BMJ Elective: A new experience leading a newer perspective….The Patient-centered learning.
By Vivek Podder
Currently, undergraduate medical education is largely limited to the lectures or textbooks based teaching-learning approach rather than a patient-centered learning in various parts of the world. Lack of formal training for students in medical school as well as lack of future incentives and motivation are not enabling a graduate doctor with necessary basic skills for critical appraisal of available evidence to make best clinical decision in their practice.  We may need to revisit the aspects of traditional medical education system that need to be optimized in order to build different mechanisms that can help student critically think, provide a patient-centered learning experience, equip with a platform where medical student can improve knowledge through conversational learning- a process keeps one involved, the facts learned to stay longer than those learned directly from the book, basic mandatory skills for critical appraisal of new evidence and by closely working with patients one can learn to build better doctor-patient relationship and thus build confidence in clinical decision through proper clinical reasoning and better clinical problem solving. I am sharing my experience of a BMJ Elective program wherein I have experienced medical education in a different way.
BMJ Elective Experience: (Pros and Cons)
BMJ elective was one of the best experience I went through which transformed my thinking from traditional medical learning system to a new blended offline-online learning system offered through BMJ Case reports under the supervision of Professor Rakesh Biswas (editorial board member, BMJ Case reports).
It was a patient-centered learning experience where through face-face interactions with the patients in the ward, ICU, SICU, HDU and outpatient department, I was collecting data (bedside clinical evaluation as well as imaging and labs) followed by sharing the de-identified raw data to web-based medical record (blog after taking consent), processing the clinical data through an online discussion in various web-based network of medical professionals providing clinical output (patients management) to our primary beneficiaries of medical education-the patients, chiefly by the supervising doctor to tailor them to match available resources where I can experience and reflect upon the consequences and causation of health disadvantage and share them with our team in the form of written text in our online forum. We were using three online platforms- WhatsApp, Tabula rasa (Facebook) and Email wherein doctors from various disciplines like internal medicine, cardiology, endocrinology, pulmonology, critical care medicine, orthopedics, oncology, hematology, radiology, pathology, microbiology, pharmacology, epidemiology etc. were involved in the discussion providing their collective patient-centered feedback through asynchronous communication. Often I needed to visit microbiology, pathology labs, radiology departments and cath labs to discuss patients’ laboratory findings with faculty doctors. I also used to make home visit for the patients previously admitted or came to our OPD and was evaluating their history and clinical progress while guiding them in various home procedures they were advised to e.g. medicine compliance, blood glucose monitoring, diet plan, temperature record in graphs (which would tell the pattern of fever) etc., and educating them about their diseases and updating their case records so that any further management plan can be applied after further discussion.
I was formatively assessed as well as supervised through our online community where all our cases are discussed regularly (and an online learning-portfolio for the student can be made from the learning interactions). I was encouraged to critically appraise the literatures using CASP check-list from PubMed , share searches on the recent evidences from UpToDate as well as reflections, and thoughts on each case with a larger community so that my inputs can actually benefit the patient in terms of generating interest and quality care from all those involved with the patient (offline and online). During this elective, I had involved 50-60 medical students from the same institution to go through the same experience and with involvement of all the stakeholders the patient was getting integrated evidence-based management and much better care even at a low resource setting which also allowed students to develop confidence in clinical decision-making process especially with the joy of knowing that their management strategy can be used effectively in an actual setting. The primary objective for which I had started this elective was initially to make case reports for BMJ and through this excellent learning experience I did make one case report which is under review and three case reports are in the pipeline for submission to BMJ Case Reports. Another global case report which I am working on to raise an issue of unnecessary coronary interventions across the globe.
In spite of many learning opportunities it gives, lack of like-minded academic peer groups during the rotation, lack of academic credit (that makes it difficult to get medical school permission), overwhelming tasks (partly due to lack of more elective students), can be improved for optimization of this elective experience.
While the shortage of doctors is of prime concern in a health system, a large force of health system, the medical students have not been utilized better in patient care in a more patient-centered way. If the way I have been involved in the patient-centered learning can also be done by all the medical students then how greatly patient care could be improved and during the process medical student could become much more confident and skillful in critical appraisal of literature, clinical problem solving, and a better empathetic doctor.
A system I expect where the mental presence will be given priority over the physical presence.
1. Kaustav Bera, Bhavna Seth, Rakesh Biswas. Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Ann Neurosci. 2013; 20(2): 37–38.