the doctor patient relationship 3) Doctor’s responsibilities in the Care of the terminally ill patient

5.    Case studies in ethics and the doctor - industry relationship

BACKGROUND

Also see module 4 in year 2. This module discusses some nuances in the doctor industry relationship

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

The Launch

It was the end of the morning session in your clinic. You were getting ready to have lunch when you are told that a drug company representative wants to meet you. You let him in and he tells you. “Sir - we are launching a new combination drug next month. We are planning a one hour meeting to introduce you to the product. The meeting will be held in Singapore and we will fly you and your spouse business class. All expenses will be borne by us. You can stay for 3 days there sir. The meeting will be held in a cruise ship. The meeting will be only for one hour sir - After that there will be a gala dinner and entertainment sir. Also to compensate you for losing your practice for those three days we will pay you an honorarium of Rs 25000 for each day that you are there. This is our way of saying thank you for all the support in the past and the support that you are going to provide in making this new molecule a success.”

Competency

Identify discuss and defend medico-legal socio-cultural professional and ethical issues as it pertains to the doctor - industry relationships

Points for discussion

1.     The influence of pharmaceutical industry on doctor’s prescription behaviour

2.     The limits of doctor industry engagement

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) Can doctors accept gifts from pharmaceutical industry? Explain your choice

Resources

The MCI, AMA Code of Medical Ethics

6.    Case studies in ethics and the doctor - industry relationship

BACKGROUND

Also see module 4 in year 2. This module discusses some nuances in the professional relationships and conflicts there of

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

The Offer

You get a call from the secretary of the promoter of the largest and most successful corporate hospital in the city asking for an appointment for you with him. You are perplexed but make it to the appointment. You enter a large well appointed room. The owner of the hospital gets up from his chair welcomes you and asks you to sit down.

“Welcome to our hospital doctor. After a few minutes of empty banter he says - My marketing executives tell me that you are the most successful practitioner in this area. As you know we are a growing organisation; we are eager to partner with you. Doctor I know that you use the services of another hospital here but we can make it worth your while to consider”. You look enquiringly. “He continues. In addition to your professional charges that you can determine we can provide you with 20% of the hospital’s collections from your patient including radiology and laboratory charges. If you send us your outpatients for consultations, laboratory or radiology we will give you back 30% of our collections. We hope that you will consider this doctor and become part of our extended family.”

Competency addressed

Identifies conflicts of interest in patient care and professional relationships and describes the correct response to these conflicts

Points for discussion

1.     Fee splitting and other practices

2.     Can doctors become enterpreneurs?

3.     Can doctors own pharmacies or hold stock in pharmaceutical companies?

4.     What comprises professional conflict of interest?

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) Fee splitting and its implications for patient care 2) conflicts in professional relationships

7.    Case studies in ethics and patient autonomy

BACKGROUND

 Also see module 4 in year 2. This module discusses ethical issues in care of children

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

The “Cruel”Parents

A six year old boy is brought to the emergency room with a single episode of generalised tonic clonic convulsions. The child is stabilised on IV anti epileptics and an oral anti epileptic is started. There are no further episodes during the hospitalisation. The child is scheduled for an EEG and an MRI. Through this time the family had been cooperative with the treatment. The parents appear to be educated and appeared to care for their son deeply. When further investigations are suggested, the parents come back to you and say - “doctor thank you for helping us at a time of need but we feel that it is against our faith to continue allopathic care. We have decided to go back to our ancestral village and our family shrine where we have scheduled a ritual tomorrow. Our priest has promised us that the child will be disease free if we perform the rites required. This convulsion is a result of the curse of our ancestors and if we do the requisite rituals to please them the child will be cured of the disease. Please do not do anymore tests or treatments. We are stopping the medications tomorrow and will get discharged. Thank you.”…

