Leadership skills: Need of an hour for medical faculty

Educational Curriculum, Assessment, Research and Outcomes: Past, Present and Future Directions

Medical and health care professional education in the 21st century: institutional, national and global perspectives

The Government of India's (GOI) initiatives to increase the number of Bachelor of Medicine and Bachelor of Surgery (MBBS) graduates by establishing more and more medical colleges have been showing their repercussions. There are several doubts over the quality of medical education (ME) and the competency of MBBS graduates. In addition, the National Medical Commission (NMC), the body that regulates ME and medical practice in India, has been busy ensuring the uniformity of ME standards by conducting regular inspections. The NMC ensures infrastructure, faculty, and patient availability before permitting colleges to admit students. Several issues are plaguing faculty, students, and other personnel working in medical colleges, which could potentially influence the educational environment (EE) and the competency of graduating students. Evidence of disparity in infrastructure, faculty, and EE in medical colleges confirms the necessity of holistic improvements. Therefore, it is suggested that the NMC utilize ombudsman services in medical institutions, which have been successfully implemented in the banking and insurance sectors.

In Reply: Kommalage and Ponnamperuma correctly point out that Sri Lanka has the highest health indicators in South Asia, which they attribute to the quality of medical education and the absence of private medical schools in Sri Lanka. However, variations in the quality of medical education constitute only one factor among many in determining population health. Significant interregional, intraregional, and within-country variations in social determinants of health play an even more important role.1,2 Factors leading to these variations include the literacy rate—particularly the literacy rate of women—the fertility rate, improved sanitation and clean water, and nutritional status.1 These social determinants of health are generally stronger in Sri Lanka, for a variety of reasons that warrant further exploration. As we have pointed out,3 private medical education is not necessarily detrimental to the quality of education. With strong accreditation systems, the high quality of both public and private schools can be enforced.3 In addition, with public policy initiatives and support, both public and private medical schools can support and strengthen the social determinants of health mentioned above through locally relevant curriculum content, education innovations, and research.4 These initiatives may include adding courses in leadership and management skills to the curriculum, greater work in and with communities, and policy advocacy to promote the strengthening of key social determinants. Excellence in medical education can be associated with good health status if excellence is defined by how well the education system is connected with improvement of the social determinants of health. Intraregional variations in health outcomes within South Asia, as highlighted by Kommalage and Ponnamperuma, inspire us to explore the relationship between health professions education and health outcomes. Zubair Amin, MD, MHPE Associate professor, Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; [email protected]. William P. Burdick, MD, MSEd Associate vice president for education, Foundation for Advancement of International Medical Education and Research (FAIMER), and clinical professor, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania. Avinash Supe, MS, MHPE Professor and head, Department of Surgical Gastroenterology, Seth Gordhandas Dunderdas Medical College (GSMC) and King Edward Memorial Hospital, Mumbai, India, and director, GSMC–Foundation for Advancement of International Medical Education and Research (FAIMER) Regional Institute, Mumbai, India. Tejinder Singh, MD, MHPE Professor, Department of Pediatrics, and vice principal, Christian Medical College Ludhiana (CMCL), Ludhiana, India, and program director, CMCL–Foundation for Advancement of International Medical Education and Research (FAIMER) Regional Institute, Ludhiana, India.

Objective Joint-PhD program is an effective way to cultivate international creative talents. Survey on intrinsic value factors of this mode is significant to improve the quality of medical educa-tion. Methods According to the questionnaire results and reports of 104 medical doctorates who attended the Joint-PhD program in PUHSC, Baldrige Performance Excellence was taken as theoretical framework. Results It showed that index influencing the quality of Joint-PhD education include social responsibility; stakeholders' expectation and market requirements; information and knowledge management support and so on. Conclusion In the process of doctoral education, advocating value of social responsibility, paying attention to the expectations of stakeholders, and attaching importance to the validity of education manage-ment ser-vices help to understand the intrinsic value of the quality management from the top universities in the world, in order to fundamentally improve the quality of doctoral education. Key words: World-class; Joint-PhD program; Quality of medical doctorate education; Value factor; Baldrige Performance Excellence

The impact of an accreditation system on the quality of undergraduate medical education in Saudi Arabia

