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Observations from the Field

Fellows share personal reflections on health professions education, health care, and life around the world.

Pediatric Palliative Care: A Laboratory for Learning Medical Humanism and Professionalism

(posted November 30, 2011)
Mercedes Bernadá, M.D. Mercedes Bernadá, M.D.
FAIMER Institute 2008 Fellow
Aggregated Professor of Pediatrics
Coordinator, Pediatric Palliative Care Unit
Pereira Rossell Hospital Centre
Universidad de la República
Montevideo, Uruguay
Outcomes of Dinesh Badyal’s fellowship innovation project
Pereira Rossell Hospital Centre Pediatric Palliative Care Team. Members include María de los Ángeles Dallo, Valeria le Pera, Fabiana Caperchionni, Patricia dall’Orso, Alicia Giordano, Silvia Guillén, Edgardo González, Roxana Carrerou, Raquel Bellora, and Mercedes Bernadá.
(click image to enlarge)

Rights of a Child with a Terminal Illness

In 1997, Dr. Lisbeth Quesada Tristán of Costa Rica wrote “The Rights of a Child with a Terminal Illness.” Dr. Bernada would like to share these rights as an important addendum to her work: http://www.cuidadopaliativo.org/childrens_rights.php

Following the completion of the first residential session of her FAIMER Institute Fellowship in 2008, Mercedes Bernadá decided that the focus of her education innovation project would be on the development of Pediatric Palliative Care (PPC) in her native country of Uruguay. Since that time, she has helped to establish the first postgraduate course on PPC in Uruguay, directed a PPC roundtable discussion at the Uruguayan Pediatric Congress, published and presented work on her findings, conducted workshops on PPC, and participated in a Delphi study on PPC for the World Health Organization. Her efforts have helped to put PPC on the Uruguayan pediatric postgraduate agenda, as well as on the agenda of the Public Health Ministry. Dr. Bernadá believes that these efforts not only improve PPC itself, but also health professions education. She feels strongly that PPC can be used as a paradigmatic health problem to teach professionalism and medical humanism to health professionals.

What follows are Dr. Bernadá’s Observations from the Field regarding her work in PPC.

Definitions
According to the World Health Organization (WHO) definition, pediatric palliative care is the integral biological, psychological, social, and spiritual care of children living with life-limiting/threatening conditions. Children with life-limiting/threatening conditions include children with cancer but also children with:

To successfully implement a palliative care strategy for children in need of it, an interdisciplinary team is necessary because no single health professional can meet the complex and multifaceted needs of these children and their families.

All over the world, the development of pediatric palliative care has come after adult palliative care. In Latin America, there has been a very inhomogeneous development across different countries. In Uruguay there wasn’t a specific pediatric unit until 2004 inside the intensive care unit. What I’ll share here is the development of the first pediatric palliative care in the country.

Context
Uruguay is a small country in the south of South America, in between Argentina on the west and Brazil on the north.

Health System

Working Methodology
Weekly meetings are held for clinical work and to plan educational activities.

Clinical Work

Educational Work

Clinical Reasoning Tool for Pediatric Palliative Care

  1. Does this child need palliative care? Why?
  2. To which Himelstein group does he/she belong?
  3. In which stage is he/she in relation to death risk?
  4. What are his/her main problems? Biological, psychological, social, communication-related, spiritual?
  5. What are the major needs and preferences of the child and family?
  6. What are the human, material, organizational, and/or management resources needed to solve the problems and satisfy the needs identified?
  7. Define together with the child (if possible) and family the care objectives and action plan.

Results (December 2008 – December 2010)

Clinical Work
Population: 77 patients with an age range of 28 days – 16 years; median age 3 years