CompEtency

Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to health care in children

Points for discussion

1.     Who has the right to decide for children?

2.     Can parents refuse treatment even in life threatening situations?

3.     What if there is a conflict?

Assessment

1.     Formative: The student may be assessed based on their active participation in the sessions

2.     Summative: Short questions on 1) Parental consent

8.    Dealing with death

Background

Thanatology is a branch of science that deals with death. Death is an event that medical students will inevitably face during the course of their professional career. Dealing with death empathetically and at the same time not being overwhelmed by it is an important coping skill for doctors

Learning experience

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

THE EMPTY BED

You are a house surgeon in the night shift of the ICU. A 19 year old girl Sharmila is wheeled in to the ICU. She has a complicated history. She had surgery for cyanotic congenital heart disease at age 8. She has a history of severe asthma often requiring admission for steroids. She lives in a home near a construction site and recently the attacks have flared up. She now has frequent admissions for asthma exacerbations. She is now constantly on steroids. In the last month she has had 3 admissions. But she fights it bravely. She carries her books with her when she comes in and after the attack settles down she sits quietly reading. Despite the struggle you noticed that the staff nurses liked her. She was positive and charming. Today was no different but the attack seemed worse. In the ER the FEV1 was horrible. They had pumped her with steroids put her on continuous nebulization, an aminophylline infusion was in place when you received her. The smile was smaller but there. The face was cushingoid with all the steroids and the body looked tired. She was moved to her usual bed number 9. Your shift was getting over at 7 a.m. but you stayed on an hour. She looked better, the smile was back you reassured her and said I’ll be back in the evening and left.

That evening you report for duty and as you look through the patients bed number 9 is empty. Have you discharged Sharmila you asked the nurse. No doctor –she developed a sudden cardiac arrest at 12 noon –we could not revive her.

POINTS FOR DISCUSSION

1.     How should doctors deal with the emotions of patients and family facing death

2.     What does the patient experience when he / she is dying? Can physicians make the process of death comfortable?

3.     What are the emotions faced by doctors when confronting death in patients? Is death a defeat for the doctor? Should the doctor be emotionally detatched from a dying patient

4.     What are the cultural aspects of dying

ALTERNATE CASE

I Have decided to die

You are a physician in a community care practice for over 20 years and caring for various patients. Mr. Bhaskara Rao is a patient in your care for the past 14 years. He is 76 years old and has diabetes for the past 30 years. He had renal failure for the past 10 years and is CKD V requiring dialysis for 3 years. While he is following up with the nephrologist he values your position in his family as a family doctor and regularly visits you to check if his treatment is correct and more often to seek reassurance. He has invited you to all his family events – the last being 1 month ago for his grandson’s wedding.

This morning you get a call from him. “Doctor! He says in his usual cheerful voice. Can I meet you tomorrow? I have fulfilled all my responsibilities in life. I am not sad. My children are all settled; my grandson is married; my wife as you know is no more. I have decided to stop my dialysis and say goodbye to this world. I thought I’ll talk you to about how to prepare for my death!”

When: Professional year 4

Hours: 5

Introduction of case 1

Self directed learning 2

Anchoring lecture: 1

Discussion and closure of case 1

POINTS FOR DISCUSSION

1.     Can patients choose to die? Is there a role for doctors in the death of patients? Can doctors assist death?

2.     How should doctors deal with the emotions of patients and family facing death

3.     What does the patient experience when he / she is dying? Can physicians make the process of death comfortable?

4.     What are the emotions faced by doctors when confronting death in patients? Is death a defeat for the doctor? Should the doctor be emotionally detatched from a dying patient

5.     What are the cultural aspects of dying

Assessment

1.     Formative: Participation in sessions may be used as part of formative assessment. Submitted narrative on the socio cultural aspects of death may be used as assessment.

2.     Summative: Short question on 1) Assisted dying

9.    Medical Negligence

Background

This introductory session allows students to be familiar with the legal aspects of care including negligence and malpractice and ways to protect themselves from such issues.

