TOACS is objective, valid, more reliable, has better educational impact and is feasible-Dr.Sirajul Haque Sheikh


 CPSP Golden Jubilee Conference Proceedings

TOACS is objective, valid, more reliable,
has better educational impact and
is feasible-Dr.Sirajul Haque Sheikh

Clinical teaching to undergraduates is challenging and
faculty development is crucial-Prof. Mohammad Tayyab

Education & training both are important for Health
Professionals Education - Dason Evans

KARACHI: Dr. Syeda Kausar Ali from Aga Khan University made a presentation on Research in Medical Education in one of the sessions during the recently held Golden Jubilee Conference of College of Physicians and Surgeons Pakistan. She pointed out that most of the studies published in Pakistan are KAP (Knowledge, Attitude and Practice) studies in medical education. Journal Club, use of morbidity and mortality meetings has also been reported. Over the yeas there has been an increase in research in this field and it is having an impact on policy and practices.

Prof. Zafar Ullah Chaudhry President of College of Physicians & Surgeons Pakistan presenting Honorary
Fellowship of CPSP to two eminent medical personalities from overseas during the recently held Golden
Jubilee Conference. Also seen in the picture are Prof. G. Asghar Channa Registrar and Prof. Khalid
Masood Gondal Regional Director of CPSP Lahore.

Continuing she said that there are challenges in medical education and research. Capacity building and randomization is difficult. In Pakistan we do not have National Research Agenda. Medical education, health services and research all need close collaboration. Now there are ample opportunities. CPSP as well as various medical universities have started diploma and Masters in medical education. Instead of being competitive, we should be collaborating with each other. There are over a dozen healthcare professionals who are trained in medical education overseas. Now some people are doing PhDs. There is interest in international linking and we need to improve our networking within the country. She suggested that we should establish a National Center for Health Professionals Education and Research, hold some round table discussions and start publication of HPE journal.
Earlier Prof. Khalid Masood Gondal talked about innovations in monitoring of training while Prof. Rakhshanda Rahman spoke about cognitive errors in medical education.
Prof. Michal Holland in his concluding remarks said that students should be involved in medical education and research. Monitoring of training of postgraduates started by the CPSP is a tribute to the college as it has now put it into practice. Prof. Ijaz Ahsan remarked that examining the PGs is a very difficult task and the number of consultants produced by the CPSP is commendable. Examining the PGs is being done by the examiners as love of labour for all these years and May God blesses them all.

