NON-SCHOLASTIC ABILITIES
COMPILED RESOURCES OF THE ONLINE DISCUSSION CARRIED OUT BY THE CMCL-FAIMER FELLOWS IN JULY 2007
MODERATORS : Dr Chetna Desai Dr Anshu FACULTY INCHARGES: Dr Tejinder Singh Dr Rita Sood
FOR MORE RESOURCES: http://nonscholastic.abilities.googlepages.com/
TABLE OF CONTENTS
SESSION ONE INTRODUCTION TO NON-SCHOLASTIC ABILITIES
1. Introduction 2. Responses to First set of Questions 3. Non-scholastic abilities 4. Non-scholastic abilities required in various specialities 5. Weightage to Extra-curricular activities 6. Theory of Multiple intelligences 7. MCI rules on Internal assessment 8. Is it necessary to be a ‘Super Student’? 9. Non-scholastic abilities required of medical educators
SESSION TWO SPECIFIC NON-SCHOLASTIC ABILITIES-PART I
1. Responses to Second set of Questions 2. Communication skills • The need for communication skills • Learning the local language • Breaking bad news • Assertiveness Vs Aggressiveness • Avoiding medical jargon • Non-verbal communication • Imparting communication skills to students 3. Scientific temper
SESSION THREE SPECIFIC NON-SCHOLASTIC ABILITIES-PART II
4. Responses to Third set of Questions 5. Social and Interpersonal skills • Getting on with colleagues 6. Leadership • Do doctors make good administrators? • Leaders Vs Managers 7. Team work • Teaching students team work/ Collaborative learning activities • Teaching Organizational skills to students 8. Emotional intelligence • Empathy • Handling stress • What makes a good doctor? 9. Service orientation • Orienting students to rural service • Report of the Task Force on Medical Education of the National Rural Health Mission • Determinants of rural orientation in medical students 10. Miscellaneous Non-scholastic abilities • Music • Sports • Intuition
SESSION FOUR ASSESSMENT OF NON-SCHOLASTIC ABILITIES
1. Why evaluate non-scholastic abilities at all? 2. Problems in assessment of Non-scholastic abilities 3. Assessment tools to evaluate non-scholastic abilities 4. Global assessment of competence 5. How to select Medical students?
TAKE HOME MESSAGE
Note: This discussion did not include ‘Professionalism’ which is an important non-scholastic ability as it is the theme of another online discussion scheduled later this year.
This session on non scholastic abilities was divided into four sessions.
• Part I (5 days) -- Warm up and awareness about non-scholastic (NS) abilities and their need in medical curriculum. • Part II and II (10 days each) -- discussion on the individual NS abilities - Why are they important and how to foster them? • Part IV (5 days) -- Evaluation of NS abilities. SESSION ONE: INTRODUCTION TO NON-SCHOLASTIC ABILITIES
CHETNA DESAI: Hello and welcome to the July intersession on "Non-scholastic abilities".
It is apt that the session begins on a Sunday when most of us are off our books, academic and "Scholarly" stuff and more in to leisure, socializing, hobbies, etc. The topic for this session will touch these and much more.
Please refer to the write up and the questions that follow and get going.
INTRODUCTION
Ability is defined as the power and skills to do, think, act and make.
The word ‘scholastic’ means “of or concerning schools and teaching”. By implication the word non-scholastic can be taken to mean “not of or concerning schools and teaching”.
We often hear that school or college grades are not all. It is also observed that in real life situations, it is not just the IQ that matters but emotional and spiritual quotient as well. In medical profession- which deals with human touch- these aspects of learning become vital. While it is inherently ingrained in some, most of us need to train to develop these abilities. In general, non-scholastic abilities include those abilities which are not traditionally taught and evaluated in schools. These abilities include attitudes, moral values, leadership, motivation, etc.
Specifically, non-scholastic abilities in the medical profession can be defined as general abilities that are not specific to medicine but these are needed for effective functioning of any caring person. These abilities reflect the later performance of the students as doctors. Hence, this is the concern of curriculum planners or medical educators.
While framing a medical curriculum following learning outcomes have been described by various institutions, bodies and policy makers: 1. Knowledge 2. Comprehension 3. Application 4. Analysis 5. Synthesis 6. Evaluation 7. Drawing and sketching skills 8. Ability to handle instruments 9. Communication skills (Skills in writing and talking) and ability to communicate with peers, teachers, patients and assertiveness) 10. Social skills (Team work and leadership, discipline, ability to share, confidence or diffidence) 11. Personal qualities (Regularity, punctuality, hard work and attitude to work, inventiveness, originality and initiative, dependability, Psychological robustness) 12. Interest 13. Positive and Scientific attitude 14. Appreciation 15. Originality and Creativity 16. Participation in sports and other extracurricular activities, hobbies, social service activities 17. Body language/ non-verbal communication 18. IT skills: Computer, internet
In general a medical graduate is expected to be alert, observant, adaptable, honest and caring.
Similarly the following abilities (both scholastic and non-scholastic) have been identified for residents.
1. History taking 2. Physical examination 3. Diagnostic approach 4. Management approach 5. Procedural skills 6. Record keeping 7. Understanding the basic mechanisms 8. Responsibility and conduct 9. Relationship with patients and their families 10. Relationship with peers and other professionals 11. Self-directed learning
In the above list items 8, 9 and 10 fall under non-scholastic abilities. Responsibility and conduct include punctuality, reliability, dependability, enthusiasm, reaction under stress, observation of work routines and standards of conduct. Relationship with patients and their families includes availability during non-working hours, caring approach to patients, giving clear and appropriate information and keeping patients’ family informed and involved. Relationship with peers and other professionals includes collaboration, giving clear / courteous instruction and information, accepting constructive criticism and maintenance of team spirit.
A survey of 25 doctors belonging to different specialties was conducted (by Dr Santosh Kumar, JIPMER) to ascertain the qualities they considered most desirable while choosing their doctors. 24 doctors responded. A total of 147 responses were obtained. Their responses could be grouped into the following pedagogically meaningful groups:
1 Be caring 2 Diagnose and manage health problems 3 Be responsible 4 Be approachable 5 Be affordable 6 Have good reputation 7 Counsel and teach 8 Be patient 9 Be willing and able to manage emergencies 10 Be aware of one’s limitations 11 Solve problems 12 Communicate well
Interestingly only group 2 belongs to scholastic abilities and all other groups belong to non- scholastic abilities. Thus, non-scholastic abilities are as important as scholastic abilities.
The MCI guidelines (1997) stipulate that • Undergraduate medical education should be oriented towards health and community as opposed to disease and hospital. • The graduate must develop humanistic qualities in discharging professional obligations and be able to function as leader of the health team in urban and rural settings. • Students’ training must aim at inculcating scientific temper, logical and scientific reasoning, clarity of expression, and ability to gather and analyze information. • The graduate should be able to appreciate the socio-psychological, cultural, economic and environmental factors, affecting health and develop humane attitude towards the patient in discharging one’s professional responsibilities. • The student should be able to work as a leading partner in health care teams and acquire proficiency in communication skills. • The graduate should have personal characteristics and attitudes required for professional life such as personal integrity, sense of responsibility and dependability and ability to relate to or show concern for other individuals.
(Adapted from: Bulletin of NTTC, September 2001; Principles of Medical Education, T Singh et al)
The focus of the first session (lasting five days) will be: • Building up an awareness of the non scholastic abilities that are necessary in medical students. • Sharing our experiences in this area in our respective specialties, either as students or as teachers.
So let us begin with responding to the following:
• Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? • Which non-scholastic abilities would you lay emphasis on, in your students and why? • Which non scholastic abilities would you like to develop or nurture in yourself? • In your opinion to what extent do non-scholastic abilities matter in medical profession? • Share with us some non-scholastic abilities that you have observed in your colleagues or students that have impressed you.
Responses to First Set of Questions
MONIKA SHARMA: Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? Yes, it is important to develop non scholastic abilities in ourselves. As rightly mentioned in the article quoted by Chandrika, we all have multiple brains. However, none of them are independent or autonomous. They are all interlinked and act as supports for each other. Isn’t it true and evident that our non-scholastic interests often act as buffers and refreshments when our scholastic abilities are exhausted and drained? At the end of a hectic day, an hour of relaxing (be it with music, TV, reading or any other hobby) can be a great rejuvenator.
While still unheard of in India, the Western world has the concept of long leaves, with most people taking breaks of several months or even a couple of years to rejuvenate and come back to work fresher and more activated.
As for students, I have often felt that students who fostered non-scholastic abilities had an uncanny grasp of the subject. They may not be the toppers in the class (simply because they spent less time with books), but they understood better, and in fact even memorized better. Most of my colleagues and juniors who nurtured their hobbies were able to remember more with a single reading than I could with two or even three- maybe because I spent all of my brain (the only one I was using) with my books and overlooked the supporters (the other brains) which could have taken a front seat while I let my exhausted brain cells regain senses.
I’ll give a personal example to reiterate my point. If I work on something serious and get really exhausted with nothing in hand at the end….and actually give up on it for a while and take a break……the ideas offering solutions suddenly spring up while in leisure and the problem is solved. Sometimes I see the solutions in my dream…may be because that is the time when the rest of my brain gets time to be active. Since, I was born to typical Indian parents who thought studies were the only solution to a bright future, I have subconsciously trained myself to study and work and that’s all, though I have had several experiences of problem solving during leisure and when I was actually not thinking about the problem, my mindset of not letting my non-scholastic abilities take over continues, only at my own loss and frustration.
Which non-scholastic abilities would you lay emphasis on, in your students and why?
Nothing in particular, because the choice may be different for different people. While I like reading fiction and anything unrelated to Pediatrics, some might like to sing, play music, paint or sew something. (Personally, cleaning up is my favorite non-scholastic activity, most relaxing and satisfying). Which non scholastic abilities would you like to develop or nurture in yourself? Writing and painting
In your opinion to what extent do non-scholastic abilities matter in medical profession? They help in the overall build of personality as it influences our attitudes and interpersonal relationships which are a vital part of our profession.
Share with us some non-scholastic abilities that you observed in your colleague or students that impressed you. Some of my juniors have great wit or shall I call it cleverness, and they always seem to get away with extra leaves and mistakes while other better counterparts seem to be getting thrashed for petty things. Wish I had that ability.
HEMLATA BADYAL: Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? I think students must develop these abilities for their overall growth as an individual and also for benefit of society.
Which non-scholastic abilities would you lay emphasis on, in your students and why? These days students are not bothered about their behaviour and respect to others, so i would like them to develop these.
Which non scholastic abilities would you like to develop or nurture in yourself? Helping the low achievers, being able to understand problems of students (non-academic) which are interfering in their academic behaviour
In your opinion to what extent do non-scholastic abilities matter in medical profession? To a large extent
Share with us some non-scholastic abilities that you observed in your colleague or students that impressed you. Leadership, multitasking (I am not able to practise it.)
HIMANSHU PANDYA: Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? It is absolutely necessary to develop and foster non-scholastic skills in ourselves and students. A medical professional, a surgeon for example, is called upon to perform various roles. He is a clinician, scientist, craftsman, manager, student, and teacher all rolled into one. It is like one person doing the work of six. Needless to say, one needs to develop various skills including non- scholastic ones to perform these roles.
Which non-scholastic abilities would you lay emphasis on, in your students and why? I would lay emphasis on development of communication and interpersonal skills amongst students in order that they become effective members of the health care team.
Which non scholastic abilities would you like to develop or nurture in yourself? Leadership qualities, sense of humor, social conscience, interests outside medicine, balance of home and career are some of the qualities I would like to develop and nurture in myself.
In your opinion to what extent do non-scholastic abilities matter in medical profession? Non-scholastic abilities do matter to a large extent in performance of a medical professional.
Share with us some non-scholastic abilities that you observed in your colleague or students that impressed you. Communicating nature of illness, options available and likely prognosis very effectively in simple language is something that I learnt from one of my supervisor during my residency days.
DINESH BADYAL: Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? Yes, for their overall development as a good doctor and human being.
Which non-scholastic abilities would you lay emphasis on, in your students and why? Behaving well with their colleagues, communicating well and being aware of his/her limitations
Which non scholastic abilities would you like to develop or nurture in yourself? As you have written most of these qualities/abilites are inherent, I would like to foster something I feel strongly about these days i.e. counselling students.
In your opinion to what extent do non-scholastic abilities matter in medical profession? A lot. To excel you need these apart from academic abilities.
Share with us some non-scholastic abilities that you observed in your colleague or students that impressed you. Communication (Anshu), be patient (TS)
MEENA PANGARKAR:
Do you think it is important to develop or foster non scholastic abilities in ourselves or our students? Why? Yes, for their personality development, so that they become good human beings also in addition to becoming good doctors.
Which non-scholastic abilities would you lay emphasis on, in your students and why? Empathizing with patients, taking the time to give your patients a good hearing, coordinating your body language to what you are saying and having a smiling face.
Which non scholastic abilities would you like to develop or nurture in yourself? I would like to develop a lot of patience.
In your opinion to what extent do non-scholastic abilities matter in medical profession? They matter a lot, they complement your scholastic ability, each without the other are not enough.
Share with us some non-scholastic abilities that you observed in your colleague or students that impressed you. Creativity, enthusiasm (Anshu) understanding (Dr TS)
Non-Scholastic Abilities
STEWART MENNIN: It's interesting for me to reflect how we separate and fragment scholastic and non scholastic abilities in general as well as in medicine. I think it's important to foster the connection between the two. When I look at you I see a whole person. Initially I don't think, "Oh, she is a non scholastic person in this way and a scholastic person in this way. I ask myself- how does it feel to be a human being with this person. How does this human being practice medicine? Caring for and attending to others is important. In Brazil, they speak about 'basic attention' instead of medical care. Giving attention, paying attention to the health and well being of someone requires scholastic and non-scholastic things be linked and that the flow between them be open and robust.
Most students have hobbies and things they like to do that help them to integrate their lives and feel fulfilled. Often these things suffer during and after medical school. How can we help students preserve and maintain a healthy life style while they go to medical school? Medical school can be a very unhealthy experience, in a stressful environment. It is ironic that we aspire to help people learn how to deal with health and lack of health in a fragmented and unhealthy way.
CHETNA DESAI: Your observation about the need to link scholastic and non scholastic abilities in a free and robust manner is quite pertinent. I am not very aware about the actual process a student in other countries goes through before choosing medicine as their profession, the quantum of scholastic abilities required and how important are the grades and general academic performance.
In India the situation is such that a student who wishes to choose a medical profession has to slog a lot in academics, and get "Blue chip" grades. Some parents are known put a halt to all hobbies, television for their kids (and themselves too!), movies, and all other "distractions" for at least two years so that the grades are sufficient enough to qualify for the admissions to this professional course. Students of medicine are by default considered to be "scholarly". These types of prototypes need to be rectified. A student needs both scholastic and non-scholastic qualities to be a "humane" doctor.
The question is "How do we change these perceptions and prototypes?"
STEWART MENNIN: You are quite right when you describe the need for "Blue chip" grades and high entry examination scores as defining criteria for entry into medical school in the present system. Our task at this time is focused on students once they are accepted and in medical school (the admissions and selection process, however, I believe it is in many ways more influential than the structured curriculum in predicting the general nature of the graduates). Once accepted into medical school, creativity and fulfillment as essential components of being human can be re-established as core elements of the "non-scholastic" curriculum and linked to caring, professional behavior, ethics, respect, etc. If we, as professors and role models, express and demonstrate repeatedly and consistently by our actions the valuing of these qualities, the students will follow. We speak often of the hidden curriculum, perhaps we can un-hide this part of the curriculum by attending to it more openly. It could be a form of positive deviance in the sea of curriculum fragmentation.
MRUNAL KETKAR: I agree fully with this. Nurturing a hobby and regularly giving time to it can be one of the best stress busters. We as teachers can stress the importance of this amongst our students. It is a handy tool to us.
What about doctors who retire? I think if you haven't cultivated your hobby during your working years it may leave a big vacuum as to what to do once the busy doctor has days off.
CHETNA DESAI: I agree with you. But just a doubt...do doctors ever retire? :-)
SHEENA SINGH: You are having an interesting exchange of views. I agree that in India there is a conscious moulding of students to pursue studies more than extra curricular activities so that they are able to do well in competitive examinations to enter medical school.
Last year I accompanied the students of my college to the National Cultural fest 'PULSE' at AIIMS (The All India Institute of Medical Sciences) and was amazed at the richness of talent displayed by them.
Sometimes 'PULSE' is looked upon with a jaundiced eye as it pinches time and attention away from studies, but I feel the students return rejuvenated.
Sometimes students transform their hobby or talent in art, writing, oration or music to fit in with opportunities the medical school offers as in designing covers for souvenirs, college T- Shirts, painting backdrops for musicals and plays, creative writing for the college magazine, participating in debates, playing the piano/ other instruments in chapel or in the musical.
At CMC Ludhiana students get ample opportunity to continue honing their talents. It is difficult to strike a balance sometimes as they can get carried away doing the things they love rather than study! Their efforts are rewarded with prizes and special mention on convocation and hostel days.
The area that is not really emphasized is in imparting caring attitudes, politeness, communication skills, interpersonal relationships, professionalism and ethics.
This remains the hidden part of the curriculum and though we all agree that these things are desirable to inculcate in our students, we really don't devote much time to them.
ANSHU: I think all colleges have their cultural festivals. But thanks to the compact curriculum with too many exams, there is a huge time crunch- no time to practice and no bunking classes anymore!
I agree with you that we need to emphasize on interpersonal relationships. If I remember correctly, Vijaya's study dealt with a facet of this- a large number of low achievers found it difficult to cope with new relationships in hostels. And this inability to adapt to environments does carry forward to one's workplace too later.
BALACHANDRA ADKOLI: It is interesting that we are shifting the paradigm of medical education to include ethics, behaviour, attitudes, values and now touching the core abilities and attributes of a health professional. I agree with Stewart that the demarcation between scholastic and non-scholastic should be considered as artificial and abolished to a great extent. But unfortunately, in a hierarchical society, this distinction is likely to stay longer.
In fact, the very process of admission based on MCQs is the first blunder in tapping right type of candidates to medicine. The mistake is continued throughout when the students are always kept under the hanging sword of examination based on "acquisition of information". The example of student festival PULSE at AIIMS is an example where students put in their best of efforts, skills, talent and hard work to the success of the show, without any consideration given in the exam. Now a days B schools have realized the need for the pursuit of hobbies and talent as an indicator of successful managers. As such weightage is given during interview if not in the written test.
The main reason for step-motherly treatment to non-scholastic abilities appears to be lack of indicators to quantify and measure these abilities. Standardized tools are difficult to get. But you can attempt to develop your own. Our good old study at JIPMER was based on our own judgment of what constituted such a competence. In retrospect, I find them crude. But subjectivity is inevitable and it should be respected. You can reduce subjectivity by multiple observations over a period of time, multiple occasions, 360 degree assessment etc., We should try to see how to capture these abilities rather than declaring that they are "out of syllabus". Whether ethics or humanistic abilities or creativity, the fundamental concern is assessment; but setting "role models" and providing rich contextual experience is perhaps more important. If we have done it, we have a reason to be proud of.
CHETNA DESAI: It is paradoxical that as teachers we appreciate and enjoy non scholastic abilities in our students but do little to identify and nurture them. None of our evaluation systems give due weightage to these abilities. It is just grades, marks and nothing else. How then do we expect our students to work towards these? While internal tests and University exams are mandatory for qualifying, participation in PULSE and like programs require special permission from the Dean. How often do we evaluate the ability to communicate/empathize/work as a team/etc in our students?
I am sure with your experience you would have a fair judgment of the actual extent of influence the non scholastic abilities have in medical profession. To what extent do grades really convert to a ‘Good Doctor’? Do enlighten us.
ANSHU: Is there a way in which the very same MCQs can be used to assess non-scholastic potential as well- especially the abilities needed to make a sensitive doctor? But on second thoughts, we'll probably have the mushrooming coaching classes teaching students how to attempt those questions and fake these abilities.
Can a mandatory one-to-one interview with a psychologist or a psychological test be of use in this scenario- so that we get entrants with the right attributes?
BALACHANDRA ADKOLI: Chetna, you have rightly echoed the sentiments expressed.
Anshu, I don't think MCQs can be used to select right kind of material for medicine, or for that matter any course involving attitudes and values. Psychological tests are more valid and useful; Qualitative tools such as document analysis, observation, indepth interview, response to case scenarios and simulations (computerized) and 360 degree assessment etc., can be utilized, but they are labour intensive, time consuming and impracticable in our situation where numbers really matter. I don’t' have any answer. But sooner or later, technology might come to help. A hanging video camera, or a chip fixed in the apron pocket can monitors the entire gamut of activities of a student and reveal his / her true color of behaviour. Watch out for academic “Tehelka” to capture the right candidate.
ANSHU: Dr Adkoli, I shudder to think of the day when we have to resort to Peeping Tom cameras to monitor our students! Tehelka or Big Brother- we've seen too much of media intrusion into our lives these days.
BALACHANDRA ADKOLI: We are caught in the trap of providing transparency and capturing non-scholastic abilities (attitudes, behaviour etc,etc) which are very important for the profession. You have furnished a strong case (including BMJ quotes) for combating depression and a host of mental illnesses affecting the medical professionals. If the care providers themselves are disturbed, who else can help? I have mentioned about electronic gadgets just to aid decision making. If they are distracting, we can find out ways and means of deploying them in a non-theatening manner. Moreover, I have proposed qualitative methods in preference to MCQs.
One more submission: Providing learning experience is more important than assessment (this is not to undermine the role of assessment). As teachers we can play a great role in reducing the exam stress, and encourage humanistic aspects. Each one of you may have your own tricks of the trade. Use them. A supporting and caring attitude may help in a big way in preventing mental disorders. Forget about video-cameras, just be what you are.
CHETNA DESAI: While we lament the lack of interest and focus in NS abilities in our teachers and students, it is interesting to read what students in UK feel about the same. Do have a look at this abstract from student BMJ:
"UK medical students feel pressured to impress with hobbies. More than two thirds of medical students feel under pressure to bolster their CV with extracurricular activities, especially with the new foundation programme seen as favouring such endeavours in the scoring process for job allocation, a BMA Student News survey found. "We are expected to be superhuman at times," said Southampton second year Anna Selby. "How is anybody supposed to be president of a university society, play a musical instrument, do volunteer work, play a sport, travel the world, and win prizes in competitions at the same time as obtaining a first class degree?"
Seventy one per cent of students questioned said that they felt under pressure to take up extra hobbies for the sake of their CV. But then again, 76% said that outside interests did make for a more well-rounded doctor, and just under two thirds said that employers should be taking notice of extracurricular activities. One student found a novel way to stand out from the crowd: "I have been a dancer at a nightclub, and I always find this attracts some attention in an interview" (www.timesonline.co.uk). Interesting isn't it?
ANSHU: I bet, if our students wrote something like this in their CV, they wouldn't be invited for an interview all their life- forget getting a job! Our societies are a world apart when it comes to freedom of expression. But this is a rather amusing difference in our perspectives.
I remember one of my early heads of department shaking his head in disapproval because I had written 'writing poems/ short stories and public speaking' as my interests in my CV. I was told anything which was not 'purely academic' needn't be on one's CV. Just write down paper presentations in conferences and publications, I was told. Now the world has changed and thankfully for the better.
MONIKA SHARMA: I don't think that is entirely true Anshu. The application format for PGIMER, Chandigarh, asks for other interests and has one empty page provided to the applicant to describe himself. You are free to describe yourself as best as you think and it does not debar extracurricular interests.
ANSHU: True. But just ask people who even bothers to read through the CVs here- some clerk/babu in the department? Who knows only exactly how many days/hours of experience you have as a senior resident or lecturer. That extracurricular activities list is one column no one reads in Indian medical schools.
MONIKA SHARMA: Here’s an interesting article: Margrain SA. Student characteristics and academic performance in higher education: A review. Research in Higher Education 1978; 8:111-123
Abstract: This is a review of the recent literature on student characteristics and their predictive potential for academic achievement. Results are not optimistic, often contradictory, and on the whole account for little variance beyond that accounted for by tests of intellectual ability. Researchers often use different performance criteria and so results are not comparable. However, there has been much complex, diverse, and unique work done on personality and motivational factors but no clear trends have emerged. Other factors investigated have been home and class background, study habits, previous withdrawal, and expectations. The review concludes by demonstrating the usefulness of the cluster analysis approach which indicates groups of students with similar patterns of characteristic criteria.
Non-Scholastic Skills Required in Various Specialities
ANSHU: Can you think of /find a good tool which can be used for all of us to do some psychological analysis on ourselves? Let's analyze whether we are in the right jobs. I for sure am that ugly duckling who has lost its way into medicine! Time to do some spring cleaning? ;-)
CHETNA DESAI: In fact I was thinking something on these lines too. Let’s debate on this.
• Leave alone circumstances that put you in this job/specialty...tell us what would have been your alternative choice(s) of profession? And back it up with a sound reasoning. Not just wishful thinking that I could have been this etc, but which NS abilities do you possess that would have made you suitable for the same? • Second, we have students coming to us before their PG counseling asking us "which subject should I specialize in? Keeping just the NS abilities in mind, how would you predict whether a particular student would make a good surgeon/ pediatrician/ physician/ anatomist/pathologist/pharmacologist and so on and so forth. Like Anshu said it’s time to introspect. One of my classmates in UG pursued his doctorate in Economics after graduation...Any such second thoughts?!
CHETNA DESAI: For example, if I am allowed to choose/select (we are not allowed to- this is wishful thinking) a student as a post graduate in Pharmacology, I would look at his/her aptitude in teaching, scientific temper, empathy and sense of justice towards animals and humans, ability to think and question, patience and perseverance.
MONIKA SHARMA: In pediatrics, I would look for empathy and sympathy for the children and their parents, a zeal for reading and a relaxed attitude.
ANSHU: I think Pathologists are the 'physician's physicians'. And here is a list of qualities that contribute towards the making of a good pathologist:
1. An eye for detail: Pathologists need to look for clues in the samples/tissues sent for their appraisal. A good pathologist must have the ability to spot anything out of the ordinary and be able to categorize it. 2. Patience: Lots of it. To wade through piles and piles of slides looking normal and not to miss the one cell that is abnormal. Even when your eyes are tired and fatigued and lids are drooping. Even when you want to leave the microscope and join your clinical friends at the coffee house, but you can't because of that one pending case which defies explanation. 3. A good memory: One of the essentials for a pathologist is to have a good visual memory. Most times we screen a slide and subconsciously compare it with a picture we have seen before. Many times when we give up, the obvious diagnosis strikes us after a refreshing sleep. And I think, this trait can be trained 4. Ability to correlate: To be able to put the pieces of clinical history, gross and microscopy together like a jigsaw puzzle and see that the picture looks perfect 5. Organizational ability: You might be the best academician around, but if you lack organizational skills you are doomed. You need to see everyday that your samples are not mixed up, your technicians are not messing up procedures and your instruments are calibrated right. Plus you need to see that your record keeping and documentation is perfect at all times- the skills of a librarian needed here. 6. Communication skills: To be able to pick up the phone and discuss with the clinician your diagnoses and your problems effectively
Besides these, other qualities like reasonable dexterity (if you are performing FNACs or biopsies or bone marrows or phlebotomies), teaching skills, and a scientific temper would also be useful.
Weightage to Extra-Curricular Activities
DINESH BADYAL: Viewpoints are now changing about students’ extracurricular activities even at higher levels. Our university has introduced giving 7% marks straightway for participating in extracurricular activities in internal assessment which is added to your final university theory marks.
In our college we have extracurricular activities of students almost every alternate month. I have seen some students getting encouragement to improve academically after they were praised for their participation in a particular extracurricular activity.
There is also transition phase in teacher's age group. Younger faculty is now joining straight as APs, these people are encouraging students or at least they are not discouraging.
TEJINDER SINGH: Dinesh, there seems to be some confusion. The marks for extra curriculars are 1% and not 7%.
