framework for incorporating

PROFESSIONALISM & ETHICS,PATIENT SAFETY, AND

COMMUNICATION SKILLS, IN THE UNDERGRADUATE MEDICAL

AND DENTAL CURRICULUM

FRAMEWORK FORINCORPORATING

JINNAH SINDH MEDICAL UNIVERSITYInstitute of Medical Education

2020

Section II

· Outcome

· Incorporation in curriculum

· Learning resources

Section I

· Introduction

Preface

List of Contributors

Communication Skills

· Recommended content

· Teaching strategies

· Evaluation

Section III


· Introduction


· Incorporation in the curriculum

· Evaluation

Patient Safety and Infection Control

Section IV

Professionalism and Ethics

· Assessment

· Outcome

· Introduction


· Outcome


· Assessment

· Incorporation in curriculum



· References

· Evaluation

Annex – C

Annex – B

· Assessment

Annexes

Annex – A

· Resources consulted

Workshop reports

0202-06

07-09

07

07

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03

07

08

08

09

09

18

19

25

15

17

16

10

17

15

10

13

09

10

10-13

12

13

13

15-18

15

15

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19-27

21

10

11

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19

PEPSCki Curriculum JSMU

Table of Contents


01

Me

ssa

ge

It is a timely initiative responding to the requirements of the educational needs dened by the Pakistan Medical and Dental Council. Most commendable in this regard is the fact that led by our IME, this curriculum was developed in collaboration with all the medical colleges and universities in Karachi and has been vetted by relevant experts. This exercise has ensured the pooling of valuable resources and collection of combined experiences from the various approaches to medical education.

I thank everyone who worked on the document and wish more success to IME and its faculty and staff.

I am pleased to learn that the Institute of Medical Education (IME) at Jinnah Sindh Medical University has developed a curricular framework for enhancing the knowledge and skills of students of medicine and dentistry in the vital areas of Professionalism & Ethics, Patient Safety and Communication Skills.

Professor

Syed Mohammad Tariq RaFounding Vice Chancellor

We are highly appreciative of the institutional leadership especially the Vice Chancellor, JSMU, Prof. S.M. Tariq Ra, deans and principals of all institutions that have contributed in the development of this document for supporting this activity. Our special thanks to the faculty and relevant subject experts who took time out of their busy schedules for this task. We are also thankful to the medical educationists who facilitated the workshops and helped in consolidating the group deliberations in the form of the rst draft.

2.� Ethics

4.� Leadership

The document was developed in three stages; the initial outline was developed in three workshops participated by faculty of medical and dental colleges. Both international and national literature and guidelines were reviewed during the workshops. The outlines were then reviewed by relevant subject experts and nalized based on their recommendations.

This mandate was welcomed by the faculty of both medical and dental colleges and universities. The importance of these areas has been recognized by health professions educators for a long time; some of these areas were already being addressed in the curriculum. However, in the majority of institutions, teaching of these subjects was limited to the rst two years. It was largely faculty dependent without any weightage given to these topics for assessment.

February 26, 2020

The Pakistan Medical and Dental Council (PM&DC) mandated adding seven new areas in the revised curriculum for undergraduate programmes in medicine and dentistry. These areas included:

This document is a collaborative effort of faculty from the medical universities (and their respective medical/dental colleges) in Karachi and presents a framework for detailed curriculum development. It was agreed that the individual universities may develop a detailed curriculum depending on their own context, institutional philosophies and resources available.

The work would not have been completed timely without the hard work of the faculty and staff of IME and the JSMU Media Cell. We greatly appreciate their effort in putting this report together.

PREFACE

1.� Communication Skills

3.� Infection Control

6.� Patient Safety

5.� Professionalism

7.� Research

The faculty at the Institute of Medical Education (IME), Jinnah Sindh Medical University, reviewed the list of topics and collapsed the areas into ve so that similar ones fell under one heading. Since JSMU already has a longitudinal curriculum for research, it was decided to initially work on three curricula namely (i) Professionalism & Ethics, (ii) Infection Control & Patient Safety and (iii) Communication Skills. IME plans to initiate work on curriculum for leadership and management skills within the rst half of 2020.

It is hoped that the framework presented in this document will be useful for curriculum developers not only in the city of Karachi but also nationally. This is not an exhaustive document and institutions should feel free to modify and use these suggestions according to their needs and resources.

We look forward to your comments and suggestions for further improvement.