Prof. M.A. H. Siddiqui Memorial Lecture

Prof. Zubair Amin delivered Prof. MAH Siddiqui memorial lecture on what and How to Assess? Competence or Performance. He discussed in detail what is the difference between competence and performance, why should we assess it and how it should be assessed. There are different methods, models available. Competence is what they can do and what they are capable of doing and assessment is what we do in practice. He discussed at length the challenges for performance assessment which can have a unique development role. He further pointed out that we are very efficient in real practices and many of us would fail in clinical examination. When the students appear in the exam they usually have a much better knowledge. He then talked about outcome of care and mentioned about morbidity, mortality, critical care and complications, practice volume, nature of patients seen, procedures performed, observation of clinical activities, feed back from peers and patients etc. General principles in performance assessment were also discussed in detail.
Earlier Prof. S. M. Rab read a citation for Prof. Siddiqui, paid him rich tributes and said that he was just like a Father to him. This brilliant young man did his FRCS in 1932 and also did Masters in Anatomy. He served as Professor of Surgery, Anatomy and established Anatomy Museums wherever he went. He was the first Project Director of CPSP and did a commendable job, Prof. Rab added.
Prof. Shahid Hassan from Malaysia spoke on how to appraise summative assessment in postgraduate medical education. He referred to Muller’s pyramid of clinical competence which is based on i.e. knows, knows how and shows how and does. Do not know, cannot do, unsafe and fails, know, can do, is safe hence pass.
What we want from the residents was discussed by Prof. Rukhsana Zuberi from Aga Khan University. She pointed out that we want the residents to be competent, their assessment should be overall to ensure that they are competent, they should have a habit of life long learning. Residents should handle daily routine, know what they cannot do but we must remember that every day routine differs and varies. The residents should be consistently competent, unconsciously competent; they are professionals and experts in their area of expertise. They should provide patient care, abide by ethical principles and at the final stage, they should be able to manage multisystem diseases.
She laid emphasis on continuous ongoing assessment of competence, clinical supervision, and direct observation in practice, efforts to improve the practice. She also talked about assessment by medical simulators as learners develop novice and experts, learning and self assessment, practice and on going assessment. She further stated that in training assessment and feed back go hand in hand and learning motivation of residents is also important. The feed back should be a win win situation for all, she added.
Prof. Sirajul Haque Sheikh Director DME at CPSP made a presentation on TOACS- the modified OSCE. He pointed out that this is the system which CPSP was practicing. TOACS stands for Task Oriented Assessment of Clinical Skills and then highlighted salient features of this method of assessment. Structured Viva has been included in OSCE and it was converted to TOACS. It was first introduced by a medical educationist from Australia. TOACS covers application of knowledge, clinical reasoning skills, communication skills, procedural skills and attitudes.
Talking about the advantages of TOACS, he said that it was objective, valid, and more reliable, has better educational impact and is feasible. It consists of ten to fifteen stations with structured clinical tasks, eight interactive stations and seven static stations. The students spend five to six minutes at each station with one minute time for change. At the interactive stations, there are patients or the clinical material on which competence is tested. Students are asked questions and clinical reasoning for solving skills. Candidates are given patient data at the static stations, it has clinical problem, and they are provide with laboratory data and imaging results. Written responses are required on SAQs. There is no interaction with the patient or the examiners. At the static stations because of logistic problems we will require much more number of examine. TOACS Dr. Siraj said was fully effectively started at the CPSP. We need to know the perceptions of the examinees, examinees about this method of assessment. Periodic use of TOACS by institutions and supervisors will improve training and their results in CPSP examination, he remarked.
Prof. Amir Zaman Khan gave details of the online examination which the CPSP intends to start soon. He pointed out that paper based examination is expensive, require lot of logistic support. Online examination will improve efficiency and will be more convenient for all. It will ensure auto grading, is flexible and time saving. No time is spent on evaluation and instant results are available. It can be timed to allow answers, it is user friendly and results are published instantly. This system is atomized, secured and projected. We will start this online examination in a specialty with limited number of candidates to begin with, he remark
Dr. Hay Derkx made a presentation on simulated and standardized patients. Why should one use them if real patients are available”? During his presentation he tried to convince the audience of its efficacy. He pointed out that they use it in small group of undergraduate medical students in the skill lab. We use simulated patients. Investing in the skills labs, he felt, is worthwhile. Students appreciate theory more. Skills lab helps students benefit from clerkship. Communication is core competence of a doctor. In the past medical training was dependent on patients. Real patients are usually first choice to motivate the students in practice skills. Now there is increased use of simulation in medical education. It has the advantage that simulated patients are available when required. They can play the same scenario. There is no learning without feed back. For postgraduates it is preferable to use real patients. During the discussion it was stated that continued assessment during the senior years is the best.