DINESH BADYAL: Sir, it is percentage of internal assessment i.e. 7% and mark is 1 out of 15 (7%)
BALACHANDRA ADKOLI: 1/15 is too little, but that is a pointer to the fact that your University has valued the contribution of extra-curricular activities. I think it is like "Bhog/Prasad" given to devotees as a receipt for their "Pooja". Something is better than nothing; I have strongly upheld the role of ECAs (Extra-curricular activities), elsewhere in the discussion.
CHETNA DESAI: I think it is a very positive step by your institution. More than the 1/15, which at the moment may sound a fraction, the fact that the institute endorses these qualities rather than looks down on them is itself a big boost for the students who wish to pursue them and a necessity for those who are not very keen to do so.
Theory of Multiple Intelligences
CHANDRIKA RAO: Non-scholastic abilities may actually be a type of intelligence in which that student excels.
Multiple intelligences is a psychologist and educational theory put forth by psychologist Howard Gardner, which suggests that an array of different kinds of "intelligence" exists in human beings. Gardner suggests that each individual manifests varying levels of these different intelligences, and thus each person has a unique "cognitive" profile." The theory was first laid out in Gardner's 1983 book, Frames of Mind: The Theory of Multiple Intelligences, and has been further refined in subsequent years.
1. Linguistic Children with this kind of intelligence enjoy writing, reading, telling stories or doing crossword puzzles. Someone with a linguistic intelligence could be an author, or a poet or some sort of analyst.
2. Logical-Mathematical Children with lots of logical intelligence are interested in patterns, categories and relationships. They are drawn to arithmetic problems, strategy games and experiments. Someone with logical-mathematical intelligence could be a scientists, or some sort of biologist, even a doctor.
3. Bodily-Kinesthetic These kids process knowledge through bodily sensations. They are often athletic, dancers or good at crafts such as sewing or woodworking. Someone with bodily-kinesthetic intelligence could be a construction worker, an athlete, dancer or repairman.
4. Spatial These children think in images and pictures. They may be fascinated with mazes or jigsaw puzzles, or spend free time drawing, building with Leggos or daydreaming. Someone with spatial intelligence could be politicians or lawyers because they can figure out puzzles and put things together very quickly.
5. Musical Musical children are always singing or drumming to themselves. They are usually quite aware of sounds others may miss. These kids are often discriminating listeners. Someone with musical intelligence could be an artist, in that could be a drawing/painting/sculpting artist or a musical artist they are very good at playing a certain instrument.
6. Interpersonal Children who are leaders among their peers, who are good at communicating and who seem to understand others' feelings and motives possess interpersonal intelligence. Someone with an interpersonal intelligence could be an authority figure, policemen, as well as a politician/president type figure. Can also be a psychiatrist because they communicate with people well, and relate easily.
7. Intrapersonal These children may be shy. They are very aware of their own feelings and are self-motivated. Someone with an intrapersonal intelligence could be an activist or some type of self motivated independent figure because they are shy, but that does not mean they are not intelligent.
Gardner's theory argues that intelligence, as it is traditionally defined, does not adequately encompass the wide variety of abilities humans display. In his conception, a child who masters the multiplication table easily is not necessarily more intelligent overall than a child who struggles to do so. The second child may be stronger in another kind of intelligence.
The first criticism is that is he using the word `intelligence` when many others would use the word `ability’. There is also a feeling that the theory may lead to a sort of intellectual relativism, wherein students' failures are explained away as being an example of a different kind of intelligence, , not a lesser one.
The second major criticism is that it is fallacious to say that someone may be good in one intelligence but not in another. Hence, it has been argued that persons who excel in one type of intelligence usually excel in several others; and many times in all.
It is common to distinguish between giftedness and talent. Children who are advanced in scholastic abilities or have a high IQ are labeled gifted, while those who show exceptional ability in an art form or an athletic area are called talented. So, different people have different abilities. What do we want in a doctor anyway?
ANSHU: I agree with the theory you posted. The trend, especially in India, is to look at only academic intelligence. Thankfully with more and more Sania Mirzas, Sunidhi Chauhans and Sunita Williams emerging from India, parents are beginning to do a rethink.
Even with teachers, the mental block is huge. I remember, fifteen years ago when I decided to stand for the college elections, my friends warned me against it, saying I would fail in class, because teachers looked down upon those who participated in 'these sort of activities'. I went ahead nevertheless- without any bruises. And I didn't think too much about it- until a few years later, when my Microbiology HOD told me he was amazed that a student who was in 'politics' (if it could be called that!), would be the first one to volunteer to participate in an Immunology seminar. Are these water tight compartments? I mean, why can't people accept that a student who dabbles in dance, art or dramatics can also study. I see this mindset even today- where teachers will pass nasty remarks in a viva to a student who has prominently stood out in a drama or musical or sports performance- even if he slips up slightly- whereas low profile non- achievers are spared from similar caustic comments.
To answer your question-- in a doctor, we are looking for alertness, ability to handle stress, compassion and a certain degree of responsibility and punctuality- which translates to professionalism. An ability to multitask will be a blessing too.
SHEENA SINGH: This makes absolute sense, Chandrika. I think a doctor needs to be a jack of all traits. Does anyone remember the popular movie Patch Adams? Remembering it might bring a smile to some. You can read more about his vision at this link: http://www.patchadams.org/hospital_project/
AVINASH SUPE: Multiple intelligences are one of the ways by which we appreciate and understand non-scholastic abilities. As you and Dr Adkoli have described there are many aspects to this issue. What we should really focus is – 1. How should we appreciate the importance of these abilities in our students? 2. Develop educational environments where we balance growth of scholastic and non scholastic abilities 3. Learn as teacher to respect, recognize and grow these abilities in students without losing focus on scholastic excellence 4. These are essential for students to reduce stress of medical education - that is so common in our set up - more than 68% 5. Role of co-curricular activities in the medical school
Sending you a questionnaire to calculate multiple intelligence (Can be accessed from the link on http://nonscholastic.abilities.googlepages.com/introduction)
CHETNA DESAI: The questionnaire is interesting. I would say there should be an aptitude test for students apart from the usual entrance tests for medicine so that the students with required attitudes and qualities are selected. That way we may have lesser stress in students
MRUNAL KETKAR: Great!!! I enjoyed reading this. One question that came to my mind was- nowadays there is this fashion of finding out a child's inclination by doing various aptitude tests. Do they have this kind of basis?
MCI Rules on Internal Assessment
TEJINDER SINGH: Avinash, Recently there was a news item about the Supreme Court ruling regarding non-addition to internal assessment marks in a case related to your University. If I understood it right, it will become another nail in the coffin of medical education (like Pre PG test for example). All the talk about non-scholastic abilities in MCI document become redundant as students need to get only 35% to become eligible to appear for final exams and there will be no incentive for them to excel. Do you have any idea regarding this case/judgment?
ANSHU: http://www.tribuneindia.com/2007/20070609/main7.htm Isn’t this the judgment you were referring to?
SHEENA SINGH: It really doesn't make sense. Students need only 35% in Internal assessment to qualify for the examination. The Internal assessment marks will not add to the marks of the external assessment in the University exams to decide pass/fail. This conveys a message to the students that they do not need to worry too much about regularity and their performance in college tests and exams. Then why spend so much effort on new guidelines for compilation of the internal assessment when it contributes so insignificantly.
CHETNA DESAI: Minimum weightage to internal marks means more "self study" at homes/hostel, internal exams will be a formality, more pressures on examiners (External exams) to pass students. A few years ago at our university, the internal marks were excluded while preparing the merit list for PG admissions (we have a merit list based on 50% in university exams and 50% of an MCQ based entrance exam). We as teachers had represented and also protested to this, but it was of no use. Looks like a similar situation will come up again. Also we link any innovative TL method introduced for the students to their internal marks to ensure a better attendance and performance. Looks like such initiatives may also be affected.
Is it necessary to be a ‘Super student’? CHANDRIKA RAO: Students nowadays aim at: 1. Strive for at least 3 distinctions 2. Need to be well rounded in every aspect of my life 3. Score well on the ENTRANCE EXAMS- in short be a `super student`.
What I mean by super students is: Extra curricular activities, and work experience.
Medical schools, on their website, list the things an accepted applicant will possess. And in addition to the expected requirements they want a "well roundedness in extracurricular activities or work experience". To be clear they give examples such as; accomplished pianist, and being apart of a team sport. Why can't they just ask for one? Why do they need a collection of non-scholastic activity?
Now I'm not saying that I can't do this or that I won't. I just feel- Does anyone just want to be able to concentrate on their studies and getting experience in MEDICINE???
It definitely makes a person more complete and rounded. On the other hand not being too diverse may also help him to focus on one subject. No one asked if Beethoven could do maths or statistics. So we cannot make doctors learn other abilities, but welcome one who is proficient in it, as there are many advantages to it.
CHETNA DESAI: Agreed that students need not be super students, but the difference between Beethoven (or any musician) and doctors, is that doctors need to interact and respond. They cannot keep to themselves. They cannot remain focused on books alone. They decide the health and well being of their patients. Hence some NS abilities may need to be developed. Maybe if a doctor is a genius/ brilliant like Beethoven, his other drawbacks maybe overlooked!
ANSHU: If there is a doctor who wants to sit in his ivory tower without communicating with the outside world- I see just one place for him/ her. He needs to lock himself up in his research lab and do some Nobel Prize winning research. Core research is the only place for a loner- not clinical practice.
CHETNA DESAI: Humor filled quotes for medical graduate- do we want our students to be like this??
You are a medical graduate if.....
• you actually hope your professor assigns homework • the words "free time" are unfamiliar to you. • you spend Saturday morning waiting for the library to open. • you've memorized your professors' home phone numbers. • \your professors know your home phone number. • you are on a first-name basis with everyone on the library staff. • you can analyze the significance of appliances you cannot operate. • you have ever, as a folklore project, attempted to track the progress of your own joke across the Internet. • you are startled to meet people who neither need nor want to read • everything reminds you of something in your discipline • you have ever discussed academic matters at a sporting event. • you have ever spent a princely sum on photocopying while researching a single paper. • you regard ibuprofen as a vitamin • you find yourself explaining to children that you are in "20th grade". • you start referring to stories like "Snow White et al." • you frequently wonder how long you can live on pasta without getting scurvy.
Do we want our students to be like this??!
ANSHU: I couldn't help sharing this powerful quote from David Sackett, the Father of Evidence Based Medicine: The most powerful therapeutic tool you’ll ever have is your own personality.
Non-scholastic Abilities Required of Medical Educators ANSHU: I just discovered this document online, which outlines the competencies required of medical educators. http://www.stfm.org/fmhub/fm2007/May/Dona343.pdf
While this document is specific for teachers of Family Medicine, a lot of it can be extended to other disciplines as well. Please do make it a point to browse through Table 1 and 2 in the article.
SESSION TWO SPECIFIC NON-SCHOLASTIC ABILITIES - I CHETNA DESAI: Posting the second part of this discussion. We intend to take up some important NS abilities in Parts 2 and 3. It promises to be exhaustive, but we are prepared. So do get going!
In the second session (that will last 10 days), let us discuss the following non-scholastic abilities: 1. Communication skills: • What constitutes good communication skills? • In your opinion what is the role of communication skills in medical profession? • How can we foster these skills in students? 2. Scientific temper: • Why is scientific temper important in medical profession? • How do we develop scientific temper? • How do we hone writing and presentation skills?
Responses to Second Set of Questions
SANJAY BEDI: Communication skills: • What constitutes good communication skills? Willingness to communicate, knowledge of language, knowledge of subject
• In your opinion what is the role of communication skills in medical profession? Enormous. Communication with patients, colleagues, superiors, juniors, contemporaries in other colleges, institutes, subjects, professions • How can we foster these skills in students? Training, group discussions, debates
Scientific temper: • Why is scientific temper important in medical profession? Willingness for enquiry, credit for original thinking • How do we hone writing and presentation skills? Trai n ing and doing
MEENA PANGARKAR: Com munication skills: • What constitutes good communication skills? a) appropriate body language b) knowledge of subject c) clarity of thought and words
• In your opinion what is the role of communication skills in medical profession? A very great role- in patient interaction, student interaction, colleague interaction, etc. Also communication skills using the internet, email, letters-official and otherwise, phone manners also.
• How can we foster these skills in students? Training-teaching, being role models, inviting good trainers.
Scientific temper: • Why is scientific temper important in medical profession? Needs constant thinking, trying new ideas and approaches and checking their validity, Willingness to keep learning daily.
• How do we develop scientific temper? By training
• How do we hone writing and presentation skills? By continuous training and doing, redoing.
MONIKA SHARMA: Communication skills: • What constitutes good communication skills? Good communication skills includes not just a good base of knowledge, it is built on compassion, interpersonal understanding, the ability to explain in understandable terms. What is spoken is not as important as what is understood by the listener.
• In your opinion what is the role of communication skills in medical profession? One of the most important accessories to our profession. We read for nearly 8 years to become specialists. All that is vain if we do not understand the importance of communication, because it entails relationships with the patients/attendants as well as with colleagues and superiors. Be it the setting for a private practitioner or a teacher in medical school, communication helps and can destroy at all levels.
• How can we foster these skills in students? Group discussions are a good way of letting students develop communication skills. Community postings are another area for the same.
Scientific temper: • Why is scientific temper important in medical profession? Medicine is not just a science to be learnt once; it is an unending process of learning. Having a scientific temper entails the interest in continuing medical education, which is the only way to be up to date to knowledge of your own practice.
• How do we develop scientific temper? Journal clubs
• How do we hone writing and presentation skills? Seminars and integrated presentations. Journal clubs for UGs and PGs. College journals/papers can provide fertile ground.
AROMA OBEROI: My responses 2 second round are 1) Communication skills demand willingness, thoughtful thinking & good command, leadership. 2) It can be developed by training, group discussion
COMMUNICATION SKILLS
The Need for Communication Skills
SANJAY BEDI: Communication is the process of generation, transmission, or reception of messages to oneself or another entity, usually via a mutually understood set of signs. http://en.wikipedia.org/wiki/Communication_basic_topics
ANSHU: I'm pasting an excerpt from Dr Atul Gawande's Commencement Address to the Harvard Medical School in 2005. Does it make sense to you? I loved it. Read on...
“...So as you become a white-coated cog in this machine, this remarkable and at the same time maddening factory of health care, how do you not disappear? How do you matter?
My Rule #1 for you comes from a favorite essay by the writer Paul Auster: "Ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them?"
On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see, two pages to return, and the hour is getting late. In the instant, all you will want is to get things over with. "Where's the pain, the lump, whatever it is?" "How long has it been there?" "Does anything make it better or worse?" "What are your past medical problems?"
You all know the drill by now.
But I want you, at an appropriate point, to take a small moment with your patient. Make yourself ask an unscripted question: "Where did you grow up?" Or "What made you move to Boston?" Or, "Did you watch last night's Red Sox game?" I¹m not looking for a deep or important question, just one that lets you make a human connection.
Some people will not be interested in making that connection. They just want you look at the lump. That's okay. Look at the lump in that case. Do your job.
You will find that many respond, however -- because they're polite, or friendly, or perhaps in need of that human contact. When this happens, see if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn. This is not a 46 year old male with a right inguinal hernia. This is a 46 year old former mortician, who hated the funeral business, with a right inguinal hernia.
You can do this for more than just patients, too. Ask a random question of the ICU nurse you see on rounds, the medical assistant who checks their vitals. It's not that doing this necessarily helps anyone. But you will start to remember the people you see, instead of having them all blur together. Sometimes you will discover the unexpected.
I learned, for instance, that an elderly Pakistani phlebotomist I saw every day in residency had been a general surgeon in Karachi for twenty years, but emigrated for the sake of his children's education. I learned that a quiet, carefully buttoned-down nurse I work with had once traveled with Jimi Hendrix on tour.
The machine will gradually feel less like a machine.”
CHETNA DESAI: That’s just what "Munnabhai" told us! My clinician friends often narrate that how inspite of the huge rushes in the OPD, the women patients would like to discuss their mothers-in- law, their kids, bahus, they would comment on the saree my friend was wearing etc etc. It takes a lot of tact and patience to listen and at the same time proceed to the next patient! One more difference in our Indian scenario-the age old "barter" system still exists. You treat a pati e nt and he showers you with what he can get-a bag of wheat, some mangoes maybe, a home made recipe and also perfume/watches from a trip abroad and anything they think they can do to "repay". The human rather than the commercial element of the barter is witnessed.
MRUNAL KETKAR: I was reminded of the very first clinic that we take for the 3rd semester students--The clinic on History taking. While elaborating about the importance of asking the name of the patient the first thing we say is- developing a rapport with the patient apart from record keeping, knowing about religion etc.
How many of us especially in OPD pay attention to this aspect? In wards after the patient is admitted, we get more time to talk and there are repeated encounters- but what about OPD?
CHETNA DESAI: Often when we go visiting patients in wards, the nurses/some doctors can place them- not by names but by their date or day of admission /ailment or diagnosis / bed number. It is like we remember students by batch numbers or roll numbers. But is it easy to remember all patients by their names especially in OPD when the actual contact time is so short?
HIMANSHU PANDYA: Please find my partial response to second session.
Important connection between communication and clinical reasoning: Understanding patient's biological, psychosocial and cultural background is necessary for effective patient care. A physician must use communication skills, biomedical knowledge and clinical judgment to generate and modify diagnostic hypotheses (i.e., clinical reasoning). Successful use of these skills is linked to important outcomes including improved diagnostic and clinical proficiency, decreased medical errors, reduced emotional distress, and increased patient and physician satisfaction. Research shows many inadequacies in clinicians' skills including incomplete solicitation of patient concerns and inconsistent exploration of psychosocial issues. These practices can lead to inappropriate prioritization of problems, impaired clinical reasoning and poor therapeutic alliances with the potential for medical error and harm.
Studies suggest that communication skills training may improve students' ability to gather accurate, relevant information. Both biomedical and psychosocial history informs clinical reasoning. Teaching communication and clinical reasoning in isolation may prevent students from understanding the important link between these skills and may lead them to undervalue the psychosocial aspects of patient care.
Attached please find an article about educational intervention to teach connection between communication skills and clinical reasoning. http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2005.0244.x
CHETNA DESAI: Thanks Himanshu, for responding and for a nice article that validates the importance of communication skills in our profession. Proper Communication not helps the doctor from becoming a robot that does repetitive jobs mechanically, but makes medicine an art. It also gives a patient the satisfaction of being attended well.
CHETNA DESAI: Posting an article which is quite elaborate touching upon various aspects of a medical interview. Worth a read. www.link.med.ed.ac.uk/RIDU/welsby/Comm%20Skills.pdf
ANSHU: See how we stop the patient from communicating with us? Here are some excerpts from the BMJ for your comments.
Key tasks in communication with patients
• Eliciting (a) the patient's main problems; (b) the patient's perceptions of these; and (c) the physical, emotional, and social impact of the patient's problems on the patient and family • Tailoring information to what the patient wants to know; checking his or her understanding • Eliciting the patient's reactions to the information given and his or her main concerns • Determining how much the patient wants to participate in decision making (when treatment options are available) • Discussing treatment options so that the patient understands the implications • Maximizing the chance that the patient will follow agreed decisions about treatment and advice about changes in lifestyle
Blocking behaviour
• Offering advice and reassurance before the main problems have been identified • Explaining away distress as normal • Attending to physical aspects only • Switching the topic • “Jollying” patients along
Reasons for patients not disclosing problems·
• Belief that nothing can be done • Reluctance to burden the doctor • Desire not to seem pathetic or ungrateful • Concern that it is not legitimate to mention them • Doctors' blocking behaviour • Worry that their fears of what is wrong with them will be confirmed
SANJAY BEDI: The Communication Process
Communication: That is what we try to do. Speak to those near us Thought: First, information exists in the mind of the sender. This can be a concept, idea, information, or feelings. Encoding: Next, a message is sent to a receiver in words or other symbols. Decoding: lastly, the receiver translates the words or symbols into a concept or information that he or she can understand.
During the transmitting of the message, two processes will be received by the receiver: content and context.
Content is the actual words or symbols of the message which is known as language - the spoken and written words combined into phrases that make grammatical and semantic sense. We all use and interpret the meanings of words differently, so even simple messages can be misunderstood. And many words have different meanings to confuse the issue even more. Context is the way the message is delivered and is known as Paralanguage - it includes the tone of voice, the look in the sender's eye's, body language, hand gestures, and state of emotions (anger, fear, uncertainty, confidence, etc.) that can be detected. Although paralanguage or context often causes messages to be misunderstood as we believe what we see more than what we hear; they are powerful communicators that help us to understand each other. Indeed, we often trust the accuracy of nonverbal behaviors more than verbal behaviors.
Some leaders think they have communicated once they told someone to do something, "I don't know why it did not get done...I told Jim to it." More than likely, Jim misunderstood the message. A message has NOT been communicated unless it is understood by the receiver (decoded). How do you know it has been properly received? By two-way communication or feedback. This feedback tells the sender that the receiver understood the message, its level of importance, and what must be done with it. Communication is an exchange, not just a give, as all parties must participate to complete the information exchange.
Barriers to Communication
Nothing is so simple that it cannot be misunderstood. - Freeman Teague, Jr.
Anything that prevents understanding of the message is a barrier to communication. Many physical and psychological barriers exist:
Culture, background, and bias - We allow our past experiences to change the meaning of the message. Our culture, background, and bias can be good as they allow us use our past experiences to understand something new, it is when they change the meaning of the message then they interfere with the communication process.
Noise - Equipment or environmental noise impede clear communication. The sender and the receiver must both be able to concentrate on the messages being sent to each other.
Ourselves - Focusing on ourselves, rather than the other person can lead to confusion and conflict. The "Me Generation" is out when it comes to effective communication. Some of the factors that cause this are defensiveness (we feel someone is attacking us), superiority (we feel we know more that the other), and ego (we feel we are the center of the activity).
Perception - If we feel the person is talking too fast, not fluently, does not articulate clearly, etc., we may dismiss the person. Also our preconceived attitudes affect our ability to listen. We listen uncritically to persons of high status and dismiss those of low status.
Message - Distractions happen when we focus on the facts rather than the idea. Our educational institutions reinforce this with tests and questions. Semantic distractions occur when a word is used differently than you prefer. For example, the word chairman instead of chairperson, may cause you to focus on the word and not the message.
Environmental - Bright lights, an attractive person, unusual sights, or any other stimulus provides a potential distraction.
Smothering - We take it for granted that the impulse to send useful information is automatic. Not true! Too often we believe that certain information has no value to others or they are already aware of the facts.
Stress - People do not see things the same way when under stress. What we see and believe at a given moment is influenced by our psychological frames of references - our beliefs, values, knowledge, experiences, and goals.
These barriers can be thought of as filters, that is, the message leaves the sender, goes through the above filters, and is then heard by the receiver. These filters muffle the message. And the way to overcome filters is through active listening and feedback.
Active Listening
Hearing and listening are not the same thing. Hearing is the act of perceiving sound. It is involuntary and simply refers to the reception of aural stimuli. Listening is a selective activity which involves the reception and the interpretation of aural stimuli. It involves decoding the sound into meaning.
Listening is divided into two main categories: passive and active. Passive listening is little more that hearing. It occurs when the receiver or the message has little motivation to listen carefully, such as music, story telling, television, or being polite.
People speak at 100 to 175 words per minute, but they can listen intelligently at 600 to 800 words per minute (WPM). Since only a part of our mind is paying attention, it is easy to go into mind drift - thinking about other things while listening to someone. The cure for this is active listening - which involves listening with a purpose. It may be to gain information, obtain directions, understand others, solve problems, share interest, see how another person feels, show support, etc . It requires that the listener attends to the words and the feelings of the sender for understanding. It takes the same amount or more energy than speaking. It requires the receiver to hear the various messages, understand the meaning, and then verify the meaning by offering feedback.
The following are a few traits of active listeners: • Spends more time listening than talking. • Do not finish the sentence of others. • Do not answer questions with questions. • Are aware of biases. We all have them...we need to control them. • Never daydreams or becomes preoccupied with their own thoughts when others talk. • Lets the other speaker talk. Does not dominate the conversation. • Plans responses after the other person has finished speaking...NOT while they are speaking. • Provides feedback, but does not interrupt incessantly. • Analyzes by looking at all the relevant factors and asking open-ended questions. • Walks the person through your analysis (summarize). • Keeps the conversation on what the speaker says...NOT on what interests them. • Takes brief notes. This forces them to concentrate on what is being said.
Feedback When you know something, say what you know. When you don't know something, say that you don't know. That is knowledge. - Kung Fu Tzu (Confucius)
The purpose of feedback is to change and alter messages so the intention of the original communicator is understood by the second communicator. It includes verbal and nonverbal responses to another person's message.
Providing feedback is accomplished by paraphrasing the words of the sender. Restate the sender's feelings or ideas in your own words, rather than repeating their words. Your words should be saying, "This is what I understand your feelings to be, am I correct?" It not only includes verbal responses, but also nonverbal ones. Nodding your head or squeezing their hand to show agreement, dipping your eyebrows shows you don't quite understand the meaning of their last phrase, or sucking air in deeply and blowing it hard shows that you are also exasperated with the situation.
Carl Roger listed five main categories of feedback. They are listed in the order in which they occur most frequently in daily conversations. Notice that we make judgments more often than we try to understand:
Evaluative: Making a judgment about the worth, goodness, or appropriateness of the other person's statement.
Interpretive: Paraphrasing - attempting to explain what the other person's statement means.
Supportive: Attempting to assist or bolster the other communicator.
Probing: Attempting to gain additional information, continue the discussion, or clarify a point.
Understanding: Attempting to discover completely what the other communicator means by her statements.
Imagine how much better daily communications would be if listeners tried to understand first, before they tried to evaluate what someone is saying.
Speaking Hints
Speak comfortable words!" - William Shakespeare
When speaking or trying to explain something, ask the listeners if they are following you. Ensure the receiver has a chance to comment or ask questions. Try to put yourself in the other person's shoes - Consider the feelings of the receiver. Be clear about what you say. Look at the receiver. Make sure your words match your tone and body language (Nonverbal Behaviors). Vary your tone and pace. Do not be vague, but on the other hand, Do not complicate what you are saying with too much detail. Do not ignore signs of confusion.
On Communication per se (a few random thoughts)
On Discussing Communication
Trying to speak of something as messy as communication in technical terms seems to be another form of the "math and science" argument, that is, math and science and technology are the answer to all of our problems. – Anonymous
But what forms of human behavior are not messy? Learning is not "antiseptic," yet it is discussed all the time -- we do not leave it to the academics, Bloom, Knowles, Dugan, or Rossett.
Leadership and management topics seems to be even messier, yet we categorize it, build models of it, index it, chop it and slice it and dice it, build pyramids out of it, and generally have a good time discussing it.
But when it comes to "communication," we call it too messy to play with and leave it up to Chomsky, Pinker, and others to write about so that we can read about it. Yet we all communicate almost every single day of our lives, which is much more than we will ever do with learning or leadership.
CHETNA DESAI: Here’s a technique for better communication: The purpose of communication is mutual understanding. Patients, their families, and doctors all need to be understood. When conflict arises, health care professionals can justifiably feel attacked and respond by defending themselves. The usual result is a closing down of the conversation and more difficulties for both doctors and patients.
Here is a nice excerpt from the family physician about the right way of communication with patients: Rather than defending yourself, it is often more effective to look for a genuine way of agreeing with patients or families, of empathizing with their positions, and of inquiring whether your perceptions are correct and whether they wish to pursue working together. This tends to open up the conversation and to promote understanding. A simple mnemonic for remembering this technique uses the vowels A, E, I, O, and U (Table 1). Table 1. Mnemonic device can help improve communication A – agreeing E – empathizing I – inquiring O – opening U – understanding http://www.cfpc.ca/cfp/2002/Aug/vol48-aug-clinical-2.asp
Learning the Local Language
DINESH BADYAL: In India, language is one of the problems, especially as doctors cross state boundaries. All the above mentioned points are very difficult to explain to patients. I joined KMC Hubli to do my MBBS through the All India premedical examination. Communication is so difficult. Patients speak and expect us to speak in typical local language. Even if you learn the language you can not speak typical dialect. Chandigarh Medical College has appointments through UPSC, so from teachers are coming from all parts of India.