Prof. Syeda Kauser Ali and Dr. Syed Moyn AlyInstitute of Medical Education, JSMU

PEPSCki CurriculumJSMU

02

Dr. Faisal Siddiqui

Assistant Professor, Dow Dental College

Principal, Dr Ishrat Ul Ebad Khan Institute of Oral Health Sciences

Dr. Kashif IkramPrincipal, Dental College

Professor and Head Department of Medicine

Dr. Shafaq Sultana

Dr. Shahjahan KatparProfessor and Dean Faculty of Dentistry

Dr. Talha M. Siddiqui

Dr. Amynah TariqPrincipal, Dow International Dental College

Dr. Anwar Ali

Dr. Shakeel Ahmed

Dr. Talea Hoor

Head of Department of Medical Education

Professor and Head Department of Pediatrics

Associate Professor

Dr. M. Ainul Haq

Vice Principal and Associate Professor

Baqai Medical University

Senior Lecturer, Bahria University

Assistant Professor, Surgery

Dr. Ruqayyah Quresh HashmiDeputy Administrator, Medical Education

Dow University of Health SciencesDr. Adnan

Dr. Arshad HasanPrincipal, Dow Dental College

Vice Principal, Dow Dental College

Professor, Dow Institute of Health Professions Education

Dr. Jaffar Zaidi

Dr. Syed Imran Mehmood

Dr. Muhammad Zubair

Professor, Dow Institute of Health Professions Education

Fatima Jinnah Dental CollegeDr. Babar AshrafHead, Department of Orthodontics

Dr. Syed Munawar AlamFaculty

Dr. Muhammad Shahid Shamim

Professor of Surgery, Dow International Medical College

Consultant Gynaecologist

Dr. M. Yawar Khan

Principal

Dr. Annum AraHamdard University

Dr. Lubna HabibGeneral Surgeon

Dr. Tasleem Hossein

Professor of Surgery

Dr. Muhammad MubeenProfessor and Head Dept. of Community Medicine

Dr. Syed Imran Hassan

Senior Lecturer, Hamdard Dental College

Principal, Dental College

Dr. Shams Nadeem AlamProfessor, Medical Education

Dr. Muhammad Ali Channa

Associate Professor

Altamash Institute of Dental Medicine

Dean of Academics

Aga Khan UniversityDr. Anita AlanaSenior Lecturer

Dr. Nargis Asad

Prof. Dr. Ambreen Afzal Ehsan

Dr. Shaur SarfarazAssistant Executive Dean/Coordinator DERD

Dr. Sheema FarhanVice Principal

Bahria University Medical & Dental College

Senior Lecturer Dr. Quratulain Omaeer

Dr. Sajid Abbas Jaffri

List of Contributors


03

Dr. Rubia Kashif

Dr. Ather Majeed Khan

Dr. Zubair Abbasi

Dr. Beenish Shah

Senior Lecturer, Community Dentistry

Associate Professor, APPNA Institute of Public Health

Senior Instructor, Professional Development Centre

Dr. Nighat Shah

Dr. Samira Adnan

Dean, Basic Medical Sciences

Associate Professor, Institute of Family Medicine

Professor and Principal, Sindh Institute of Oral Health Sciences

Professor and Principal Sindh Medical College

Dr. Sughra Perveen

Senior Lecturer, Community Medicine

Dr. Faiza Siddiqui

Liaquat College of Medicine & Dentistry

Dr. Mohid Abrar Lone

Assistant Professor, SIOHS

Assistant Professor, SIOHS

Dr. Shiraz Shaikh

Dean, Faculty of Surgery

Dr. Tabinda Ashfaq

Assistant Professor, AIPH

Dr. Sarwar Qureshi

Professor, Community Health Sciences

Dr. Munnawar Haque

Lecturer, Medical Education

Dr. Samir AzeemHead, Department of Oral Medicine

Dr. Fauzia Akhter

Dr. Jamshed Akhtar

Assistant Professor, Institute of Family Medicine

Dr. Javeria Sikandar

Dr. Mehmood Hasan

Professor, Advisor to the Vice Chancellor

Dr. Erum Behroze

Associate Professor and Head, Department of Community Medicine

Lecturer, Sindh Institute of Oral Health Sciences

Dr. Imrana Khan

Assistant Professor, Sindh Institute of Oral Health Sciences

Lecturer, Institute of Medical Education

Dr. Ata Ur Rehman

Professor and Head, Department of Biochemistry

Dr. Ghazala Usman

Dr. Azhar Mughal

Professor and Head, Dept. of Pediatric Surgery,

Dr. Hina Khalid

National Institute of Child Health

Pro VC, Professor and Dean, APPNA Institute of Public Health

Professor and Head, Department of Pharmacology

Dr. M. Iqbal Afridi Professor and Dean of Medicine

Dr. Lubna Baig

Dr. Marie AndradesProfessor and Head, Institute of Family Medicine

Professor and Head, Department of Pathology

Jinnah Medical & Dental CollegeDr. Fadieleha SohailDirector, Medical Education

Dr. M. Junaid LakhaniAssociate Professor and Vice Principal (Dental)

Dr. Marium IqbalProfessor, Operative Dentistry

Dr. Aneela Altaf

Dr. Shama Mashood

Professor and Head, Department of Physiology

Managing Editor, Publications and Media Cell

Karachi Medical & Dental College

Head, Department of Community Dentistry

Principal (Dental)

Jinnah Sindh Medical University

Dr. Mohsin Girach

Associate Professor, Medical Education

Assistant Professor, Institute of Family Medicine.