The National Medical Commission (NMC) in India has introduced new guidelines for the eligibility qualifications of faculty in medical institutions in 2022, aimed at enhancing the quality of medical education and healthcare in the country. The guidelines include an increased minimum publication requirement for promotion to professorship, the consideration of various types of publications, and mandatory courses in biomedical research and medical education technology. The guidelines also recommend reputable indexing databases and journals to improve the quality of research work. The NMC's efforts are expected to promote research collaboration, evidence-based clinical practice, and consistent teaching standards. However, it is essential to ensure that the recommended databases and journals are legitimate and credible. Overall, the NMC's initiatives to improve medical education in India are commendable, and it is hoped that they will lead to significant improvements in the quality of healthcare in the country.

The University of Vermont Larner College of Medicine.

Introduction and objective: Road Survey to evaluate and analyze the views of Pakistani doctors working in various developed countries about the quality of undergraduate and postgraduate medical education they received in Pakistan and how well it prepared them for their role as senior physicians in a multicultural healthcare workforce in many countries and in terms of parity to the medical education in their current country of work.
 Methodology: A web-based survey consisting of twenty item questions with graded answer choices, was prepared by the authors to include a multidimensional comprehensive questionnaire to collect the views of the target participants. The survey was completed anonymously on a mobile device or a computer with internet access and took 5 to 10 minutes to complete.
 Results: The results of this qualitative survey indicate that there is generally a broad convergence of opinion regarding the quality of Pakistani medical education, with primary medical education, more consistently considered higher quality, amongst the Pakistani physicians currently working in UK, USA and Middle Eastern countries.
 Conclusion: Overall the Pakistani education seems to be of a satisfactory level, but cannot be considered to be superior to the counterpart education from these countries, based on this survey results. Areas such as research methodology appear to be particularly weak and there was a divergence of opinion regarding what the top priority should be to address within Pakistani medical education and training environment. Many of these physicians would like to work in Pakistan again, provided that the working conditions are favorable.

The objective of this study was to evaluate the changes in foreign students' satisfaction with the quality of dental and medical education considering the impact of the war in Ukraine. The present study was organized in the form of a questionnaire-based survey among 300 foreign students of Medical Faculty and Faculty of Dentistry in Ukraine. The questionnaire was ad mistered via Google form in a multiple-choice, closed-ended format. Students' satisfaction with environment safety and comfort (p < 0.05) and with the collaborative learning offered (p < 0.05) statistically decreased during the war. Sixty percent of the variability in the mean of students' satisfaction with the quality of education during the war could be explained by the satisfaction rate before the war. The need of migration from Ukraine had a stronger inverse correlation with education quality (r = -0.58) than the fact of the war itself (r = -0.32). The war in Ukraine has had a negative impact on the educational process of foreign medical and dental students, even though the quality of education was considered by students to be as high as before and during the war. The personal effort of professors, the quality of study materials, and adequate technical support could potentially overcome the negative impact of the war on student satisfaction with the quality of medical and dental education by the online mode, if the academic medium could be protected from the direct impact of the war or if the influence of the war within the university community could be minimized.

Medical education is a systematic process wherein interested and eligible individuals are trained to become physicians/surgeons. It is assumed that a person who completes the Bachelor of Science and Bachelor of Medicine (MBBS) degree will be competent enough to perform the duties of a physician of first contact. However, it is not the case with graduates from India. Most MBBS graduates prefer to pursue a postgraduate degree and become unavailable to people or governments. The doctor-to-patient ratio in India (1:1,655) does not currently satisfy the World Health Organization’s prescribed ratio (1:1,000). The Government of India, therefore, has been taking initiatives to increase the number of MBBS graduates. Moreover, there are several doubts over the quality of medical education and the competency of medical students. In addition, the National Medical Commission, the epic body that regulates the medical education and practice in India, has recently been conducting medical education technology workshops to improve teachers and has devised a new curriculum to elevate the standards of medical education in India. This editorial attempts to provide readers with the current status of medical education and research in India.