Conditions appropriate for PPC (Himelstein Groups) Pathologies Children: n (%)
Conditions for which curative treatment is possible but may fail Severe congenital heart disease (2)
Intracranial tumor (1)
Cervical medulloblastoma (1)		 4 (5%)
Conditions requiring intensive long-term treatment aimed at maintaining the quality of life Chronic respiratory failure (7)
Cystic fibrosis (6)
Myotubular myopathy (1)
Keratitis ichthyosis deafness (KID) syndrome (1)		 15 (19%)
Progressive conditions in which treatment is exclusively palliative after diagnosis Undetermined congenital metabolic error (2)
22 Trysomy (1)
13 Trysomy (1)
Di George syndrome (1)		 5 (7%)
Conditions involving severe, non-progressive disability, causing extreme vulnerability to health complications Chronic encephalopathy
  • Unclear cause (11)
  • Perinatal hypoxia (11)
  • CNS malformation (10)
  • Post resuscitation (6)
  • Status epilepticus (4)
  • CNS infection (3)
  • Battered child (3)
  • Extreme prematurity (2)
  • Traffic injury (2)
Paraplegia/gunshot wound (1) 		53 (69%)

Most frequent admission causes were: respiratory infections, seizures, gastrointestinal problems, or problems with different prosthesis (tracheostomy, gastrostomy tubes).

Main psychosocial problems were: fear of death, fear of loss of quality of life, guilt, depression, extreme poverty, single parent families, lack of community support, and family/staff communication problems.

22% of the patients died during the two years, most of them at the hospital.

Educational Work

Conclusions

Achievements

Barriers to success

Future challenges

Why “Pediatric Palliative Care, a Laboratory for Learning Medical Humanism and Professionalism?”

My 2008 FAIMER project was about the introduction of “Medical humanities in the school of medicine.” None of the pediatric problems managed before have taught me more than this about the need for demonstration, learning, and teaching of all of the following characteristics of professionalism:

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125 Years of Health Professions Education at the Fiji School of Medicine

(posted December 20, 2010)
Christian Ezeala, M.Sc., Ph.D. Christian Ezeala, M.Sc., Ph.D.
Southern Africa-FAIMER Regional Institute 2008 Fellow
Head of Pharmacology Division
Department of Health Science
Fiji National University
Suva, Fiji

Bula! That is the friendly welcome you receive upon arrival at the Nadi International Airport. You are greeted by a number of smiling faces eager to help you find your way. Fiji is a relatively safe and quiet place to spend a holiday. Come cruise the creeks abundant in crystal clear waters!

A little over a year ago, I moved to the Fiji Islands to commence my appointment as faculty at the Fiji School of Medicine in Suva. As this institution celebrates its 125th anniversary, I report on the educational experiences of this foremost regional institution of the South Pacific.

The Fiji School of Medicine was established in 1885 as the Suva Medical School to train vaccinators/native practitioners following outbreaks of measles, influenza, and dysentery during the preceding years. Over the years, this school grew from a local institution for the education and training of medical assistants to a regional health professions educational institution that produces specialist doctors and other health professionals for the entire Pacific island countries and beyond. Renamed the Fiji School of Medicine in 1961, the school until recently awarded degrees on behalf of the University of the South Pacific. Early in 2010, precisely in its 125th year, the Fiji School of Medicine was amalgamated with five other institutions in Fiji to form Fiji National University. Together with the Fiji School of Nursing, the Fiji School of Medicine became the College of Medicine, Nursing, and Health Sciences, one of the five constituent colleges of the new university. The departments in the School of Medicine include Health Sciences, Medical Sciences, Oral Health, and Public Health. The school offers undergraduate and postgraduate courses in medicine, surgery, dentistry, public health, pharmacy, medical laboratory sciences, medical imaging, and physiotherapy. At present, there are three campuses spread across the country with the administrative head office at the Hoodless House Campus on Brown Street, Suva. Facilities for clinical training are located in the Colonial War Memorial Hospital (CWMH), and other regional hospitals. The students are drawn from Fiji, other Pacific island countries, and internationally, with the majority registered in the medicine/surgery program.

Educational Strategies

The programs in the school use diverse curriculum models and instructional strategies. Whereas the M.B.B.S. program is structured entirely on problem based learning (PBL), the dentistry program uses a combination of PBL and lectures, while other programs are fully lecture based.

In the PBL programs, students are placed in groups of about 10, and each fortnight they work through specific clinical problems related to topics in the curriculum. PBL tutors facilitate these sessions. Discipline experts provide supplementary resource sessions to the entire class on each of the discipline areas related to the problem.

