Telemedicine as an enabler of success: revisiting the undergraduate medical curriculum

Neel Mistry,¹ Paul Rooprai,¹ Stefan de Laplante,¹

¹Faculty of Medicine, University of Ottawa, Ontario, Canada

Telemedicine has grown substantially since the advent of the COVID-19 pandemic. As global cases surged in March 2020, hospitals and primary care clinics quickly turned to telemedicine – the provision of medical care using telecommunication technology over a virtual platform – to increase access to safe and effective patient care.1 Among US medical schools, an increase in telemedicine training in clerkship has been reported over the last five years.2,3 In contrast, only one medical school in Canada includes a formal telemedicine program in the undergraduate medical curriculum.4 As COVID-19 cases continue to surge across the country, the need for medical trainees to achieve competence in telemedicine is crucial. In this paper, we provide an overview of the benefits and challenges of formalizing telemedicine training and discuss steps that Canadian medical schools can take to successfully implement this change.

The future of healthcare

Telemedicine is not yet formalized in the undergraduate curriculum at most Canadian medical schools and very few include it in post-graduate training. In stark contrast, over 25% of US medical schools include telemedicine training in pre-clerkship, and nearly half offer mandatory sessions in clerkship.2 Recently, Wayne State University conducted a pilot study in which third-year medical students were introduced to telemedicine during their core internal medicine rotation.2 The results were encouraging, with 95% of clerks acknowledging the importance of virtual care services and more than 80% considering it to significantly affect their future practice.2 Similar findings were reported at Harvard Medical School, which instigated telemedicine training in clerkship at the start of this pandemic.5 Why, then, is Canada lagging behind when there are just as many reasons, if not more, to promote virtual care as there are south of the border?

An early introduction to telemedicine and virtual care provides multiple educational advantages to medical trainees. Aside from contributing to core competencies in patient care, clinical knowledge, and practice-based learning, it also fosters a greater sense of familiarity, preparing students for a practice where telemedicine is used and may be growing. This can be done in multiple ways. First, asynchronous learning can occur by creating videos that demonstrate how to perform physical exams virtually and allowing clerks to shadow their attending physician via video. Second, visiting electives that were originally suspended for the 2020-2021 cycle can still take place in a virtual format. This would allow students to diversify their clinical experience and, at the same time, help them decide which institution they would like to attend for post-graduate training. Finally, telemedicine can be included in core clerkship rotations such as family medicine, internal medicine, and surgery. Doing so would provide students with opportunities for independent practice while experiencing an array of topics including ethical dilemma, telemedicine-based cases, teleassessments, and procedural skills.

A call to action

The COVID-19 pandemic has instigated unprecedented change across healthcare settings. With hospitals and clinics rapidly shifting to virtual care, a few undergraduate medical programs have begun to implement virtual care; however, training must be formalized across all Canadian medical schools. An early introduction to virtual care offers numerous benefits to trainees as the use of telemedicine grows. This can be done in three main ways: (1) incorporating virtual shadowing opportunities, (2) re-instituting visiting electives via a virtual format, and (3) integrating students into virtual patient consults during clinical rotations. With COVID-19 accelerating the adoption of telemedicine, the need to prepare future doctors to deliver care virtually has never been greater.

References

  1. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 2020; 20:1193. https://doi.org/10.1186/s12889-020-09301-4
  2. Waseh S, Dicker AP. Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review. JMIR Med Educ. 2019;5(1): e12515. https://doi.org/10.2196/12515
  3. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and Medical Education in the Age of COVID-19. Europe PMC. 2020; 95(12):1838-1843. https://doi.org/10.1097/acm.0000000000003711
  4. Aires LM, Finley JP. Telemedicine activity at a Canadian university medical school and its teaching hospitals. J Telemed Telecare. 2000;6(1):31-35. https://doi.org/10.1258/1357633001933916
  5. The Harvard Gazette. The mother of invention, 2020 [Internet]. Available from: https://news.harvard.edu/gazette/story/2020/05/harvard-medical-school-uses-telemedicine-as-a-way-forward/ [Accessed December 30, 2020].

La pandémie de COVID-19 affecte-t-elle votre ouverture d’esprit ?

Does the COVID-19 pandemic affect your mindset?

(English translation below)

Dr Alexandre Lafleur,1 Mme Claudie Michaud-Couture,2 et Dre Miriam Lacasse3

  1. Professeur agrégé de clinique. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD
  2. Assistante de recherche. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada
  3. Professeur agrégée. Département de médecine familiale et de médecine d’urgence. Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD

Ressentez-vous de l’anxiété ou de la frustration lorsque vous sortez de votre zone de confort? Êtes-vous démotivé lorsqu’un collègue ou un supérieur vous donne une rétroaction? Ruminez-vous pendant des heures lorsque vous n’avez pu atteindre le résultat escompté?

Si vous avez répondu « oui », vous êtes davantage sujet à adopter une position de fermeture face aux apprentissages (fixed mindset en anglais)1. Ne craignez rien, en prendre connaissance est déjà une partie de la solution ! En tant qu’étudiant, résident et médecin, vous avez fort probablement vécu des expériences qui vous ont confronté à vos limites physiques, émotionnelles ou intellectuelles. En pareilles situations, vous avez avantage à adopter un état d’esprit d’ouverture face aux défis à relever (growth mindset)1. Vous apprendrez plus, tout en ayant un plus grand sentiment d’accomplissement et de contrôle.