Prof. Fazal Ellahi Memorial Lecture

Prof. S. Adeebul Hassan Rizvi from SIUT delivered Prof. Fazal Ellahi Memoiral Lecture. His topic was Transplant surgery in Pakistan. Prof. Rizvi stated that over one hundred thousand transplants are performed globally every year and now it is a success story. It was Lt. Gen.Shukat Hassan and Col. Mukhtar Hamid Shah who did the first kidney transplant in the Army hospital Rawalpindi. At the SIUT all patients are served free with dignity. We have 2638 registered patients and in 2011, 3484 emergency dialysis were performed. Most of the patients, he said, die due to infections and sepsis. We started kidney transplant in 1985 and in 2009 we performed the maximum number of kidney transplants i.e. 544. We slowed down between 2009-2011. We ensure life long maintenance therapy for donors and recipients. He also talked about the issues in living organ donors and said that refusal rate for organ donation has decreased in Pakistan. However, deceased donor transplantation has not taken off in Pakistan. The main problems which we face include infection, rejection and immunosuppression. Our transplant results are comparable with India, Turkey and Iran.
Talking about measures to control infection he mentioned universal prophylaxis, pre treatment screening of donors, recipients. We have failed to start deceased donor pregame due to apathy of the medical profession. People are afraid to come forward and declare brain death. Trade in kidney goes on. Now stem cells and an era of regeneration medicine are on. Lot of work is going on in tissue and organ engineering. Time has come that we in Pakistan embark on deceased donor programme, he remarked. Later Prof. Ali Mohammad Ansari a noted orthopaedic surgeon and former councilor of CPSP presented a memento to Prof.Adeeb Rizvi.
In the next session Dr. Amina Ahmad talked about self and peer assessment of emotional intelligence fostering leadership in medical education. Leadership, she said, is a potential combination of self management and relationship skills. MCPS in Health Professional Education programme aims to prepare education leaders trained to bring about evidence based educational programme. At present seventeen candidates are enrolled in this programme, she added.
Dr. Sohail Sabir discussed impact on healthcare professionals after a workshop in first two steps of evidence based medicine. In EBM, he stated, there are five steps i.e. Ask, acquire, appraise, apply and assess. There was positive impact of short academic interventions on competency of the participants in this study, he added.
Non-academic attributes of hidden curriculum in medical schools was discussed by Prof. Amer Zaman Khan. The study enrolled final year medical students of two medical colleges of Lahore. Two hundred thirty four questionnaires were returned which showed that education does make them problem solver, human, improve their communication skills and they also learn to respect their peers. In Japan and USA there is no gender bias in medical students but it is found in Islamic countries. He suggested that we should inculcate positive attitudes in students by organizing seminars, workshops and work at faculty development at the institutions.
Dr. Abrar Ashraf Ali talked about communication skills training of undergraduates and pointed out that while learning environment at KEMU Lahore was comfortable, training was not supervised and it was also not structured. There is no faculty development programme at KEMU and their confidence level was not up to the mark. They have inability in written communication and presentation skills for which there was a need for a structured training programme.
Prof. Col. Aqeel Safdar from CMH Medical College Lahore spoke about empathy and sympathy. This, he said, ensures understanding and faster recovery from disease. It is important that the patients go out of hospital in a better condition. Change in empathy is more from undergraduates to postgraduates as they progress in their studies. We lack strong role models and there are negative attributes from clinical faculty. We have intimidating educational environment. There is uncertainly in the final professional examination. I have discovered the idea of showing movies to the students to inculcate in them empathy, I intend to do that as empathy does help make better doctors, he remarked.
In the next session Prof. Mohammad Tayyab discussed reflective teaching for undergraduates in clinical years. He pointed out that the faculty has no training in teaching and learning, faculty does not know the students. We have a poor system of rewards and recognition. Then there are competing demands and pressures on the faculty. This study tried to find out whether the students were participatory and which part of the session they enjoyed. It also looked at class room management, whether it was too fast or too slow. The tools used and whether the teaching was palatable. He also talked about patients privacy and dignity, lack of clear objectives, expectations, poor observations and students feed back. Reflective teaching looks at what I am doing in class and can I do it better. He was of the view that clinical teaching to undergraduates is challenging and faculty development is crucial.
Prof. Hamid Mahmood discussed validity and reliability of MCQs and SAQs in undergraduate ophthalmology examination. He pointed out that MCQs are more objective, easy to construct while SAQs are more subjective. He suggested a combination of properly constructed MCQs and SAQs for assessment.
Dr. Masood Jawaid from Dow International Medical College presented the results of his study on student’s perception of educational environment at a public sector university in Pakistan while Dr. Mehwash Naheed talked about surgical residency in Pakistan.