Learning hours : 4

COMPETENCIES

49. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues  pertaining to medical negligence	KH
50. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues  pertaining to malpractice	KH

Learning method

Interactive panel discussion by students with legal experts and senior members of the medical profession. A written summary of learning may be provided by the student based on the learning

Assessment

1.     Formative: Submitted summary may be used as assessment

2.     Summative: Short question on 1) medical negligence

 

 

 

 

 

Section III

Competency Acquisition Log -  Suggested Log Book pattern
Name of student	Roll Number	Year of joining
	Specific competency #
Competency required to graduate	Universal competency#
Communicate diagnostic and therapeutic options to patient and family in a simulated environment (Dreyfus level - advanced beginner)
Competency must be acquired at the end of professional year	IV
Is the acquisition of this competency a prerequisite to advancement to the next phase	Yes/ No
Does this competency require performance in a patient	Yes/ No
Number of times the student must have performed the skill
	Date Completed	Supervisor
Certified by Faculty name, Date and UID
Student’s descriptive narrative of skill acquired
Faculty only: If the student has not completed the competency write down the reasons and remedial suggested

Competency Acquisition : Suggested Log Book pattern
Name of student	Roll number	Year of joining
	Specific competency #
Competency required to graduate	Universal competency#
Administer informed consent to a patient undergoing surgery in a simulated environment (Dreyfus level advanced beginner)
Competency must be acquired at the end of professional year	IV
Is the acquisition of this competency a prerequisite to advancement to the next phase	Yes/ No
Does this competency require performance in a patient	Yes/ No
Number of times the student must have performed the skill
	Date Completed	Supervisor
Certified by Faculty name Date and UID
Student’s descriptive narrative of skill acquired
Faculty only: If the student has not completed the competency write down the reasons and remedial suggested

Section IV

Desirable competencies of attitudinal and communication skills that may be included in whole or part of the formative assessment of the student

	Competency	PY1	PY2	PY3	PY4
C#	Indicate as appropriate to the level of training DME : Does not meet expectations.  ME - Meets expectations N/A : Not applicable
25	demonstrate ability to work in a team of peers and superiors
27	demonstrates respect to patient privacy
28	demonstrate ability to maintain confidentiality in patient care
30	demonstrate a commitment to continued learning
32	demonstrate responsibility and work ethics while working in the health care team
31	demonstrate respect in relationship with patients fellow team members superiors and other health care workers
33	demonstrates ability to maintain required documentation in health care (including correct use of medical records)
34	demonstrates personal grooming that is adequate and appropriate for health care responsibilities
35	demonstrates adequate knowledge and use of information technology that permits appropriate patient care and continued learning
36	demonstrates respect and follows the correct procedure when handling cadavers and other biologic tissue
41	demonstrates awareness of limitations and seeks help and consultations appropriately
42	demonstrates appropriate respect to colleagues in the profession
	Feed back provided to student (Y/N)
	Signed by Mentor/tutor Name:                  Faculty ID	Initial/Date	Initial/Date	Initial/Date	Initial/ Date

 

Appendix 1

List of competencies in Attitudes and Communication

Note: Competencies from 1 - 39 are core competencies. Competencies 40 -54 are non-core (desirable) competencies that be assessed formatively