Miser notre réussite uniquement sur notre performance apporte un grand sentiment de réalisation lorsque les résultats convoités sont obtenus. Toutefois, face à l’échec nous vivons des frustrations.  L’estime de soi, la motivation et le plaisir d’apprendre diminuent2. D’autant qu’en médecine, les résultats échappent souvent à notre contrôle. Bien que cela soit appelé à changer, les études médicales nous outillaient peu sur la résilience face à l’erreur ou l’échec3. L’erreur n’indique pas que nous ne sommes pas intelligents. C’est signe qu’il faut continuer de se perfectionner.

Un esprit fixe croira que l’intelligence et les talents ont tout à voir avec la chance; ces dés qui ont été lancés à la naissance. Que si vous n’arriviez pas à jouer des accords à la guitare, réussir votre intubation ou encore rassurer adéquatement un patient endeuillé : « Ce n’est pas fait pour moi, je n’ai pas ce talent ». Vraiment? Le défi est-il une menace à notre intelligence? Une personne qui vise à accroitre ses savoirs dans un état d’ouverture d’esprit vous répondra : « Je ne sais effectivement pas faire cela, pas encore »1.  L’échec et les remises en question les atteignent, mais sans toutefois les définir. Ils demeurent pragmatiques. Ils ne croient pas devenir exceptionnels dans tout, mais certainement meilleurs, avec le temps et les efforts.

Traduit et adapté de Dweck CS1 par les auteurs

Bien qu’elle ne soit pas à balayer du revers de la main, une méthode pédagogique qui met uniquement l’accent sur l’évaluation de la performance mène les apprenants à se juger et à se comparer, amenant son lot de stress. D’ailleurs, nous sommes exposés à un environnement compétitif parfois depuis nos premiers pas : « Tu marches trois mois plus tôt que ta sœur! » La performance de l’un est récompensée au détriment des efforts de l’autre. Or, Carole Dweck, professeure à l’Université Stanford, a démontré que les enfants qui apprenaient à valoriser uniquement la performance plutôt que l’effort, délaissaient les buts d’apprentissage à long terme.2 Le risque est de vouloir sembler performant aux yeux d’autrui plutôt que de devenir réellement compétent.4

Au cœur de cette pandémie, où chacun doit sortir de sa zone de confort, c’est l’occasion idéale de réagir positivement aux nouveaux défis et de les aborder comme des opportunités d’apprentissage. Ce n’est pas le temps de conserver des pensées fixes qui nous incitent à croire que nous allons échouer, que nous ne sommes pas assez qualifiés ou encore que notre intelligence sera minée.

Certaines notions vous manquent? Vous doutez de vos compétences? Changez votre mentalité et considérez cette occasion unique d’apprendre et d’aider. Essayez, lorsqu’un défi se présente, de considérer l’opportunité de devenir meilleur, plutôt que de croire que vous n’êtes pas en mesure de le relever. Profitez des critiques et des commentaires pour vous améliorer. Félicitez les efforts de vos collègues et redoublez d’ardeur pour atteindre encore plus de qualifications.

Vous pouvez aider vos étudiants et collègues à accroitre leur ouverture d’esprit.5 Ciblez vos rétroactions sur le processus plutôt qu’exclusivement sur le résultat. Formulées sous forme de questions, vos rétroactions laisseront place à la discussion : « connais-tu une autre manière de faire? ».  Donnez-leur l’opportunité d’initier eux-mêmes les moyens à mettre en œuvre et appuyez leurs efforts.4 Créez un climat de travail positif dans lequel votre entourage se sentira à l’aise de demander conseils, sans peur d’être jugé.

Nous espérons qu’en terminant la lecture de ce texte, vous penserez : «  Je ne suis pas toujours ouvert d’esprit … pas encore, mais j’ai hâte d’y travailler ! »


Do you feel anxious or frustrated when you go outside of your comfort zone? Are you feeling down when a colleague or superior gives you feedback? Do you grumble for hours when you have not been able to achieve the desired result?

If you answered “yes”, you are more likely to adopt a fixed mindset1 towards learning. Don’t panic, learning about it is already part of the solution! As a student, intern and doctor, you most likely have had experiences that challenged your physical, emotional or intellectual limitations. In such situations, it is to your advantage to adopt a growth mindset1 position to face the challenges that lie ahead. You will learn more, while having a greater sense of accomplishment and control.

Betting our success solely on our performance brings a great sense of accomplishment when the desired results are achieved. However, when confronted with failure, we experience frustration. Self-esteem, motivation and the pleasure of learning diminish.2 Especially since in medicine, results are often beyond our control. Although this is bound to change, medical studies have given us little insight into resilience when dealing with error or failure.3 Error does not mean that we are not smart. It is a sign telling us that we need to keep improving.

A fixed mindset will believe that intelligence and talent have everything to do with luck; those dice that were thrown at birth. That, if you can’t play chords on the guitar, succeed an intubation or adequately reassure a bereaved patient: “This is not for me, I don’t have that talent.” Really? Is the challenge a threat to our intelligence? Someone who aims to increase his or her knowledge in a growth mindset attitude will answer: “I don’t really know how to do this, not yet.1 Failure and questioning affects them, but without defining them. They remain pragmatic. They do not believe they will become exceptional in everything, but certainly better with time and effort.