Professor of Medicine

Dr. Sarosh Mehdi

Dr. Mahmood Haider

Principal (Dental)

Dr. Aijaz Qureshi

Dr. Aisha Ambreen

Ms. Asya Aziz


04


05

Assistant Professor, Periodontics

Dr. Farhat BashirUnited Medical & Dental College

Professor of Orthodontics, Head of Dental Section

Sir Syed College of Medical SciencesDr. H.R. Sukhia

Dr. Muhammad WaseemPrincipal and Professor of Ophthalmology

Dr. Yousuf Moosa

Professor, Department of Forensic Medicine & Toxicology

Professor of Medicine

Director, Department of Educational DevelopmentDr. Iram Kursheed

Dr. Qudsia Hassan

Ziauddin University

Dr. Shanila Khan

Dr. Mervyn Hosein

Professor of Community Medicine

Dr. Fatima Jahangir

Oral & Maxillofacial Surgeon

Dr. Murad Qadir

Senior Lecturer, Medical Education

Assistant Professor

Dr. Sumera SaeedSenior Lecturer, Medical Education

Head, Department of Oral Pathology

Assistant Professor, Department of Health and Continuing Education

Dr. Mehnaz UmairLecturer, Department of Health and Continuing Education

Dr. Sana Anwar

Dr. Uzma Zameer

Dr. Sobia Ali

Dr. Afa Tabassum

Associate Professor, Department of Health and Continuing Education

Assistant Professor, Head of Microbiology

Liaquat National Hospital Medical College

Note: Above information veried until December 2019

& Prevention,

Senior Manager, Quality and Patient Safety

Consultant, Quality and Patient Safety

Ms. Rozina RoshanHead, Department of Infection Prevention

Patient Safety & Infection Control

Dr. Lubna Mushtaq

Aga Khan University

Dr Fozia Asif

Indus Hospital

Dr. Sana AnwarAssistant Professor, Head Infection Control

Liaquat National Hospital

Ms. Shaheen AsifTabba Heart Hospital

Dr. Sughra PerveenDean, Faculty of Surgery,Jinnah Sindh Medical University

Dr Syed Faisal MahmoodAssociate ProfessorSection of Infectious Diseases,

Aga Khan UniversityDepartment of Medicine

Dr. Tabinda AshfaqAssociate Professor, Institute of Family Medicine

Dr. Zubair Abbasi

Riphah Institute of Health Improvement and Safety


Professionalism & Ethics

Project Director,

Professor and Principal, Sindh Institute of Oral Health Sciences,


Dr. M. Iqbal Afridi




Professor and Head, Institute of Family Medicine


Communication Skills

Dr. Aamir Jafarey

Dean, Faculty of Medicine

Dr. M. Shahid Shamim

Professor of Pediatric Surgery

Dr. Zakiuddin Ahmed

Faculty, Centre for Bioethics & Culture

Dr Jamshed Akhtar

Sindh Institute of Urology & Transplant

Professor, Department of Health Professions Education

Aga Khan University

Ms. Asya Aziz

Dr. Aisha Ambreen

Faculty, Aga Khan Medical College

Managing Editor, Publications

Assistant Professor, Institute of Family Medicine

Dr. Marie Andrades



Dr. Anita Allana

Dow University of Health Sciences

Dr Syed Moyn AlyDirector, Institute of Medical Education

List of Subject Experts (Reviewers)


06

INTRODUCTION

COMMUNICATION SKILLS

“Communication Skill” is the ability to convey information to another person effectively and efciently. Professionals with good verbal, non-verbal and written communication skills help facilitate the sharing of information between people within a group for its benet.

The main purposes of cultivating communication skills in healthcare professionals are to ultimately improve patient care, develop oneself professionally, abide by the legal and ethical requirements of communication and generate a more collegial atmosphere in one's surroundings.

OUTCOME

By the end of the programme, graduates will be able to communicate effectively and efciently in order to positively impact health care delivery and for their own professional development.

RECOMMENDED CONTENT

I.� Basic Principles of Communication:

1.� Denition

2.� Models of communication

Although this is not an exhaustive document on Communication Skills, institutions should feel free to modify and use these suggestions according to their needs and resources.

3.� Communication process and principles (basic elements and group dynamics)

The purpose of this document is to provide guidelines to institutions so that Communication Skills could be formally taught as a core component of medical expertise.