Formal lectures for lecture-based courses are as interactive as possible, with emphasis on student-teacher and peer-peer interactions and feedback. Computer-assisted learning is common practice, and wet laboratory practical sessions are often supplemented with simulation labs. Assessment methods include standard referenced written and oral examinations and OSCE and OSPE sessions.

A unique feature of most programs in the school is the multi-entry, multi-exit policy, whereby students can exit the program with a certificate or diploma and re-enter to upgrade to a degree much later, after professional experience. This policy ensures a good supply of mid-level workforce for the public health service while at the same time providing career advancement opportunities for this caliber of worker.

An important health care delivery and health workforce development issue in Fiji (and most other Pacific island countries) is communication, as this country comprises about 300 islands of which more than 100 are inhabited. In response to this, the school developed a hybrid model of e-learning, employing a combination of on-line classes and face-to-face classroom studies. This is particularly suited to bridging re-entry students, who still hold appointments in remote locations of the country.

In the Fiji School of Medicine, innovation is our strength, and the school constantly explores novel approaches to curriculum design and delivery, and for monitoring and evaluation of its programs.

Vinaka vaka levu, and welcome to the beautiful islands of Fiji.

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Christina Tan Leads Award-Winning OSCE Team

(posted September 8, 2010)
Christina Tan, M.B.B.S. Christina Tan, M.B.B.S.
Professor and Head, Medical Education and Research Development Unit
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
The University of Malaya Faculty of Medicine OSCE Team of Coordinators
The University of Malaya Faculty of Medicine OSCE Team of Coordinators, from left to right:
Yang Faridah Abdul Aziz, Anushya Vijayananthan, Azura Mansor, Rokiah Pendek, Christina Tan
(click image to enlarge)

Congratulations to Christina Tan (PHIL 2005) who, with her Objective Structured Clinical Exam (OSCE) Team of Coordinators, recently received the University of Malaya’s Excellence Award in Teaching. Below, Christina shares the story of her team’s accomplishments.

University of Malaya Excellence Awards

The University of Malaya Excellence Awards were established in 2009 to honour and recognise excellent accomplishments at the university and the individuals who achieved them. They were also intended to create and sustain a culture of outstanding performance and productive competition within the campus community. The award is given in 10 categories, one of which is for teaching. The award carries a certificate and a cash prize of MYR 10,000 (approximately US $3,200).

The OSCE Examination and OSCE Team

The OSCE Team of Coordinators in the Faculty of Medicine currently comprises five faculty members: Rokiah Pendek (Internal Medicine - Endocrinology), Yang Faridah Abdul Aziz (Biomedical Imaging), Anushya Vijayananthan (Biomedical Imaging), Azura Mansor (Orthopaedic Surgery), and myself (Family Medicine). It started in 2003 with just Rokiah and me, when the Faculty had embarked on a new undergraduate medical curriculum that had an OSCE as a component of the final integrated exit examination. Over the years, the examination became more complex logistically, with an increasing number of students and an expanded team of coordinators. The responsibilities of the OSCE Coordinators can be divided into four main areas of focus, namely (a) the content of OSCE questions, (b) the process and conduct of the entire examination, (c) quality assurance of the OSCE, to include standard setting and blueprinting, and (d) providing feedback on student performance and looking into areas for improvement (such as conducting training workshops).

The OSCE in the final exit examination comprises 16 stations, each five minutes in length, for 200-260 students. To conduct the examination for all students on the same day, three to four simultaneous tracks are run per round, with a total of four to six rounds. Stations that require examiners to be present therefore need a minimum of three to four examiners per station. Some clinical disciplines use more than three to four examiners for the whole examination, changing examiners in mid-round.

Observations made during actual OSCEs in these final-year exit examinations revealed several problems. Some examiners engaged in inappropriate behaviours, such as prompting, indicating to the candidate how they had performed in the station, and teaching/correcting the candidate. There were also apparent differences in the way examiners used the mark sheets their departments had developed. For stations that changed examiners during rounds in the examination, there did not appear to be any consistency in the way checklists had been marked from one examiner to the next.

It was evident that examiners required some form of training to draw their attention to their own behaviours and to look for ways of ensuring consistency in marking checklists. So, the OSCE team began conducting workshops.