Adapted from CS Dweck1 by the authors

Although it does not have to be brushed aside, a teaching method that focuses solely on performance assessment leads learners to judge and compare themselves, bringing its share of stress. In fact, we have been exposed to a competitive environment sometimes from the very start: “You’re walking three months ahead of your sister!” One person’s performance is rewarded at the expense of the other’s efforts. But Carol Dweck, a professor at Stanford University, has shown that children who learn to value performance rather than effort only, neglect long-term learning goals.2 The risk is to want to appear to perform well in the eyes of others rather than to become truly competent.4

In the midst of this pandemic, where everyone has to get out of their comfort zone, this is an ideal opportunity to react positively to new challenges and approach them as learning opportunities. This is not the time to hold fixed thoughts that lead us to believe that we will fail, that we are not sufficiently qualified or that intelligence will be undermined.

Are you missing any notions? Do you have doubts about your abilities? Change your mentality and consider this unique opportunity for you to learn and help. Try, when faced with a challenge, to consider the opportunity to become better, rather than believing that you are not up to it. Take advantage of criticism and feedback to improve yourself. Praise the efforts of your colleagues and work harder to achieve even more qualifications.

You can help your students and colleagues to increase their growth mindset.5 Focus your feedback on the process rather than exclusively on the outcome. Your feedback should be in the forms of questions, and should include a discussion: “Do you know another way to do this?” Give them the opportunity to initiate the means to implement themselves and support their efforts.4 Create a positive work environment in which those around you feel comfortable asking for advice, without fear of being judged.

We hope that when you finish reading this post, you will think: “I’m not always open-minded… not yet, but I look forward to working on it!”

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Empowering Canadian Medical Students with Financial Literacy: The Financial Transition to Practice Group

Shaishav Datta, Sabrina Fitzgerald, Wafa Khoja, Harrison Watt, Alain J. Azzi

alain.azzi@mail.mcgill.ca

Conflicts of interest: The authors are all Financial Transition to Practice (FTP) Ambassadors at their respective institutions. Funding: There is no source of funding.

Medical training in Canada requires many years of commitment to develop skills necessary for effective patient-centered care. However, there is more to a successful practice than diagnosis, treatment, and pathophysiology. Today, many early-career physicians find themselves unprepared for the complexities of the personal and professional financial decisions they must make on a daily basis, even with hired assistance.1 These include understanding billing systems, insurance plans, tax policies, accounting, investments, debt management, and other financial decisions associated with starting a new practice. Research shows that most early-career physicians learn about financial literacy from their peers or through independent research.1 Formal education on financial literacy remains minimal while the process of learning these skills concurrent to making a transition to practice provides undue stress and is implicated in contributing to early-physician burnout.1,2

Further, medical learners accrue significant personal financial burden as a direct result of the cost and length of their training. This is especially reflected in trainees who pursue longer residencies and fellowships, as they continue to work at a lower income level than they would make if they had entered practice directly. Many studies have suggested that medical learners have low personal financial literacy and are not well prepared to manage their own finances.3

Thus, while the Canadian medical education system prepares its trainees to become world-class clinicians, it falls short in equipping graduates with the skills to navigate the complexities of personal and professional finance. To address this issue, basic financial literacy must be introduced early, during medical school, and extended into residency training as they approach independent practice.

Over the last decade, various organizations have initiated programs that serve to contribute towards financial literacy in medical learners. Table 1 provides a brief overview of some national-level resources (Table 1). Available upon request.

Table 1. Various platforms for trainees to learn about basic personal and professional finance.

  1. Canadian Medical Association (CMA): https://www.cma.ca/physician-wellness-hub/topics/personal-finance Practice management topics from Joule and MD Financial Management
  1. Canadian Federation of Medical Students (CFMS):https://www.cfms.org/resources/finances/ Financial planning and education provided by MD Financial Management and CFMS, insurance discount information, free tax filing services.
  1. Federation of Medical Women of Canada (FMWC): https://fmwc.ca/resources/mdfm/ Written resources, tools, and calculators for medical students, residents, practitioners, and retirees provided by MD Financial Management.
  1. Association of American Medical Colleges (AAMC): https://aamcfinancialwellness.com/index.cfm Financial Wellness resource provides courses, individualized recommendations, and tracking tools in an independent manner.

While these resources are useful, they are often created and supported by commercial organizations that stand to gain benefit from their users. This often leads to unanswered questions regarding conflicts of interest causing medical trainees to remain distrustful of the information provided by these sources.1 Additionally, teaching financial skills using non-interactive modalities makes it difficult for learners to engage with and apply their knowledge, leading to poor long-term retention and application of the information.4 While single interventions understandably improve short-term behaviors, we believe financial literacy education should be provided through comprehensive tutorials that are incorporated at key points of contact with students, from on-boarding to financial aid disbursement to exit counseling. In this way, the importance of responsible financial decision-making is reinforced over time.4

Medical institutions recognize this gap, and many are developing financial curricula to address these challenges. As an example, the Temerty Faculty of Medicine, University of Toronto has incorporated ~10 hours of dedicated didactic and interactive module-based learning over the academic year. However, there is currently a lack of national standardization of the content, resulting in discrepancies in access to the same educational quality.

The Financial Transition to Practice (FTP) group was established with the hopes to mitigate the aforementioned gaps in knowledge. It is a grassroots initiative, currently functioning through a social media platform, aimed at increasing awareness and knowledge to medical students across Canada. Since its debut in early October 2020, over 1800 Canadian trainees have joined the group, validating the interest medical students have in enhancing their financial literacy. At the core of the group are student leaders acting as ambassadors for each of the seventeen Canadian medical schools. By providing knowledge, we hope to empower medical students to gain confidence and autonomy over their finances and related decision making. Current membership is free of charge and all content is non-sponsored to ensure minimized conflicts of interest.