4.� Speaking in conferences and at scientic fora

III.� Patient Care and Communication

3.� Responding to questions

6.� Questioning techniques

5.� Using audio visual aids effectively

2. Communicating with relatives

4.� Non-verbal communication

3. Communicating with other health care professionals

II.� Presentation Skills

1. Breaking bad news

4. Communicating with special patients (aggressive patients, children and teenagers, geriatric patients, mentally challenged patients, visually and auditorily challenged patients)

6. Counselling skills

2.� Developing MS PowerPoint presentations based on principles of multimedia design

1.� Developing posters

5.� Active listening

5. Consultation on phone


07

3.� Taking a viva/ oral examination

5.� Writing personal essays

7. Dealing with anxious patients or relatives

8. Explaining diagnosis, investigation and treatment

9. Giving instructions on discharge

13. Seeking informed consent/clarication

14. Medical documentation (Writing patient notes, prescriptions sick leaves, death certicates, referrals etc.)

2.� Communicating with cultural sensitivity

IV.� Inter-Personal Communication

12. Involving the patient in the decision-making

3.� Conict management

4.� Dealing with impending/violent situations at work

V.� Communicating for Professional Development

2.� Reective writing

10. Giving advice on lifestyle, health promotion or risk factors

1.� Assertive communication

11. Handing over patients

1.� Communicating during a job interview

4.� Writing clear professional emails

TEACHING STRATEGIES

2.� Independent, guided learning

A wide array of teaching methodologies is advocated. These range from the traditional lectures, for providing information efciently, to scheduling practice sessions where learners get a chance to watch and perform under guidance and supervision. Feedback is the crux of learning and has to be built into all student-centered teaching sessions. Some of the suggested methods of teaching are:

6.� Writing resumes

Since communication, by nature, is a contextual activity, it should be integrated in the disciplines being taught. For example, it is not necessary that there should be just a workshop on breaking bad news; students could be exposed to a simulated set up of a (e.g.) Dermatology clinic where the clinician is giving a patient bad news that he has eczema which cannot be cured. Students can then be given a chance to practice in this skills lab with simulated patients, trained in giving feedback.

3.� Lectures (only for orientation and basic information)

INCORPORATION IN THE CURRICULUM

Communication skills should not be included as a stand-alone activity or course, nor should it be a series of isolated workshops with no overarching purpose. Communication skills must be closely relevant to the purpose of the degree programme and has to be relevant to practice. Hence, a longitudinal design would benet the learners more. Course designers should start with simple skills and move on to more complex and clinically relevant ones as the years progress.

1.� Case-based discussions using vignettes


08

6.� Workshops

Learners must have the theoretical basis of the topics in order to be able to internalize the issues. This knowledge component need not be 'taught' via lectures; students could be given handouts online to read and understand. They could also be given weblinks of videos which explain background information. This would save class time (for practice) and inculcate the habit of independent learning.

LEARNING RESOURCES

In order to make the teaching sessions effective, and depending on the sub-skill being taught, the facilitators will have to incorporate intelligently developed audio-visual aids, mannequins, and simulated patients. A number of software can be used to develop e-learning sessions which students can watch, learn from, and practice at their leisure. These could be visual and/ or auditory.

5.� Simulated patients

ASSESSMENT

Assessing communication skills is a complex task since this skill in itself is not a unitary concept; communication has not only breadth but also depth. Faculty members who are responsible for designing and implementing this course will have to ask them one basic question: which aspect or aspects of communication skills do they wish to assess?

Once the faculty has this list of (to-be-assessed) skills, the assessment tool must match that skill as closely as is possible. One activity that can be done is mapping the content against the list of assessment tools. It is recommended that a skill be assessed more than once so that a correct picture of the skill acquisition is obtained. After every assessment event, students must be given feedback so that they get a fair chance of improving their learning.

Not every assessment has to have marks which will be added to the nal exams. Such tests, which are not given any marks or whose marks are not added to the nal grade are called formative. Others tests, the marks of which are added to the nal exam, are summative. A good balance of the two would be best.

4.� Role plays and feedback

The course of Communication Skills needs to be evaluated in order to nd out how effective and useful the end-users, that is, the students, feel about it. Faculty perceptions are also essential. The Higher Education Commission (HEC) website has a number of feedback forms which may be used as such or modied to meet the institutions' needs. Qualitative information, through written narratives, comments must also be obtained. Interviews and even informal discussions with students and faculty will generate authentic and reliable information.

Some of the most common assessment tools for communication skills are:

EVALUATION

Such data gathering should be used to improve the quality of the course.

� Written assessment (prescriptions, referral letters, notes, resume writing etc.)

� Mini-CEX (formative)

� OSCE


09

6. Safe surgery and surgical process redesigning

PATIENT SAFETY & INFECTION CONTROL

2. Patient identication

4. Informed Consent

5. Adverse incident reporting (adverse drug reporting)

6. Prevention of errors in surgery (sharing protocols, following protocols etc.)

By the end of the programme, graduates will be able to understand the occurrence of errors in healthcare leading to unintended patient harm, understand the contribution of human factors and develop a systems approach to minimize these errors; By acquiring knowledge, skills, and attitudes for minimizing patient morbidity, mortality, and building a safer system of health care delivery.

“Patient safety is the prevention of errors and adverse effects to patients associated with health care”. Patient safety is about being mindful of an expectation that mistakes can happen and consistently looking to prevent them.