OSCE Examiner Training Workshops

To conduct the workshop, a mini OSCE comprising four stations is set up in the Clinical Skills Laboratory with a one-way mirror and audio-visual recording equipment. An examiner is present at each station to assess the performance of the student doing the required tasks and to mark the checklist provided. Other examiners are present in an adjoining room observing the same station and individually marking the same checklist. This process is repeated with each of the remaining three stations.

The number of examiners participating in each training workshop is limited to 12 to allow for a more effective hands-on experience.

After a four-station circuit has been completed, there is a group discussion of the conduct of the OSCE facilitated by the OSCE team. The discussion can cover a wide range of issues, including student performance, question design and setting, and consistency of marking. Feedback is provided on the performance of the examiner in the station. Marks on checklists are tabulated and projected, and further discussion of the different raters’ marks takes place.

The mini OSCE is then run again, but this time with a fresh batch of students and a fresh batch of examiners. The main difference this time is that the examiners agree on standardising their marking prior to the examination. The marks obtained in this second round are tabulated after the OSCE and compared with the first set of marks, followed by a discussion of the results and the changes that have occurred.

Impact of the Training Workshops

These workshops have been in place since 2006, and to date 20 workshops have been conducted in the Faculty of Medicine, University of Malaya. A total of 185 academic staff members have been trained. In addition, a modified version of this workshop has been conducted in other locations nationally as well as internationally (in South Africa and Pakistan). Academic staff members who have attended the workshops have expressed an increased awareness of their own behaviour during the OSCE examinations and recognition of the need for consistency and standardisation of certain assessment procedures.

The Dean of the Faculty of Medicine now requires academic staff to undergo workshop training prior to receiving permission to conduct OSCEs. From a broader perspective, the training workshops have contributed to personal and professional development of academic staff in examiner training.

This standardisation of OSCE examiner training has also led to an improvement in the quality of OSCE examination questions, as the workshops illustrated how validity was compromised by poorly designed questions.

The OSCE Team of Coordinators all perform clinical service work in addition to teaching and research activities, but they are bonded together by a common passion for medical education. They have demonstrated true teamwork in ensuring that the quality of the OSCE examination is maintained from start to finish, and they have promoted a stronger and more sustainable approach to faculty development both through their individual expertise and by having a wider influence as a team than any single individual could achieve.

The Role of FAIMER

The whole idea of OSCE examiner training that started as my FAIMER project during the 2005 FAIMER Institute has now germinated and firmly taken root. All this would not have been possible if I had not become part of the FAIMER family. So thank you to FAIMER and all the people I have met who have greatly enriched my life!

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Converting a Dream into a Reality: Dinesh Badyal Tells the Story of His FAIMER Fellowship Innovation Project

(posted June 17, 2010)
Dinesh Badyal, M.D. Dinesh Badyal, M.D.
Professor and Head
Department of Pharmacology
Christian Medical College
Ludhiana, India
Outcomes of Dinesh Badyal’s fellowship innovation project
Outcomes of Dinesh Badyal’s fellowship innovation project
(click image to enlarge)

I have been associated with the CMCL-FAIMER Regional Institute (CMCL-FRI) right from its inception—I am a CMCL-FRI 2007 Fellow. One of the requirements for the fellowship is completion of an innovation project, and I did my project on “Implementation of Computer Simulation Models (CSM) as Replacement of Animal Experiments in Teaching Undergraduate Pharmacology.”

As all Fellows do, I worked on my project thinking of it as a one-year assignment to go along with the fellowship. Then I started the first residential session in January 2007 in Ludhiana, India. During the program evaluation and project discussion sessions, I came to know that I needed to think about the bigger picture for my project. I was told to develop intermediate and long-term outcomes at that time. I had never thought of that when I planned my project. I was a bit confused and worried about how I could make a difference with my project. However, the words of faculty members about how the project will benefit the community had a big impact on me. I started thinking about the usefulness of the project to others, expanding it, and making a big difference.