Informational content presented through the group has included live question and answer sessions hosted by both rural and urban professionals that directly addressed inquiries made by group members. Recorded webinars regarding basics of accounting and debt management through the continuum of training have been shared. Webinars that allow for interactive versions of basics of investments and insurance, incorporation, shareholder agreements, buying a practice, financial ethics, and practice management are in development. These are examples of high-yield financial literacy topics the group hopes to share with members, as literature shows it is beneficial to be familiar with such topics prior to transitioning into practice.1,3 Through this national effort, we hope to mitigate gaps in current medical education in order to assist Canadian medical students to transition into practice with the necessary financial knowledge and strategies needed to be autonomous, informed, and proficient practitioners.

References
1. Bar-Or YD, Fessler HE, Desai DA, Zakaria S. Implementation of a Comprehensive Curriculum in Personal Finance for Medical Fellows. Cureus. 2018;10(1):e2013. https://doi.org/10.7759/cureus.2013
2. West CP, Shanafelt TD, Kolars JC. Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents. JAMA. 2011;306(9):952–960. https://doi.org/10.1001/jama.2011.1247
3. Comber S, Crawford KC, Wilson L. Competencies physicians need to lead – a Canadian case. Leadersh Health Serv (Bradf Engl). 2018;31(2):195-209. https://doi.org/10.1108/lhs-06-2017-0037
4. Lujan HL, DiCarlo SE. Too much teaching, not enough learning: what is the solution? Adv Physiol Educ. 2006;30(1):17-22. https://doi.org/10.1152/advan.00061.2005

Medical School, Going Virtual

Aazad Abbas
University of Toronto

Burnout among healthcare professionals has been extensively documented.1 In their piece titled “Physician Burnout, Interrupted”, Hartzband and Groopman⁠ shed light on how sweeping changes in healthcare systems have led to unprecedented rates of burnout among physicians in recent decades.2 Fundamentally, their perspective is widespread implementation of electronic health record (EHR) systems and performance metrics have eroded the intrinsic motivation of modern physicians.3

Hartzband and Groopman present compelling arguments dissecting how the core pillars supporting professionals’ intrinsic motivation and psychological well-being – autonomy, competence, and relatedness – have eroded over the last half century.4 Autonomy has disappeared through constant surveillance. Competence was replaced by checking off boxes. Relatedness is threatened by a system increasingly driven by money and metrics. These changes represent a shift to extrinsic factors becoming the dominant motivating force among modern physicians. They argue this is the very reason why burnout is almost a universal experience among medical professionals, from budding medical students to veteran physicians.

From the shift to evidence-based medicine in the 1900s, to the invention of one of the most successful surgical procedure in the modern times – the hip arthroplasty – medicine has been at the forefront of innovation.5 Medical practitioners are constantly integrating scientific discoveries with technological innovations to bring forward the next revolution in healthcare. Except this time an unforeseen natural threat has forced us to adapt medical practice: COVID-19. Medical schools shifting their curricula online; clerks having countless rotations cancelled; residents being moved to unplanned services; physicians scrambling to take care of their patients. These are just a handful of ways in which medical professionals have adapted to the pandemic, willingly or otherwise.
With these changes, it is important to ask how these changes affect the experiences of medical students. Medical school is a time of immense change, as you cram to study as many topics as possible, learn a plethora of skills rotating through all specialties, and home in on your professional skills. This training camp of medical school is made bearable through the sense of bonding with peers, as you all traverse this together. At least that was true until very recently. The motivation of students across the globe has plummeted, with a generalized sense of uncertainty for the future.6

No more shadowing, no more scrubbing in for the first time, no more going to lecture with your colleagues. Medical institutions have gone above and beyond in ensuring the medical school experience is maintained as much as possible. However, the recent pandemic has stolen valuable opportunities for medical students, eroding their intrinsic motivation. 6 Passing courses and meeting assignment deadlines have become the primary factors pushing students. Asides from the hopes of returning to normal once a vaccine is delivered, students have lost their drive for learning. This loss of drive, combined with an overarching sense of anxiety about the future, chips away at the feelings of belonging. It seems like there is no light at the end of this tunnel.

How does one repair the damage done? Is it the responsibility of medical schools to motivate students? Is it the responsibility of the friends and family to urge students not to give up? Or is the responsibility of the medical community as a whole to recognize and repair every crack in the system? Fixing the damage starts with looking at one’s self. Being a medical student is a privilege, something most medical students have worked hard to achieve. Due to the demands of medical school, this is something easily forgotten. Students should remind themselves why they went to medical school in the first place. Why they have chosen to walk this long and arduous path. Each student has their own motivations for pursuing medicine, from the death of close relatives to the drive to reduce systematic racism in medical institutions. These reasons speak to the deeply personal intrinsic motivations of medical professionals. At the end of the day, medical professionals seek to better the lives of others. Remembering this core tenant of medicine is the only way we may seek to keep our passion thriving, for everything around us seems to be on fire.

It is time for medical students to adapt to the current climate of uncertainty. To address the issue of burnout, and to continue innovating into the future, medical students need to adapt to this reality. This pandemic is an opportunity to bring about the change desperately needed in medicine. The way medicine will be practiced, the shape of the Canadian healthcare system, and the very status of physicians in society will be shaped by this generation of medical students.

aazad.abbas@mail.utoronto.ca

References
1. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016. DOI: 10.1016/S0140-6736(16)31279-X.
2. Hartzband P and Groopman J. Physician Burnout, Interrupted. N Engl J Med 2020. DOI: 10.1056/nejmp2003149.
3. Friedberg MW, Chen PG, Van Busum K,R., et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Health Q 2014.
4. Gagné M and Deci EL. Self-determination theory and work motivation. J Organiz Behav 2005. DOI: 10.1002/job.322.
5. Knight SR, Aujla R and Biswas SP. Total Hip Arthroplasty – over 100 years of operative history. Orthop Rev 2011. DOI: 10.4081/or.2011.e16.
6. Bentata Y. The COVID-19 pandemic and international federation of medical students’ association exchanges: thousands of students deprived of their clinical and research exchanges. Medical Education Online 2020. DOI: 10.1080/10872981.2020.1783784.