INTRODUCTION

This document provides guidelines to institutions where there are undergraduate students pursuing degree programmes related to patient care. It is earnestly hoped that 'Patient Safety' can be incorporated in undergraduate curricula and institutionalized in health care settings.

I. Introduction to Patient Safety

1. Introduction to International Patient Safety Goals

2. What is patient safety and concept of quality in healthcare? (What, when, how, why)

OUTCOME

3. Ethical practice and patient safety

4. Introduction to clinical environment and basic aspects of patient safety process

5. Clinical and procedural skills training including safe instrument and equipment handling

RECOMMENDED CONTENT

II. Documentation

1. Importance of complete and timely documentation

3. Identication of patients at risk (unaccompanied minor vulnerable population)

7. Role of Morbidity-Mortality meetings in patient safety

III. Infection Prevention and Control

1. Aseptic technique (standard precautions, gowning, scrubbing, proper disposal, cleaning and disinfection, sterilization, validation of sterilization)

2. Hand hygiene

3. Transmission based/isolation precautions

5. Appropriate use of prophylactic antibiotics

4. Vaccination (importance, guidelines)


10

7. Adverse effects / Sentinel events

5. L earning from errors – building a just culture

VII. Conict Resolution

V. Errors and Risk Management

2. A systems approach to understanding errors

6. Identify risks in the clinical setting and introduction to risk management

5. Drug interactions

4. Role denition

VIII. Respecting Colleagues

7. Patient engagement

The integration of patient safety competencies in the basic science years' subjects such as microbiology, pharmacology, pathology and community medicine can be done by developing material relevant to these areas of medical education such as medication safety and Inter Professional Care.

6. High alert medications


The teaching of Patient Safety must be closely relevant to the purpose of the degree program in which it is included and has to be relevant to practice. Hence, a longitudinal design would benet the learners more. Topics from Patient Safety should be sequenced on an increasing ladder of complexity, with the more serious clinical issues placed in senior years.

VI. Procedural Safety

8. Process improvement tools and methods

3. Importance of being a team player in the health care setting/ Role of effective teamwork in patient care

Because safety of the patient is a joint responsibility, learners of one program can and should be taught by experts from various relevant disciplines. Nursing experts can teach medical and dental students about patient safety, not just clinicians. This is food for thought for institutions to consider.

The undergraduate learner needs to be able to look at patient safety from multiple angles since he/ she is to become a generalist, whether a physician or a dentist and has to work with other members of the healthcare team such as, a nurse, a physical therapist or a laboratory technician. Hence, patient safety needs to be taught in context just like any other topic/ discipline. Learners need to realize that there may be breaches to safety for not only the patient but also to colleagues. These breaches may be from multiple sources. Graduates need to be able to learn these sources in the work place environment instead of in classrooms only. This workplace could be a pathological laboratory, an anatomy dissection hall, emergency care or an operation theatre.

1. Why errors occur – Introduction to Human Factors

IV. Drug Safety

1. Prescription writing

2. Correct dosage

3. Drug toxicity

6. Equipment safety, devices/apparatus guidelines

7. Exposure to blood and body uids

4. Transfusion


11

5. Practice in Skills Lab (for example as role plays/ simulation)

1. Bedside / chair-side teaching

In the clinical years, patient safety issues are linked to clerkships such as medicine, paediatrics, and surgery and behavioural sciences, which may cover areas such as communication, teamwork and patient and physician relationship, behaviour and interaction and the inuence of these factors on the practice of medicine.

Material for non-traditional components (such as human factors, systems thinking, and effective teamwork) can be included in individual clinical courses, or, a separate course may be developed to teach these areas of patient safety. For example, diagnostic error has been commonly associated with medicine, medication error with pediatrics, and teamwork and communication with surgery.

Moreover, it will be of benet to introduce an elective fourth year patient safety course offering more in-depth knowledge on the competencies.

We suggest to develop a patient safety curriculum that includes patient safety priority areas to help students understand how to reduce the incidence of medical errors and adverse events.

TEACHING STRATEGIES

A wide array of teaching methodologies is advocated. These range from the traditional lectures, for providing information efciently, to scheduling contextualized discussions in small groups and observations in clinical settings. Contextualization, is dened as the process of identifying individual patient circumstances and modifying the plan of care to accommodate those circumstances.

A very important tool for development of professional acumen is reection. Students must be allowed to reect-on action; they should be able to observe how safety procedures are being put into practice or jeopardized in daily practice; they should then be allowed to reect on what happened and why and what possible solutions there can be. Most of these solutions should be based on national or international safety guidelines.

Some of the suggested methods of teaching are:

2. Demonstrations and discussions in laboratories, wards, clinics, emergency rooms, operation theatres etc.

3. Independent, guided learning

4. Lectures

LEARNING RESOURCES

8. Tutorials

In order to make the teaching sessions effective, and depending on the content being taught, the faculty will have to develop professionally relevant written scenarios, videos and role plays so that learners can have opportunities for discussions. It is recommended that lectures be reserved for providing background information only where necessary.