In Punjab also if you are in government sector, and posted in a dispensary, it is difficult to understand the typical words. There are 3 types of Punjabi languages in Punjab. I served in a dispensary in a remote area in my internship.
ANSHU: I remember when I first joined medical college, history taking was a tough one, because it was crazy understanding the rural dialects in Marathi. But I had it far easier than some CBSE students who had come from the south or the far-east. I remember one Keralite senior giving up his hard earned PG seat in Medicine because he couldn't read the name of the patient written in Marathi on OPD forms, call out their names or communicate effectively. At that time, I thought he was crazy to do that. But now I understand his predicament. India, being so vast, will always have this problem. I think JIPMER used to conduct classes in Tamil for its non-Tamil speaking students.
Other than language, local customs make a huge difference. Here in Maharashtra, it is respectful to address a female patient as 'Bai', while in the North, you will be instantly thrashed for uttering that word. In the Punjab, addressing a woman as 'Bibi' is respectful, elsewhere expect a whacking from your patient if you ever dared that. I have known doctors trained in one part of the country finding it tough to adapt to a different form of address.
So the principle essentially is- In Rome do as the Romans do.
TEJINDER SINGH: True Anshu. It can at times be both funny and disastrous. I remember, one of our non-Punjabi speaking doctors telling the mother of a child with measles- 'Bibi, ye to khusra hai'. You can imagine, what must have happened then.
CHETNA DESAI: Just to lighten up your weekend and rejuvenate u all, a few actual medical notes! The woes of bad written communication!
• The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately. • Exam of genitalia reveals that he is circus sized. • The skin was moist and dry. • Rectal exam revealed a normal size thyroid. • She stated that she had been constipated for most of her life until 1989 when she got a divorce. • The patient was in his usual state of good health until his airplane ran out of gas and crashed. • I saw your patient today, who is still under our car for physical therapy. • The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week. • Bleeding started in the rectal area and continued all the way to Los Angeles. • She is numb from her toes down. • The patient had waffles for breakfast and anorexia for lunch. • Exam of genitalia was completely negative except for the right foot. • While in the emergency room, she was examined, X-rated and sent home. • The lab test indicated abnormal lover function. • The patient was to have a bowel resection. However he took a job as a stockbroker instead. • Occasional, constant, infrequent headaches. • Coming from Detroit, this man has no children. • Examination reveals a well-developed male lying in bed with his family in no distress. • Patient was alert and unresponsive. • When she fainted, her eyes rolled around the room. • She has no rigors or shaking chills, but her husband states she was very hot in bed last night. • Patient has chest pain if she lies on her left side for over a year. • On the second day the knee was better, and on the third day it disappeared. • The patient is tearful and crying constantly. She also appears to be depressed. • The patient has been depressed since she began seeing me in 1993. • Discharge status: Alive but without my permission. • Healthy appearing decrepit 69 year old male, mentally alert but forgetful. • The patient refused autopsy. • The patient has no previous history of suicides. • Patient has left white blood cells at another hospital. • Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days. • Patient had waffles for breakfast and anorexia for lunch. • Both breasts are equal and reactive to light and accommodation. • The lab test indicated abnormal lover function. • Skin: somewhat pale but present. • The pelvic exam will be done later on the floor. • Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree. • Large brown stool ambulating in the hall. • Patient has two teenage children, but no other abnormalities.
Breaking Bad News
CHETNA DESAI: A vital duty of a doctor is conveying bad news to patients or their relatives, be it a bad prognosis, mortality or sometimes probable difficulties like huge expenses etc.
Nothing tests our communication skills so much as breaking bad news. Such conversations can be extremely emotional for both doctor and patient. The right words said in the right way make a huge difference. Here are some tips:
• Be well informed about the case, including the details. The patient may ask questions that may need convincing answers. • Speak to the nurse in charge of the patient and ask him or her to be present during the conversation • Ensure privacy • Arranging the conversation in advance and ensure that appropriate family members or carers are present • Introduce yourself and ask questions that will give you clues to the patient's ideas, concerns, and expectations • Avoid jargon. Give information slowly and clearly, making sure that the patient has time to understand • The crucial point in the conversation is the "bad news" itself. Explain the situation in a simple, unambiguous way and let the information sink in. • Be flexible in your approach; depending on the patient's reaction and response. • Discuss further options, Remember to give hope as well as information. • Observe experienced seniors and also ask for feedback from nurses.
More on this on this link http://www.aafp.org/afp/20011215/1975.html
ANSHU: Your mail reminded me of the time when I was a naive week-old house officer in Surgery. One Saturday afternoon, there was an accident where a Trax had turned turtle and a number of people had died. My ward was choc-a-bloc with patients and relatives- mostly with minor cuts and bruises. Except one young man with a severe head injury with a bad prognosis.
It was extremely difficult to move around in the ward with around 25-30 relatives surrounding each bed. To top it all, there was a gang of saffron wielding boys in that group who saw threatening doctors as the best way to get their patient more attention. I had the misfortune of being with an extremely spineless casual registrar and an even more irresponsible medical officer. None of them bothered to either talk to the relatives about the prognosis or even request them to leave the ward politely or understand my predicament of being new to the job. I did my best- with the informed consent and my requests to leave the ward in peace. But the very same gangsters came down to some very abusive screaming in the wards.
On Sunday morning, the patient with the head injury collapsed further- there was no scope of his recovery by then. And though we had done a CT scan the previous evening, my Medical Officer wanted me to get a repeat CT scan again after the rounds. A tracheostomy was first done and moments later I was instructed to shift the patient to Radiology, despite my protests that I needed to ensure that some resident was there in CT Scan before I took the stretcher there. It was the scariest trip of my life. Behind the stretcher, there were at least 30 of these tough political hooligans- who kept threatening to kill me if something happened to their patient- and I was all alone. When I reached the CT room- my worst fears came true- the Radiology resident was missing. And while I managed to shift the stretcher inside and get the resident there- the worst happened- the tracheostomy was perhaps not done properly by the ENT chaps and started bleeding profusely. To manage the patient and survive from that crowd- was the worst nightmare I could have had. We abandoned the CT and rushed the patient to the ICU where he expired in a few hours. But the nurses didn't allow me to leave the ICU till 5 in the evening through a back door saying the crowd was baying for my blood. I was told not to come for the evening rounds either because those guys smashed a lot of things in the ward, threatening to bring in the journalists and media.
It was extremely tough, and I was absolutely shaken. I always felt I had just followed instructions and did my best- but I had never been taught to cope with relatives like these. I still hold my seniors responsible because they all wanted their Sunday off, and didn't bother to stand by me, even when they knew I was new to the job.
Now, I hear stories in the media off and on about residents being manhandled and abused. What is the way out- when emotions and tempers run high- logic flies out of the window? Where's the solution?
CHETNA DESAI: It sure is difficult being a junior in an emergency such as this. A few years ago, the situation was similar at our hospital too. Residents would fend for themselves on Sundays and seniors called ONLY when necessary as per hierarchy. Actually assistant professors were supposed to remain present or at least accessible but they never were. You know what set things right? A relative of a political "VIP" was at the "suffering" end-and then we had posting orders, checks etc etc. Like they say "It happens only in India" Now we had APs round the clock and seniors on call.
But I guess it should be rule rather than a political compulsion. Emergencies such as what you described should not be handled this way. Out here too we have instances of residents slapped/beaten up by relatives of patients. A flash strike follows and what not. It leaves us wondering whose fault it is- the patient's relatives or the resident (who is often overworked) or the system?
TEJINDER SINGH: The major reason, in my experience, of relatives showing aggressive behaviors is most often lack of adequate communication. If you keep the relatives well informed right from the beginning, taking care not to give any false hopes- most of them want this and often will 'trap' the doctor into saying that patient will become alright- then they take even an adverse outcome well. Some degree of emotional outburst is normal but targeting of doctors is seen only when there has been a breakdown of communication. I have seen parents touching my feet before going even after death of their child and also those threatening to lodge a police case. In my introspection, keeping them well informed-correctly- will avoid this problem.
CHETNA DESAI: Patients believe that doctors are Gods and in difficult situations such as emergencies or serious/terminal illnesses, this belief becomes a wishful thinking. At such times, as you rightly mentioned, it’s important not to give them false hopes and also remind them that we are not God. Such honesty usually avoids problems.
MRUNAL KETKAR: I too will say that keeping the relatives well informed goes long way to avoid such problems. It is always a good practice - that after seeing especially a critical patient, explain patient's condition to some responsible and sensible relatives in layman's terms as they would not understand medical jargon.
Anshu, I would slightly differ from your opinion. Not all doctors are heartless. They have the compassion that comes automatically with the training.
ANSHU: Dear Mrunal, I'm sorry, but did I say anywhere that I think doctors are heartless? I didn't. I don't hold that opinion at all.
AVINASH SUPE: This is one of the most necessary and useful skills we want our students to learn.
The doctor should be able to recognize the situation, prepare relatives for the adverse event and make relatives accept the death of loved ones. The situation can be very alarming and may require lot of maturity.
As Tejinder said - we do come across these situations very often and learn to handle it well with experience.
MONIKA SHARMA: The most suitable approach is to keep the relatives informed of daily happenings. Once a day talk with patients not only gives them a sense of information it also helps in creating a sense of trust in the doctor.
Most of the sad situations arise when we talk less with the patient or leave it on the residents to do the talking and arrive only in the end. Also in such situations having a prior idea about what the resident has spoken prior to your arrival helps. Speaking a different thing creates an embarrassing situation.
But there are some people who are aggressive in every situation in life- only tact can help you then.
BALACHANDRA ADKOLI: The importance of right communication has been amply stated in our ancient scripture in Sanskrit - "Satyam brooyat, Priyam brooyat; Na brooyat Sathyam- apriyam"; Speak truth, speak in a sweet manner; don't speak bitter truth".
Most problems can be avoided when we explain clearly the diagnosis and the prognosis in a correct and palatable manner.
I think this can be emphasized during bed-side teaching or ward rounds in concert with the health team members, especially the nursing staff, and a medico social worker.
As Tejinder has put it, giving false hopes is more atrocious than accepting the limitations of a system with humility. In case of chronic and terminal patients, counselling the immediate kin would be highly desirable to prepare the family for the eventuality.
Assertiveness Vs Aggressiveness
CHETNA DESAI: Consider the following scenarios that we encounter:
• Your patient does not follow your instructions and insists on breaking rules. • You have a conflict with your colleague with regard to a clinical diagnosis/policy matter in the department. • Communicating with patients requires skill and tact. Frayed tempers, aggressive and demanding patients/relatives and verbal assaults are witnessed in OPDs very often. While the patients usually respond and comply with the doctor's instructions, some are aggressive and uncooperative. How then we deal with these situations? Similarly conflicts and difference of opinion with colleagues happen.
How to be assertive with your patients/colleagues without being aggressive? Here are a few tips...
• be clear about what you feel, what you need and how it can be achieved • communicate calmly without attacking another person • saying "yes" when you want to, and saying "no" when you mean "no" (rather than agreeing to do something just to please someone else) • deciding on, and sticking to, clear boundaries • being confident about handling conflict if it occurs • understanding how to negotiate if two people want different outcomes • being able to talk openly about yourself and being able to listen to others • having confident, open body language • being able to give and receive positive and negative feedback • having a positive, optimistic outlook
Is it easy? I am not sure. Your thoughts please.
CHETNA DESAI: Here is a nice article on handling aggressive patients I am sure all of you with busy OPDs do come across such situations often. You will find the tips useful. Please refer to this link http://careerfocus.bmj.com/cgi/reprint/333/7563/63-a.pdf
MONIKA SHARMA: Though I am not the kind to argue, even if it is to prove my own point and usually don't have hassles with colleagues, my silence and often lack of assertiveness ends with me having to end up in unhappy and misunderstood situations. Though I cannot point to a particular situation, it has happened in most of my work situations, be it college, post graduation or further. Though I was never wrong, at that point I was misunderstood because I was not the first to explain my position or maybe explain convincingly.
I admire people with the skill to convince people and get their point across without itching people around. I have often felt the need to develop this skill of talking effectively. And because I lack this skill, I keep my mouth shut which only aggravates the situation.
ANSHU: I think a lot of your problems deal with the issue that Chetna raised previously i.e. being assertive without being aggressive. I was in a college council meeting this evening, and came back highly impressed with one particular professor who managed to say his bit in a highly hostile environment. All this just because he used the right bit of humor, which relaxed the tension instantly. One need not offend when one puts one's point forward. But I agree that it needs practice and tact to speak your mind without bruising egos. One needn't flatter others either. And I guess when you speak without beating around the bush always, people learn to take you seriously, and accept that you are someone who doesn't believe in sycophancy.
As for me, when I can't give vent to my feelings by speaking out, I make it a point to write my point across. So my poor Head of Department is now used to receiving emails when I think something is out of place and can be improved. Writing helps me because no one interrupts my train of thought and I can express myself more clearly. There are times when I cannot sleep when something plagues me, and I am a frequent 1 a.m. mail writer!
CHETNA DESAI: Writing mails is a good way. The situation of conflict would have cooled down by the time the person reads the mail and things can be viewed more objectively. However it may also convey that we are not upfront/ bold enough to speak up. Keeping your head cool by "counting ten" also helps. It is also not always necessary to be assertive through words. Action can also display assertiveness. But there is a very thin line between aggressiveness and assertiveness. While we may think we are being assertive, the other person who may be "affected" by our assertiveness will label you as aggressive. So it’s all a game of balancing the situation.
TEJINDER SINGH: Assertiveness is a skill, which can definitely to learnt and mastered with practice. A number of times, we are passive, at others, aggressive (sometimes even passive aggressive, like banging the doors etc) but not assertive. There are a number of small self help books giving small lessons on assertiveness. Some of the tips that they teach are very simple but imaginative and meaningful.
SANJAY BEDI: One award winning book on this topic is “Don't Say Yes When You Want to Say No”. I read it years ago and refer it again and again.
Avoiding Medical Jargon
ANSHU: Yes, please let's discuss how we can speak to the patient avoiding medical jargon. It is pretty tough to explain technical stuff in plain English, forget about translating it into the local language.
CHETNA DESAI: Which is easier? Teaching medical jargon to millions of patients, or teaching people in the health care industry to talk and write in plain English? It amounts to "health illiteracy". A few problems commonly observed are:
People cannot understand instructions on how to take medicines and care for their own illnesses. Those instructions often appear on patient information sheets and handouts.
Patients also have to deal with consent forms for procedures like surgery; health insurance claim forms; advertising for prescription drugs; safety warnings on package labels; instructions for using medical devices; and other written material. Studies reveal that health literacy is not just a problem of poor, uneducated people who lack general reading and writing skills. Even well educated people have trouble understanding doctors and nurses. The problem is compounded in India due to various dialects and low awareness of patients too.
How to avoid medical jargon:
• Be conversational in your approach, going to patients' level of understanding if necessary. • Use simple language and cut the jargon. • Explain technical terms. • Write in the active voice. • In case of insurance claim forms, consent forms etc, have a dry run on volunteers.
Incidentally the GCP guidelines for clinical trials make it mandatory that the informed consent forms for patients/volunteers participating in a trial should be in written in the language that the patient understands. But what about the other documents used in day to day practice or can we say for the patients- ‘Ignorance is bliss’?
ANSHU: I am reminded of the time when I was being investigated before I donated my kidney and my radiologist incidentally discovered gallstones. As my flamboyant surgeon discussed with me why he had changed his opinion about removing my left kidney (which was easier) - to a right nephrectomy with cholecystectomy- presumably to allay my fears he said, “We have published entire series about this kind of dual surgery!" To which my instant response was," Excuse me Sir, am I just another thesis case to you?!" and for a moment his jaw dropped! We shared that private joke and he always referred to me as 'thesis case' thereafter.
But on hindsight, as a doctor, I understood his need to flaunt statistics. How would it have sounded to a layperson?
MONIKA SHARMA: Your remarks on the overt display of statistics is not new, however, there are situations where it is essential.
I encountered this situation very often in my neonatal unit posting. Though it is not uncommon in other fields either (your case is one example), where parents would want to know the prognosis of a certain disease state, for e.g. prognosis regarding the final expected outcome of a baby born with a weight of less than 1000 grams. Since we have no hold over future, it is usually difficult to comment on an individual case. There have been n number of cases where a well looking 800 gram neonate died suddenly on the 40th day of life as a result of aspiration of feeds, and sick looking 600 gramers survive to go home.
The best response in such a situation while talking to parents is to give the statistics as such and let them decide for their baby.
I have attended a couple of lectures on how to talk to parents and it has always been taught to be acquainted with the statistics.
Of course, communication skills are important here too. I can't just say that survival rate is 40% and expect the less literate or even literate parents to understand how it stands for their child. Use of laymen terms to get your point across is essential.
Communication is an art that either comes naturally or is acquired over time. I really appreciate the natural communicators. I am reminded of one of my seniors in Chandigarh. We (as senior residents) were expected to present every mortality in front of the department, which meant being skinned for every petty mistake that may have been made during the management. LAMAs (left against medical advice) however escaped presentation on occasions. This resulted in some senior residents devising what we nicknamed as ‘lama-therapy’, where parents were counseled by the responsible SR regarding the status and prognosis of the child. This counseling session often resulted in some parents refusing further treatment and opting to go home with a baby that was dead by the time they reached home (it was pathetic that such a thing was done, but before you comment on it, let me tell you it goes on in most institutes. We as consultants need to think about it too.)
Well, this particular SR was just too good at his ‘lama’ counseling. At the end of his session, parents would be asking for lama, while he would be apparently trying not to send them, which meant he would present it as, 'I tried to convince them not to go, but they were adamant and signed for lama'
I have always appreciated his communication skills though have also loathed his casual approach to patients, not to forget that at the end of his tenure, he went off red faced for other unethical acts committed.
CHETNA DESAI: I have always felt that statistics mean little to patients/relatives. Even if the patient is told that the chances of survival is-let’s say 1%- he would always insist/wishfully think that he belongs to the likely to survive 1% rather than the remaining 99%. Best is we should not try to play God and inform them as objectively as possible without sounding unconcerned or helpless. Our patients usually believe in destiny and fate and are able to accept things rather stoically in most cases.
Non verbal communication
ANSHU: Your mail about communication without words leads me to wonder: How much do non-verbal cues and body language matter in the life of a doctor? When you are looked upon as a saviour and as God, how human can you afford to be? Does one have to exude confidence even when one feels unsure? Why do surgeons always look cocksure- an inherent trait?
SANJAY BEDI: Nonverbal Behaviors of Communication
Without knowing the force of words it is impossible to know men." – Confucius
To deliver the full impact of a message, use nonverbal behaviors to raise the channel of interpersonal communication:
Eye contact: This helps to regulate the flow of communication. It signals interest in others and increases the speaker's credibility. People who make eye contact open the flow of communication and convey interest, concern, warmth, and credibility.
Facial Expressions: Smiling is a powerful cue that transmits happiness, friendliness, warmth, and liking. So, if you smile frequently you will be perceived as more likable, friendly, warm and approachable. Smiling is often contagious and people will react favorably. They will be more comfortable around you and will want to listen more.
Gestures: If you fail to gesture while speaking you may be perceived as boring and stiff. A lively speaking style captures the listener's attention, makes the conversation more interesting, and facilitates understanding.
Posture and body orientation: You communicate numerous messages by the way you talk and move. Standing erect and leaning forward communicates to listeners that you are approachable, receptive and friendly. Interpersonal closeness results when you and the listener face each other. Speaking with your back turned or looking at the floor or ceiling should be avoided as it communicates disinterest.
Proximity: Cultural norms dictate a comfortable distance for interaction with others. You should look for signals of discomfort caused by invading the other person's space. Some of these are: rocking, leg swinging, tapping, and gaze aversion.
Vocal: Speaking can signal nonverbal communication when you include such vocal elements as: tone, pitch, rhythm, timbre, loudness, and inflection. For maximum teaching effectiveness, learn to vary these six elements of your voice. One of the major criticisms of many speakers is that they speak in a monotone voice. Listeners perceive this type of speaker as boring and dull.
Paul Ekman
In the mid 1960s, Paul Ekman studied emotions and discovered six facial expressions that almost everyone recognizes world-wide: happiness, sadness, anger, fear, disgust, and surprise. Although they were controversial at first, he was booed off the stage when he first presented it to a group of anthropologists and later called a fascist and a racist, they are now widely accepted. One of the controversies still lingering is the amount of context needed to interpret them. For example, if someone reports to me that they have this great ideal that they would like to implement, and I say that would be great, but I look on them with a frown, is it possible that I could be thinking about something else? The trouble with these extra signals is that we do not always have the full context. What if the person emailed me and I replied great (while frowning). Would it evoke the same response?
Emotions Trust your instincts. Most emotions are difficult to imitate. For example, when you are truly happy, the muscles used for smiling are controlled by the limbic system and others, which are not under voluntary control. When you force a smile, a different part of the brain is used -- the cerebral cortex (under voluntary control), hence different muscles are used. This is why a clerk, who might not have any real interest in you, has a "fake" look when he forces a smile. Of course, some actors learn to control all of their face muscles, while others draw on a past emotional experience to produce the emotional state they want. But this is not an easy trick to pull off all the time. There is a good reason for this -- part of our emotions evolved to deal with other people and our empathic nature. If these emotions could easily be faked, they would do more harm than good (Pinker, 1997).
So our emotions not only guide our decisions, they can also communicated to others to help them in their decisions -- of course their emotions will be the ultimate guide, but the emotions they discover in others becomes part of their knowledge base.
Mehrabian and the 7%-38%-55% Myth
We often hear that the content of a message is composed of:
55% of the content from the visual component 38% from the auditory component 7% from language
However, the above percentages only apply in a very narrow context. A researcher named Mehrabian was interested in where people get information about a speaker's general attitude is positive, neutral, or negative, towards the person the speaker is addressing in situations where the facial expression, the tone, and the words might be sending conflicting signals. Thus, he designed a couple of experiments. In one, Mehrabian and Ferris (1967) researched the interaction of speech, facial expressions, and tone. Three different speakers were instructed to say "maybe" with three different attitudes towards their listener (positive, neutral, or negative). Next, photographs of the faces of three female models were taken as they attempted to convey the emotions of like, neutrality, and dislike.
Test groups were then instructed to listen to the various renditions of the word "maybe," with the pictures of the models, and were asked to rate the attitude of the speaker. Note that the emotion and tone were often mixed, such as a facial expression showing dislike, with the word "maybe" spoken in a positive tone.
Significant effects of facial expression and tone were found in that the study suggested that the combined effect of simultaneous verbal, vocal and facial attitude communications is a weighted sum of their independent effects with the coefficients of .07, .38, and .55, respectively.
Mehrabian and Ferris also wrote about a deep limitation to their research: "These findings regarding the relative contribution of the tonal component of a verbal message can be safely extended only to communication situations in which no additional information about the communicator-addressee relationship is available." Thus, what can be concluded is that when people communicate, listeners derive information about the speaker's attitudes towards the listener from visual, tonal, and verbal cues; yet the percentage derived can vary greatly depending upon a number of other factors, such as actions, context of the communication, and how well they know that person.
References Butler, Gillian, Ph.D. and Hope, Tony, M.D. (1996). Managing Your Mind. New York: Oxford University Press. Mehrabian, Albert and Morton Wiener, 1967, "Decoding of inconsistent communications," Journal of Personality and Social Psychology 6:109-114 Mehrabian, Albert and Susan R. Ferris, 1967, "Inference of attitudes from nonverbal communication in two channels," Journal of Consulting Psychology 31:248-252. Pearson, J. (1983). Interpersonal Communication. Glenview, Illinois: Scott, Foreman and Company. Pinker, Steven (1997). How the Mind Works. New York: W. W. Norton & Company.
ANSHU: One thing which always infuriates me is the reaction of my postgraduates when they have to deal with an immunocompromised patient. The sight of a suspected HIV patient sends them scurrying away. They are scared to touch the patient, and worse- their noses get wrinkled. The tone and manner of speaking gets snobbish and superior. The patient might not hear words which are harsh, but the rude mannerisms are hard to ignore. All too often, the reason they were judgmental- (because they thought it was HIV)- turns out to be something else- cancer or tuberculosis.
It is so difficult to get them to behave normally with some patients. The best you can do is be a role model yourself. I do wonder if some straight talking would help. After all we are at most risk of contracting HIV infection, aren't we? You will know what it feels like when you have to undergo a HIV test- I've known the turmoil in my head before my kidney donation- one never knows which blood sample was contaminated and handled by you- and how you will be stigmatized next if you turned out to be positive.
CHANDRAKANT PATANKAR: Sharing a personal experience of 'kahani aur karani mein antar hota hai'. It is setting of a workshop on HIV/AIDS in 1994-94. A big official was giving a sermon on how HIV is not transmitted by using the same utensils/glasses. I had asked a simple question- how many of the faculty and the attendees have dared to use the same glass used by a patient, forget, HIV infected individuals.
The answer was a great deafening silence !!!!!!!
I fully agree with you about role modeling -though it takes time to change a person who is sensitive and observant-that change is permanent. Rider- not all change. But it still is worth it.
ANSHU: I agree, that we need to be role models. One of our very respected senior faculty members is acclaimed nationally and internationally. So it came as a shock when I overheard some final year students criticizing him. Apparently this person doesn't even examine poor patients, letting his postgraduates do the job. He touches/ examines only well to do patients. It struck me how perceptive and observant our students are- when they can see through the sham. We need to practice what we preach- we are perpetually under the microscope.
Imparting communication skills to students
AVINASH SUPE: We do conduct a session for our students at GSMC during our co curricular program - Shidori - Our psychiatry department has written nice role plays and are conducted with debriefing. This makes students aware of finer communication issues and prepares them better to face such situations.
It is essential "out of syllabus" activity that every institution must conduct. Do others have any experience to share regarding such training - we would appreciate your sharing.
CHETNA DESAI: While revising our practical curriculum in pharmacology, one of the areas we are laying emphasis on is communication skills. We are focusing particularly on how to communicate with patients on
• The importance drug compliance • How to take a particular medicine including the necessity to stick to time schedules and other precautions. • How to use special dosage forms such as inhalers or transdermal patches, prepare solutions from dry syrups etc • How to detect any adverse event and report to the doctor.
Additionally the concept of informed consent in clinical research and in certain medical and surgical procedures will also be introduced to the students.
BALACHANDRA ADKOLI: “Setting role model" - is perhaps one word which is most recurring in our discussions. This comes in-born with some and it is cultivable to a great extent with training.
ANSHU: Here's a useful document on teaching communication skills. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365- 2929.2006.02500.x?journalCode=med I understand some of you are carrying out training workshops etc on communication skills for students. What is the approach like? Do one time seminars/ workshops help in ingraining the essentials?
ANSHU: I'm posting some more excerpts from the BMJ. Do you follow this pattern at your place?
Effective teaching methods
• Provide evidence of current deficiencies in communication, reasons for them, and the consequences for patients and doctors • Offer an evidence base for the skills needed to overcome these deficiencies • Demonstrate the skills to be learned and elicit reactions to these • Provide an opportunity to practise the skills under controlled and safe conditions • Give constructive feedback on performance and reflect on the reasons for any blocking behaviour
This table lists the teaching methods for helping doctors to acquire relevant communication skills and stop using blocking behaviour. These methods have been used in undergraduate and postgraduate teaching. A “good” doctor, wanting to audit and improve his or her skills, should ensure that any course or workshop they attend includes three components of learning:
• cognitive input, • modelling, and • practice of key skills.
Cognitive input: Courses should provide detailed handouts or short lectures, or both, that provide evidence of current deficiencies in communication with patients, reasons for these deficiencies, and the adverse consequences for patients and clinicians. Participants should be told about the communication skills and changes in attitude that remedy deficiencies and be given evidence of their usefulness in clinical practice.
Modelling: Trainers should demonstrate key skills in action—with audiotapes or videotapes of real consultations. The participants should discuss the impact of these skills on the patient and doctor.