Why some students easily tend to cheat during online examinations? A perspective based on theory of planned behaviour

Drs. Rajasekhar and Kumar. Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Yet another topic of concern related to COVID-19 academic is the students’ etiquette during online sessions and examinations. Students, who had been taking examinations in physically restricted atmosphere under rigorous invigilation, are now free from the clutches of supervision and this is the time when academic integrity gets tested. Since bioethics became a topic of interest, we overwhelmed students with barrages of non-canonical teaching on ethics and professionalism. So, it is the time to test whether we have been successful and if they have internalized something.

Indeed, we were interested to check this phenomenon out before commencing online examinations and our question was, “Would the students self-regulate when seemingly ‘invisible’ opportunities are available for cheating or fall prey to the impulse of cheating?” Upon examination, we felt that there is no prescribed definition of cheating or academic dishonesty during online examinations. Like, carrying unauthorized material into examination halls or peeping into a peer’s examination paper shall constitute a culpable evidence of cheating in conventional examinations. We don’t have any such time-tested invigilation tricks while going online. Both examiners and examinees are novices with respect to that and students are way more tech-savvy compared to middle-aged examiners who learned to share screens in Zoom® just few a months ago. So, we surfed the net to map out the possible techniques by which a student could cheat when he / she is allowed to take examinations from home. Interestingly, Google® provided us more ways than what we could have thought of and now we were puzzled about what could happen if students were similarly searching (not at all improbable).

In our experience with online examinations, we have pre-empted certain methods that can be used by the students to cheat in the examination and we have prepared certain rules to prevent cheating. We have communicated those rules to the students before they take the examination. In this way we have tried to reduce certain methods employed while cheating in an online examination. In spite of our effort to thwart cheating during online examinations the students have come up with a range of methods to cheat. While conducting the model examinations in an online mode, we have observed that the students had used cheating methods which were not so clever such as reading from the schematics pasted on the wall behind the computer screen, and certain very clever ways such as employing the voice recognising personal assistant software to search for answers to the questions, that are read aloud. Therefore, the ways and means with which the students would be able to cheat are manyfold. The purpose of the examination conducted in online format will lose its relevance unless the student decides to be truthful while taking the examination. If the student decides to cheat in the online examination, then it is very difficult for the examiners to administer a fool proof examination, which will stand the test of all online cheating methods. Factors such as ethical behaviour and self-control on the part of the students will alone prevent cheating in online examinations.

Taking cues from Icek Ajzen’s theory of planned behaviour 1, student’s behavioural control is a summative influence of attitude, subjective norms and perceived behavioural control. A) Attitude: the students’ behaviour to cheat or not to cheat depends on how the student feels about the act of cheating. The students’ feelings are manifested based on his past experience, moral certitude and personal ethical standards. B) Subjective norms: The decision to cheat or not to cheat may also be influenced by the behaviour of students’ peer group and often the student conforms to the group behaviour. C) Perceived behavioural control: The student might consider that the cheating brings enormous amount of pressure and may result in a negative outcome, and hence does not subscribe to the idea of cheating and compel themselves to stay away from cheating. On the other hand, morally compromised students may perceive the cheating as an opportunity that is readily available to compensate for their lack of preparation for the examination. Certain students often lose self-control and are tempted to cheat in the examination just because it is easy to do so.

All the above factors, such as attitude, subjective norms and perceived behavioural control may form the foundation of the thinking and may influence the intension of the student as to cheat or not to cheat. Ultimately, the intension manifests as the behaviour of cheating or abstaining from cheating in the online examination. Sometimes the perceived behavioural control can independently control the behaviour and manifest the action.

What can be done to prevent students from cheating in the online exams? Firstly, there is a need to delink the process of learning with the quest to attain good grades in the examination. Secondly, we have to inculcate in the minds of the students that any breach in the ethical behaviour, major or minor, may once for all take away the value system in ones behaviour, and no amount of justification will ever legitimise the unethical behaviour among the students. There is need to impress up on the students that examination is a process of feedback of learning process in order to augment the very process of learning. Only a honest and legitimate examination will truly assess the quantum of learning. Generating an active orientation and a constant awareness about the philosophy of maintaining personal ethics and bioethics to the students throughout their learning career may be the way forward.

Reference:
1. Ajzen I. The theory of planned behavior. In: Lange PAM, Kruglanski AW, Higgins ET (eds.) Handbook of theories of social psychology. London, United Kingdom: Sage. 2012, p. 438-59.

You may reach Drs. Rajasekhar and Kumar:
sekhar5883@gmail.com
dinesh.88560@gmail.com

Uncertainty, over-cautiousness and assumptions: How clinical reasoning got crushed during the COVID-19 pandemic

Even our wildest nightmares in the earlier months of the year wouldn’t have hinted about the incalculable magnitude of the loss we are facing in postgraduate training. Our confidence that the virus wouldn’t cause much havoc in tropical countries like India shattered like bad crystal falling unceremoniously upon the wood floor and the vogue lock-down dramatically reduced the number of teaching cases for months on end.