Reply to

In India, there is a strong need of reform measures to improve the quality of medical education being imparted in various medical colleges and institutions. This is partly aggravated by the shortage of healthcare practitioners. As a solution for improving the quality of medical education, an emerging form of eLearning, namely, Massive Open Online Courseware (MOOC) could be used as a potential tool. With its varied advantages, MOOCs have a wide acceptance amongst the global community. MOOC replaces the traditional brick and mortar classrooms by providing an open online knowledge repository and enables a collaborative learning environment. However, for MOOCs to be accepted as a medium for imparting medical education in India, it is necessary that MOOCs is recognised by all the medical colleges and institutions. MOOCs would not only improve the quality of medical education but also, as a spin off, would result in the improvement of healthcare service delivery, thereby benefitting each and every citizen of India.

Background: Although the number of older patients is increasing in almost all medical specialties, the interest of medical students in geriatrics as a career is still low. Because quality of medical education and educators strongly influences student career decisions, it is important to develop curricula that motivate students to become self-directed, lifelong learners in the field of geriatric medicine. Objectives: We evaluated training aspects in terms of time, core content of teaching goals, and quality of undergraduate geriatric education in medical schools in Austria and Germany. Methods: A standardized paper questionnaire was sent to all 36 German and 4 Austrian medical faculties to evaluate quantitative aspects, content, and quality of pregraduate medical education in geriatrics. Results were compared to the recommendations of the Geriatric Medicine Section of the European Union of Medical Specialists (UEMS). Results: A total of 33/36 (92 of the German medical faculties) and 4/4 (100 of the Austrian medical faculties) responded to the questionnaire. In most of the faculties, geriatric medicine was taught as an independent discipline in the core curriculum, with learning objectives absent in almost one third of the faculties. A medical student's first contact with geriatric medicine occurred on average during the second clinical year (median 8th semester). Although the content of geriatric curricula strongly varied among the faculties, core knowledge as recommended by the UEMS was integrated into most of the curricula. Teaching strategies regarding the development of attitudes and skills also recommended by the UEMS were identified in the curriculum of only some faculties. Conclusions: Geriatrics seems to be an established subject in most German and Austrian faculties. However, the current data clearly indicate highly variable quality in geriatric pregraduate training at German and Austrian universities. Because curricula should prepare young people using competence-based training and assessment methods, room for improvement remains not only in terms of structure, but also regarding quality of training to develop self-directed lifelong learners.