Alternatively, an “interactive demonstration” can be used. A facilitator conducts a consultation as he or she does in real life but using a simulated patient. The interviewer asks the group to suggest strategies that he or she should use to begin the consultation. Competing strategies are tried out for a few minutes then the interviewer asks for people's views and feelings about the strategies used. They are asked to predict the impact on the patient. Unlike audiotaped or videotaped feedback of real consultations, the “patient” can also give feedback. This confirms or refutes the group's suggestions. This process is repeated to work through a consultation so that the group learns about the utility of key skills.
Practising key skills
If doctors are to acquire skills and relinquish blocking behaviour, they must have an opportunity to practise and to receive feedback about performance. However, the risk of distressing and deskilling the doctor must be minimized.
Practising with simulated patients or actors has the advantage that the nature and complexity of the task can be controlled. “Time out” can be called when the interviewer gets stuck. The group can then suggest how the interviewer might best proceed. This helps to minimize deskilling. In contrast, asking the doctor to perform a complete interview may cause the doctor to lose confidence because “errors” are repeated.
Asking doctors to simulate patients they have known well and portray their predicament makes the simulation realistic. It gives doctors insights into how patients are affected by different communication strategies.
For a simulation exercise to be effective, doctors must be given feedback objectively by audiotape or videotape. To minimize deskilling, clear ground rules should be followed:
• Positive comments should be offered about what strategies (oral and non-oral) were liked and why • Constructive criticism should be allowed only after all positive comments have been exhausted • Participants offering constructive criticisms should be asked to suggest alternative strategies and give reasons for their suggestions • Any blocking behaviour should be highlighted and the interviewer asked to consider why it was used (including underlying attitudes and fears) • The group should be asked to acknowledge if they have used similar blocking behaviour and why • To reinforce learning, the doctor should be asked to reflect on what he has learned, what went well, and what might have been done differently.
Context of learning Some doctors feel safer learning within their own discipline. Others welcome the challenge of learning with those from other disciplines, such as nursing; multidisciplinary groups enable doctors to understand and improve communication between disciplines. The relative merits of these two different environments have still to be determined.
Limiting the size of the group to four to six participants creates the sense of personal safety required for participants to disclose and explore relevant attitudes and feelings. It also allows more opportunity to practise key communication tasks. Facilitators who have had similar feedback training are more effective in promoting learning than those who have not. Residential workshops lasting three days are as effective as day workshops lasting five days. Whether longer courses are more effective than workshops plus follow up workshops needs to be determined.
SCIENTIFIC TEMPER CHETNA DESAI: The medical curriculum in India is designed to give comprehensive knowledge of health care delivery. However it fails to do so. One of the reasons is the quality of reading the students do. Let’s have a look at the current scenario:
• Most reading and training of our students is through text books and evaluation is based on the knowledge acquired from these text books. • A few years ago the text books that were recommended and read were richer, with a wider scope, books that dealt with concepts rather than brief summaries (that are designed to be memorized for reproducing in exams). • Now, numerous books on any subject by various authors are available. No doubt it’s a welcome change, but what about the quality? We have more guides, "read yourselves" books, preparatory manuals, "made easy" books and all types that inculcate the habit of memorizing, reproducing and forgetting. Application of knowledge, self directed learning and developing other skills in the process suffers. • The subjects themselves are very vast and sometimes students may find it difficult to comprehend books by western authors. • Very few students actually visit libraries to do literature search or read scientific journals or reference books. On the other hand, reading rooms are overcrowded particularly when exams are due.
All this at the cost of developing scientific temper! Your comments please...
HIMANSHU PANDYA: Attached please find an article about educational intervention to teach connection between communication skills and clinical reasoning. http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2005.0244.x
CHETNA DESAI: Here is an excerpt from an Editorial that appeared in BMJ some years ago. While it mainly deals with the reading preferences of doctors, it does put a question mark on the scientific temper in doctors. It invited a lot of debate. Your comments please.
Doctors are not scientists
“Some doctors are scientists—just as some politicians are scientists—but most are not. As medical students they were filled full with information on biochemistry, anatomy, physiology, and other sciences, but information does not a scientist make—otherwise, you could become a scientist by watching the Discovery channel. A scientist is somebody who constantly questions, generates falsifiable hypotheses, and collects data from well designed experiments—the kind of people who brush their teeth on only one side of their mouth to see whether brushing your teeth has any benefit. Most doctors follow familiar patterns and rules, often improvising around those rules. In their methods of working they are more like jazz musicians than scientists.
Questioning whether doctors are scientists may seem outrageous, but most doctors know that they are not scientists. I once asked a room of perhaps 150 medically trained educators which of them thought of themselves as scientists. About five put up their hands. If doctors are not scientists then it seems odd to supply them, as medical journals do, with a steady stream of original scientific studies. Teachers and social workers are not sent original research. Nurses are sent some, but are they simply aping the illogical ways of doctors?
The inevitable consequence is that most readers of medical journals don't read the original articles. They may scan the abstract, but it's the rarest of beasts who reads an article from beginning to end, critically appraising it as he or she goes. Indeed, most doctors are incapable of critically appraising an article. They have never been trained to do so. Instead, they must accept the judgment of the editorial team and its peer reviewers—until one of the rare beasts writes in and points out that a study is scientifically nonsensical.
Sometimes readers will alight on an article as a bee alights on a flower to suck a little honey. They will alight, I suspect, for reasons that are more personal than scientific. I am interested in the study showing a steady rise in hospital admissions for acute pancreatitis from 1963 to 1998 because my brother had pancreatitis—maybe, indeed, that link had something to do with the study making it into the journal just as it's been suggested that the BMJ publishes on toenail fungus because so many of the editorial team suffer from it. The authors note that the prognosis of acute pancreatitis is poor and that mortality after admission has not fallen since the 1970s—reflecting the absence of innovations in treatment. “
I’m sending the link to the article. It also has the rapid responses by readers ranging from assent to dissent. http://www.bmj.com/cgi/content/full/328/7454/0-h
One response that I particularly liked said something like this- "What makes the difference is not what doctors do, but how they think. We must not confine the definition of a scientist to a person who works in research, rather a scientist is one who thinks like one when solving problems, draws logical inferences from information gathered by him and then acts."
A doctor may be in a primary care setting with minimal infrastructure, leave alone facilities for hard core research, but if he thinks and acts with a scientific temper, he does qualifies to be a scientist.
HARPREET KAPOOR: Excellent excerpt, Chetna- makes one do some introspection! As Smith has pointed out in his Editorial only around 3% of the audience of Medical Educators believed that they were scientists, I think this in a way is also linked to our curriculum. We really need to consider whether we are giving ample opportunities to our students to think and rationalize, especially in the Indian medical schools. Although heredity/ genes do help in producing a 'born scientist', but environmental factors do have their own pertinent role to play!
CHETNA DESAI: You know I always found it a bit funny and more disturbing, that our postgraduates bank on us while choosing dissertation topics. Few have their original ideas. They either look back on older dissertations or look upon their guide. It speaks volumes of their training in scientific temper during their undergraduate days! Few UG students are aware of ICMR fundings, KVPY and the likes that promote research by UGs. We are not looking for Nobel Prize winners, but at least some awareness about medicine as a science and not just a profession.
Introducing project work and such other initiatives that promotes science in Medicine should be a part of the UG curriculum.
SESSION THREE SPECIFIC NON-SCHOLASTIC ABILITIES - II
CHETNA DESAI: In the past 10 days we have discussed some non scholastic abilities that are particularly useful in the medical profession and that must be fostered in all. Proceeding to the third part of this discussion we shall discuss:
Social and Interpersonal skills: Team work, Leadership, Handling stress, Attitude to work, Ability to share
Emotional intelligence: Compassion, Professionalism, Ability to adjust in rural and urban situations, Awareness of health economics of our patients and Willingness to serve
Extracurricular activities: Sports, hobbies, social service activities
The questions that we want you to respond to are: 1. How are each of the above skills/ traits important in medical students and how do we encourage and foster them? 2. How can we train medical students in acquiring the above skills?
Please share any specific anecdotes/ experiences where you felt the need for these
Responses to third set of questions
SANJAY BEDI:
How are each of the above skills/ traits important in medical students and how do we encourage and foster them? How can we train medical students in acquiring the above skills? Please share any specific anecdotes/ experiences where you felt the need for these skills most. This is very important and they can be encouraged by group activities. I held a competition once on chart making skills on various subjects in Pathology (Basically I needed charts to decorate the museum in Pathology). I divided the class into teams of 4 each and gave them a Chapter each. Since we have BDS also, I gave them General Pathology. There a sense of competition as well as camaraderie and the students learned the topics allotted as well. Mind blowing skills in making charts were displayed using images from Internet. Oil paintings were made by some girls. The inflammation process was displayed in 3D using thermocol sheets.
DINESH BADYAL: How are each of the above skills/ traits important in medical students and how do we encourage and foster them? How can we train medical students in acquiring the above skills? Please share any specific anecdotes/ experiences where you felt the need for these skills most. My response: All are important, but I shall give slightly more weightage to social and interpersonal skills, because this one help you a lot to achieve the other two. I would like to share an experience here. I started seminars for UGs in MBBS on topics which were already covered. The whole event is managed by UGs. There are 25 topics. Each time the class chooses a leader and a rapporteur. The leader introduces the topics and speakers and handles all discussions. The rapporteur summarizes in the end.
2 students are given one topic and one week to prepare. They use Power Point, share the resources, share the presentation, interact with teachers and work together.
What I have observed was that, there is tremendous improvement in students. This improvement was in areas like sharing, leadership qualities, team work (2 topics are presented in 1 hour- so 2 teams work together), communication, their interaction with teachers and enthusiasm to work. Students who were shy; or those we thought were not so good, did excellent work.
So this activity was different what we were doing usually for teaching, but was able to achieve what we wanted to achieve.
Extracurricular activities do help you a lot in developing yourself as a better person and human being, but in general, medical students get less time for this.
HEMLATA BADYAL: How are each of the above skills/ traits important in medical students and how do we encourage and foster them? How can we train medical students in acquiring the above skills? Please share any specific anecdotes/ experiences where you felt the need for these skills most.
All the above skills are important. You have already mentioned how they are important for most of the issues under headings. Extracurricular activities are usually inherent e.g. hobbies. Social service components can be inculcated during training of medicos by taking them to rural centres, involving them in camps for community etc. Social and interpersonal activities are part of medical education. They are indirectly taught throughout the studies. Emotional intelligence is one skill where we can try to learn a lot throughout our career. I first felt the need of these during the fellowship programme in 2006. Although I might have felt it earlier, I was not aware of all these.
MONIKA SHARMA: How are each of the above skills/ traits important in medical students and how do we encourage and foster them? Each of the mentioned non-scholastic abilities, namely interpersonal relationships, emotional quotient and extracurricular activities are important for medical students. Because all these abilities are essential for a doctor, not only to help out his patients medically, but also emotionally- besides remaining sane himself.
Interpersonal skills can be encouraged by stimulating group activities, be it academic discussions or accomplishment of tasks, including social college activities etc.
How can we train medical students in acquiring the above skills? I can't think of any formal training suited to the medical school environment. However, having a college sports club is a good idea. Most colleges have a sports club for UGs. Although usually it is utilized only by boys, with girls being left out though it is never intended to be so. Girls end up staying out as boys keep the area occupied. I remember we had a separate play area in our college for girls-it was always locked (the reason being that when it was opened earlier, boys occupied this one too). Thanks to a very active girl in our class who also became the girls’ representative we had the area opened.
Please share any specific anecdotes/ experiences where you felt the need for these skills most. Though I am not the kind to argue, even if it is to prove my own point and usually don't have hassles with colleagues, my silence and often lack of assertiveness ends with me having to end up in unhappy and misunderstood situations. Though I cannot point to a particular situation, it has happened in most of my work situations, be it college, post-graduation or further. Though I was never wrong, at that point I was misunderstood because I was not the first to explain my position or maybe explain convincingly. I admire people with the skill to convince people and get their point across without itching people around. I have often felt the need to develop this skill of talking effectively. And because I lack this skill, I keep my mouth shut which only aggravates the situation.
MRUNAL KETKAR: How are each of the above skills/ traits important in medical students and how do we encourage and foster them? I think the first two (social and interpersonal skills & emotional intelligence) are very important to make a medical student a better human being and a good health care professional as a whole. The third (hobbies and social service activities), I suppose is important for personal benefit. Though, social service activities will also give lot of emotional satisfaction.
Many of the ways have already been mentioned, I feel a teacher can act as a good role model for things that cannot be taught by way of routine curriculum e.g. attitude to work, handling stress, social service etc.
How can we train medical students in acquiring the above skills? Apart from educational activities mentioned by others, role plays and skits.
AROMA OBEROI: My responses are: All the skills play an important role to develop the over all personality of medicos. As teachers we should try to solve their personal problems. We can act as role models.
SOCIAL AND INTERPERSONAL SKILLS
Getting on with Colleagues
ANSHU: As far as interpersonal skills are concerned we are at all times dealing with 1. Colleagues and Peers 2. Students 3. Technical and nursing staff 4. Class IV staff
How do we maintain our equation and extract the best in terms of performance in each of these relationships?
CHETNA DESAI: The following links are about the importance of interpersonal skills in doctors and an interpersonal skills rating form for doctors. http://www.ljm.org.ly/articles/AOP/AOP070620.pdf http://acgme.net/outcome/downloads/IandC_6.pdf
ANSHU: Well, just have a look at the types of difficult consultants one encounters.
1. The authoritarian, bullying consultant 2. The indecisive and disorganised consultant 3. The controlling consultant, who has difficulties delegating 4. The burnt-out consultant 5. The consultant who is never there 6. The consultant who is biding time to retirement 7. The flirtatious consultant 8. The poor teacher and communicator
Nobody is perfect. But what are the problems one faces with each one of these personality types? It is frustrating being subdued by an autocratic head, while an indecisive head is worse because he can't take a stand and keeps sitting on the fence. In clinical branches a consultant who is never there can be a blessing in disguise, when you learn to handle emergencies yourself. But the worst kind I have heard of -are those who give telephonic orders and backtrack when things go wrong, leaving their juniors in the lurch. I guess it takes all kinds to make this topsy turvy world!
CHETNA DESAI: Handling all types of consultants/bosses and colleagues is an NS ability!
ANSHU: I was just reading an article in a Psychiatry journal and came across this list of personal characteristics and factors that lead to strained relationships with senior colleagues:
Competitiveness (promotion, merit awards, salaries and national recognition) Quality of leadership Inability to deal with anger in a constructive fashion Different therapeutic approaches to clinical work Team players vs individualists Thinkers vs doers Innovators vs conservatives Optimists vs pessimists Prejudice vs tolerance Joiners-in vs loners Controllers vs delegators Quick responders vs prevaricators Thick- vs thin-skinned individuals
I think on most occasions, it is differences of opinion which are left unresolved and later blow out of proportion. But then a lot of times there are personalities which are radically different from your own, which you find difficulty in understanding. I don't know if you people feel similarly, but usually you get the right or wrong vibes and I know whether I can trust this person or get along with them or long in a few minutes.
CHETNA DESAI: That’s interesting Anshu. Although we have known/experienced this, it spells it out quite lucidly. Can you send the article please? Human behavior is very complex and it keeps changing dynamically. Relations at work place change as hierarchy and equations change. That makes things unpredictable too and one has to be malleable to adjust.
But 2 statements keep coming to my mind always: DR TS: “Problems arise because people tend to behave at workplace the same way as they do at home.” My Boss: “No matter what. Keep working. Do not let your work be affected by such trivialities.”
Both very practical statements. I think we will have more on this in our next month’s discussion on professionalism.
ANSHU: The whole article is very interesting. Please take time out to go through this. http://apt.rcpsych.org/cgi/reprint/10/3/225.pdf
LEADERSHIP ANSHU: There are situations when we have leadership thrust on us. And this is not easy considering the fact that not all of us are born leaders. For doctors, it usually is when you are made Unit Incharge with no prior expertise in leading a team. What shapes a personality- what makes one an autocratic leader, and another a democratic one?
How effective is one in understanding the needs and aspirations of their team members? And how does one inspire others to excel?
We all have our role models in medicine. Can you share what you like best about the leaders you have encountered and what puts you off about them?
SANJAY BEDI: Leadership is a huge topic. However basic understanding of human nature with concern for the team, with a human touch regarding the welfare of the patients (you may need to be firm as well) are sufficient. Autocracy shows very fast and very soon your entire team starts avoiding you. CHETNA DESAI: I have been thinking all day about a leader as a role model. You know the funny and disturbing part is none. It’s not that we do not have leaders, but it is difficult to find all qualities in one person. I have come across some of my seniors who have a potential to be a good leader, but I have observed that they get carried away by their own achievements and start becoming autocratic. A beautiful article I came across in BMJ equates many situations in medicine to aviation skills, the captain is equated to the Chief surgeon. There are many other such situations where team work and leadership skills are vital to optimum medical care: A few examples:
• Any surgery • Management of trauma and other disasters • Good housekeeping in a hospital • Human resource management in a hospital • Managing hospital infections • ICCU care • Managing an outpatient department In medical education team work is required for:
• Deciding and revising curricula • Deciding and implementing teaching • Implementing research projects • Conducting examinations • Organizing recreational and extracurricular activities for students
To share an actual leadership quality I observed in 2 of our students. Recently there was a sanitation problem in our hostels. Actually the bathrooms were being renovated and due to some mismanagement by the building contractors, things went a bit haywire. Two students took up the issue, contacted the authorities, took the persons responsible to task and ensured that their grievances were addressed. It was a small example of taking up the mantle of leadership and responsibility. And the best part is the students in question were academically brilliant too. NS and scholastic abilities definitely can go hand in hand, as suggested by Stewart very early in our discussion.
VENUGOPAL RAO: We have to develop self managing leadership. Remember, it is in your moments of decision that your destiny is shaped.
Who is a true leader? “One who never reacts, but observes, understands, analyzes and then acts decisively"
The eight attitudes needed for a successful leader are- 1. Power to listen 2. Availability 3. Tolerance 4. Adaptability 5. Discrimination 6. Decision making 7. Ability to respond 8. Team spirit If you see, Lord Ganesha has all the leadership capabilities in him. Ears show that he is a good listener, presence of mind shows availability, he has strength to tolerate anything, stomach shows power of accommodation, and his small eyes tell us foresightedness and discriminating ability that he has. He had the strength to take up responsibility. His posture shows that decisions he took were uninfluenced and impartial. He is the leader who attains success through wisdom.
DINESH BADYAL: Good discussion going on leadership. I think this is one of the most important qualities as these days you very frequently get charge of so many things academic or non-academic.
The most important quality of a leader is how they carry others along with them, while at the same time being able to get work done from all.
I am really get fascinated by good leaders. I remember my HOD at PGI and then one of my seniors who was doing DM when I was doing MD. He is now HOD at Rohtak. I really appreciate their leadership qualities. And now I am lucky to have TS, you are well aware of his leadership qualities.
To survive in these days of competition either you need natural leadership qualities or you must develop these abilities. It is like bacteria who are trying to survive, they must develop something to get away the antimicrobials. Like the increasing number of antimicrobials, there are increasing number of challenges/ responsibilities we have.
I wonder if anyone can comment on leadership at home?!
SANJAY BEDI: Fatherhood is a big leadership responsibility. To direct the whole family including mothers along a positive direction is big job. A certain amount of family politics is always there. You have to understand it and then push forwards.
TEJINDER SINGH: I came across a very different but very pertinent definition of leader- a person who contributes to other persons' life in any form!
DINESH BADYAL: That is a quite thought provoking definition of leader. I thought of all possibilities after this definition and it really fits well for some situations.
ANSHU: That's a rather thought provoking definition- but I feel it doesn't quite portray all that a leader does. Leadership is intentional. It is not a chance influence by which one makes a difference in another's life.
I was just browsing the net and came across Richard Smith's interesting Power Point presentation where he argues that doctors and leadership are like oil and water! According to him- Doctors are used to working primarily as individuals. They guard their independence jealously. They value autonomy highly - but leadership is about working with others.
Doctors feel uneasy about power and think of it negatively. At the same time they are often unwilling to cede power - something that is important in empowering and leading. They are wary of abandoning control to others - yet that is what leadership is often about. They are too used to telling people (patients) what to do rather than inspiring or empowering them. They are driven by science and suffering to behave tactically and reactively rather than strategically. They are too fond of hierarchies. They are wary of expressing emotion in themselves. Doctors for these reasons have problems being leaders and being led.
You can catch the entire presentation at http://resources.bmj.com/files/talks/oilandwater.ppt
ANSHU: Incidentally, I came across this verse about the difference between a boss and a leader
The Boss drives his men, The Leader inspires them. The Boss depends on authority. The Leader depends on goodwill. The Boss evokes fear The Leader radiates love. The Boss says “I”. The Leader says “We”. The Boss shows who is wrong. The Leader shows what is wrong. The Boss knows how it is done. The Leader knows how to do it. The Boss demands respect. The Leader commands respect. So be a Leader, Not a Boss.
CHETNA DESAI: Leadership is about giving and let go. Outwardly we always get impressed by a person who is authoritative and a bit loud, but there are many "quiet" leaders and their leadership is "felt" by people around. They are so confident about their capabilities and position that they do not mind giving other people a chance or helping them or sometimes even projecting them upfront. That’s true and mature leadership.
VIVEK SAOJI: Defining leadership is really a difficult task and it may mean different to different people. There are as many definitions of leadership as there are people who tried to define it. It is much like words democracy, love, peace and so on.
However I came across an apt definition and it says "Leadership is a process whereby an individual influences a group of individuals to achieve a common goal".
And some of the major leadership traits described in literature are: • Intelligence • Self-confidence • Determination • Integrity • Sociability
A true leader will empower his followers.
DINESH BADYAL: When you head a department you learn all these things automatically, otherwise life becomes hell for you. Ask anyone heading a department around you. This applies to most of other activities also, where we are incharge or leaders. Dinesh
ANSHU: Dinesh, I disagree with you when you say one learns these things automatically as a head. By then it is too late to teach an old dog new tricks! I have seen heads who are bad just because they keep to themselves, and cannot share their vision; and others who are bad administrators because they want to be in the good books of every Tom, Dick and Harry.
Isn't there a way one is groomed to develop these skills? Meaning how can we train doctors to improve doctor-doctor, doctor- patient and doctor-nurse relationships?
SHEENA SINGH: Dinesh, I agree completely. Once you are the Head of a Department you are the conductor of the Orchestra. It requires us to tap into our Emotional Intelligence when we deal with our Department Team.
It is my constant endeavour to be able to get the best possible output from the staff and one has to be perceptive to the atmosphere (which is as fickle as the weather), and respond as necessary.
If people are respected they give their best. Always see things from the other person's point of view. Be patient with people. Be firm and mean what you say.
DINESH BADYAL: Sheena, I agree with you. You need to create a conducive atmosphere and respect all. I think you need to use a lot of your abilities which you developed throughout your career at this stage. It is not that you need to learn everything about administration or you know everything about administration. Initially you do make mistakes, everyone tries to take advantage, buttering goes on, some are trying to disturb atmosphere of dept etc. Multitasking is handy at that stage.
Do doctors make good administrators?
CHETNA DESAI: This discussion about heading a department and when and how these skills are learnt is interesting. I wish to share an interesting fact.
A few years ago there was a move in our state to designate IAS officers as Dean or on other senior administrative posts. The logic put forward was that doctors may not be good administrators and most clinicians do not wish to give up their posts in clinical departments to work as Full time administrators. While the second point is a personal decision of the doctor in question, there was lot of hue and cry about the first "assumption" Is it true that doctors may not be able to do justice to an administrator's post?
Can we debate on this issue? Dr TS, Vivek, and our senior faculty who have held administrative posts in their respective institutions, can we have your views please.
Do doctors need a formal training in administration before they take up responsible posts or does experience and "Common sense" alone help?
VIVEK SAOJI: There is no right or a wrong answer to the point you have raised. There are a number of things that go in making a good leader, administration may be but one aspect of the leadership. I do not see any reason as to why doctors can not be good administrators. I think some training is always useful, if not formal some quality literature reading is a must and only experience may not be sufficient. A lot depends on one’s personality and how one perceives administrative jobs as an opportunity to influence others and to do more then their speciality or as a liability. I therefore feel that if doctors perceive it in this way and have some background knowledge / training they can make better administrators.
HIMANSHU PANDYA: I am reproducing some lines from an article by K Bk Soh in the Singapore Medical Journal
Management is the process of planning, organising, leading and controlling the human, material, and financial resources of an organisation. Managers are responsible for achieving organisational ends through people. This he does by supervising and motivating people in work organisations. A good manager must understand organisational behaviour which is the scientific study of behaviour and attitudes of people in organisations which contribute to organisational effectiveness. He must understand the use of motivation, organisational control and rewards systems, job design and employee reactions to work. He must also be able to grapple with work group dynamics, problem solving, creativity, conflict management, and the use of influence processes like power and leadership. Management skills are intangible and difficult to assess. Many business writers have argued fervently about what makes a good leader, and have even identified a few important managerial traits that will sieve the wheat from the chaff. But the pre-eminent necessity is simply to know and discipline oneself. "The good leader seeks virtues and goes about disciplining himself so as to effect control over his success. Otherwise he may know how to win but yet is unable to do"
You can access this article on http://www.sma.org.sg/smj/3904/articles/3904ra1.html
ANSHU: To answer your question, I do not think we need a formal degree in administration, though a refresher course of sorts can help. When my father joined as a school principal I remember him going through these courses, where they gave a little information on official government rules and financial stuff. I guess that helped- especially on areas where rules could be twisted or misused. And I do distinctly remember him personally calling a legal guy and getting trained in administrative rules (The jargon there is worse than medical jargon) - that was a personal effort to keep abreast with the latest. Maybe occasional courses like that for medical administrators can be useful.
Training in leading a team needs to start pretty early. At school, the introduction of 'houses' and posts like school pupil leader, house captain, sports captain are just the start of leadership training. You learn to take your classmates together. Then come organizational skills which are inculcated when you begin organizing small events like an elocution competition- moving to bigger things like a Parent's Day or an annual day.
In Medical college, students who are part of the NCC or NSS or Literary organization or Dramatics society or sports teams imbibe a little of the organization skills. And as we join as faculty, the burden of administration gradually increases. Stock checking, store organization, student council organization, conducting CMEs and workshops- eventually you get dragged in everywhere. I am reminded of that Tata Steel ad where after listing a number of activities they conclude- "We also make steel'!
Similarly, we spend our time as faculty doing a thousand other things and- we also see patients! On field training in administration!
CHETNA DESAI: Good well informed opinions. Yes there is no reason why doctors cannot be good administrators. One point in favor of this is that they would also know the intricacies and requirements of medical care. At the same time some formal training will be an added advantage. In a system where hierarchy and seniority is a criterion for selecting people to these posts, those who are not adequately equipped with the necessary skills may benefit from such training.
ANSHU: I remember one of my teachers in Pathology, who people still rave about. She had a vision for the department and knew where she needed to take it. And the best part was that she picked up competent people and got them trained in subspecialities. Thus when she retired, each section was in capable hands. People were happy as they were academically satisfied and the department got a reputation of being good one.
The problem I see with most heads is that they are not satisfied themselves with where they are going as junior staff members. So when they become heads, they are far too busy promoting themselves rather than promoting others in the department. Whether it is going for training programmes, writing papers, asking for projects- they are reluctant to let the strings out of their hands. I guess I will perhaps be one of the same kinds if I don't get the freedom to be what I want now. It is a hangover from your days as a junior that continues.
One can be a good manager, but being a good leader is a different ballgame altogether.
Leaders Vs Managers
ANSHU: Most of us are good managers, but not necessarily good leaders. We often confuse between the two concepts.
A manager tells his subordinates what to do, and both get paid for getting the job done. The relationship is essentially transactional. He needs a formal authority to exert that influence on his juniors. They are usually averse to taking risks and go by the book.
However, a leader inspires his 'followers' to do as he says. The action of his followers is voluntary and the relationship is transformational. Leaders are essentially risk takers and think out of the box. Leaders have a vision. They take blame for what goes wrong and give credit where it is due. People are more loyal to leaders than managers because they manage to stir your emotions.