Learners must have the theoretical basis of the topics in order to be able to internalize the issues. This knowledge component need not be 'taught' via lectures; students could be given handouts on-line to read and understand. They could also be given web-links of videos which explain background information. This would save class time (for practice) and inculcate the habit of independent learning.

6. Small group discussions (as case-based learning or reective writing sessions)

7. Team-based learning

9. Workshops (e.g. aseptic techniques)

To understand the concepts above it is suggested to develop a booklet with scenarios from real-life situations. Clinicians can be encouraged to provide the scenarios and these can be published with the contributor's details.


12


13

ASSESSMENT

The tools of assessment will, hence, vary according to the depth and the target. Some programmes may require learners to identify areas where patient safety is and is not being followed and later to demonstrate that they are performing patient safety while doing certain procedures; others might want learners to work on projects to improve patient safety in their areas of work.

Once the faculty has this list of (to-be-assessed) sub-skills, the assessment tool must match that skill as closely as is possible. One activity that can be done is mapping the content against the list of assessment tools. To give detailed idea of mapping, a sample table from Florida State University College of Medicine is being shown here.

For inculcating patient safety as a routine practice for students, it is suggested that the components of patient safety may be assessed repeatedly along with other clinical skills (Ex: incorporating component of hand hygiene in the check list for all OSCE /Mini CEX)

Not every assessment has to have marks which will be added to the nal exams. Such tests, which are not given any marks or whose marks are not added to the nal grade are called formative. Other tests, the marks of which are added to the nal exam, are summative. A good balance of the two would be best.

Some of the most common assessment tools for patient safety and infection control skills are:

For the purpose of assessments, the broad topic of 'Patient Safety' will have to be considered in components or sub-skills.

· Essays (e.g. reective writing, case scenarios)

· Mini-CEX (formative)

· OSCE

It is recommended that a skill be assessed more than once so that a correct picture of the skill acquisition is obtained. After every assessment event, students must be given feedback so that they get a fair chance of improving their learning.

· Portfolios (containing reective writing, critical incidence reports. Videos from workplace, project reports etc. Portfolios will require rubrics for grading.)

· Written assessment (e.g. MCQs, preferably targeting knowledge application)

EVALUATION

The Journal of the International Association of Medical Science Educators Med Sci Educ 2012; 22(2): 65-72.

The course of Patient Safety must be evaluated to determine its effectiveness and usefulness. Both faculty and students' perceptions are essential. Qualitative information, through written narratives, comments, and even informal discussions with students and faculty will generate authentic and reliable information.


14


15

4. Justice and equity�

1. Privacy and condentiality

Ethics deals with human interaction in societies. Every profession has its codes and principles that govern the interaction between the professional and the client. A common understanding of ethical values and principles is vital to create a harmonious experience leading to satisfactory outcomes.

The purpose of this document is to provide guidelines to institutions so that Professionalism and Ethics could be ofcially taught as core components of medical expertise.

OUTCOMES

This document goes on to state that “From within this framework, medical professionalism embraces a wide variety of behaviours, which can be articulated as specic competencies. Frequently articulated competencies include a commitment to carrying out professional responsibilities and an adherence to ethical principles; demonstration of compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession;

1and sensitivity and responsiveness to a diverse patient population.”

Behave professionally with members of their own profession, patients, their caretakers and all those with whom they come in contact and analyze ethical dilemmas in workplaces using bioethical principle and values.

The AMEE guide 612 points out three challenges in integrating Professionalism in the curriculum. It places as number one the inculcation of personal qualities and values which are essential in the culture in which the curriculum is embedded. Then it emphasizes continuous support of student learning of these competencies. Linked to learning, and as a third step, the Guide gives importance to the appropriate assessment of Professionalism.

Experts emphasize that Professionalism has a cognitive basis and that, at the start, this has to be taught overtly. As a parallel activity, experiential learning activities must be integrated in the curriculum to reinforce the concepts and help the learners internalize the ethos of Professionalism.

I. Introduction

INTRODUCTION

PROFESSIONALISM AND ETHICS

The American Board of Medical Specialties, in 2017, dene medical professionalism as “a belief system in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals”.

Many experts agree that there can be no general curriculum on Professionalism and that every university must develop its own based on its environment; hence, a curriculum on Professionalism has to be realistic, focused towards the needs and heavy on reection. Hand in hand with didactic teaching of Professionalism (to provide knowledge base), there is great stress on role modeling and mentoring as key strategies to the learning of this competence. Workplace, as the main site for learning, is preferred over classroom learning if professional behaviour is to be adopted by the learners.