Restrictive Medicare chart documentation policies threaten the quality of medical student education by limiting the use of students' chart notes in the medical record. According to the latest Association of American Medical Colleges (AAMC) tutorial "Medicare Teaching Physician Documentation Instructions," teaching physicians may only refer to and use student documentation of the "review of systems and past family and social history."1 In the ambulatory setting, these aspects represent a small part of the chart note, especially on a follow-up visit. Medicare suggests that the presence of a student note in lieu of a full preceptor note indicates that preceptors are committing fraud by charging for care that they are not actually delivering. However, it is essential for all medical students to learn to become skilled at charting. The 1998 report of the AAMC Medical School Objectives Project states that medical students must have demonstrated, to the satisfaction of the faculty, "the ability to communicate effectively, both orally and in writing, with patients, patients' families, colleagues, and others" before graduation from medical school.2 Written communication between colleagues is essentially the medical record. If student charting is no longer valued or required we run the risk of not fulfilling this important educational objective for physicians-in-training. Student charting is also a major time-saving method for preceptors.3 At a time when productivity demands on community preceptors is at an all-time high, decreasing students' contributions to patient care documentation may lead to the loss of valuable preceptor time spent duplicating or replacing students' charting efforts. Given that most medical schools do not compensate community preceptors for their teaching time,4 the preceptors' time lost meeting these government regulations may threaten preceptor recruitment and retention in the future. In one review, the authors give the opinion that the safest, least complicated way to adhere to the HCFA guidelines is to have no student documentation in any patient record. These authors recommend that preceptors not rely on student notes even in those encounters in which Medicare was not the third-party payer.5 Fields et al. surveyed core clerkship directors to see how they perceived these guidelines were affecting participation of university- and community-based preceptors in clinical clerkships.6 These core clerkship directors expressed concerns that the Medicare guidelines had resulted in a number of negative consequences, including loss of student independence and active participation in the patient care environment, changing balance between education and service, loss of preceptors, decreased morale, and decreased quality of care for patients.6 Following implementation of the Medicare guidelines in the inpatient setting, Fihn et al. found that physicians reported a large increase in overall time spent attending on the wards, with a decrease in time spent teaching. This study relied on self-reported perception, as did the study of clerkship directors.7 We decided to do a true observational study of the outpatient setting. Our hypothesis is that medical students' chart notes are as good as or better than preceptors' notes. This means that not allowing students' notes to be used as valid documentation may have a negative effect on the quality of the patients' charts. We wanted to see whether referring to or relying on a student's chart note would be Medicare fraud. We designed the study to evaluate the quality of students' notes compared with preceptors' notes in the outpatient setting. We decided to observe the preceptors to determine whether they would review the students' notes and see the patients when students' notes were included in charts. The ultimate goal was to provide real observational data to be used to inform future policymakers to create rational Medicare chart documentation guidelines, ones that support high-quality medical education, patient care, and documentation. Method We recruited family medicine preceptors who were teaching third-year family medicine clerkship students in their offices. All the available preceptors were contacted by e-mail and phone, and only three preceptors agreed to be observed. Each preceptor was observed on two different days. Six medical students working with these preceptors agreed to be observed, and 31 patient encounters and charts were evaluated. Observation and chart review criteria were developed. Observational method was based on the methods used to study "exemplary preceptors."3 To protect confidentiality, we do not report the preceptors' names, and did not record the types of medical insurance carried by the patients. Two medical student observers used stopwatches to time each preceptor on a day when they were working with third-year medical students in an outpatient setting. An entire encounter was defined as the cumulative time spent by the preceptor and student working with one patient. We used an observational instrument to document the preceptors' times with students and patients, and a second instrument to document preceptor—patient interactions without students present.3 The chart notes from the encounters observed were evaluated at the end of the day and scored using explicit criteria developed by the study team. Two of three team members reviewed all completed chart notes written by student—preceptor teams and preceptors alone for 20 items including legibility, comprehensibility, completeness, and preceptors' changes. Chart note legibility was assessed by reading the first ten words in the subjective part of the note (following the chief complaint). General comprehension was assessed subjectively by the investigators using a three-point scale in which 1 = poor, 2 = average, 3 = high comprehensibility. Completeness of the note was assessed using a number of parameters for each section of the SOAP note. (SOAP is a commonly used acronym in medical documentation in which the letters refer to the following portions of the chart note: Subjective, Objective, Assessment, and Plan.) Finally, preceptors' changes to the students' notes were assessed. Did the preceptors read and contribute to the students' chart notes? How many additions, deletions, and corrections were made? Where corrections were made? Were the corrections made in the middle or the end of the note? Or was the note totally rewritten? Means, standard deviations, and independent-sample t-tests were performed using standard statistical software. Significance level was set at p < 0.5. Results During the summer of 2000, 31 patient encounters and charts were evaluated. The encounters were relatively evenly divided among the three preceptors, with 12, ten, and nine encounters for the individual preceptors evaluated. See Table 1 for a comparison of preceptor times per patient with and without students present.TABLE 1: A Comparison of Preceptor Times per Patient with and without Students PresentThe students' chart notes were all rated at the top of the legibility scale by each of the three separate reviewers (9 to 10, with means of 9.8 to 10). Three is the best score on the comprehension scale and 10 is the best score on the legibility scale. The preceptors' notes were more varied in