It is said that managers do things right, while leaders do the right thing. Management is essential for keeping things on track, and leadership is about creating new opportunities by motivating and inspiring others. Have a look at this table below which clarifies the differences further.
Subject Leader Manager
Essence Change Stability Focus Leading people Managing work Have Followers Subordinates Horizon Long-term Short-term Seeks Vision Objectives Approach Sets direction Plans detail Decision Facilitates Makes Power Personal charisma Formal authority Appeal to Heart Head Energy Passion Control Dynamic Proactive Reactive Persuasion Sell Tell Style Transformational Transactional Exchange Excitement for work Money for work Likes Striving Action Wants Achievement Results Risk Takes Minimizes Rules Breaks Makes Conflict Uses Avoids Direction New roads Existing roads Truth Seeks Establishes Concern What is right Being right Credit Gives Takes Blame Takes Blames
SANJAY BEDI: Excellent Anshu. Now the point is should one take the leadership role or managerial role. Both are important. Growth takes place through leadership role but it is risky. While managerial role is important once the leader establishes the viability and necessity of a project. But in the process can harm himself because any change management process is initially met with lot of resistance sometimes physical and hostile as well.
ANSHU: I agree- both roles are important. One must first possess managerial skills to see that a project is on track. And then leadership gives the project wings of its own- it gives people a chance to fly. Any difference of opinion?
MADAN LAL GILL: Very informative and useful article on managers vs. leaders. I feel good number of people have mix of both. Are you a leader or manager or both?
ANSHU: I think I'm a better manager than a leader! I tend to be too aggressive as a leader than I intend to when I'm in the thick of work, losing out on friends when I don't intend to.
MONIKA SHARMA: Anshu, your comparative list on leadership and manager-ship is very interesting and right too. As for Sanjay's question about what should one be a leader or a manager, I would say that though both are important and essential, both come more naturally than as a learned nature. Leaders are born. Their personalities inspire and their zest for work, effort and influence is unattainable by the natural managers. Being a manager also comes naturally, though this is one trait which can be learnt and practiced. E.g. Gandhi was a leader, but I don't know if I can/should comment on his managerial skills.
And I am sure everybody else (at least after reading the list) would want to be a leader, but if I have to comment on myself I do feel I am better at managing things.
Leaders are not hard to recognize. Remember seeing kids who end up becoming the leader of their groups in every class and during vacation games? Managers too can be seen well. The best example that comes to my mind right now is my son. He is four, but he has a knack for keeping things in order. Even as a one and half year old he would stack slippers in order. He will always place in books, bag and shoes in their proper place and will pass a comment on us if we delay placing utensils back in place, before doing it himself.
SANJAY BEDI: I have noticed that when I take a leadership role, soon some manager like personality comes along from somewhere to look after the details. So I offload the project to him/her and get on with life on some other project. But this has some dangers also. You get blamed also. And quite often the manager like personality gets the benefits too much. I am somewhat of a starter.
DINESH BADYAL: That's what a leader should expect. When he is leading he will get good things as well as bad things. He might be at receiving end also. But if he is not ready for this, then he is a manager not a leader.
ANSHU: Two of my favourite quotes: 1. There's a lot you can do if you don't bother about who gets the credit. 2. Lead. Follow. Or get out of the way!!!
VENUGOPAL RAO: Here are some additions about Leader Vs Manager: Leader is one who transforms information into vision.
We are going through rapid, delicate changing times. In this change we have to remember 3 important points:
• There is no turning back • We must find new bearings • Different skills are required We have to analyze our selves by SWOT.
Organizations demand leaders and not just managers. In order to be a successful manager, one has to be an effective leader. Manager stays at the back and pushes people into the system. Leader stands in front and pulls the people along with him. Manager administers and maintains, leader innovates and develops. Manager relies on systems and counts on controls. Leader relies on people and counts on their trust. Manager enables things to be done right. Leader does the right things through inspiration.
TEAM WORK ANSHU: Let's discuss team work. My wordless start with two pictures:
CHETNA DESAI: This and other discussions on FAIMER have an element of good teamwork- shared responsibilities by the moderators, active participation by all and prodding guidance from the faculty. Thanks to FAIMER for helping us learn by doing.
MONIKA SHARMA: A team is a group of people with a common goal. With all of us trying to be high achievers in our own work areas, we must all realize that most of our actions cannot be solely accomplished by our own efforts even if given the 100%. We all depend on a small or large group of people as required to finish our task. There are however, certain basic and easily recognizable differences amongst a team and a group.
A team is a group of people influencing each other, while in a group the members are together and aware of each other but not influencing each others actions in any way.
Characteristics of team members: Mutual accountability, small in number, complimentary skills, defined approach and with meaningful purpose.
A worldwide survey found that the most important values given for a team are their shared values, followed by mutual trust, inspiration and the last important thing being the rewards for the activity.
17 laws of teamwork by Maxwell (http://www.1000ventures.com/business_guide/crosscuttings/team_main.html)
1. The Law of Significance: One Is Too Small a Number to Achieve Greatness 2. The Law of the Big Picture: The Goal is More Important Than the Role 3. The Law of the Niche: All Players Have a Place Where They Add the Most Value 4. The Law of the Great Challenge ("Mount Everest"): As the Challenge Escalates, the Need for Teamwork Elevates 5. The Law of the Chain: The Strength of the Team Is Impacted by Its Weakest Link 6. The Law of the Catalyst: Winning Teams Have Players Who Make Things Happen 7. The Law of the Vision ("Compass"): Vision Gives Team Members Direction and Confidence 8. The Law of the Bad Apple: Rotten Attitudes Ruin a Team 9. The Law of Countability: Teammates Must Be Able to Count on Each Other When It Counts 10. The Law of the Price Tag: The Team Fails to Reach Its Potential When It Fails to Pay the Price 11. The Law of the Scoreboard: The Team Can Make Adjustments When It Knows Where It Stands 12. The Law of the Bench: Great Teams Have Great Depth 13. The Law of Identity: Shared Values Define the Team 14. The Law of Communication: Interaction Fuels Action 15. The Law of the Edge: The Difference Between Two Equally Talented Teams Is Leadership 16. The Law of High Morale: When You're Winning, Nothing Hurts 17. The Law of Dividends: Investing in the Team Compounds Over Time
TEJINDER SINGH: Look at this like this-
A group is a collection of people with common interest (e.g. people in a stadium gathering to watch a cricket match). However, groups do not compensate for weaknesses in the collective. A team, on the other hand is group of people who compensate for the weaknesses and strength (e.g. the cricket team)
MONIKA SHARMA: http://www.heartquotes.net/teamwork-quotes.html Here are some wonderful quotes on teamwork. Here are some that touch me now-
Robert F. Bales: Effective teamwork will not take the place of knowing how to do the job or how to manage the work. Poor teamwork, however, can prevent effective final performance. And it can also prevent team members from gaining satisfaction in being a member of a team and the organization. Max DePree: The key elements in the art of working together are how to deal with change, how to deal with conflict, and how to reach our potential. The needs of the team are best met when we meet the needs of individual persons.
Will Schutz: Team members who feel threatened but who are not aware of it become rigid — and that stops teamwork.
DINESH BADYAL: Team work is a key to successful ventures. I agree.
The most important function in a team work is that of the leader. The leader has to identify weaknesses and strengths of individuals and then see how work is assigned. But I have seen most of persons not interested in team work; they work individually for individual goals. Look around you!
SANJAY BEDI: I find the understanding of cybernetics a very handy tool in teamwork situations. One definition of which is “the art of ensuring the efficacy of action". For some details see http://en.wikipedia.org/wiki/Cybernetics
ANSHU: That's a nice description of a team. The added bonus being distinguishing clearly between a team and a group.
As doctors, we always deliver health care which is as good as the quality of the teams we are part of. We work in small units where correct communication, verbalization of tasks, correct interpretation of directions, and then execution of the task depends on each member of the team. If you notice personality types, some are team players and others are loners. I think anesthesia, surgery and emergency medicine are areas where team play is at the forefront. Basically, any one who works in an institute needs to be a team player. Loners prefer going alone and setting up their private practice. But though they work on their own, they need to build up a supporting team in any case.
ANSHU: I think one of the first places where our ability to work in teams assumes important dimensions is when we work as residents. I think residents need to be primed at some stage where they are taught accountability, punctuality, organizational skills- in other words- professionalism. Is that being done at any centre?
While we are at this, here are some important differences between effective and ineffective teams that I picked up online.
Effective team: Goals are clarified and changed to meet everyone's needs; structured cooperatively. Ineffective team: Members accept imposed goals; competitively structured.
Effective team: Team norms are explicitly stated and agreed upon. Ineffective team: Norms are assumed
Effective team: Communication is two-way; open and accurate expression of both ideas and feelings. Ineffective team: One-way communication. Either ideas or feelings suppressed.
Effective team: Participation and leadership are distributed amongst all team members. Ineffective team: Leadership delegated; unequal participation.
Effective team: Decision-making procedures are matched with the situation. Ineffective team: Decisions always made by highest authority; little group discussion.
Effective team: Controversy and conflict are positive opportunities. Ineffective team: Controversy and conflict ignored, suppressed, and avoided.
Effective team: Interpersonally, there are high levels of inclusion, control, and affection. Ineffective team: Functions are emphasized; cohesion ignored; rigid conformity promoted.
Effective team: The team evaluates itself and decides on improvements. Ineffective team: Highest authority evaluates team; internal maintenance and development ignored.
ANSHU: Here's an excerpt from an NHS study on how doctors perceive the need for team work. Teamwork and skill mix Although doctors are accountable for their conduct and practice on an individual basis, increasingly they must work in teams. Team working is necessary in many circumstances and the role of the doctor depends on the task to be done and the experience and knowledge needed. Increasingly new ways of working have developed in the health service, including more team and multi-disciplinary working. Cohort doctors were asked their views on a series of statements regarding teamwork and skill mix. Whilst most of the cohort (86%) agree that leadership of a multi-disciplinary approach to care should fall to the most appropriate professional, only 42% agree that the natural leaders of such a multi-disciplinary team are doctors. Three- quarters (74%) of the cohort agree that the opinions of all members of a multi- disciplinary team should be of equal value. Only a quarter (24%) of cohort doctors agree that the traditional role and duties of a doctor should be protected against moves to give parts of their job to other health professionals. Only a quarter (28%) of cohort doctors agree that doctors work most effectively as autonomous medical practitioners and two-thirds (68%) agree that doctors should be able to lead in the management of the health sector.
Views on statements regarding teamwork and skill mix (%)
CHETNA DESAI: Teamwork and performance of a medical procedure/task have a high correlation, possibly because an effective team by definition moves forward with problem solving over time and communicates productively. Here is a study that quantifies this. http://www.anestech.org/media/Publications/IMMS_2004/Spillane.pdf
CHETNA DESAI: We all agree that team work is important. All would have experienced that a team that is otherwise doing fine has a few detractors. They would put a spanner in your works, demotivate, and also try to break rather than make. At the same time due to their position in the management matrix, they cannot be ignored. How do we handle this? Any thoughts?
ANSHU: I think one strategy is to make them feel important and responsible. My father used to say that the key to discipline in a class is to make the naughtiest chap the class monitor. I have seen him do that, and it transforms the person instantly. The new mantle that he takes over makes him more responsible, and even if it to show off how good he his- he sets an example to the class by behaving well.
Maybe, something similar can be adopted with negative people. I have seen this being followed in conferences organized in colleges. Some people don't work but need the 'bhaav'. So they are made heads of committees and given some grand sounding name/ position. But the key to organization is to place some very responsible people in the same committee who can work even without their leader's motivation. Having been in some committees like that I can say that it works- to the extent that the person stops negative activities. There have been two occasions where I have written, edited, proof read complete souvenirs and designed cover pages and the credit completely went to someone who didn't even know who the printer was.
Having said that, I must say that different people respond differently- some take active interest when given responsibility; while some completely wash their hands off the thing and go on leave! I have seen both kinds.
CHETNA DESAI: I think that’s a practical way of doing things; but don't you think it also encourages such behavior and may send a wrong message to others in the team?
ANSHU: Yes it does. The solution is a very temporary one to get past a detractor and get a show going. I just wrote about what one can do in dire circumstances- when doing a job is more important than fighting detractors. Any other solutions you can think of?
CHETNA DESAI: Using the stakeholder matrix can help. You may have to take higher ups in to confidence, although it needs a tact and the confidence that the higher ups will understand the situation! Otherwise it can backfire and you can be in a bigger soup!
Teaching students team work/ Collaborative learning activities
ANSHU: How does one teach students the importance of team work? It can come in giving them group projects, letting them participate in group discussions and buzz sessions. One interesting way to sensitize them to the health economics of our patients and make them work in a team can be -what we follow in Sevagram. Students are allotted 2-3 families in a neighbouring village in the first year. Under the guidance of PSM teachers, they first describe the social and environmental conditions their families live in. Throughout the five years of their MBBS they make fortnightly visits to their families and as they learn they try to influence the families to improve sanitation and hygiene. They solve health issues or direct them to the hospital when required. In this course, they also carry out small surveys in teams, which they present in sessions.
While we are at this, maybe it is time to recollect Tuckman's stages of norming, forming, storming and performing that we were taught in Ludhiana.
ANSHU: One of the best methods of teaching the importance of team work is to make students work together. If you remember our session in Ludhiana, most of it dealt with group work. If you recollect the way we were told to pair with our neighbours and brainstorm on a problem frequently- that is a classroom teaching tip most of us could follow.
To see more on collaborative learning, please see this interesting link http://www.wcer.wisc.edu/archive/CL1/CL/doingcl/DCL1.asp
To give you a sneak peek, here are some similar collaborative learning activities which we could adopt in our classrooms:
Think-pair-share: In think-pair-share, the instructor poses a challenging or open-ended question and gives students a half to one minute to think about the question. Students then pair with a collaborative group member or neighbor sitting nearby and discuss their ideas about the question for several minutes. (The instructor may wish to always have students pair with a non-collaborative group member to expose them to more learning styles.) After several minutes the instructor solicits student comments or takes a classroom "vote." Students are much more willing to respond after they have had a chance to discuss their ideas with a classmate because if the answer is wrong, the embarrassment is shared. Also, the responses received are often more intellectually concise since students have had a chance to reflect on their ideas. The think-pair-share structure also enhances the student's oral communication skills as they discuss their ideas with the one another.
Structured Problem Solving: Student groups are given a problem to solve within a specified time limit. A mini-lecture preceding the group problem solving may be appropriate depending on the specific activity. Each student is identified by counting off (e.g., from 1 to 4). The group is instructed to solve the problem such that all members agree on a solution and can explain the answer and strategy used to solve the problem. After the specified time, the instructor announces the number (e.g., "2") of the student to present the group's solution to the other groups. Besides the collaborative exchange, students become familiar with problem solving strategies, improve their communication skills, and reinforce their interdependence with other group members. Also, if this problem solving task is given right after a mini-lecture, the students are able to work with the concepts immediately.
Discovery method: This method is similar to the structured problem solving method except that student teams are asked to find the information they need to solve the problem on their own without the benefit of a mini-lecture. The instructor can structure a multi-layer discovery task. This way groups to ensure that groups that work faster than other groups can delve more deeply into the problem.
Send a problem: This task involves several groups generating solutions to problems or analyzing possible solutions. A problem can be created by the instructor or by the students in an earlier class. Once prepared, groups are either given a problem by the instructor or choose one themselves. Using a folder with the problem clipped to the outside, the group generates as many solutions to the problem as they can within a specified time. The solutions are written down and placed inside the folder. After the specified time, the folder is passed to another group which is permitted to see the problem but not the solutions generated by the first group. The second group also generates as many possible solutions to the problem within the time limit and places them inside the folder. A third group receives the folder and is given the task of selecting the best two solutions. This group reviews the solutions, consolidates them if necessary, and adds new ones as needed. The last step is a higher level thought process that involves synthesis and evaluation.
Think-Pair-Square: This is similar to Think-Pair-Share. Students first discuss problem-solving strategies in pairs and then in groups of fours. Since problem solving strategies can be complicated, this structure may be more appropriate with experienced collaborative groups. The instructor poses a problem. Problems that have a "right" answer work more effectively in this structure though open-ended problems also work. Students are given time to think about the question and then form groups of four. Two pairs of two students gather, each pair working to solve the problem. They then re-assemble as four and compare answers and methodologies. The think-pair-square structure gives students the opportunity to discuss their ideas and provides a means for them to see other problem solving methodologies. If one student pair is unable to solve the problem, the other student pair can often explain their answer and methodology. Finally, if the problem posed does not have a "right" answer, the two student pairs can combine their results and generate a more comprehensive answer.
Drill review pairs: This structure is useful for courses that require drill and practice. Four students are grouped together as two pairs. Each pair is given two problems to solve. The two students are assigned roles of explainer (the person who describes step-by-step how to do the problem) and an accuracy checker (the person who verifies the correctness of the methodology used to solve the problem and encourages the other student if needed). After the first problem is completed, the roles switch for the second problem. After both problems are finished, the two pairs of students re-group and review the two problems. If the four are in agreement, the group forms pairs again and continues solving more problems. If there is disagreement, the group reviews the problem and reaches consensus on the solution to the problem. This structure can be beneficial following mini-lectures since it provides immediate reinforcement of any concepts or methodologies presented. When students are first learning a difficult concept they may need to help each other play the role of explainer.
Thinking Aloud Pair Problem Solving (TAPPS): The idea behind TAPPS is that presenting aloud the problem-solving process helps analytical reasoning skills. The dialogue associated with TAPPS helps build the contextual framework needed for comprehension. Similarly, TAPPS permits students to rehearse the concepts, relate them to existing frameworks, and produce a deeper understanding of the material Students are paired and given a series of problems. The two students are given specific roles that switch with each problem: Problem Solver and Listener. The problem solver reads the problem aloud and talks through the solution to the problem. The listener follows all of the problem solver's steps and catches any errors that occur. For the listener to be effective, he or she must also understand the reasoning process behind the steps. This may require the listener to ask questions if the problem solver's thought process becomes unclear. The questions asked, however, should not guide the problem solver to a solution nor should they explicitly highlight a specific error except to comment that an error has been made.
Do try to go through more fun learning activities on the site.
CHETNA DESAI: The post earthquake period in Gujarat was one of the very good examples of team work. I’m posting a report by the St John's Medical College Team. Please read the "Thoughts" part. It’s touching as well as motivating. I guess if students are put in to such situations they would learn teamwork and management skills faster and better. An excerpt…
"…We care and so we help…sixty three volunteer names within 27 hours…A friend of St. Johns arranges for financial commitment within eight hours for team support…1.6 tons medical supplies in 5 hours sorted and packed by pharmacy staff…medical students helping with packing…security guards and interns loading…administration sanctioning unconditional loans and permissions…Professors and HAM enthusiastic tracking down team…Janvikas control room assisting 24 hours a day…SPARK the adventure club loaning tents, sleeping bags and rucksacks for team kits…Indian Airlines baggage staff and ground staff most helpful and accommodating…Citizens and corporates helping with finances, supplies, and just being available…a logistic nightmare of sending a team of thirteen along with 1.6 tons of supplies and enough food and water to last more than a couple of days so as not to be a burden on local resources…a great team effort…encouragement for the future…He shall live because of me!…"
More on this link: http://www.onlinevolunteers.org/relief/medical-0217-thoughts.html
The Complete report by the St. John's team also details the debriefing and other strategies adopted by the team: http://www.onlinevolunteers.org/relief/medical-0217.rtf
HEMLATA BADYAL: Conducting practical examination is also team work at departmental level. Arranging examiners, posting letters, transport, accommodation, meals, arranging animals/human volunteers and then on day of examination assigning different responsibilities to all.
ANSHU: Another place where teachers need to work as a team is in planning integrated teaching. All too often they lack the cohesion, and we see repetition of the same thing by different teachers. Teachers find it tough to let go what they see their domain.
Similar things happen at a larger level during curriculum planning, when there is lack of interaction between different disciplines. You keep adding new things to the curriculum, and forget to remove what is redundant, or it is repeated in subject after subject. The poor student has to cope with the burgeoning syllabus.
SANJAY BEDI: Reporting Pathology slides is quite often a team work as we take opinions among faculty or even friends across the NET. These days almost everything is a teamwork blood bank a team collects blood another team registers it and delivers for testing. Another team converts it to components. Still another one cross matches and delivers to patients. And another one transfuses.
ANSHU: Yes Sanjay. And now just imagine a weak link in any one of those steps that you mentioned, and understand the chaos that will follow if even one person is negligent or casual about his/ her work. A chain is as strong as its weakest link!
Teaching Organizational Skills to Students
CHETNA DESAI: Dinesh, you are right when you say that medical students cannot spare much time to develop NS abilities and nurture their hobbies. However we can help them by using some teaching methods that make use of these NS abilities. Seminars, group discussion, project work or any such method that requires them to work in a group teaches them to interact, give, share, be accommodative to others needs and so on.
ANSHU: Interestingly, the draft of the revised curriculum circulated by the GoI emphasizes using all these group work kind of T-L methods. I jumped an inch when I saw my FAIMER project receiving approval of sorts from the higher ups!
One method I tried a few years back with slow learners was getting them to teach their own class with a little guidance, and sensible choice of easy topics. It worked wonders for their confidence and I was their favorite teacher for that term, with them buzzing around me for every advice they could think of!
CHETNA DESAI: Hem, emotional intelligence is very difficult to develop. It’s easier said than done. Our emotions get disturbed by slightest of slights! But yes we can certainly learn a lot by observation and experience. No matter how much we know or read about EQ, what is important is how we react to particular situation when it actually happens! We have an NMO in our college. Let me share some of the activities conducted by students under this banner, with you all:
• Cleanliness drive- instead of cribbing about insanitation, they are encouraged to adopt a portion of their hostel premises and encouraged to keep it green and clean. • HIV awareness campaigns through skits and plays • Elocution competition on certain important days like the birthday of Swami Vivekananda. • Poster and Rangoli competitions on important themes such as save the girl child etc. • Cycle rallies-for save the environment campaigns.
All these seem trivial but it encourages organizational capabilities, improves social awareness apart from giving them change from their mundane routine of memorizing facts from text books.
ANSHU: Chetna, your mail reminded me of the Red Ribbon Alliance that Subodh has started here by virtue of his being the NSS coordinator of our institute. Undergraduate students carry out HIV/AIDS and sex education classes in neighbouring schools and colleges. From what I hear, the young folks are doing a great job in sharing knowledge with students of their own age in the local language. They are confident, composed and eloquent and handle even the most awkward questions with aplomb. The entire experience shows how when responsibility is thrust on someone- they rise to the occasion displaying organizational capacity, maturity and leadership in full measure.
DINESH BADYAL: A few things which I started here are: • Pharmacology quiz-for all MBBS batches together. Prelims and then finals. This is now an annual event • Seminars- which I have already mentioned • Poster making from students on pharmacology topics then awarding them in internal assessment for best poster • Debates: e.g. on animal use in pharmacology What I have observed is that students learn fast and remember for a longer period with this activity
ANSHU: Dinesh, that was interesting. We too have an Academy of Basic Medical Sciences where first year students pick up topics from Anatomy, Physiology and Biochemistry and in a phase wise manner each student has to present a topic. Each month, the best few get selected to participate in the next phase and in the final term in a keenly fought contest the best three are awarded. The office bearers are all students, and the quality of models and creativity has to be seen to be believed.
EMOTIONAL INTELLIGENCE CHETNA DESAI: We know that persons with average IQ often excel. This is attributed to their high EQ. While we are on these various NS abilities let’s keep in mind the context of our discussions.
• How important is the NS ability being discussed important in medical profession and why do you think so? • How will you sensitize your students that these abilities are necessary? • Tell us about any initiatives that have been taken or can be taken in developing these abilities in the students.
SANJAY BEDI: Components of Emotional Intelligence:
Self-awareness: Being mindful of one's moods, emotions and drives. Self-regulation: The ability to think before acting and control negative impulses and moods. Empathy: Being able to put oneself in another's shoes. Social skill: The ability to build and manage relationships and influence others. Motivation: Drive that is internally generated rather than resting on external rewards or financial compensation
Empathy
ANSHU: Sanjay, among the various components that you mentioned- one is empathy- the ability to put oneself in another's shoes.
It is important when we prescribe drugs/ treatment to know how much your patient can afford and to prescribe tailor-made therapy. Unfortunately, I do not think except for an occasional class in SPM where they teach you Kuppuswamy's classification of the social status (Hopefully that has changed since I was taught it); we were not taught to link a person's economic status with your management protocol. In India, health insurance is not as well developed as elsewhere, and the patients who can get their fees reimbursed are but a handful. How can we teach our students to respond appropriately?
I think awareness of the socio-economic differences will make it easier in a way to get doctors to serve in rural areas too. The challenges there are tremendous, but the job satisfaction disappears when one has to cope with red tape, bureaucracy and lack of funds.
CHETNA DESAI: While we are discussing why these abilities are important, it is also useful to share ‘how to nurture these abilities’. Your concern about affordability by patients is rightly placed. Health and life insurance policies survive on "fear factor" i.e. what if....
Since our country does not have a mechanism for health and social security, each one is left to fend for themselves. Added to it are the woes of inadequate government run healthcare facilities. It is a common knowledge that the expenses of a bypass surgery could buy a small one BHK flat in a B or C grade city! Medicines are very expensive and put many a patient in debt. Are we as doctors conscious of this situation? The least our students should be trained to do is to be sensitive enough to the patients' financial situation and minimize expenses wherever possible. At our department we are trying to do our bit by including:
• Prescription audit • Pharmacoeconomics • Rational drug therapeutics i.e. the Right medicine for the Rightly diagnosed ailment in the Right dose and dose form, at a price that the patient can afford.
But then therapeutics and patient care is much more than writing prescriptions. Each department needs to take up this initiative where students are taught how to cut costs during patient care.
Handling Stress
CHETNA DESAI: Medical students are a stressed out lot. The first year is when we have most cases of suicides and depressions. Pre examination period is also critical for such students. The rate of suicidal tendencies is higher in medical students, both because of pressures and easy access to fatal medicines. Teachers and friends are usually the first to detect these, even earlier than parents. So how can we help them?
CHETNA DESAI: I came across this wonderful study carried out by Dr Avinash in 1998 (Findings stand good even today) available on
http://www.jpgmonline.com/text.asp?1998/44/1/1/389
The study concludes that
• Stress in medical students is common and is process oriented. • It is more in second and third year. (My misconception was that it’s more in the first year) • Academic factors are greater perceived cause of stress in medical students at Seth GS Medical College. • Emotional factors are found to be significantly more in First MBBS. • It is dependent on person's ways of coping and social support.
HEMLATA BADYAL: I have something to share here. I was approached by parents of a student to help her. The student had a history of suicidal attempt in hostel. When I met her she was depressed. One of the reasons she told me was stress of studies, later on it came out to be the most important cause in her case. I was little bit worried also, because she will talk about suicidal tendency. Then I decided to help her out of this.
I counseled her almost for 7-8 months. She also started responding and she passed first professional with good marks. But it took a lot of sessions with her, sometimes an hour on phone. Her mother was a great support during those days. She is now doing internship, and comes to meet me frequently. She does feel stress of studies, but now she is able to manage on her own.
CHETNA DESAI: That’s good. It’s not very often that we get to know our student's problem. Sometimes timely action can save a life. While your role in this case was really positive and important, it also helped that the mother was supportive. I have come across a few instances where the parents have high expectations from the student and are more disturbed than the child when the latter does not perform. Having their children undergo psychiatric treatment is in itself considered to be a stigma. That increases the stress and a viscous cycle sets in. The College Council and the Student Welfare Committees can do a lot to help. Individual sensitive and committed teachers (like Hem's example) can also work wonders.
MONIKA SHARMA: Hem, it is great to know that you were able to counsel her effectively. However, many of us may not be the best counselors. My advice to all those reading this would be (since we know ourselves best) that trying to counsel a suicidal individual may be very tricky.
Patients with such a tendency should not be left alone....however it may be difficult to explain this to their friends or peers. Since I do not have any scientific knowledge about this, I would advice the parents to have a psychiatric consultation while continuing with my impromptu counseling alongside.