Our bedside learning teaching activities suddenly transitioned into online domains where the nuances of skills training was equated with hours of SOP / guidelines monologue and slowly we started disorienting ourselves from our reasoning abilities as well. Uncertainty is not uncommon in postgraduate residency and we could say that experts etch themselves out of diagnosing ill-defined or vague features. But the uncertainty surrounding this pandemic is something we have never encountered before.

The flexibility of the iterative diagnostic process was compromised because both patients and authorities weren’t intentional enough in tolerating uncertainty. Everyone had their own sense of urgency and bounded rationality. Patients and their supporters were concerned about the social stigmatization in the earlier months and so were concealing crucial parts of their histories. In subsequent months, emphasis was levied on prescribed pathognomonic pattern of disease and this lead to representative bias. The pressure to diagnose COVID-19 circumvented the basic need of asking the simple things like a history of exposure to allergens in the living room. Even an experienced clinician decides to take a swab the moment he developed an irritation in his throat. Such is the level of ‘anchoring’ induced by the disease incidence and prevalence.

Why so? Why have we conveniently ignored the hard-earned and reliable reasoning skill at time of this pandemic? Why could we not intentionally reason or self-explain or hypothetically-deduct when reality confronts us? Simple. Our training was more on certain grounds and the cases used for our training were grounded in contextual factors. We reason well when we stay emotionally composite and follow a well-practiced structural paradigm of case solving. Encountering multiple independent variables in an emotionally vulnerable dilemma forces us to adopt intuitive reasoning and a reductionist coping strategy. This wasn’t learned in conventional clinical reasoning sessions where we simply solved narrowly designed case vignettes without much emotional distractions or contextual noise.

What’s next? The pandemic outbreak is a clear example of ‘disorienting dilemma’ in the field of clinical reasoning. It has transformed our way of thinking and obviously, the way clinical reasoning has been conceptualized. We don’t know when we shall be rid of COVID-19 as a diagnosis at hindsight and start reasoning in analytical fashion as before. As the days pass by, the fear of contracting the disease from random patient encounter also escalates and this indeed might increase the dis-junction and cognitive fatigue.

We have been taught that clinical reasoning and decision making are not a bed or roses. It is indeed a bumpy road of handling tensions, navigating uncertainties, learning from failure and not succumbing to cognitive biases lurking in our brains. But, we could not deny the fact that post-graduate residencies all over the world have suffered a worst hit during this time of pandemic and unlike other turmoil, we don’t have a hint about the salvage point. The only thing at our hands is using the uncertainty to shape ourselves and develop adaptive expertise of decision making in the “new normal” ward settings.

Dr. Dinesh Kumar, Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Dr. Shuriya Prabha, Postgraduate resident, Department of Paediatrics, Rajah Muthiah Medical College, Tamil Nadu, India