Azmi Memorial Lecture

Dr. Dason Evans from UK delivered Azmi Memorial lecture. Prof. Irshad Waheed read the citation for late Dr. M. B. Azmi who served as Registrar of CPSP for ten years and paid him rich tributes for his contributions for the CPSP. The topic of Dason Evans presentation was training vs. education in health professional’s education. The advantages of training he said are that it should be well defined, transparent and equitable expressive. He also discussed the language of discourse and training. Good patient care, he opined, cannot be described nor trained for. Advantages of educational approach are that the future professionals have high rate of clinical reasoning, flexibility, transferable skills, understanding, managing complexity and developing professional identity.
The language of discourse, he opined, should focus on learner motivation, they develop expertise through experience and electives. He opined that we must start training doctors now for medicine for the future. They should know how to deal with uncertainty, must be prepared to work outside the guidelines. The problem with educational approach to HPE is difficult to measure. Concord aero plane, he said was never designed to be cost effective but it was the fastest plane. His conclusions were that education and training both are important. We should be clear with learners, he added.

Strengthening Monitoring and Training

This was followed by a panel discussion on strengthening monitoring and training which was moderated by Prof. Rizwan Azmi. The panelists included Prof. Zafarullah Chaudhry, Prof. Anil Madaree, Dr.Zubair Amin, Dr. Sirajul Haque Sheikh, Prof. Naeem Jafary and Prof. John Kortbeck. Some of the issues which cam up for discussion included monitoring technical expertise, is the society satisfied with the surgeons we are producing, are they providing satisfactory services. We must produce specialists which practice safely. Each case should be documented and then we must look at the mistakes and see what went wrong. What is the weakness in CPSP model of training, the tools used in training, identify the weakness in the system and then suggest measures to strengthen it. We now have an unmanageable number of trainees and the number of accredited institutions is not enough. How the learning can be regularized? The number of supervisors who were checking and making entries in the e log book, Prof. Zafar Ullah Chaudhry stated was very low and some of them were reminded of their duties. We are getting quarterly feed back from the trainees and supervisors and we should try to find out how to motivate the supervisors to do better? In an under resources country, we have problems with faculty development and there is dearth of good supervisors. Some of the participants felt that the supervisors must have some recognition otherwise why they should work for the CPSP.
Measures to optimize the use of e log book were also discussed. How the supervisors and trainees should be mobilized to use it, how to improve the feed back through e log system, various measures were suggested for further strengthening the monitoring system. The supervisors must know that they are being monitored; hence they must sign off the e log books on time. Some sort of rewards and incentives for good supervisors were also suggested. At present there are seventeen thousand trainees and how to absorb them in various disciplines in accredited institutions was a problem. All the stake holders, it was suggested should come forward with suggestions to improve the present situation.
Prof. Amjad from Lahore opined that we must give importance to supervisors, involve them in CPSP affairs, they should be offered workshops free, and the government should be asked to give them some incentives. One of the participants opined that most of the supervisors are overworked, they have lot of duties to do from teaching to patient care, and hence the registrars should be allowed to fill in the e log books on their behalf. At this Prof. Zafar Ullah Chaudhry remarked that there are eight postgraduates for each supervisor and in case there are more eligible candidates available, they can be appointed as supervisors. Another participant said that negative response from the supervisor should also be recorded in the e log book. President of CPSP Prof. Zafar Ullah Chaudhry informed the participants that he had discussions with chief ministers of different provinces asking them to give some incentives to the supervisors, they did make promise but these promises have not been fulfilled. Most of the participants felt that we need indigenous solutions to our problems and experts from overseas cannot help us in this regard. They can just share with us their own experience and how they solved these problems in their own countries.