ANSHU: Coming back to our original problem, though we are dealing with enormous numbers, can the final psycho-analysis be done in a second test conducted by the institute where the student is joining? Can't a psychological test be made mandatory- if we really think it makes a difference?
And the problem is not as small as it seems. Each year we hear of suicides by medical students who turn out to be undiagnosed schizophrenics or depressives. Only recently, we had a postgraduate student who was clearly mentally ill, and had been pushed by undergraduate examiners every year to pass and had reached our Department. Having him meant a very tense time for all of us, because he would turn violent and abusive without notice, threaten to commit suicide if reprimanded, and make terrible errors with patient reports. He couldn't cope with either colleagues or studies. He refused medication because it made him sleepy. When we finally got him to compulsorily see a psychiatrist, he resigned from his residency. Last year we heard on a news channel that he'd committed suicide, blaming his newly-wed wife for the decision. I'm sure we all have our stories to share.
Quoting from the BMJ: “The prevalence of any common mental disorder in doctors is as high as 28% compared with 15% in the general population. Specifically, depression occurs in 10% of doctors, compared with 5% of the general population. Suicide rates are worse too, with male doctors twice as likely and female doctors three to four times more likely to commit suicide than the general population.”
Do we have a solution in sight?
MONIKA SHARMA: Anshu, one of the reasons why medical students have several psychiatric problems is that they are in this line, for several reasons other than their own choice. Though I joined medicine by choice, or so I thought till I joined MBBS, I can now retrospectively say that it was my father who convinced me so well that I started thinking that it was my choice to be a doctor. I always wanted to be a teacher, even as a five year old, my favourite vacation game was to play a teacher of all my friends.
I still believe that 17-18 years olds generally have no sense of direction. It may not sound sensible to start motivating first year students to realize their choices and start quitting medicine, but encouraging their non-scholastic abilities and modifying their interests to suit medicine should do. For e.g. students who realize their managerial skills, might be encouraged to think of hospital management etc.
It’s not always possible to leave the road when the traffic is too fast and unfriendly, it is always possible to slow down or get to the side for a while and plan the further drive.
HIMANSHU PANDYA: Foundation course for undergraduates: We at our institute are planning a foundation course of one week for the new batch of undergraduates in the first week of August.
The main purpose of foundation course at this stage is to help the learners in adjusting to the new environment in a medical college and develop skills for learning, so as to cope up with a vast curriculum. Many students who might have pursued rote learning in secondary/higher secondary education would find it difficult to cope up with new subjects. It is also necessary to sensitize students with interpersonal and communication skills, besides the role of information and communication technology.
The topics suggested for foundation course at this stage are as mentioned above. 1. History of Medicine 2. Study Skills, learning Techniques, use of Computers and information retrieval including use of internet. 3. Management of time. 4. Behavioral skills, group dynamics. 5. Stress management and coping skills. 6. Introduction to ethics, professional etiquettes. 7. Community based Medicine 8. Psychosocial issues and introduction to health economics. Teaching Learning Methods may include Structured interactive sessions, Case studies and simulated cases and triggers, Role play/Role Models, Video Clippings.
ANSHU: Your proposed course sounds very interesting. I would like to hear in detail about how you plan to teach students stress management and coping skills. I often am approached by students who say they have problems adjusting in the hostels with their peers. And because they have all through been the cream of academic achievement in their schooling years, the shock of being unable to cope with others much better than themselves- and being called mediocre- is too much to take.
When the mantle of counsellor is suddenly thrust on me I don't know how to react and how far to extract details. Could you share more details of your planned course?
CHETNA DESAI: It’s a nice initiative by your college. The topics include many NS abilities too. Could you share with us the actual dynamics of the course and the student feedback? Do you meet any resistance from any of your colleagues? Are they cynical or enthusiastic about it? Also how do you deal with the language problem faced by some students from rural Gujarat who may not be very conversant with English? Also do you have some students from other states? Do you conduct any formal lessons in Gujarati for them?
HEMLATA BADYAL: Your one week course seems very interesting. I think all of us can think about this. At most of places there are few introductory days, when students are taken around the institute. I have one question, is it possible to cover so many issues in one week? That when students are in new environment and struggling with accommodation, ragging or other problems.
TEJINDER SINGH: We have been experimenting with this type of introductory program for many years. There was a time in 1990s, when it used to be almost a month long with students spending that time in OPDs and wards, interacting with patients and visitors. It changed a number of times. However, what we realized is that fresh students find it difficult to concentrate on these issues, which are alien to them. Finally we narrowed on 3 important concepts- study skills, social skills and coping skills. It seems to be the right mix to us. However, an important issue is for the faculty is to role model these behaviors. If we teach them study skills but carry on only with rote lectures, for example, the concept is lost.
What Makes a Good Doctor?
ANSHU: Read this excerpt from one of the BMJ readers. Do you agree with Robert Rudolph's logic? !
“Aside from the obvious benefits of a fine medical school, great teachers, and lots of hands on clinical experience, I think the very best way to produce a good (sympathetic and humane) doctor is to force student doctors or residents to become patients.
I believe every doctor in pupa should have many tubes of blood drawn over a few days by poor phlebotomists, have a nasogastric tube inserted once or twice, undergo a thorough sigmoidoscopy, barium enema, and bowel preparation, and perhaps even be made to spend a night or two confined to a hospital bed, plugged into an intravenous drip, and then be subjected to harried and uncaring staff doctors and nurses while bedridden.
I'll bet a case of wine that this trenchant exercise will produce far more empathetic, sympathetic, and good doctors then multiple lectures on sensitivity and humanism by some medical academic, ethics professor, or member of the cloth. I daresay that I truly believe that my experiences of being a patient as a student sure as hell helped mould me into the caring and sensitive practitioner I am today! ”
Robert I Rudolph, clinical professor of dermatology.University of Pennsylvania School of Medicine
MRUNAL KETKAR: No, I don't think I agree.
ANSHU: The BMJ survey reveals what people think makes a good doctor. Makes interesting reading.
EDITOR Altogether 102 people wrote in response to our questions "what makes a good doctor?" and "how can we make one?"1 They were clearer on the first question than the second, listing more than 70 qualities a good doctor should have. Among the usual compassion, understanding, empathy, honesty, competence, commitment, humanity were the less predictable: courage, creativity, a sense of justice, respect, optimism, grace.
Responses came in from 24 countries all over the world, and almost all of the respondents had something different to say, indicating, as one respondent put it, that "a good doctor will be different things to different people at different times." For some, the notion was very simple: a doctor who satisfies his or her patients; a doctor you would trust yourself; a doctor who likes people and likes the job; even "a doctor who feels for himself the sorrow of human kind."
For others, it was more difficult. Like describing a good car, a good play, or good weather it all depends on your perspective. A member of the library faculty at a New York university described a good doctor as one who "reads and reads and reads." A professor of bioethics (with an interest in medical history) argued that good doctors are also good historians, adding that medical history should take up at least a quarter of the undergraduate curriculum. Educators gave a high priority to being a good teacher, coach, and mentor. And a quality improvement specialist thought a good doctor was one who critically examined what he or she did and tried to improve on it.
Patients, however, wanted little more than a doctor who listened to them.
From this great diversity a few common themes emerged.
Firstly, there are plenty of good doctors around and we should nurture them better.
Secondly, to be a good doctor, you first have to be a good human being: "a good spouse, a good colleague, a good customer at the supermarket, a good driver on the road."
Thirdly, it's easier to be a good doctor if you like people and genuinely want to help them. A general practitioner from Wolverhampton wrote: "To like other people, from this all else follows. Liking your patients will get you through the grind and tedium of your working day, and patient contact will be a source of strength and renewal. You may even do some good."
Finally, good doctors, unlike good engineers, good accountants, or good firemen, are not just better than average at their job. They are special in some other way too. Extra dedicated, extra humane, or extra selfless. More traditional contributors wanted doctors to sacrifice themselves for the good of their patients. Others said doctors must look after themselves first or they wouldn't be able to help anyone. Doctors are patients too.
Few respondents had anything to say about what makes a good doctor in specialties with little patient contact. Pathology, for example, or epidemiology. There wasn't much either on what makes a good surgeon. One of only eight contributing surgeons (a urologist from Saudi Arabia) wrote that good surgeons are "good doctors with extras." Another surgeon said that it was important for doctors to find medicine fun, fascinating, and stimulating.
Making a good doctor seemed a greater challenge than defining one. There was general agreement, though, that we aren't very good at it. To paraphrase 13 responses: all we can hope to do is select students with the right gifts (not the right exam results) and somehow stop them from going rotten through overload cynicism and neglect during their training and early career.
One first year intern from Israel echoed several others when she suggested bad societies were unlikely to produce good doctors: "Whilst doctors are overworked, underpaid, and abused, the debate on defining a good doctor will remain academic," she wrote. "Our society undervalues doctors yet expects and will accept nothing short of perfection . . . Even with perfect risk management mistakes will be `made' . . . people will die young or decline with age, and not all pregnancies will have a good outcome. Unfortunately doctors are more easily sued than God, and moreover . . . pay cash."
Alison Tonks, freelance medical journalist.
ANSHU: Here’s a standardized patient’s perspective: http://www.slate.com/id/2169480/ Enjoy!
SERVICE ORIENTATION
Orienting students to rural service
CHETNA DESAI: With the GOI emphasizing on rural service post- internship, how do we help students accept this change? Which qualities are especially important to work in a rural setting and how can urban bred young ambitious doctors adjust and work effectively in such situations?
ANSHU: One of the issues that we need to discuss is the lack of doctors serving in rural areas. Before we begin the easy way out- criticize the government for not doing what it ought to- let us first do some introspection. Where are we failing as doctors in motivating our students to serve the people who need them most? (Then we can have a thorough government bashing session later!;-0 )
Since MGIMS Sevagram is India's first rural hospital- which was started in 1969 with the mission of orienting medical students to serve in rural areas- let me share with you our experience here.
We follow the following seven innovations, most of which are now adopted by other colleges as well:
2 year Rural Placement
Internship: Rural postings
ROME Camp: Reorientation of Med Educatio
Adopting rural families for 5 years
Social Service Camp: Orientation to village life
Orientation Camp in Gandhi Ashram
Pre Medical Test with Paper in Gandhian Thought
Right in their first year, students participate in the Social Service camp- where they stay in a village for 15 days. And as I mentioned in a previous mail, MGIMS, Sevagram has an old tradition of adopting a village for each batch of medical students. Each student of the batch is allotted 4-6 families for their camp activities and follow-up activities for the next 4 years. They live like the villagers do, eat the food they eat and experience their surroundings. Initially it is tough getting used to pit toilets and makeshift bathrooms, but in the recent years, depending on the prosperity of the village, students have had the fortune of using proper toilets as well. The bond between the student and families usually is so strong that patients usually seek the student before they seek the consultant in case they visit the hospital.
Each department has been allotted time in these 15 days where the consultants visit and carry out free diagnostic camps. Patients who are referred to the hospital get free treatment, and the village is insured that year. Daily general OPD is run by the Department of Community Medicine. Specialists from each speciality also visit the village. Health education of the villagers is done at household and community level. A health exhibition is also organized in the village Panchayat building. Apart from these, the other activities that are carried out during the camp are school health check-up, tree plantation, promotion of soakage pits and kitchen gardens, promotion of organic farming, organization of 'Healthy baby, Conscious Parents' competition and organization of Kishori Melawa (meeting of adolescent girls).
Reorientation of Medical Education (ROME) camp is organized in our rural training centre for 12 days. They are provided clinical demonstration of the association of social and environmental factors in health and disease at family level. The students also understand the treatment seeking behavior of the villagers. Visits are arranged to the subcenter, PHC, CHC and Anganwadi so that the students can see the health care infrastructure in rural India. The students carry out small surveys in the community and analyze and present the data during the valedictory session, thus equipping them with skills of survey technology, data analysis and report writing. They also provide health education in various schools of the area.
The students are divided into small groups for participatory learning of various National Health Programs. Students are provided training in 'data management through computers' as part of the ROME camp. Students also analyze data collected by themselves on various issues of public health importance using EPI INFO 6.
Problem Solving for Better Health: Final year students do a project in community medicine in their adopted village under the guidance of a faculty member from the department during the Problem Solving for Better Health (PSBH) workshop, which is conducted in collaboration with Dreyfus Health Foundation, USA and Health Action by People, Trivandrum. Projects with some sort of intervention are encouraged so that the community also gets benefited.
Like other colleges we have rural postings in internship. We were among the first to introduce 2 year rural service after internship. In fact the eligibility criterion for a PG seat is a certificate that you have served in a rural area for two years in an NGO recognized by the institute. We have 101 NGOs all over the country which are recognized for rural service.
ANSHU: The last mail was longer than intended, so I thought these lines would get lost; so sending them separately.
Having said all that about orienting our students to rural service, I cannot honestly claim that a large number of students are actually working in rural areas. I do not have the exact numbers, but the general perception is that people will do as they please. The mindset that comes from home doesn't change much. If you think it is fashionable to be a doctor with a posh consulting chamber and want to live in a city with all the amenities, I don't think anything changes it. Students, who originally belong to villages, if sensitive to the thought of serving the poor, will automatically go there. Other rural students who want to climb up the social ladder and want a 'good' life (read city) automatically choose to work in the cities.
I can say the same thing about the staff as well. I have noticed that faculty who are not very finicky about the kind of houses they live in or enjoy the simplicity of this village, stay on. I can now look at a person who has joined and predict if he will stay on or is just bidding time before joining a corporate/ city hospital. If money, pompousness, the so called good things in life attract you, rural service will not suit you.
To cut a long story short, it is how one perceives one's life to be. It depends entirely on the person and his priorities.
MONIKA SHARMA: Well, Anshu your second mail covered some of the questions that cropped up in my mind while reading your first one!
Yes every college has the customary rural posting, definitely with a lot of question marks behind. We had a compulsory rural posting for 3 months during our internship. Since the college I studied from was run by the municipal corporation, the rural areas it undertook were supposed to be within a specific radius from the main institute, and with the expanding borders of the city, most of these actually were not really rural.
It's not just the 'rurality' of the centre that was a factor in the posting being utterly useless, it was also the fact that students were given a choice to decide what centre they wanted to go to. Since we had no knowledge of it, we were 'guided' by our seniors to choose the most convenient centres, which meant selecting a centre requiring minimum hassles. I only have faint memories of my rural posting because I went there only twice. We formed a group of ten (5boys and 5 girls) and further divided into a smaller group of 5, each group going alternately, which was once a week. The MS of the rural hospital was too busy with his farming to really bother about the hospital and the staff.
What I have described happened 9 years ago. But I am sure it is still happening. The lazier students ended up being assigned centers that required more efforts and dedication while the smarter ones got away with nothing to do. Though I wasn't utilizing this free time for anything constructive, there seemed to be no motivation to go to the rural centre. There were various reasons that demotivated me and my friends- living, food, poor patient load (which should be blamed on the doctors themselves, there were several private nursing homes around) and actually nobody really scrutinizing us.
Programme evaluation is an important and essential part of every project and lack of it was what I felt, demeaning the whole rural project at the time.
My question here is: Compulsory rural posting for a year after MBBS has been introduced at several places, but with a larger number of private and autonomous medical colleges in India, how applicable is this rule to them?
All said and done, I appreciate the concept, for the reason that the 4 and half years of MBBS, do not serve the purpose it is intended to-to create a basic doctor. It is not uncommon to see fresh PG entrants confused over a patient with a mild illness. One of the most irritating things in a heavy OPD is to have a first year post graduate come up to you with a patient with URI, asking what to prescribe and what to advice.
Speaking to some students who have been through a rural posting for more than a year (through CMC) is comforting. Most of them are happy about it and feel it gave them more confidence to work than one year of internship in college. I have a resident who used to perform caesareans in his rural posting. Would he ever have done that in internship (even Ob/Gyn PGs don't get to do many).
I believe in two contradictory statements: "Feelings come from within" "Anything done repeatedly/forcefully eventually becomes a part of our personality"
I would translate this for our subject as- rural service or the feeling of serving/helping people/learning does come from within. But the rule of rural posting if followed to the line will eventually give our students a better look into rural health problems and will be a good motivator for the same.
ANSHU: Monika, I do not blame your fresh PGs at all. In fact one of my most frightening experiences as an intern was in Pediatrics. I hated OPD days. I was sent to sit all alone in what was called a Follow-up OPD or some such thing. I was raw and was told to write 'Continue all' where in doubt! Believe me, my knowledge of Pharmacology was weak, but passable for an adult patient. I spent half my time worrying whether I would kill a child, because I didn't understand the doses at all. To say I was scared was an understatement. I learnt nothing in Pediatrics except collecting CT and X ray reports. They wouldn't let the interns take blood samples either as the veins would get spoilt. If this is the state of affairs in internship, how else do you expect a fresh PG to react? Be thankful, that at least they dare to ask you what the right thing is. My seniors were so frightening and so far, that I had to walk to an OPD 10 minutes away if I needed help and couldn't do that because the patients just kept pouring in.
MONIKA SHARMA: So right, the situation hasn't changed. In the end we are to blame for everything we crib about. Our interns hate work because we don't give them interesting work to do.
Some time back, somebody in CMC took feedback from interns and Pediatrics was the most disliked dept for all the reasons you mentioned. Well, after I got to know of the details, I try to make a point to ask the residents in my team to involve the interns as much as possible. Interested interns often do blood sampling and lumbar puncture considered a bonus and appreciation for their true efforts.
As far as the residents are concerned, teaching them is a little different and a very difficult task. Kids now a days are smart and getting smarter. I find more PGs trying to find excuses than making an effort themselves. One PG will never call for help because somebody earlier troubled him for calling in the middle of the night and another will call every five minutes because I scolded him for not calling when in trouble. Is it the brains that are deteriorating or again- is the problem with the way we deal with people.
We definitely need to work on how to teach PGs and how to make them learn.
One thing that I am yet to gain an insight to is how to motivate pgs to learn- not read? (Did we miss this point in our discussions on motivation)
TEJINDER SINGH: One of our faculty members once coined the term FRCS for interns. Not that they did the Fellowship but they are used only to fetch reports and collect samples. There is no doubt that motivation to learn has gone down but who is to blame? Would you also have 'wasted' time learning skills, if you knew that your future depends more on a stupid MCQ paper of questionable validity than on learning skills?
ANSHU: Monika, it is difficult to do- but never forget the time when you were a PG yourself. And perhaps you'll understand why they behave so 'weirdly'! Make a list of all the idiotic things you did as a PG and you'll probably feel better!
CHETNA DESAI: Anshu, thanks for the detailed post. Wardha Sevagram has been known for an innovative and practical approach in rural service. Are there any such other centres that also do something similar? NSS and ROME programs are implemented in our college too. The PSM department is doing a good job at it. But while the students do it willingly or otherwise during their UG, when it comes to compulsory postings (1 year in Gujarat) after completing their internship all the escapism begins. They either pay up the bond money or pull strings. No wonder many of our remote PHCs are unmanned.
ANSHU: I remember MGIMS Sevagram started off as a rural hospital. But being a tertiary care hospital we were compelled by existing circumstances to keep adding technology to keep up with the times- though the prices have been kept affordable for the rural population. So though the setting is rural, the technology is up to date. With the huge burden of the curriculum it is becoming almost impossible to keep sending our students for our yearly village camps. If I am not mistaken, the camp durations had to be cut down eventually so as to cope with the burgeoning syllabus. So while the report says bulk of our training should be in these centres- I am rather skeptical how we can manage this unless a massive rehaul of our curriculum is done.
Here I see students coming back very happy after their rural service. I guess that is because they get paid really well, and get the position of authority and the NGOs are chosen after much thought. So maybe something similar should help- add perks, improve condition of the hospitals and make living there worth it (easier said than done). What I'm not happy about, is the way they talk to patients after those two years- that touch of superiority and arrogance sets in very fast.
Another thing I feel strongly about is the need to revive the institution of the family doctor. If it could be made the in thing to become a general practitioner like the NHS it would be great. And since the craze for being an MD isn't going to subside so soon in India, MD (Family Medicine) is one of the best things that can happen. Are their numbers going to be more than the remaining specialties?
SHEENA SINGH: Anshu, I will take the liberty of responding to each of your paragraphs.
Since Sevagram has tried and tested you are in a good position to evaluate your program and see how parts of the syllabus could be covered in the camps perhaps.
Yes that is an interesting thought. I remember my 3 month rural posting. It had its plus and minus points as Monika has enumerated. The plus points were that I really enjoyed the simple living, riding a bike into the villages, interacting with the village folk, cooking our own meals, and we learnt to work independently and got the feel of being responsible for a patient.
Many of our graduates actually learn a great deal after their Rural service commitment as is apparent in their interviews for PG selection. They are able to answer the questions that follow brief case summaries much better than those fresh out of internship. And many have performed surgery during their rural service period. Arrogance is certainly not a desirable outcome and sessions on Medical Ethics and interpersonal relationships during MBBS training should be introduced.
Yes as Monica has pointed out, there is a DNB course in Family Medicine and an MD would be a good idea.
What is your opinion on my suggestion of having colleges dedicated to creating doctors for the community and having a new curriculum focused on the diagnosis and management and prevention of common diseases? A separate stream of Community based doctors?
ANSHU: Sheena, regarding your question below, I am not too sure it would work, because I feel creating a separate cadre will create a sort of snobbishness between doctors of the two streams. And I do not like the idea of increasing the already existing rural-urban divide into a chasm.
However, can there be a choice somewhere midway in MBBS to have an elective subject (I'm simply thinking aloud)? Students choosing (a) to serve in the community (b) to open their own NGOs (c) to serve in govt. posts (d) to teach in medical colleges (e) to become private practitioners (f) to become health administrators etc can receive special training. Some sort of certificate courses with credits or grades which will fetch you more stars at interviews ahead. A vacation course of sorts, if the time frame cannot be increased. What do you think?
ANSHU: In fact Subodh's FAIMER project seeks to evaluate a part of this exercise i.e. the Social Service Camp. Analyzing the whole endeavour is a gigantic task, but something tells me Subodh is coaxing his departmental colleagues to do it in piecemeal fashion like him.
MONIKA SHARMA: Anshu, that's a difficult idea too. What if I chose rural practice in MBBS and after 2 years realized I was missing out all the money? How could I go back and study all over again for private practice?
Well, the type of practice one chooses is really not related to what is taught in medical school. It comes from our own perceptions and understanding of the world around us, how it affects us and how we decide to react to it in general?
I chose to teach because I liked teaching. It's not as if I don't love the material pleasures that I miss with my limited pay, but I do realize that one works to earn not to enjoy it really. It’s always the next generation who has the fun!!
This is my philosophical explanation of my preferences. Each one has his own explanation for his choice of way of life and practice- it cannot be programmed in college.
ANSHU: The key word that you missed was 'elective'. So what if you changed your mind. A short certificate course of a few weeks wouldn't be too tough to re-do. Let's focus on competency rather than theoretical hogwash in these courses.
SHEENA SINGH: Anshu, I understand your concerns for not widening the urban-rural divide.
I have found an interesting article on the Barefoot doctors of China. They were recruited and trained from the year 1965.The system of barefoot doctors was among the most important inspirations for the WHO conference in Alma Ata, in 1978.Eventually these doctors were asked to take a national exam and those who passed became village doctors, the rest became village health aides. The system was abolished in 1981.
The article is titled: 'Health for the Masses: China's 'Barefoot Doctors' http://www.npr.org/templates/story/story.php?storyId=4990242
I like the idea of an elective. Students should be encouraged to realise if they feel passionately about serving in the rural areas. But that is only the first step. There has to be a system of mentorship, so that they pursue their dream and do not get waylaid and discouraged.
We have many altenative streams of medicine being formally taught in India like Homeopathy, Ayurveda and they get their share of importance too. Why not Family Medicine or a parallel stream of Community Practitioners?
I think that if students have strong role models engaged in community service, teaching and epidemiological research, they will be inspired to take it up by choice and not by chance.
CHETNA DESAI: The generation gaps these days are coming sooner. Even a five year gap is a wider in terms of perceptions, needs etc. Over a period of years I have observed our students are more focused on their career needs, practical and less demonstrative. These traits are sometimes misunderstood as disobedience, indiscipline and "smartness". Perhaps we are trained by our seniors to think so. But Anshu has a point. We forget what we were as students/PGs. If we remember, we could be more sensitive to the needs of our students and maybe start treating them as adults.
DINESH BADYAL: Things have changed so much, and if we do not change ourselves, then we might feel this generation gap. I agree with Chetna, that we should not expect from PGs of this era what we used to do. We would not enter restaurants where our teachers were present, nor other shops or places. These days it is entirely the opposite- teachers avoid going to restaurants where students are there, their own students!. Take it easy, do your work, let them do theirs.
DINESH BADYAL: From next year MBBS course is going to be 6 and half year with one year compulsory rural posting!
TEJINDER SINGH/ PAGE MORAHAN: For those of you who are trying to increase the number of medical students who enter into rural or community practice, this survey instrument may be of use.
'Decision criteria in health professionals choosing a rural practice setting: development of the Careers in Rural Health Tracking Survey (CIRHTS)'
Are you interested in the workforce outcomes of rural health professional education? This new data collection instrument from Australia will provide interesting new information. http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=666
Report of the Task Force on Medical Education of the National Rural Health Mission
ANSHU: Here are some interesting observations from the Report of the Task Force on Medical Education of the National Rural Health Mission. (http://mohfw.nic.in/NRHM/Documents/Task_Group_Medical_Education.pdf )
The terms of reference of the Task Force are as under:
To examine the possibility of revamping Medical Education with reference to the requirements of medical professionals under the National Rural Health Mission.
There is a widespread perception in the country that the MBBS curriculum is too theoretical in its content. After 4 ½ years of the main course and I year of internship, the finished graduate has very little ‘hands-on’ experience. Most graduates are not confident enough at that stage to even provide primary healthcare services independently. The MBBS curriculum is closely linked to a tertiary care hospital. And, therefore, the graduates cannot function in a setting where there is no multi-disciplinary support, or advanced diagnostic hardware. A large percentage of the graduates treat that stage as a launching pad for the post-graduate course. It is generally assumed that the clinical experience to equip the doctor to deliver medical services is only gained at the post-graduate stage. Whether this situation is inescapable, has never been critically examined. The medical graduate course of 5 ½ years is one of the longest professional courses. Lawyers undergo a 5 year course (after 12th standard), Masters of Business Administration a 2 year course (after graduation), Engineers a 4 years course (after 12th standard), etc. These other courses equip the individual to pursue their professions independently, though, of course, the standard of performance improves with time. It is only in the case of the medical graduate that an assertion is made that even 5 ½ years of professional training is not enough, as the management of health of a human being is a uniquely complex and demanding responsibility. As a solution it is suggested that the duration of the course be further extended in order to provide more intensive clinical experience.
The Task Force has carefully examined this issue and feels that the claim of clinical complexity of the medical profession is an over-stated one. Any professional course should equip the fresh graduate to practice his profession at the level of the more common tasks and services. If the medical graduate does not have the requisite skills and confidence at the time of graduation, the fault lies with the curriculum and the pedagogic methodology.
The Committee was of the view that a fresh graduate must at least be able to deliver services contained in the primary healthcare package. The suggestion that the duration of the course be extended to give more intensive clinical exposure is not a practical proposition. As it is, the graduate medical course is one of the longest professional courses, and the students and their guardians, are exposed to a prolonged financial and familial burden. With the extended time and substantial financial resources involved in a medical education, graduates are increasingly drawn towards the more lucrative specialisations, their choice often being in direct conflict with broad community requirements. Increasing the duration of the graduate course would only worsen those pressures.
SHEENA SINGH: Anshu, thanks for this reference. The following paragraphs caught my attention. (scroll down)
These are very real reasons for Young graduates not opting for Rural Service.
In CMC Ludhiana Rural Outreach Services are of paramount importance. We serve many villages around Ludhiana. We have many examples of our Alumni who have spent their entire life serving in rural areas. Some of our students have a service commitment with Mission Hospitals in Rural India right from the outset and serve for periods of 2 - 5 years after graduating. During the introductory program they were taken to 2 Mission Hospitals for them to get the feel of a Hospital in Rural settings and to generate interest and awareness.