Personal development during the pandemic: an online journey for a faculty member

‘The coin’ was an excellent idea. Most other participants seemed to agree. We were attending an online workshop on Team-based learning (TBL) as part of the faculty development activities at the International Medical University in Kuala Lumpur, Malaysia. We were using the Microsoft Teams platform and following the plenary were working on an actual TBL case in small groups of five or six faculty members. We completed the individual readiness assurance test (IRAT) before joining our groups and were now working through the group readiness assurance test (GRAT). We discussed the correct answer in our group, arrived at a consensus regarding the same and now scratched the card to reveal the correct answer. It was a tense moment. An electronic coin was available to maneuver to scratch the card and reveal the correct answer. We received immediate feedback on our choice. If the choice was incorrect, the group discussed further before choosing the next option. As the marks obtained decreased with each wrong choice, we were cautious and guarded. It was a lesson on how assessment can provide immediate feedback on learning
Small group learning (SGL) sessions for large number of students using a single facilitator can be conducted using TBL. The workshop provided me with a good working knowledge about TBL and its theoretical underpinnings. I interacted with and got to know other faculty members and educational technology staff at the institution.
I had completed all formalities to join the IMU Centre for Education at the International Medical University in Kuala Lumpur, Malaysia but was not able to physically join as the corona virus pandemic exploded on the world scene in mid-March. All travel was closed and most countries were under lock-down. In the pre-internet era, the old adage ‘Out of sight out of mind’ would have been very true. In today’s world, the internet allowed me to stay in touch with my new colleagues and interact with them.
I participated in the Centre meetings and the online workshops and had a good overview of the activities of the Centre. The sudden shift to online learning at the University required a lot of support to be provided to faculty members by the IMU Centre for Education (ICE). I did not yet have access to the learning management system (LMS) and an institutional e-mail. My colleagues were kind enough to help me with material as and when required. In some ways my personal situation was similar to the King Trishanku in Indian mythology. Due to the pandemic (and the availability of modern information technology) I was suspended midway between my new job and colleagues and my present location at my parental home in Mumbai, India. I interacted with my colleagues online and participated in some of the activities and deliberations. However, I could not yet contribute fully to the activities of the center. I was not present fully in either location and felt suspended in between the two worlds. Trishanku wanted to enter heaven in his physical, mortal body. He obtained help from the sage, Vishwamitra who using his spiritual powers transported him to heaven. The Gods were alarmed and the King of the Gods, Indra pushed Trishanku back down toward earth. The sage used his powers to arrest Trishanku’s fall and he was suspended upside down midway between heaven and earth. The sage created a new heaven for Trishanku where the king resided in his mortal body.
I participated in other online learning sessions and workshops on writing cases for problem-based learning sessions, using Zoom for online sessions especially the break out rooms feature for small groups, using Articulate storyline and a session on aligning program educational objectives and program learning outcomes. The key learning point for me was not confining the measurement of learning outcomes to the conclusion of the educational program but moving forward and relooking the outcomes after the graduate has worked at a job for a few years. I felt this was a useful concept as it also considered the impact of learning on the job on learning outcomes at the time of graduation.
I also attended a mandatory workshop on the fundamentals of teaching-learning for all new faculty. The workshop was from 9 am to 5 pm and the time difference between India and Malaysia meant I had to start early. Doing a daily eight-hour session entirely online for three days was a novel experience for me, the other participants and the resource persons. Working together with faculty members from pharmacy, nutrition, dentistry, Chinese medicine and other areas provided me with an understanding of teaching-learning in these areas. We worked on aligning learning outcomes and teaching-learning methods and creating assessments based on the learning outcomes.
The ‘virtual’ small group activities were an important learning point for me as an educator. I had facilitated many small group sessions face-to-face but doing the same online was a new experience. Sharing screens, documents, interacting through audio and video and collaborating on a task was a rich learning experience. The two commonly used platforms Zoom and Teams both have the option of creating breakout rooms. The facilitator/s could move between rooms providing support and guidance when required.
The major personal impact of the pandemic was a reminder by Nature of human frailty and vulnerability. After the second world war, medicine had impressive success against infectious and communicable diseases. With antibiotics, improved sanitation and vaccination most infections were no longer the monsters they once were. The medical curriculum and the media started focusing more on chronic diseases. Investment in antimicrobial drugs declined. Many nations still had weak public health systems and did not invest enough on health. The recommendation that at least 5% of the budget should be invested on health and another 5% on education was not followed. I read about the Spanish flu and the massive death toll but like most others wrongly believed that we in the modern brave new world were immune to the ancient plagues. I was afraid especially when neighbors in our apartment building tested COVID-positive and relieved when they were discharged from treatment facilities without complications. I believe we may need to provide infectious diseases, antimicrobials, epidemic control and prevention their rightful place in the curriculum.
The lock-down had a major impact on economic activity. As academicians we often debate whether we can shift learning and assessment totally online. I think we may have to see the bigger picture. Even today economic activity cannot take place optimally without face-to-face interaction and free movement of people. For some time, we may be able to enforce movement restrictions but in the longer-term economic catastrophe is inevitable. With economic hardships funding for education will likely slow down with a serious impact on universities and colleges.
We live in a very uncertain time. For me, the pandemic and the subsequent lock-down has created a roller coaster of emotions. I feel privileged to contribute to the center for education, work and collaborate with like-minded colleagues and participate in training and education sessions but sad and concerned about the COVID-19 pandemic, the lock-down, travel restrictions, the possible collapse of an old way of life and the delay in physically joining my colleagues and taking up the new assignment. I am also certain that medical education will not be the same post-pandemic and technology and blended learning approaches will play an increasingly important role. Face-to-face lectures for large groups of students may become much less common. Scientists predict with climate change and increased population growth, the potential for pandemics is going to increase. So, their early detection and containment may be the key to human survival. Often, I think it ironic that as human beings we expend so many resources and so much time and effort on devising better ways of killing each other being oblivious of the microscopic assassins lurking all around us!

P Ravi Shankar
IMU Centre for Education
International Medical University
Kuala Lumpur, Malaysia.

Matching to a pandemic

In early March my classmates and I were packed like sardines into a bar, all of us wearing the same white t-shirt. Words like “Western”, “Gen Surg”, “UBC”, “Family”, and in my case “Toronto” and “Emerg” scrawled hastily on the front. Ecstatic at having matched, coronaviruses, social distancing, and PPE could not have been farther from our minds.

This scene is inconceivable now, especially as the final few weeks of our medical school careers were abruptly cancelled with an email one Thursday evening. No one thought that our final lecture would be a sparsely attended affair on herbal medicine, that we would be receiving our degrees by courier instead of on a stage, or that many of us won’t see each other again before residency begins. I am fortunate to be in the privileged position of having my future residency training position secured, of having a safe place to live, and of having money to pay for the essentials. These elements give my mind the opportunity to wander, to consider the bizarre space that those of us in this position now inhabit. Aside from a few thousand dollars in fees paid to a variety of organizations with four-lettered acronyms, I am exactly as competent (or incompetent) today as I will be on July 1st. The difference will be that on that day I will take on the mantle of ‘resident’ and be expected to jump headfirst into whatever the world looks like from the doors of the emergency department at whatever hour my first shift begins.

I am excited, and more than a little scared, about this moment. I’m anxious to be able to do something tangible to help more experienced practitioners (read: everyone) provide care to the never ending parade of humanity that arrives at the hospital doors every day. With recent news of senior medical students being called to begin residency early, perhaps that day will come sooner than expected, although I sincerely hope it does not come to that. But the fact remains that the past four years have conditioned us to always be on the lookout for a way to help the team. The famous last words of every medical student’s day are, after all: “Is there anything else I can help with?”

So, what can I, and those like me, help with? Of course, staying physically distant from others, scrubbing my hands like my attending is watching, and supporting friends and family who may not be as fortunate. Medical students across the country have organized to provide childcare, collect much needed PPE, and check in on seniors, the goal being to lift even a tiny amount of stress from healthcare workers stretched thin. We are constantly on the lookout for ways to serve, and many classes have reached out to health authorities to lend a hand wherever and whenever we might be useful. But my mind continually jumps ahead to the first of July.