their legibility, and their mean scores fell in the middle of the legibility range (range of 4 to 10 and means of 4.5 to 8.4). The general comprehension mean rating was far higher for the students, from 2.9 to 3 (range 2 to 3) and in the preceptors' notes ranged from 1 to 3, with a mean of 1 to 2.9 for the three observers. All of the students' notes were read and signed by the preceptors. Twenty-one percent of the notes had one addition made and 26% had three to four additions made. There were no complete deletions, but 11% of the chart notes had some type of correction performed by the preceptor. All of the corrections and additions that were made were recorded within the body of the student note. The scores for completeness are summarized below:Table: No Caption AvailableEvery student—preceptor note (note written by a student and reviewed by a preceptor) included a blood pressure measurement and documentation of the physical exam, whereas only 92% of the preceptors' notes documented these areas. Student—preceptor notes received superior scores in four out of seven completeness categories and were equal in one category. The student—preceptor notes were far better at documenting follow-up plans and health education. The only area in which student—preceptor notes were statistically less complete was in explaining the diagnosis or differential diagnosis (42% versus 58%). Discussion The preceptor saved 3.3 minutes per patient when a medical student was involved in patient care, and much of the time saved was from student charting. This gave the preceptor time for teaching. The patient received on average over nine minutes of direct time and attention from the preceptor when the student was involved. Although this was less than the average of 12.9 minutes measured for the preceptor alone, the patient received more total time from the student—preceptor team than from the preceptor alone (24.9 minutes versus 12.9 minutes). The students' notes were of an overall higher quality than the notes of the preceptors alone. Students' notes were on average more legible and comprehensible than preceptors' notes. Overall, the students' notes were more complete than those written by preceptors alone. Students' notes received superior scores in four of seven completeness categories. The one area in which the preceptors' notes were rated more highly on average was naming the diagnosis or listing a differential diagnosis. While physicians' handwriting and completeness of notes do deteriorate over time under the pressure to see more patients in less time and complete enormous quantities of ever-increasing paperwork, the preceptor still has greater knowledge of patient assessment and diagnosis. This is an area in which the preceptors may help students learn if they have the time to teach the students. This precious teaching time needs to be preserved to keep up the quality of medical education in our country. The paperwork demands of the current Medicare guidelines threaten this teaching time. In this study, the three preceptors did rely on the reviewed and signed student notes for the sole documentation in the chart and did see all the patients. In other clinical settings, preceptors often spend their time copying over students' notes or writing their own notes to meet Medicare guidelines. The preceptors' time lost charting (an average of 4 minutes/patient in our study) may cut down on valuable patient contact time or teaching time. While it is essential for preceptors to see the patients previously evaluated by the students to assure high quality of care and teaching, a preceptor's note in the patient's chart does not prove that the preceptor saw the patient. My informal discussions with medical students suggest that the Medicare guidelines lead students to feel undervalued and discourage them from practicing documentation skills. The students want to contribute to patient care and documentation. If the student note does not count, then the student has less of an incentive to write a note and the preceptor may not give feedback to the student on documentation. While the students' notes in this study were far more legible, readable, and complete than the preceptors' notes, the preceptors in our study did edit the notes to provide needed feedback to the students as well as to ensure quality control for the charts. Limitations of this study include the small sample size and the fact that the students and preceptors knew that they were being watched. This is because it is hard to get community preceptors to allow outside observers to time their patient care and teaching. While a larger chart study could have been done without the observations, we felt that it was critical to correlate the patient care and teaching behaviors with the charting. My informal discussions with teaching physicians and medical students indicate that both parties believe that students' notes are in fact more legible, comprehensible, and complete than teaching physicians' notes. Even though the preceptors knew their charts were being reviewed and could have attempted to write better notes, the study data confirm this common belief held by most physicians and students. One might claim that the preceptor participants reviewed all the notes and saw all the patients because they were being watched. However, these preceptors and their students claimed that this was their normal teaching practice during all practice sessions. While this small study is not generalizable to all teaching physicians in all locations across the country, it does give some insight into the issues that surround ambulatory teaching, charting, and practice. This study and a previous study indicate that the major time saving that a student brings to the clinical setting is his or her assistance in chart documentation.3 If followed, the Medicare guidelines appear punitive to the teaching physicians by taking away the assistance that students provide by charting. If the guidelines are not followed, the community preceptor may be at risk for being charged and convicted of billing fraud.5 Neither alternative is acceptable at a time when physicians are under great pressure to see more patients in less time and to spend more time with increasing paperwork. Recruiting and retaining community preceptors continues to be difficult, and community teaching remains an underfunded aspect of medical education. We cannot afford to lose our community preceptors at a time when academic health centers are not equipped to provide ambulatory training to the large numbers of medical students throughout our nation. If we are going to keep our vastly unpaid or underpaid community preceptors involved in volunteer student teaching, we need to re-examine the Medicare documentation guidelines. The Medicare policy was written to prevent billing fraud. While teaching physicians need to see student-evaluated patients for quality of care and teaching purposes, refusing to allow students' notes to stand as valid documentation in the medical record does not accomplish this goal. The current Medicare guidelines threaten the quality of medical education, threaten the morale of our students and community teachers, diminish the quality of patient documentation, and do not accomplish the government goal of preventing fraud.