But yes, I agree that how many students will take up a lifetime of rural service of their own accord? Very few.
Should there be some Medical Colleges that have a specially designed curriculum to train doctors for the community.
Students can choose to be either specialists in the City or doctors serving the Rural community right at the start, and be clear about their goals.
Also the Rural Hospitals and Clinics should aim to provide the doctors some comforts of life and an access to internet and medical literature so that a doctor can also attend CMEs, publish papers, attend conferences...there needs to be a whole infrastructure for a lifetime of development for Doctors serving the rural masses.
EXCERPT from the Report of the Task Force on Medical Education of the National Rural Health Mission:-
4.1.6 Looking to the nature of complaints of the fresh graduates, it is unlikely that government can radically relieve these in a generalized manner in the near future. The shortcomings perceived by the fresh medical graduates are principally the outcome of their urban orientation and the skewed pattern of their aspirations. Most of them have only lived and trained in the urban setting. The few with a rural background acquire an urban mindset in the course of their training that is focused around a tertiary care hospital. They do not have the confidence to function in a setting in which there is no multi-disciplinary support or advanced diagnostic hardware. Most graduates aspire to spend their career in the same urban ambience that they are familiar with. This is, in a way, a distant ripple effect of the macrotrend of the commodification of health services observed globally over the last two decades. It is often felt that it is because of this fixed mind-set that the young graduates fail to position themselves comfortably in the social ambience of the country, and also fail to recognize health services as a fundamental requirement of the community.
4.1.7 As a result, primary healthcare comes to be neglected and high-tech tertiary care is the single preferred option. It is often emphasised that to fulfill the basic requirements of the broad-based community, the social orientation of the students would have to be altered. For medical education to serve the community, it would have to be socially oriented towards primary healthcare. The pedagogic methodology would have to be problem based – where the non-clinical principles would have to be meshed with clinical training. In short, it is felt that medical training should largely be in a decentralized setting outside a tertiary care hospital, in close proximity with the public health and social environment.
4.1.8 Conceptually, private health services were always visualised to be distinct from other commercial services. It is obvious that health services would only be delivered on payment, as no one can expect it to be a charitable activity. However, with a different orientation to the curriculum, and a community centric pedagogy, one can reasonably expect a much more even spread of service providers over the country. The government has previously tried any number of initiatives to improve the spread of the graduate service providers in the public sector at least. Compulsory rural attachment for fresh graduates has been tried out in several states; priority admission to the post-graduate courses after a stint of rural posting has been offered as an incentive; and, enhanced allowances, with an assurance of a rotational transfer policy, so that those who serve in the rural areas, can expect a more socially congenial posting at a later stage, have also been attempted. However, all these attempts have failed on account of brazen defiance, subterfuge, nepotism, etc. As a result, even five decades after independence we face an indefensible situation in which we are not able to provide trained primary healthcare over large parts of the country.
MONIKA SHARMA: At least the National Board has started with a 3 years course in family medicine.
Determinants of Rural Orientation in Medical Students
CHETNA DESAI: Physicians' service orientation and understanding of patient expectations for service quality enhances both bedside manner and working relationships health care professionals maintain with patients and coworkers. Until recently, however, service orientation has received little interest. The reasons for this general lack of attention to service orientation include:
--- regarding the act of service as not being prestigious nor requiring much skill --- believing that anyone can acquire these skills because they are so easy to develop --- extreme and one-sided focus on the scientific and technical elements of providing health care ---- a generalized belief that highly developed social abilities are a natural by-product of being a health care professional.
In fact, service orientation is considered one of the key characteristics that bestows professional status upon an occupation (Reed and Evans, 1987). Paradoxically, there is a strong consensus that it is largely absent among many health professionals, especially physicians. Thus, one should not take for granted that higher levels of service orientation exist naturally among health care professionals, but that it is necessary to help them better understand and develop it.
The present study seeks to more fully understand service orientation as it exists among a key group of future health care professionals, namely medical students. The purpose of this paper is to present a description of an investigation of service orientation among a sample of medical students. It examines service orientation and how it is influenced by the students' perceptions of patient expectations for service quality and a variety of sociodemographic measures such as age, gender, marital status, and estimated future income. The survey instrument administered to the medical students in this study included items developed by the authors as well as scales and measures obtained from other sources. The survey included measures of medical student perceptions of patient service quality expectations, medical student service orientation, and other questions regarding age, gender, marital status, and estimated employment-related income for their first year of practice (following residency training). It was observed that those medical students who exhibit greater levels of service orientation are those who are older, female, married, and who place greater emphasis on their future incomes and perceptions of patient expectations for responsiveness and tangibles. In a sense, this knowledge provides a rudimentary delineation or profile of what a service-oriented medical student is like. http://www.sba.muohio.edu/management/mwAcademy/2000/38c.pdf The article also describes the survey instrument used i.e. the 20-item SERVQUAL scale
MISCELLANEOUS NON-SCHOLASTIC ABILITIES
Music
MRUNAL KETKAR: Music is one of my non-scholastic abilities which I enjoy the most i.e. singing, listening to music & collecting good music.
ANSHU: We have heard that soothing music helps heal faster. I wonder what the surgeons have to say about their favourite music in the operating room.
CHETNA DESAI: Music sure helps, but should not distract. I have come across surgeons listening to radio FM, classical music too; some religiously inclined listen to hymns and chants. I was just wondering though- the patient is either sedated or anesthetized. So is the music in the OR for the surgeon or the patient? :-)
Here’s another interesting fact. Some time ago a patient who had undergone a surgery revealed (to a surgeon I know) in a lighter vein at the time of paying his bills that he had listened to the conversation between the anesthetist and the surgeon on topics ranging from movies, share markets, other gossip etc. Commonly surgeries become a mechanical ritual for most surgeons and hence once the patient is settled and sedated and after the initial incisions et al, the hands work, but mild chatter takes place, oblivious to the fact that the patient may be listening. Put yourself in the patient's shoes and think.
AVINASH SUPE: Music in OR is always useful. We have soft music in our theatres - Instrumental or classical- Loud music does cause distraction.
There are two advantages: 1. It keeps unnecessary conversations to minimum - every one is engaged 2. Slow rhythmic music improves your pace and concentration in surgery
This is commonly used in business offices. In fact there are many evidences. • Agriculturally, trees and flowers grow better with music - PAPER FROM ANNMALAI UNIVERSITY • It improves business performance • For patients - there are now enough evidences to suggest that some diseases such as hypertension, IBS, and other disease are amenable to classical music - special ragas
I am not sure whether we should use music while doing educational activities - It is not a norm yet
HARPREET KAPOOR: I do agree with Avinash, especially on the point that it keeps unnecessary conversation to the minimum. We as Ophthalmologists have to be very acutely aware of the fact that our patient is always listening to all that’s happening in the theatre, as majority of our surgeries are performed under Local Anesthesia. In a medical school setting it becomes all the more relevant as at times when we are trying to help our residents with a surgery we need to make a conscious effort not to take him/her through the surgical steps verbally - the patient might decide to get up and go if he gets to know that he is being treated as a guinea pig. Inculcating 'Theatre etiquettes' is an important aspect of postgraduate medical education.
MRUNAL KETKAR: We are not allowed to play any music in the OR. I feel instrumental music surely will lighten the atmosphere in the OT and may also help to calm the nerves of an anxious patient.
Yes, we do discuss other topics apart from training our junior doctors in surgery or anaesthesia, but taking care that the patient is at least under sedation. You are right in saying that after few years it really becomes a mechanical job, but at the same time no two patients are the same.
CHETNA DESAI: The incident I mentioned had come as a surprise to the surgeon too. At the end, the results of the surgery matter. These are some of the lighter moments of our profession that are otherwise peppered with tense moments, mortality and high expectations from patients.
CHETNA DESAI: Sangeet Samrat Tansen was known to heal through music. According to music therapists, some of the ragas that have a positive effect on health are: Bhairavi: Tuberculosis, asthma, cough Asavari: Circulatory system, blood purification Malhar: Anger, mental instability.
In India there are some centres that research the effect of music on health and healing. To all the music lovers, I’m sending an excerpt of an article on this topic. http://www.akhandjyoti.org/?Akhand-Jyoti/2004/Sept-Oct/MusicTherapyRagas/
TEJINDER SINGH: We once tried putting a soft instrumental music as a background for a power point presentation. Many liked the concept, and many said it is a distracter. I suppose, it is all a matter of personal preferences. I usually put a classical instrumental while working and feel that it soothes. Research has shown (do not ask for reference, as I just read it somewhere) that putting an instrumental tune distracts as the mind starts to identify with the song being played but if it an instrumental one, whose lyrics are not known, then it helps.
STEWART MENNIN: In earlier times (several hundred years ago), many physicians were also musicians and "scientists" (in that they questioned, disagreed, observed, experimented and reformulated their understanding based on systematic experiences). This was so among Arabic healers circa 1000, during the renaissance in the west, and probably elsewhere (my ignorance). Is there such a history in India? Or in the region? Have we lost something over the years? This links the present thread about communication to the previous one about non- scholastic activities.
ANSHU: Yes Stewart, Indian classical music does have a rich heritage of healing and soothing as Chetna's attachment reveals.
One question I would like you, since you are a musician, and other music aficionados is: what is it about music that makes you a better doctor? To which facet of your personality does music add the extra zest?
STEWART MENNIN: Music is about the whole; wholeness, integration, completion, harmony~dissonance. It is a way to communicate ideas without language, without words - communication that goes deep and direct without the imposition of other symbols (language, etc). It includes emotional well being and feelings.
Music is about spatial and temporal relationships, patterns (like diagnosis and treatment), intervals between notes, time, empty space (rests) and history (melody). It has dynamic patterns (repeats of melodies with variations) that are pleasing (recognition). To play music is to give, to share with others. To heal is to help another to recreate, reorganize their wholeness in the moment and continuously. There is a flow, a free exchange of energy so that one can self-organize anew (heal) and be alive in the moment, every moment. I think music and healing share similarities.
VIVEK SAOJI: Well light music is good for any occasion and is a great stress buster, so ORs are no exceptions and it’s good to have it in Ors. we do have this facility in all our ORs
Excellent Stewart and you’re absolutely right. You expressed in words what most of us feel but are short of words
BALACHANDRA ADKOLI: Stewart, that's great delineation on the role of music. I am a strong music preacher and a practitioner. But, I am not aware of the scientific mechanism in which the music works in the healing process, nor the pharmaco-kinetics of music therapy. Chetna has done wonderful job of citing the value of some raags in curing.
I believe in the soothing role of music on all living beings including the human beings, animals and plants. Music and "mantras" (vedic chanting) are supposed to send vibration to the external cosmos, purify the air and thus help in overcoming environment pollution. The practice of music also helps in cleansing our internal organs as the different notes (SARGAM) originate from the seven "chakras" the activation of which ultimately lead to the "awakening of Kundalini" the supreme seat of creative energies in human being.
Though the elements of music (sur, lay, and taal) deal with the techniques, I feel the emotion "Bhaav" is at the heart of music which connects the soul.
Hence my prescription is as follows:
1. Music should be encouraged in all sittings and settings wherever feasible (cultural activities, community activities, and health education). I am not sure if the music therapy will benefit a terminal patient who is subject to a lot of pain; but a subtle kind of music with prayer component and meditation approach might be useful. 2. Many of the academic sessions can start with invocation. We borrow the services of beautiful girls, mostly freshers, only for the inaugural function of big conferences- why can’t each exam start with an invocation? 3. Light instrumental music can be played in the waiting halls of crowded OPDs as stress busters. Our RP Centre (Eye centre) is using channel music with success. 4. Community Medicine faculty can introduce parodies, jingles, FM Ad kind of stuff to create public awareness for the field projects; 5. Last controversial suggestion: All assessment promotion for faculty (including HOD) should have some weightage for the music talent. (Not necessarily singing, but at least an "ear" for music can be accepted)
Medical science deals with service. So "Sing while you serve" should be the new slogan!
MONIKA SHARMA: At a hospital where I worked earlier, the latest Sony music system was installed in the new OT complex. We have a CD player in our PICU too- only it is used mostly for entertainment of the staff present, while the morning and office hours are spent listening to soft devotional songs, the rhythm tends to get faster in the evenings and later. It is part of the parcel.
Scientifically speaking there are a few articles emphasizing the usefulness of music. Some studies on neonates suggest that babies (studied with ear phones on) had stable vitals (respiratory rates and heart rates).
If I were a resident in the PICU, however, the music would hardly matter to me while working on a sick patient, might even sound stupid to me!
HARPREET KAPOOR: We can feel the passion flowing across oceans Stewart... next time you have to play for us!
SHEENA SINGH: Wonderful discussion on music in the OR. Music touches the soul. It brought back memories of my late father, a surgeon, who had soft instrumental music playing while he operated. He was also a good singer and artist.
At CMC, background instrumental music regularly plays in our Dental OPD while procedures are being done.
In our Physiology classroom, we have played soft music while students were filling up a questionnaire, and during short breaks between classes.
At a trip to Auroville in Pondicherry I picked up an audio cassette titled 'Hirrudaya: Music for heart disorders' by Dr P Bharati MD. It has 2 ragas: Ahir Bahirav and Chandrakauns.
ANSHU: Well Stewart that was beautifully put. I can see how passionately you feel about music. Just as passionately you feel about medical education.
MADAN LAL GILL: I totally agree that music is wholeness as well as that communication without words is much effective and stronger than speaking.
Sports
SANJAY BEDI: I have seen that generally those students are good at some sport are also good at studies generally. (Except few who are too good at sports but otherwise duds, but in the long run they turn out successful too). Besides simple good health sports provide many other abilities especially mental toughness.
CHETNA DESAI: Sports and other hobbies do form a very vital part of our lives. They not only help us be fit, but also help us learn to accept defeat sportingly and enjoy winning gracefully. They help develop competitive edge and also team spirit. Mind games like chess exercise our minds too. Maybe all members can share their favorite sport and tell us why they like it.
ANSHU: Sport and I are poles apart- I can hardly get on the field. But yes, my favourite games are all indoor board and word games. I can see most of you screwing up your noses and saying ---'Are you kidding- are they sports?' But I get my high from winning Scrabble! Lately have been addicted to Yahoo Games- especially Literati and Graffiti! Graffiti is all about drawing a word so that the others guess it. These are games which allow you to be flexible with words- I learn new words and in a fun way too.
CHETNA DESAI: Let me share my favorite sports with you all too. I was good at all throws (discus, shotput etc) and tried my hand (legs?!) at running races and other athletics. But no- it did not work. I like mind games like puzzles, crosswords, sudoku (and sometimes kiddish games like snakes and ladders) with the little ones.
MONIKA SHARMA: Well, like a true studious Indian kid, I have no serious interest in sports. Though I do enjoy running around with my son at times and used to enjoy games in the PT classes at school. Hey that reminds me, I used to play baseball and yes I liked it! It seems like I am rediscovering my interests. I like mindgames like scrabble, and my recent interest is a game of quadra-pop on my mobile.
SANJAY BEDI: Well I have played multiple sports during different periods of my life. As a child I loved lawn tennis and used to visit the local Lawn Tennis Club at Amritsar. Since I have a hereditary weight problem it is necessary for me to be on some programme of exercise and diet always.
During my MBBS days we had a very good coach who used to teach martial arts Taekwon-do to students and made them exercise a lot. I went to him and he saw my physique and what a brainwave he had. He asked to come at 5 AM every morning and made me exercise and practice the skills of taekwondo. I for the first time came to know that martial arts are more mental games than physical games. Anyway to cut the story short he trained me for six months. Since he was giving so much attention to me I also went to him as wanted. He sent my name for the Inter-University championship and I landed up with a gold medal in the Nationals in my category entirely due to my coach's hard work on me.
But this training in taekwondo taught me the art of concentrating my energies and even in life in any direction whether mental or physical in general if I direct my concentrated effort I am confident that I can come out successful.
I could not continue my Taekwondo practice due academic pressure but fitness culture is definitely there. Otherwise I went for mountain climbing again a very spiritual exercise. You feel the walk of life as mountain trek, swimming etc.
MRUNAL KETKAR: I enjoy solving the cross word puzzles if it could be considered as a sport.
Intuition
SANJAY BEDI: We forgot one non-scholastic skill called Intuition which is very important for Clinicians. I remember in my father a TB chest specialist used to demonstrate it to me about the look in the eyes of tuberculosis patients before seeing the X-ray.
And here's the story, as written in the New England Journal of Medicine: Oscar the Cat Predicts Patients' Deaths http://www.sun-sentinel.com/features/health/sns-ap-death-cat,0,713126.story http://content.nejm.org/cgi/reprint/357/4/328.pdf
...It demonstrates the usage of tacit knowledge in medicine, in this particular instance in a cat.
It reminded me of tales of physicians/seers of yore who were said to have predicted not only their patient deaths but also their own deaths right down to the last minute and would generally choose to depart in style surrounded by their initially disbelieving relations.
Off course this may not be generalized to all physicians and this particular cat too needed to have been gifted to have found its place in NEJM (unless he was as success theorists like to believe just being at the right place at the right time).
In recent times another mention of tacit knowledge in physicians (British Journal of General Practice, May 2002 395) particularly with reference to predicting patient death has been made by a well known author physician and the paper also raises issues on EBM as EBM is definitely a way of reducing over-reliance on tacit knowledge in physicians:
That night, I went home and told my husband that I had seen a man who was going to die. He did indeed die, fourdays later, despite normal bloods and observation chart throughout. Postmortem showed a strangulated volvulus. This story raises a number of questions about the appropriate clinical management of the patient in hospital, but I include it here to show that intuitive insights are commonplace in general practice, and they may or may not save lives. They are rarely as impressive as the one I first heard quoted by Professor Nigel Stott (and which I subsequently analysed in detail1) from a GP in Cardiff: 'I got a call from a lady saying her three-year-old daughter had had diarrhoea and was behaving strangely. I knew the family well, and was sufficiently concerned to break off my morning surgery and visit immediately.' This GP's hunch led him to diagnose correctly, and treat successfully, a case of meningococcal meningitis on the basis of two non-specific symptoms reported over the phone -- an estimated 'hit rate' for that particular GP of one in 96 000 consultations, and a veritable tour de force for clinical intuition. The intuitive judgements we make on a daily basis in clinical practice are generally less dramatic but no easier to explain on a rational level.
I wonder if FAIMERians would like to comment on this parallel movement and is there a possibility of developing an experimental design to study these phenomena in medicine?
ANSHU: That story was simply amazing. Intuition is something most of us do have. I have often noticed that when I pick up a slide to report from a tray, there is something in my head which says, this one is going to have a malarial parasite- look carefully! And it comes true. Thankfully, I don't predict deaths like Oscar. But when something bad is about to happen, I can foresee some things and be mentally prepared to face it. A woman's intuition- isn't that what they call it?!
The question however is that whether this is a necessary non-scholastic ability. Unless something scientific comes up, I'll be a sceptic! And puh-lease , dont go ahead and ask me how to assess intuitive capabilities of medical students!!!! I really don't know!!!
ANSHU: I didn't think too much about your intuition mail, but strangely stumbled on these two articles while googling for something else. This author asks: Is intuition the secret of research success? Ask any Nobel Prize winner (I asked four) or any great inventor: "To what capacity do you owe your success?" The more self-assured, the more honest the respondent, the more success will attributed to intuition.
Whoever today neglects intuition does so at the peril of failure, especially in the hard-boiled realm of research and development. The reason is that in every research project, intuition is crucial at the beginning (the hunch), in the middle (the choice of optimal method), and in the end (application). As for a "thing" (an industrial product) coming into the hands of people, its marketing and selling can hardly be done without the nose, the Midas touch, the gut feeling— intuition. http://www.winstonbrill.com/bril001/html/article_index/articles/1-50/article26_body.html
And guess what, there are tests called IQ2 (Intuition Quotient) being tried to measure this capacity! http://www.winstonbrill.com/bril001/html/article_index/articles/1-50/article47_body.html I didn't want to deviate the discussion, but I was quite amused at the way these articles opened up on my laptop without my intention!
SANJAY BEDI: Just a bit about the NEJM cat Oscar and the underlying currents on which it rests.
Michael Polanyi has had an enormous contribution to understanding what he calls tacit knowledge for which his slogan is "We know more than we can tell." Check out the wiki on tacit knowledge.
Like a surgeon's skills can not be learnt by gleaning information over the net. It has to be experienced by the body. It is as if the body knows but the brain doesn't have an inkling.
SESSION FOUR ASSESSMENT OF NON-SCHOLASTIC ABILITIES CHETNA DESAI: This discussion is coming to the last part. We have discussed myriad NS abilities, some briefly, and others in detail. We discussed why they are important, how to promote and nurture them and also shared our experiences and perceptions about these.
It has been rightly pointed out by some of the Fellows and faculty that not everyone possesses all these abilities in equal measure. Hence to nurture an existing ability or develop one that is lacking, we need to first evaluate. Further when an intervention is carried out to nurture these abilities, we need to evaluate if the interventions are successful.
Hence coming to a very relevant issue in this area, let’s devote the last five days of this discussion to:
• How will you judge if your students/colleagues possess one or more of these abilities? • How will you evaluate these non scholastic abilities? Why evaluate non-scholastic abilities at all?
CHANDRIKA RAO: I hope you will agree to let me disagree with these questions. I feel that there is no need absolutely to evaluate these skills as a part of medical training. Yes, it should be encouraged and the doctor should be able to use these abilities in other fields. But, why evaluate?
A qualitative judgment can be done. However it may not be very objective.
TEJINDER SINGH: Chandrika, you have in fact given the answer yourself. Passing a qualitative judgment is actually the definition of evaluation!
CHANDRIKA RAO: Evaluation is the process of determining significance or worth, usually by careful appraisal and study. Without going into details of what is evaluation, it is also said to be the process of determining the worth or value of something. This involves assigning values to the thing or person being evaluated. This is what I was referring to. Will an evaluation of an ability which is not the primary ability of the speciality not affect the student or bias the faculty?
ANSHU: Chandrika, feel free to disagree on this forum, because it is a good debate which spices up the discussion.
However, as expected, I completely disagree with you, when you say that there is absolutely no need to evaluate non-scholastic skills in medical students. Here are my arguments why:
1. If one is to practice the 'art' of medicine (notice, no one says 'science' of medicine!) one needs to communicate well, be sensitive, be compassionate, be able to work in a team and get along with colleagues. In other words, one needs to do scores of other things, besides cramming up thick textbooks to be effective. After the last three weeks of discussion, I think that there should be no difference of opinion on whether these skills are essential in the making of a good doctor or not. In case, you still feel otherwise, remember the first write-up that Chetna posted, where she quoted Dr Santosh Kumar's study? Of 12 qualities that go into the making of a good doctor, only 1 was a scholastic ability. If you remove these non-scholastic qualities, you could have a computerized system to diagnose disease and manage it. Without the human touch, what is a doctor?
2. Evaluation of these qualities is essential for two reasons. One, anything which is not evaluated is never learnt properly. You might pick up things by observation, but if you know something is going to be assessed, you learn it thoroughly, whether it is theory, practical or attitudinal. Two, the evaluation system itself is a motivating factor to imbibe these skills into one's personality.
3. It is not as if non-scholastic skills are not being assessed in our present systems of evaluation. The traditional viva does just that- sees if a student can express himself. The long case does just that- assesses his/ her ability to reason out a diagnosis. The group discussions/ projects test one's ability to work in a team. The only problem is that all this is being done haphazardly. We do need to know whether the student can talk to his patient, counsel him etc. And we need to find tools to suit the ability we are testing. That is our job as the Gen-Next of medical educators!
4. I understand your predicament when you say 'a qualitative judgment' can be done. These areas are fuzzy areas which cannot be assessed by 'valid' tools like MCQs. So we need to find relevant tools which suit us. It is another whole topic of discussion as to when and where we can assess these skills (we'll take that up a little later). But as of now, we can use rating scales, observational checklists and questionnaires to test these skills. They are not completely unreliable and give us a fair idea of whether the student is competent in a skill or not. An OSCE designed creatively will show you whether a student has learnt to counsel a patient. His peers, the nursing staff, his seniors can assess whether he is good at team work or not.
5. As Stewart said, one cannot separate scholastic from non-scholastic abilities and view them in isolation. I wouldn't look at you and say she is a good doctor because she knows each page of Nelson perfectly. You are a good doctor because you have knowledge and the ability to transfer that knowledge for the patient's benefit, with sensitivity, with compassion and with professionalism. I would go to the extent of saying that non-scholastic abilities are not just 'nice to have' or 'desirable to have', but 'must have' qualities. And since they are 'must have'- every effort must go into learning them.
6. Evaluation will also give the student an opportunity to know where he needs to improve. It is aimed at remedying the lacunae which exist. In my opinion, if you remove the non-scholastic part of a doctor, any robot with a heart of steel can do the job.
Hope that convinces you.
STEWART MENNIN: Another way to consider evaluation is that it provides information to improve something or someone, not just to prove. Frequent and multiple sources of information joined together are value-able.
CHANDRIKA RAO: Well, I wholeheartedly agree with the fact that doctors need to strengthen other aspects of their personality, which holds true for any person in any profession.
Coming to assessment, a long term periodic observation of the so called `must have` non- scholastic skills when given as a feedback will help an individual to grow and develop. However in a viva though skills are important, I still mark the candidates on the knowledge and not because he/she spoke well, though it would influence me. Should we have columns for marking of these abilities, like in OSCE, we mark for greeting a patient?
Motivation is necessary. However is evaluation the only way to motivate? I agree that an assessment will help us to strengthen our teaching of students as to what they should be developing.
I came across an admission site of The University of Maryland School of Medicine, which tells its applicants what they want and why. http://medschool.umaryland.edu/osa/pdf/handbook.pdf (Page 25-27) CHETNA DESAI: Quite some debate on whether to evaluate! I beg to disagree with your disagreements for 2 reasons:
• As I mentioned earlier too, not everyone possess all these abilities that we listed. However some may be important. For example, communication skills. If it is detected early on that a student could improve on this skill, intervention and efforts may be planned. • Secondly as Stewart wrote, not all evaluation is summative. Formative evaluation also helps us correct the intervention process. The actual evaluation may not be so simple since it has many variables, the parameters are subjective in nature and it largely involves the affective domain which is the most difficult to evaluate.
The article on Assessment of Non-scholastic abilities in Principles of Medical Education by Dr TS, lucidly outlines some checklists and rating scales that could be of use.
TEJINDER SINGH: Then there is another thing also, called Hawthorne effect. The fact that someone is watching you, in itself changes the performance. Unless we give weightage to these abilities- howsoever small it may be- it may be difficult to induce the students to learn them.
MONIKA SHARMA: I would agree with the view to evaluate non-scholastic needs.
Over the last three weeks we have been discussing why it is necessary and useful to have and nurture non scholastic abilities, and it has been a common observation that we need it not just to relax but also to build up on our scholastic needs and also because many of our non- scholastic 'talents' can actually form a sort of a buffer that helps us against the stresses of our job.
Many of us do not realize our non-scholastic abilities and having an evaluation system or a system to explore these may help the hidden talents or the introvert observers to come out and unknowingly display them.
However, I would not be all for going out and forcing our students to carry on with some extracurricular activity, because there may still be a fraction who really doesn’t want to follow an extracurricular trend.
Isn't it a little unfair to have internal assessment based on extracurricular activity? Does it mean that those few who do not nurture such a talent end up getting a zero- even if it is out of 1?
CHETNA DESAI: Monika, let’s just rethink and ponder. Do you know any colleague/student who does not possess even one of the NS abilities that we discussed? Latent or otherwise? Having agreed to agree that these are important to our professional and personal lives as well (same stands true for students too), why not go a step further and make it a part of our educational setup-and that includes evaluation too.
MONIKA SHARMA: I agree all of us have some NS abilities. But, there would surely be some who don't pursue it or want to do it in medical school. I don't know how to justify a forceful pursuance in form of internal assessment.