Two months ago, none of us could have imagined that our match would coincide with this once-a-century pandemic. Instead of being concerned with finishing classes, celebrating with family and planning for that treasured pre-residency vacation, I am left with a gnawing anxiety. Memories of Match Day, that now seem to have been formed in a different era, have been displaced by questions about what all of us brand new PGY1’s be walking into. Will I be a burden or have the capacity to help? How will our excitement to begin our chosen specialties meld with the weariness of those who have been on the front lines of this pandemic since Day 1? How can I make the most of this newfound time? And so, we read and learn, stress and relax, hoping to be ready to dive in and help whenever we can. Until then, you’ll catch me here, >6 feet away from anyone else.

James Riggs

The “Heart” in Medical Education is Distributed

by Manish Ranpara

Distributed Medical Education (DME) is the concept of diversifying the experience of students across cultures, communities, borders and hearts. Yes hearts – it is an addition to the definition that you will not find anywhere but it is arguably the most important.

The parts of medical education: The head represents education, the heart represents formation, and the hands represent training.

The benefits of students gaining different experiences during training are multiple. Canada is a vast and has a heterogeneous population with different needs. Training learners in remote communities teaches them about the needs of the communities and how they can be better addressed. The knowledge can be passed on and be used to improve the health of the local population.
In the special edition of CMEJ, Brown and colleagues describe an innovative program, where theatre was used to advocate the needs of the local homeless population and educate healthcare professionals. DME allows for a greater immersion and therefore appreciation and understanding of local healthcare needs in underserved areas, and this can result in the learner gaining valuable clinical and non-clinical skills. The medical program at the Northern Ontario School of Medicine (NOSM) is one of Canada’s success stories for DME. Strasser and colleagues tell us how community engagement is crucial to the university’s socially accountable curriculum. They explain the various hats of community engagement at NOSM such as participation in the medical student admission process.
Medical students often do not know which specialty they would like to enter. Gaining varied experience through DME helps budding clinicians make more informed decisions about future career choices. However, there is an argument that students placed in remote regions do not get adequate exposure to some medical specialties and “cutting edge” innovation because these tend to be more centralized in urban areas. Jattan et al. elaborate this issue further in the special edition of CMEJ. They found family medicine residents in rural locations had fewer teaching opportunities than their urban counterparts. This can potentially hinder and discourage residents and physicians with an interest in academics pursuing a career in rural Canada.
DME has many benefits, and all medical universities in Canada integrate DME in their curriculum to some extent. The social accountability of the medical profession has gained significant momentum in recent years and universities are on board to train physicians today to address the needs of Canadians today and tomorrow. Several steps have been taken to bridge the gap for example more money has been invested in recruiting and retaining rural physicians and training programs have been revised to be more socially accountable. Still, plenty of work needs to be done as several regions and communities within Canada lack ample healthcare professionals, and health inequalities remain unacceptably high. What else can be done to address the needs of underserved communities?

Dr. Manish Ranpara trained at Cardiff University, UK. After working as a doctor for 2 years in England, he immigrated to Canada. He was involved in research at the University of Calgary, and he is currently a family medicine resident affiliated with the University of Toronto. You may find him in an exercise class, reading a classic,  or singing his heart away (earplugs not provided).

Is medical education app-happy?

There’s an app. for that!

Dr. Manish Ranpara

I was recently browsing my mobile’s application store for applications to help me prepare for my upcoming medical examinations. I was rather surprised (and pleased!) to see a vast array of medical applications available on the market. Applications for drug calculations, anatomy demonstrations, pathology quizzes and clinical case studies were among the many applications available to download at the click of a button.

Medical education was once largely a pedantic, classroom based endeavor. Over the years, it has evolved significantly to become the multidimensional model we know today. Universities from around the world employ several methods of teaching, from classic large group lecturing and small group tutoring where physical presence is required, to virtual classrooms and online lectures where students can learn from a remote coffee shop. Some universities have even tapped into the mobile application craze and offer some services such as recorded lectures through them.

Apart from student and physician education, medical applications have found their way into the pockets of patients. Several exist to help the general population understand and treat their disease better; from applications which track glucose monitoring in diabetics to applications which provide cognitive behavior therapy for depression.

While it is humbling to see the progression of medical education through the digital era,  it does raise some concerns. The internet and indeed the application world remains a largely unregulated domain. Consequently, a lot of questionable material exists in this brave new virtual world. Ethical dilemmas include the following: Can and should a doctor be allowed to create a medical application which has the capacity to reach millions of users including the general public without the application undergoing peer review? Is it acceptable to provide medical education for free using technology when enrollment to a university is required to obtain a degree? What codes of practice apply to research done through mobile applications and virtual enrollment? These are all interesting and complex questions which we should try to answer as we venture to the unknown world of tomorrow, armed with a stethoscope and a mobile phone/computer.

As we rapidly advance through the digital age (where politicians and business leaders are debating artificial intelligence), it is crucial for our profession to keep pace with the exciting and challenging changes of technology. While I believe that a greater investment in digital understanding should be made by stakeholders in the medical field it is also vital to support patient safety by leading the way in setting regulations and standards for the dissemination of medical information exploding through the proliferation of commercial apps. It’s never been more appropriate to say: ‘There’s an app. for that’ – but is it a good one?

Dr. Manish Ranpara trained at Cardiff University, UK. After working as a doctor for 2 years in England, he immigrated to Canada. He was involved in research at the University of Calgary, and he is currently a family medicine resident affiliated with the University of Toronto. You may find him in an exercise class, reading a classic,  or singing his heart away (earplugs not provided).