The next year I worked on my project and completed it successfully with few hassles. I got very good insights about my project when I started it at my institute. I read a lot of information related to simulation, simulation in teaching, etc. I thought of modifying the curriculum of pharmacology practical exams, including using simulation to replace animal experiments. In the process, I wrote my first book, Practical Manual of Pharmacology, published by Jaypee Brothers, the leading medical book publisher of India. The book was released in April 2008 during a workshop on medical education sponsored by the Medical Council of India (MCI). An MCI representative released my book. This was one of the outcomes of my project.

The book has become very successful and the publisher has asked to print a second edition to coincide with the new curriculum for medical undergraduate courses from MCI in 2010. This curriculum mentions that simulation should be used to replace animal experiments. This is exactly what I had written in the introduction to my project.

I presented my project during the second residential session of CMCL-FRI in January 2008, and then went ahead and expanded it. I completely replaced animal experiments in undergraduate pharmacology teaching during the next year (2008), and animal mortality was reduced to zero. I then presented a paper on the expanded project at the 6th Asia Pacific Medical Education Conference at the National University of Singapore, Singapore, in February 2009. I interacted with other international medical educationists there and acquired more knowledge about research in medical education. I went deeper into scholarship and published the extended project as full paper, “Computer simulation models are implementable as replacements for animal experiments,” in the indexed international journal ATLA (Alternatives to Lab Animals). The paper was highly appreciated, and I still keep getting requests from around the world for PDF copies.

While I was writing the paper, I came to know that most of the teachers in pharmacology are not aware of alternatives to animal experimentation, which are available freely or at a negligible cost in India. I planned to conduct a Continuing Medical Education (CME) program to make other teachers aware of these alternatives. I extended it to other subjects where alternatives are needed (one of the intermediate outcomes of my project). I chose physiology, as this is the other subject where alternatives to animals are needed. I struggled hard to find a physiologist, as well as alternatives that are available in India. I contacted a lot of physiology faculty in India. After two months of searching, I found the appropriate resources. I needed funds for the CME program, because I planned to call on pioneers in simulation in India in pharmacology and physiology. I contacted them; they happily agreed.

Somehow my personal growth during the fellowship period helped me to project myself as a good pharmacologist and medical educationist, and I was elected as the Editor of The Clinical Researcher, the official publication of the Clinical Research Board. I conducted two big events at my institute: a CME program on depression and a three-day “Workshop on Clinical Research,” sponsored by the Indian Council of Medical Research (ICMR). Just two months after that I was invited as a guest speaker at an international conference by the University of Hong Kong. After that I was a guest speaker with Dr. K. Satyanarayana, Editor of the Indian Journal of Medical Research (IJMR) (the only Indian journal with an impact factor of 1.883), to conduct a workshop on writing scientific papers at the National Conference on Health Professionals’ Education in Pune.

These developments helped me a lot, and with each development, CMCL-FRI was somehow involved. I got a lot of support from FAIMER Fellows. A number of Fellows belong to my specialty, pharmacology, so we got together to improve our specialty at a national level.

I wrote to MCI in July 2009 to ask them to sponsor a CME program. They agreed and we successfully conducted “Alternatives to Animals in Medical Education” in February 2010. The CME program was attended by 150 delegates from all over India. Some of them (including one of the top medical colleges in Delhi) have now written me that they have started using simulation models. This was another of my project’s intermediate outcomes.

In October 2009, I attended the FAIMER Institute in Philadelphia in the United States. On International Medical Education (IME) Day, I met an administrator from a national body in India, who encouraged me and, in principle, agreed to sponsor my expanded project on “Simulation Lab to Replace Animals” (my project’s long-term outcome). The suggestion was made to develop such a lab to cater to basic and paraclinical sciences, and then replicate it at other colleges.

When I started writing my project in 2006, I never thought of all the possible outcomes. Now in 2010 (five years down the line) I am planning to start the long-term outcomes. A bigger dream became reality. My wife says, “You Pisceans dream a lot,” and I tell her I do this so that I can convert them into realities. I thank all medical educationists; FAIMER, in particular FAIMER Fellows and CMCL-FRI; MCI; ICMR; and my mentors for their constant support and encouragement.