I will talk of myself. Some of my NS abilities include painting, writing and the typical girlish handiwork (crafts, making things etc). I did all of it in vacations and free time, but my time in medical school was totally devoted to reading, strictly. Appreciate it or not, that is how I like to study. I multitask with everything, but not with studies. Even now if I have to study I try to cut down on all my other responsibilities because I wouldn't want to compromise my concentration on knowledge. After all it will go with me a long way! After a spell of reading I take time out and relax.
Wouldn't there be students like me too? They may be the ones we consider as very studious and bookworms. But they have there talents too which are actually not hidden- just given a back seat.
Problems in Assessment of Non-scholastic abilities
BALACHANDRA ADKOLI: The main reason for step-motherly treatment to non-scholastic abilities appears to be lack of indicators to quantify and measure these abilities. Standardized tools are difficult to get. But you can attempt to develop your own. Our good old study at JIPMER was based on our own judgment of what constituted such a competence. In retrospect, I find them crude. But subjectivity is inevitable and it should be respected. You can reduce subjectivity by multiple observations over a period of time, multiple occasions, 360 degree assessment etc. We should try to see how to capture these abilities rather than declaring that they are "out of syllabus". Whether ethics or humanistic abilities or creativity, the fundamental concern is assessment; but setting "role models" and providing rich contextual experience is perhaps more important. If we have done it, we have a reason to be proud of.
CHETNA DESAI: It is paradoxical that as teachers we appreciate and enjoy non scholastic abilities in our students but do little to identify and nurture them. None of our evaluation systems give due weightage to these abilities. It is just grades, marks and nothing else. How then do we expect our students to work towards these? While internal tests and University exams are mandatory for qualifying, participation in PULSE and like programs require special permission from the Dean. How often do we evaluate the ability to communicate/empathize/work as a team/etc in our students?
I am sure with your experience you would have a fair judgment of the actual extent of influence the non scholastic abilities have in medical profession. To what extent do grades really convert to a ‘Good Doctor’? Do enlighten us.
ANSHU: Is there a way in which the very same MCQs can be used to assess non-scholastic potential as well- especially the abilities needed to make a sensitive doctor? But on second thoughts, we'll probably have the mushrooming coaching classes teaching students how to attempt those questions and fake these abilities.
Can a mandatory one-to-one interview with a psychologist or a psychological test be of use in this scenario- so that we get entrants with the right attributes?
BALACHANDRA ADKOLI: Chetna, you have rightly echoed the sentiments expressed.
Anshu, I don't think MCQs can be used to select right kind of material for medicine, or for that matter any course involving attitudes and values. Psychological tests are more valid and useful; Qualitative tools such as document analysis, observation, indepth interview, response to case scenarios and simulations (computerized) and 360 degree assessment etc., can be utilized, but they are labour intensive, time consuming and impracticable in our situation where numbers really matter. I don’t' have any answer. But sooner or later, technology might come to help. A hanging video camera, or a chip fixed in the apron pocket can monitors the entire gamut of activities of a student and reveal his / her true color of behaviour. Watch out for academic “Tehelka” to capture the right candidate.
ANSHU: Dr Adkoli, I shudder to think of the day when we have to resort to Peeping Tom cameras to monitor our students! Tehelka or Big Brother- we've seen too much of media intrusion into our lives these days.
BALACHANDRA ADKOLI: We are caught in the trap of providing transparency and capturing non-scholastic abilities (attitudes, behaviour etc. etc.) which are very important for the profession. You have furnished a strong case (including BMJ quotes) for combating depression and a host of mental illnesses affecting the medical professionals. If the care providers themselves are disturbed, who else can help? I have mentioned about electronic gadgets just to aid decision making. If they are distracting, we can find out ways and means of deploying them in a non-theatening manner. Moreover, I have proposed qualitative methods in preference to MCQs.
One more submission: Providing learning experience is more important than assessment (this is not to undermine the role of assessment). As teachers we can play a great role in reducing the exam stress, and encourage humanistic aspects. Each one of you may have your own tricks of the trade. Use them. A supporting and caring attitude may help in a big way in preventing mental disorders. Forget about video-cameras, just be what you are.
AVINASH SUPE: Please see this webpage from Indian Academy of Pediatrics. http://edu4med.com/prncpl/ch16.htm
TEJINDER SINGH: Thank you for sending the page. Actually, it is a chapter from my book on Medical Education!
BALACHANDRA ADKOLI: I am supposed to talk on the recent trends in assessment. I am thinking in similar lines which CMCL FAIMER has brought out during its discussions. Let me outline the message to check from you all whether these could be good take home messages for the workshop participants:
• The global trend in assessment is to enhance the fundamental attributes (relevance, validity, reliability, and feasibility); • Traditional systems have overemphasized the knowledge, and to some extent skills, but we need to focus on the whole gamut of competencies, which requires a comprehensive tool box; ACGME grid can be illustrated as a starting point, but subject to modification depending upon the local conditions, expertise available with those who are incharge of assessment; • It has been challenging for the teachers to capture abilities and outcomes such as critical thinking, communication skills, leadership & team work, professionalism including ethics, humanistic aspects, which bring about the need to assess (and foster) non-scholastic abilities in a systematic and comprehensive manner; We need to find/develop new tools and techniques; • While the pendulum of assessment is swinging from subjectivity to objectivity (e.g., better structuring of the long answer/long case in to elements), there is also a move to go back, have a relook at the advantage of "holistic view" and retain the advantage of these modalities; • On one hand the measurement is becoming more precise by using standardized approaches. On the other hand there is also a dilemma that we need to be more global, observant, student friendly and play "supporting role" rather than "judgment role" in fostering student learning. • The assessment scenario which is unfolding in India and elsewhere is likely to face this unique challenge. Faculty development and capacity building play crucial role. I shall be happy if you can agree/disagree/add/delete/question/comment to enrich my session. It will be my pleasure to acknowledge the contribution of this think-tank, in the vast ocean of medical teachers.
ANSHU: Thank you for involving the CMCL fellows in your endeavour and valuing our opinions. I read your take home message and thought about it. It is crisp and covers most aspects. I just wanted to add one point.
I feel formative assessment is completely neglected in India. Like Arjuna's focus on the bird's eye, the teachers' and students' focus is on passing the final exam. I don't see any effort being made to tell students explicitly that these are the competencies that you need to have. Somehow I feel a formal document has to be given to them right in the beginning of the course and they should be able to periodically mark where they have reached by a particular time frame. This also means that as teachers we need to have formative assessments more frequently. I am not referring to the internal assessments by this. I mean friendly feedback to each student at each step of learning of where the lacunae in his/her learning lie. This obviously will mean lots of hard work on our part, as it will almost mean a personalized approach for each class rather than the easy methods we use. My take is that formative assessment needs much more focus than we give to the summative assessment.
Assessment Tools to Evaluate Non-scholastic Abilities ANSHU: Please take a look at this table where the best suggested evaluation tools for each competency have been outlined http://www.acgme.org/Outcome/assess/ToolTable.pdf
The Sunday theme for brain storming for all of you is:
Do you agree with the methods outlined for each of the non-scholastic competencies- and can you add to these methods? Where do you disagree with it?
Where do you believe these methods can be introduced in our present system- in the formative assessment or as part of summative assessment?
CHETNA DESAI: I’m posting a study that assesses the student's perception of formative vs summative evaluation and self assessment vs peer review of their communication skills. http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1365-2923.2002.01300.x?cookieSet=1
The key learning points were: While students seem to value formative methods of assessing their communication skills, they do not appear to value summative methods such as OSCEs. Students have different opinions about who should assess their oral communication skills. Despite student criticism of OSCEs, students suggest that summative assessment is necessary to motivate students to learn communication skills.
CHETNA DESAI: Yet another document which could be of interest. It’s a self assessment tool for important competencies of a medical student, developed by the University of Florida, College of Medicine. http://www.medicine.ufl.edu/3rd_year_clerkship/documents/FORMATIVESELFASSESS04.pdf
SHEENA SINGH: This is a useful find by Chetna. I did some searching and have found a Faculty assessment form as well. http://medinfo.ufl.edu/year3/igc/grade_eval.html CHETNA DESAI: Empathy is a major component of a satisfactory doctor–patient relationship and the cultivation of empathy is important. The study in the given link addresses the measurement of empathy, its development and its correlates in medical schools. http://www.blackwell-synergy.com/doi/abs/10.1046/j.1365- 2923.2002.01234.x?journalCode=med
It tests two hypotheses: • Firstly, that medical students with higher empathy scores would obtain higher ratings of clinical competence in core clinical clerkships • Secondly, that women would obtain higher empathy scores than men.
A 20-item empathy scale was used (Jefferson scale of physician empathy).
Both research hypotheses were confirmed. Empathy scores were associated with ratings of clinical competence and gender, but not with performance in objective examinations such as the Medical College Admission Test (MCAT), and Steps 1 and 2 of the US Medical Licensing Examinations (USMLE)
Another must read- http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1365- 2923.2002.01234.x
Also, here’s a nice article on Ethical and professional conduct of medical students: a review of current assessment measures and controversies. http://jme.bmj.com/cgi/reprint/30/2/221.pdf
DINESH BADYAL: Judgment can be made based on observation. How they work, their attitude towards patients and colleagues. Evaluation methods can be selected based on which ability you want to measure. Hence it is not possible to comment in general. All principles of evaluation have to be taken into consideration for a particular ability.
SANJAY BEDI: One source is the bio data form we make each one fill on beginning of each professional under the column ‘Hobbies’. Also organizing a small students festival, giving duties to students during conferences also brings out the non-scholastic abilities.
ANSHU: Here are some assessment tools from a paper on surgical skills which could be adapted in our context:
Multi-source feedback (MSF)
This is an opportunity for a range of assessors (including doctors, nurses, and other healthcare workers) to give feedback about an individual doctor’s performance in the workplace; the trainee selects the assessor. When complete, the educational supervisor discusses the feedback with the trainee and advises on what they are doing well and on areas for improvement. The trainees can compare their results with their peers to see how they are doing.
There are two MSFs, and trainees will complete one or the other. They are the mini-peer assessment tool (mini-PAT) and the team assessment of behaviour (TAB). The mini-PAT uses eight assessors and the trainees fill out one form themselves; the TAB uses 10 assessors, of which at least five must be qualified nurses and three must be doctors.
Clinical evaluation exercise (mini CEX)
This is a 15-20 minute appraisal of a doctor/patient consultation. The structured checklist is designed to promote the use of "Good Medical Practice." The assessor records an evaluation and then gives feedback after the consultation.
ANSHU: Here's a paper on assessment of Communication skills and Interpersonal skills. Please do take a look at the Table on different assessment methods used in the paper. http://www.aemj.org/cgi/reprint/9/11/1257.pdf
SANJAY BEDI: This is one paper whose abstract I found. I could not find the full text.
Tandon SP; Natarajan V; Rao MS; Vaidyanathan S; Jindal RK; Goswami AK Assessment of nonscholastic abilities in the M. Ch (urology) curriculum. Indian Journal of Urology. 1985 Sep.; 2(1): 26-32
ABSTRACT: At present the non-scholastic abilities such as human relationship, moral reasoning, creativity, initiative, leadership qualities, decision making etc. are being neglected in the M. Ch Urology residency programme, as compared to scholastic or technical abilities. The non- cognitive personal attributes have been shown to be better predictors of academic as well as vocational success than only the cognitive abilities. The present method of evaluation of the former qualities, if it exists at all, suffers from major shortcomings such as lack of objective assessment, and failure to use the assessment as a motivating tool. An objective methodology for the self-assessment of non-scholastic abilites is suggested for the continuous monitoring and development of non-scholastic behaviour in urology residents. Such an assessment is expected to reveal indirectly the lacunae, if any, in the urology department/institution, pointing thereby towards precise remedial measures to be instituted promptly so that urological administrators, teachers and residents can mutually continue to strive for standards of excellence, consequently reflected as improved total performance.
ANSHU: Please also see the attached example of a Standardized Direct Observational Assessment Tool www.emtests.com/2006%20Material/CORD%20SDOT%20Anchors%20-%202005.doc
RITA SOOD: These are very important and key competences that we need to develop in our students and also assess for their acquisition. I've often used the following scale (given to me by Dr Sethuraman who was at JIPMER till sometime ago) for formative assessment of postgraduates. You may find it useful.
Resident evaluation checklist on professionalism 0 1 2 3 4 - unsatisfactory 5 6 7 8 - satisfactory 9 10 - exemplary
1. Empathy in patient care 2. Appropriate fund of knowledge 3. Soundness of clinical judgment 4. Technical expertise with diagnostic and therapeutic procedures 5. Communication with patients, families and staff 6. Sensitivity and responsiveness to individual patient differences in economic status, ethnicity, age, gender and disabilities 7. Honesty in dealing with patients and colleagues 8. Accountability for actions 9. Conflict resolution skills 10. Adherence to regulatory, institutional and departmental norms
CHETNA DESAI: Here is a simple and doable assessment scale for evaluating leadership and teamwork http://www.griffith.edu.au/centre/gihe/griffith_graduate/toolkit/teamwork/teach07.htm
Global Assessment of Competence
STEWART MENNIN: I think the more complex the behavior or ability you wish to assess, the more global is the assessment. You can't break a complex issue down into its component parts and hope to make valid inferences from the bits and pieces of data you get. It's not a machine made up of parts. It's better to make global judgments based on criteria that have been agreed upon by all concerned, then tested with students and then readjusted. Also, when teachers pay attention to an ability, comment on it, provide feedback and act as role models, the students value it.
ANSHU: I agree with Stewart's mail where he emphasizes the need for global assessment. Each skill that we have discussed in the last three weeks cannot be assessed in isolation. Here is an article on competency based curriculum for residents. http://www.stfm.org/fmhub/fm2007/February/Frederick116.pdf
In the same manner (see table in paper above) can we outline the skills required, the year in which we can judge them and the instrument to be used for assessment?
CHETNA DESAI: I guess what you say is true especially when we wish to evaluate NS abilities. But as I see it, the complexity of the issue also makes the assessment scale, its analysis and interpretation equally complex. Do you know of any such scales?
DINESH BADYAL: I was also thinking on same lines, that if we generalize evaluation for these abilities then it might become too complex. But Stewart has other views. I am not still convinced
STEWART MENNIN: It's important to see that the ranking or selections have descriptors or criteria. These can be modified by a group of teachers if they all agree. The difficult part is the faculty development necessary in order that all teachers involved are familiar with the instrument and able to use it well.
CHETNA DESAI: The traditional Indian system of education even to this day emphasizes and gives undue importance to acquisition of knowledge from books and evaluation systems that test memory rather than analytical thinking and reasoning. This trend continues in higher education too including medicine. The teachers are also conditioned to think so. There is a gradual and silent revolution taking place both in the primary and higher education. It’s hence important to first develop faculty towards the newer desired changes, so that they can impart the right message to the students by the right methods. We have to begin with the basics and have a simplified approach and then proceed to the complex. And that makes the faculty development as suggested by you all the more vital.
How to Select Medical Students
CHETNA DESAI: These days are deciding days for students in Gujarat as they choose their professions, be it medicine, pharmacy, engineering, physiotherapy, nursing, dentistry and so on. We have the centralized admissions going on. Some of my peers and contemporaries have their wards at the crossroads with a dilemma on which career to choose. I faced a similar situation last year. Some students who score very well have all the choices they can make. I often wonder, barring parental pressures, how do the students judge themselves before deciding that they are suitable for medicine? How do they see themselves? Do they know what is expected from them as doctors?
If we were to play a role of counseller, merit apart, what particular qualities would we look for in a student to judge if he/she is suitable for the medical profession. How do we detect these qualities?
ANSHU: Coming back to our original problem, though we are dealing with enormous numbers, can the final psycho-analysis be done in a second test conducted by the institute where the student is joining? After all AFMC, does have its fitness test- and they are very strict about it. One of my batchmates was the AFMC topper (she stood first that year) and was still rejected on grounds of fitness. Can't a psychological test be made mandatory- if we really think it makes a difference?
And the problem is not as small as it seems. Each year we hear of suicides by medical students who turn out to be undiagnosed schizophrenics or depressives. Only recently, we had a postgraduate student who was clearly mentally ill, and had been pushed by undergraduate examiners every year to pass and had reached our Department. Having him meant a very tense time for all of us, because he would turn violent and abusive without notice, threaten to commit suicide if reprimanded, and make terrible errors with patient reports. He couldn't cope with either colleagues or studies. He refused medication because it made him sleepy. When we finally got him to compulsorily see a psychiatrist, he resigned from his residency. Last year we heard on a news channel that he'd committed suicide, blaming his newly-wed wife for the decision. I'm sure we all have our stories to share.
Quoting from the BMJ: The prevalence of any common mental disorder in doctors is as high as 28%, compared with 15% in the general population. Specifically, depression occurs in 10% of doctors, compared with 5% of the general population. Suicide rates are worse too, with male doctors twice as likely and female doctors three to four times more likely to commit suicide than the general population.
Do we have a solution in sight?
TEJINDER SINGH: This is the unfortunate part, Anshu- the definition of merit. Unfortunately, the Supreme Court judgment restricted merit to MCQ tests (of questionable value by themselves). And now, the new ruling on internal assessment is going to spell doom for any efforts to make the things better. Judiciary has to go with the letter, even if it means killing the spirit.
The educational side effects of these things take time to manifest but when they do, generally, it is a point of no return.
STEWART MENNIN: The University of Newcastle, Australia has modified its admissions process using interviews and non-scholastic data. They have shown that if you take the top 10% instead of the top 1% of candidates (based on entry scores on a national exam) the results in school performance are the same (see research published by David Powis).
MONIKA SHARMA: The definition of merit may be different for different view points and for different persons. We are far from establishing a definition of 'holistic merit' in our systems. But, it is not just the definition to be blamed for the rising psychological problems in medical school. It is also the general expectation of everybody around.
From parents to teachers, friends, peers, colleagues, superiors etc. every person has a certain level of expectation from the other that tends to push us to the edge.
I believe if we cannot change the system to suit us (at least not in the nearest future), at least we should be able to modify ourselves and build on our inner strengths to get over the stress of it. While we are all talking about modifying our merit system, we also need to add 'stress busters' to our system. That is where I feel non-scholastic abilities come in.
STEWART MENNIN: Dear Anshu, Here is the work of Powis on admissions. Quite prolific and among the best published anywhere.
Neame RLB, Powis DA & Bristow T (1992). Should medical students be selected only from recent school leavers who have studied science? Medical Education 26, 433-440
Powis DA, McManus IC & Cleave-Hogg D (1992). Selection of medical students: The philosophic, social and educational bases. Teaching and Learning in Medicine 4, 25-34
Powis DA (1994).Selecting medical students. Medical Education 28, 443-469
Barnsley L, Cameron R, Engel CE, Feletti GI, Hazell P, McPherson J, Murphy LB, Pearson S-A, Powis DA, Rolfe I, Smith AJ, Saunders NA & Wallis BJ (1994) Ratings of performance of graduates from traditional and non-traditional medical schools Teaching and Learning in Medicine 6, 179-184
Powis DA (with T Bristow) (1997).“Selection of Medical Students at Newcastle” In: Imperatives in Medical Education : The Newcastle Approach, ed: RL Henry, K Byrne and CE Engel, University of Newcastle, Australia (pp 236 - 248)
Rolfe I, Pearson S-A, Smith AJ & Powis DA (1995). Time for a review of admission to medical school? Lancet 346, 1329-1333
Powis DA & Rolfe I (1998) Selection and performance of medical students at Newcastle, New South Wales Education for Health 11, 15-23
Powis DA (1998).Should medical school selection include an aptitude test or interview? Australian Medicine, 10 May 1998, 10-11
Powis DA (1998).How to do it: Select Medical Students. British Medical Journal 317, 1149-1150 Rolfe I & Powis DA (1998).An evidence-based admissions process at Newcastle (New South Wales) Medical School Letter to Editor.Education for Health 11, 409-412
Powis DA (1999) Choosing Tomorrow’s Doctors Book Review Education for Health, 12, 120-121
Powis DA (1999). Superior Selection System. Australian Medicine, 7 June, pp6-7. A self-report measure of ethical behaviour potential for medical students. Presentation to XXVII International Congress of Psychology, Stockholm, Sweden, July 2000. International Journal of Psychology 35, p119
How do Australian doctors with different pre-medical school backgrounds perform as interns? Education for Health 14, 87-96
Selecting Medical Students. e-letter to editor .British Medical Journal 324, 28 May Powis DA, Hamilton JD & Gordon JJ (2004). Are graduate entry programs the answer to recruiting and selecting tomorrow’s doctors? Medical Education 38, 1147-1153
Bore M, Munro D & Powis D (2004) The Schwartz value model and a three-factor model of morality. Presentation to Society of Australasian Social Psychologists Annual Conference, Auckland, New Zealand, April 15-18. Australian Journal of Psychology, 56, Supplement, 58.
Bore M, Dempsey S, Lyall D & Powis DA (2003).Broadening the Criteria for medical Radiation Science Student Selection. Presentation to The Network: Towards Unity for Health, Newcastle, Australia 2003, Proceedings, p203
Bore M, Powis DA, Munro D & Kerridge I (2003) Selecting medical students: differences between school-leaver and older applicants. Presentation to The Network: Towards Unity for Health, Newcastle, Australia 2003, Proceedings, p204
Bore MR, Munro D, Kerridge I & Powis DA (2005). Selection of medical students according to their moral orientation. Medical Education 39, 266-275
Powis DA (2003).Selecting Medical Students. Editorial. Medical Education 37, 1064-1065
Powis D, Bore M, Munro D & Lumsden MA (2005). Development of the Personal Qualities Assessment as a tool for selecting medical students. Journal of Adult and Continuing Education 11, 3-14
Bore MR, Lyall DG, Dempsey SE & Powis DA (2005) Assessment of personal qualities in selection of medical
Also another article of interest on this question.
Jean-Francois Lemay, Jocelyn M Lockyer, V Terri Collin & A Keith W Brownell. Assessment of non-cognitive traits through the admissions multiple mini-interview.Medical Education 2007: 41: 573–579
CHETNA DESAI: Sending an interesting article through this link on "Selecting medical staff--some new approaches" http://www.bmj.com/cgi/content/full/316/7134/S2-7134 ANSHU: Here are the links to two BMJ articles on how to select medical students. http://www.bmj.com/cgi/content/full/317/7166/1149 http://www.bmj.com/cgi/content/full/324/7347/1170?maxtoshow=&HITS=10&hits=10&RESULT FORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT
What caught my eye was the last line: Finally, we wish to make a plea that faculties trial their selection instruments before using them and publish their results, good or bad, just as one would with a clinical trial for a new therapeutic regimen.
We need to carefully select a tool for aptitude testing. Given below is also a link to Personal Qualities Assessment developed by David Powis and colleagues. PQA is a portfolio of psychometric tests that they have designed to measure some of the qualities that the literature and many surveys have indicated should be looked for in applicants to medical school. http://www.pqa.net.au/
MADAN LAL GILL: Both the links are nice articles to produce quality professionals. I feel in India, a number of factors matter when it comes to developing certain qualities- socioeconomic status, place of stay, opportunities to education, type of educational institutions, living culture. Selection merely based on academic achievement may not do justice in a country where there are very wide gaps in opportunities of personal development.
CHETNA DESAI: A short, light and breezy article on the benefits of aptitude testing for selecting medical students. http://www.bmj.com/cgi/reprint/331/7516/559.pdf
ANSHU: While we are at this, have a look at David Powis' paper on how to select medical students. (Has this paper been discussed here earlier? I don't quite remember) http://www.bmj.com/cgi/reprint/317/7166/1149
SHEENA SINGH: Interesting article Anshu, Thanks. I feel that comprehensive testing is good once reliability, validity and predictive outcome are established.
ANSHU: I think we all agree that non-scholastic abilities are imperative to the making of a complete doctor. Of the whole list, communication and interpersonal skills, team work, leadership and the science of reasoning are most important. (Professionalism too is a big attribute, but we left it for the other month's online learning)
These skills need to be assessed during the course of training of a medical graduate. These competencies cannot be evaluated in isolation. In fact, almost all these can be evaluated in some measure on a single patient. While assessing these aptitudes, attitudes and abilities is not an easy task, an attempt has to be made to tailor our curriculum depending on the competencies we need in a medical graduate. Emphasis needs to be given on formative as well as summative assessment, as evaluation of these skills helps students in identifying the lacunae and are a remedial measure. TAKE HOME MESSAGE
• Developing and nurturing non-scholastic abilities are vital to the holistic and professional development of oneself and of medical students. It is also important to foster the connection between the scholastic and non-scholastic abilities. Giving attention, paying attention to the health and well being of someone requires that scholastic and non- scholastic things be linked and that the flow between them be open and robust. • The present admission process to medical courses, be it undergraduate or postgraduate, is marks/grade based and assesses only the scholastic abilities, but not the non-scholastic abilities or aptitude of the student. • The weightage to be given to the non-scholastic abilities is debatable, but world over these abilities are finding their well-deserved place. Certain institutions now include these abilities as a part of students’ CV and encourage programs and activities that nurture these abilities. • Soft skills like good communication skills, ability to empathize, to work in a team, professionalism, to counsel well, interest in sports and other hobbies are some of the non-scholastic abilities identified as important for medical students. • Although these non-scholastic abilities are not formally included in the medical curricula, teachers can inculcate and nurture them in their students in a subconscious manner by being role models i.e. teaching by example, organizing and encouraging activities that promote and help develop these abilities. We need to respect, recognize and grow these abilities in students without losing focus on scholastic excellence. • The non-scholastic abilities that particularly help develop a complete medical professional include: Good communication skills: the ability to communicate effectively and with empathy, to be assertive without being aggressive, to be able to communicate bad news and medical jargon to the patients or their relatives Interpersonal skills Ability to work effectively in a team Leadership qualities Scientific temper Empathy Good emotional quotient Punctuality and self discipline An aptitude towards social service The ability to handle stress Hobbies like music, sports or anything that helps relieve stress and unwind • Evaluation of these qualities is essential for two reasons. One, anything which is not evaluated is never learnt properly. You might pick up things by observation, but if you know something is going to be assessed, you learn it thoroughly, whether it is theory, practical or attitudinal. Two, the evaluation system itself is a motivating factor to imbibe these skills into one's personality. • The main reason for step-motherly treatment to non-scholastic abilities appears to be lack of indicators to quantify and measure these abilities. Standardized tools are difficult to get. Good B schools do evaluate these during personal interviews and group discussions. But medicine is yet to see this revolution in evaluation. • One can attempt to develop their own evaluation tool. You can reduce subjectivity by multiple observations over a period of time, multiple occasions, 360 degree assessment etc. We should try to see how to capture these abilities rather than declaring that they are "out of syllabus". Whether ethics or humanistic abilities or creativity, the fundamental concern is assessment; but setting "role models" and providing rich contextual experience is perhaps more important. • The more complex the behavior or ability you wish to assess, the more global is the assessment. You can't break a complex issue down into its component parts and hope to make valid inferences from the bits and pieces of data you get. It's not a machine made up of parts. It's better to make global judgments based on criteria that have been agreed upon by all concerned, then tested with students and then readjusted. • A need is felt to include the non scholastic skills in the selection of students in to the medical profession. It is also necessary to identify the subtle and hidden non-scholastic abilities in the students through formal training methods. The teachers themselves can also imbibe and nurture these abilities in the students by acting as role models. • This discussion might initiate a process of recommendations to the regulators and policy makers to include non scholastic abilities at appropriate time and for appropriate duration in the medical curriculum.
PARTICIPANTS
• Anshu • Aroma Oberoi • Avinash Supe • Balchandra Adkoli • Chandrakant Patankar • Chandrika Rao • Chetna Desai • Dinesh Badyal • Harpreet Kapoor • Hemlata Badyal • Himanshu Pandya • Madan Lal Gill • Meena Pangarkar • Monika Sharma • Mrunal Ketkar • Page Morahan • Rita Sood • Sanjay Bedi • Sheena Singh • Stewart Mennin • Tejinder Singh • Venugopal Rao • Vivek Saoji
FOR MORE RESOURCES: http://nonscholastic.abilities.googlepages.com/