COMPETENCY The student should be able to	K/KH/SH/P
1. Enumerate and describe professional qualities and roles of a physician	KH
2. Describe and discuss the commitment to lifelong learning as an important part of physician growth	KH
3. Describe and discuss the role of non maleficence  as a guiding principle in patient care	KH
4. Describe and discuss the role of autonomy and shared responsibility  as a guiding principle in patient care	KH
5. Describe and discuss the role of beneficence of a guiding principle in patient care	KH
6. Describe and discuss the role of a physician in health care system	KH
7. Describe and discuss the role of justice as a guiding principle in patient care	KH
8. Identify discuss medico-legal socioeconomic and ethical issues  as it pertains to organ donation	KH
9. Identify discuss and defend medico-legal socioeconomic and ethical issues  as it pertains to abortion / medical termination of pregnancy and reproductive rights	KH
10. Identify discuss and defend medico-legal socio-cultural economic and ethical issues  as it pertains to rights, equity and justice in access to health care	KH
11. Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to confidentiality in patient care	KH
12. Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to patient autonomy, patient rights and shared responsibility in health care	KH
13. Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to decision making in health care including advanced directives and  surrogate decision making	KH
14. Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to decision making in emergency care including situations where patients do not have the capability or capacity to give consent	KH
15. Identify discuss and defend medico-legal socio-cultural and ethical issues  as it pertains to research in human subjects	KH
16. Identify, discuss and defend medico-legal,socio-cultural and ethical issues  as they pertain to health care in children (including parental right to refuse treatment)	KH
17. Identify discuss and defend medico-legal socio-cultural and ethical issues  as they pertain to health care in children including parental rights	KH
18. Identify, discuss and defend, medico-legal, socio-cultural and ethical issues  as they pertain to consent for surgical procedures	KH
19. Identify, discuss and defend medico-legal socio-cultural professional and ethical issues  as it pertains to the physician patient relationship (including fiduciary duty)	KH
20. Identify ,discuss physician’s role and responsibility to society and the community that she/ he serves	KH
21. Identify discuss and defend medico-legal socio-cultural professional and ethical issues  in physician industry relationships	KH
22. Demonstrate ability to work in a team of peers and superiors	SH
23. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non judgemental  and empathetic manner	SH
24. Demonstrate respect to patient privacy	SH
25. Demonstrate ability to maintain confidentiality in patient care	SH
26. Demonstrate a commitment to continued learning	SH
27. Demonstrate respect in relationship with patients, fellow team members, superiors and other health care workers	SH
28. Demonstrate responsibility and work ethics while working in the health care team	SH
29. Demonstrate ability to maintain required documentation in health care (including correct use of medical records)	SH
30. Demonstrate personal grooming that is adequate and appropriate for health care responsibilities	SH
31. Demonstrate adequate knowledge and use of information technology that permits appropriate patient care and continued learning	SH
32. Demonstrate respect and follows the correct procedure when handling cadavers and other biologic tissue	SH
33. Administer informed consent and appropriately address patient queries to a patient undergoing a surgical procedure in a simulated environment	SH
34. Communicate diagnostic and therapeutic opitons to patient and family in a simulated environment	SH
35. Communicate care options to patient and family with a terminal illness in a simulated environment	SH
36. Demonstrate awareness of limitations and seeks help and consultations appropriately	SH
37. Demonstrate appropriate respect to colleagues in the profession	SH
38. Demonstrate an understanding of the implications and the appropriate procedure and response to be followed in the event of medical errors	SH
39. Identify conflicts of interest in patient care and professional relationships and describes the correct response to these conflicts	SH
40. Demonstrate empathy in patient encounters	SH
41. Demonstrate ability to balance personal professional priorities	SH
42. Demonstrate ability to manage time appropriately	SH
43. Demonstrate ability to form and function in appropriate professional networks	SH
44. Demonstrate ability to pursue and seek career advancement	SH
45. Demonstrate ability to follow risk management and medical error reduction practices where appropriate	SH
46. Demonstrate ability to work in a mentoring relationship with junior colleagues	SH
47. Demonstrate commitment to learning and scholarship	SH
48. Identify, discuss and defend medico-legal, socio-cultural, economic and ethical issues  as they pertain to in vitro fertilisation donor insemination and surrogate motherhood	KH
49. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues  pertaining to medical negligence	KH
50. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues  pertaining to malpractice	KH
51. Identify,  discuss and defend medico-legal, socio-cultural professional and ethical issues  in dealing with impaired physicians	KH
52. Identify, discuss and defend medico-legal, socio-cultural and ethical issues  as they pertain to refusal of care including do not resuscitate and withdrawal of life support	KH
53. demonstrate altruism	SH
54. administer informed consent and appropriately address patient queries to a patient being enrolled in a research protocol in a simulated environment	SH

APPENDIX 2

Communication skills rating scale adapted from Kalamazoo consensus statement

Rating 1-3 - Poor, 4 -6 Satisfactory 6 -10 Superior

Criteria
Builds relationship
Opens the discussion
Gathers information
Understands the patient’s perspective
Shares information
Manages flow
Overall rating

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