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Vanessa Burch, M.B.Ch.B., M.Med., Ph.D., Gives Inaugural Lecture as Professor and Chair of Clinical Medicine at University of Cape Town

(posted December 21, 2009)
Vanessa Burch, M.B.Ch.B., M.Med., Ph.D. Vanessa Burch, M.B.Ch.B., M.Med., Ph.D.
Professor and Chair of Clinical Medicine
University of Cape Town
Cape Town, South Africa

Vanessa Burch (PHIL 2001) recently gave her inaugural lecture as professor and chair of clinical medicine in the University of Cape Town’s Department of Medicine. Her lecture was entitled Health Care in South Africa Today and focused on the challenges facing South Africa in meeting the United Nations 2015 Millennium Development Goals. Her perspective is that of an educator facing head-on the health care needs of her region. Following are some highlights from her lecture, which began with excerpts from a few recent articles from the South African newspaper Cape Argus on the subject of health care:

Health Care Today

Epidemics: Disease & Injury

Funding Health Care

The Health Care Workforce

The Way Forward

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David Cameron, M.B.Ch.B., M.Med., M.Phil., Reflects on Providing Care in Rural South Africa

(posted February 5, 2008)
David Cameron, M.B.Ch.B., M.Med., M.Phil. David Cameron, M.B.Ch.B., M.Med., M.Phil.
Associate Professor, Department of Family Medicine
University of Pretoria
Pretoria, South Africa

Here’s a brief reflection I wrote two years ago following a home visit in a small rural village where I was working:

Home based care? Flies circle like lazy vultures parting the air saturated with the smell of
cervical cancer. Too weak to sit up, she reached out and grasped my hand, 33
degrees outside, it felt like 40 under the low tin roof.
"Hospital?" I suggested.
"No, people die there."
Six pairs of weary eyes watch my every move.

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My Experience in Sierra Leone

(posted May 31, 2007)
Elsie Kiguli-Malwadde, M.B.Ch.B., M. Med. Elsie Kiguli-Malwadde, M.B.Ch.B., M. Med.
Head, Department of Radiology
Makerere University
Kampala, Uganda
Sierra Leone thumbnail image 1 Sierra Leone thumbnail image 2 Sierra Leone thumbnail image 3 Sierra Leone thumbnail image 4

At the beginning of this year, I found my self in Sierra Leone. If you had asked me a few years back whether I would ever go there, I would have asked you, “What for?” Here I am in Sierra Leone and enjoying it.

Sierra Leone is a small country of 71,740 sq km with a population of 6 million, in comparison to my country, Uganda, of 236,000 sq km and 26 million people. In many aspects, both countries are similar: they have had civil wars and are developing countries that are on their way to recovery. Uganda has had a relatively longer period of peace, 20 years, compared to Sierra Leone, which has been peaceful for seven years. Both countries became independent around the same time in the early 1960s and were colonized by the British.

The people of Sierra Leone are friendly and very welcoming. They will greet and welcome you to their country in a warm way that makes one feel welcome instantly. They have many languages but the local official language, Krio, is the one that’s widely spoken. Krio is a mixture of English, Portuguese, French, and local African languages. It is distinct from Pidgin English. Most people are fooled into believing at the beginning that English speakers will understand Krio, but they get surprised when they start hearing it. I have started taking classes in Krio and I love it. It is challenging but enjoyable.

The health structure in Sierra Leone, like in so many African countries, is not functioning properly and the hospitals are poorly equipped. Brain drain has not spared it, with most of the professionals working in developed countries. Life expectancy is 46 years. There is one radiologist in the country. They have one medical school and their basic training takes six years. Their curriculum is community-based and teaches radiology in an integrated manner. Both aspects are similar to what is done at Makerere University where I teach; my university has just started this while, in Sierra Leone, they have been doing it for a long time. Unfortunately, most of their doctors don’t stay.

Sierra Leone is a beautiful country; it is green and has tropical forests but what have attracted me most are its beaches. This may be because I am from a landlocked country. They have great beaches with clean sand and ideal conditions for swimming, especially since the temperatures can be quite high — 30 degrees Celsius. Freetown, its capital, is a hilly city and one can see the beach from most places in the city. I learned from Page at FAIMER to look out for the good in life and appreciate it, and that is the attitude that has made my life a lot more enjoyable far away from home.

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[last update: November 30, 2011]