By the end of the programme, graduates will be able to:

RECOMMENDED CONTENT

1.� Core values and principles of Bioethics-building a moral argument and positioning

2.� Medical Ethics – legal (medicine and dentistry), social, and religious perspectives

3.� Truth telling, honesty, integrity, and respect

II. Clinical Ethics

2. Duties of a medical/dental doctor

3. End of life care

5. Medical error and negligence

III. Codes and Guidelines

IV. Research Ethics

1. Taking informed consent for research

2. National guidelines (code of ethics) of Ethics ( ) h�p://pmdc.org.pk/Ethics/tabid/101/Default.aspx

2. Research integrity and intellectual property

4. Institutional Review Board

V. Professionalism

2. Accountability

1. Institutional code of conduct

3. Conict of interest

4. Honour and Integrity

5. Public Health ethics

5. Professional boundaries and harassment

6. Role of doctor in different healthcare settings

3. Research publication ethics (papers/articles/books)

1. Altruism

4. Informed consent in clinical practice


Professionalism and Ethics (P and E) should not be isolated activities or a one-time course. Nor should these be merely a series of workshops with no overarching purpose. P and E must be closely relevant not only to the purpose of the degree programme but also to practice4. Hence, a longitudinal design, with as much experiential learning embedded in the workplace, would benet the learners more. Course designers should start with simple issues and move on to more complex and clinically relevant ones as the years progress.

Since ethical and professional behaviours, by nature, are contextual, they should be integrated in the disciplines being taught. For example, 'dynamics of healthcare team' can best be learnt in the Emergency Room or anywhere requiring close professional liaison.

3.� Flipped classroom

4.� Independent, guided learning

5.� Interactive lectures

3,4TEACHING STRATEGIES

6.� Mentoring

2.� E-learning (online fora)

7.� Panel discussions and debates

A wide array of teaching methodologies is advocated. These range from the traditional lectures, for providing information efciently, to any form of small group discussion where students get a chance to apply the principles learnt and solve problems in a safe environment, to workshops where they get a chance to do role plays and receive feedback to practice in real-life settings followed by reection. Role modeling of professional and ethical behaviours is key to learning. Reection-on-action must be taught early on followed by reection-in-action in later years. Feedback is the crux of learning and has to be built into all student-centered teaching sessions. Some of the suggested methods of teaching (in alphabetical order) are:

1.� Case-based discussions


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10.� Seminars

In order to make the teaching sessions effective, and depending on the sub-skill being taught, the facilitators will have to incorporate intelligently developed audio-visual aids, mannequins and simulated patients. A number of softwares can be used to develop e-learning sessions which students can watch, learn from and practice at their leisure. These could be visual and/ or auditory. Course developers and implementers must have the opportunity to utilize the workplace settings as teaching grounds.

The course of Professionalism and Ethics needs to be evaluated in order to nd out the effectiveness for end-users, that is, the students. Faculty perceptions are also essential. If at all possible, patient view must be considered.

Assessing professional and ethical behaviours is still an evolving eld. Faculty members who are responsible for designing and implementing this course will have to ask themselves one basic question: which aspect or aspects of professionalism and ethics do they wish to assess? The assessment should, ideally, be aligned with the objectives and the programme outcomes.

Currently, not all topics taught need to be assessed for summative purposes; as this course evolves5, it might be feasible that a number of issues be assessed formatively. There aren't many tools available which can match the taught constructs. Only those tools should be employed for summative purposes which have been researched on internationally and nationally, which are feasible to implement and cost effective. A good balance of the two would be best. Validity concerns must be addressed as much as possible to infuse quality in the course. After every assessment event, the concerned faculty must give students feedback so that they get a fair chance of improving their learning.

8.� Role modeling (by teachers/mentors at work place)

5,6ASSESSMENT

� Direct observations in real and simulated settings

Such data gathering should be used to improve the quality of the course.

EVALUATION

6Some of the most common assessment tools are :

11.� Workshops

LEARNING RESOURCES

It is emphasized that successful implementation of this course cannot occur without the presence of champions, or role models, especially in the patient-care settings.

Learners must have the theoretical basis of the topics in order to be able to internalize the issues3,5. This knowledge component need not be 'taught' via lectures; students could be given handouts on-line to read and understand. They could also be given web-links of videos which explain background information. This would save class time (for practice) and inculcate the habit of independent learning.

9.� Role plays and feedback

� Multi-source feedback

� Written assessment

� P-MEX

� OSCE

HEC website has a number of feedback forms which may be used as such or modied to meet the institutions' needs. Qualitative information, through written narratives, comments must also be obtained. Interviews and even informal discussions with patients, students and faculty will generate authentic and reliable information.


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4. Hafferty FW, Papadakis M, Sullivan W, Wynia MK. ABMS Denition of Medical Professionalism (Long Form). Developed by the Ethics and Professionalism Committee-ABMS Professionalism Work Group. www.abms.org/media/84742/abms-defini�on-of-medical-professionalism.pdf Accessed January 18, 2020

1. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach. 2013;35(7):e1252-e1266. doi:10.3109/0142159X.2013.789132

7. Morihara SK, Jackson DS, and Chun MBJ. Making the professionalism curriculum for undergraduate medical education more relevant. Med Teach 2013, 1–7, Early Online

Resources consulted:

2. El Tarhouny SA, Mansour TM, Wassif GA, Desouky MK. Teaching bioethics for undergraduate medical students. Biomed Res 2017;28 (22): 9840-9844

3. Ghias K, Ali SK, Khan KS, et al. How we developed a bioethics theme in an undergraduate medical curriculum. Med Teach. 2011;33(12):974-977. doi:10.3109/0142159X.2011.588890

5. Li H, Ding N, Zhang Y, Liu Y, Wen D. Assessing medical professionalism: A systematic review of instruments and their measurement properties. PLoS ONE 2017; 12(5): e0177321.

6. Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and ethics: A proposed curriculum for undergraduates. Int J Appl Basic Med Res. 2016;6(3):157-163. doi:10.4103/2229-516X.186963

8. O' Sullivan H, van Mook W, 2 Fewtrell R, Wass V. Integrating professionalism into the curriculum: AMEE Guide No. 61. Med Teach 2012; 34: e64–e77

9. Rodriguez E, Siegelman J, Leone K, Kessler C. Assessing Professionalism: Summary of the Working Group on Assessment of Observable Learner Performance. Acad Emer Med 2012;19 (12): 1372-8.


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Annexes

ANNEXURE-A

Report of the Workshop on Identifying Curriculum for Communication Skills

4.� Demonstrate sensitivity while communicating in culturally diverse situations

6.� Maintain accurate and comprehensive documentation/medical records

� Communication process and principles (basic elements and group dynamics)

� Phases and models of consultation

1.� Apply principles of communication in interaction at personal and professional levels

� Cultural sensitivity in health care communication (myths and misconceptions and gender sensitivity)

2.� Demonstrate empathy in communicating with patients

8.� Provide effective feedback

Content

� Administrative communication skills

5.� Use reection for self-improvement

� Conict resolution

Outcomes/Terminal Objectives:

� Use of digital technology

3.� Counsel patients effectively using all stages of consultation

� Workshops

� Audio visuals: Use of video clips and video recordings of patient consultation

� Forum theaters

Teaching/learning strategies

� Simulated patients (standardized patients)

�

At the end of the programme, the students will be able to:

� Case based discussions / Experiential sessions

� Inter Professional/Inter Disciplinary collaboration and consultations

� Presentation skills, interview skills, and CV writing

� e-learning

� Medical record keeping

� Dealing with challenging clinical, professional, and personal situations

7.� Perform as effective team members

� Giving and taking feedback

� Microteaching (Portfolios)

� Role plays


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� Mini-CEX (formative)

� OSCE

Assessment

Responsibility

The group discussed the current practices regarding teaching of communication skills and it transpired that except for Aga Khan University and Jinnah Medical & Dental College (College of Medicine only), it is not being taught formally as a structured course. Workshops were the most used method of teaching and experts from outside the institution or in some institutions, interested local faculty i.e. clinicians, psychologists and faculty from Behavioural Sciences, was being utilized. In majority of institutions, it was the responsibility of the Department of Health Professions Education to organize/conduct these activities.

The assessment of Communication Skills was also not uniform in all institutions with it being mostly assessed in the Objective Structured Clinical Examinations (OSCE) as part of clinical assessment.

It was proposed that Communications Skills be included as a longitudinal theme and responsibility be assigned to a group comprising medical educationist and faculty with a passion in the concerned area. The group should come under the curriculum committee. It was suggested that there is a dire need to institutionalize communication skills with the help of institutional leadership at the medical and dental college and attached hospital.

Another suggestion by the group was that as far as the delivery of all longitudinal themes is concerned, it would be ideal if an integrated approach is used.

� Written assessment (prescriptions, referral letters, notes etc.)


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8. Interpret the interpretation of lab reports

Patient Safety & Infection Control


5. Identify the areas of high risk in clinical setting:

a. Co-Morbids

ANNEXURE-B

Objectives:

1. Dene patient safety

· Bleeding disorders (including acquired)

· Uncontrolled Diabetes Mellitus

b. Areas/ factors that may increase the risk

· Pregnancy

At the end of the session, the BDS/MBBS students will be able to:

2. Relate the importance of good history taking and thorough clinical examination to patient safety

Report of the Workshop on Identifying Curriculum for

· Hypertension

· Chronic liver and kidney disease

· Blood Borne Viruses (BBV)

4. Decide when and whom to refer

· Mentally challenged / people with special needs

· Ischaemic Heart Disease (IHD)

· Drug allergies

3. Describe the importance of patient selection for different procedures

· Anxious patients

6. Identify the high-risk procedures

7. Describe the protocols for performing the dental procedures safely

· Extremes of age (paediatric and geriatric patients)

10. Interpret vital signs

12. Identify the protocols for grievance policy of the hospital for patient complaints

11. Reect on adverse incidents

II. Documentation

1. Relate the importance of documentation to patient safety

5. Demonstrate the correct steps of adverse incident reporting

6. Document patient handover

2. List steps of patient identication

3. Identify high risk patients

9. Report vital signs

4. Demonstrate steps of taking written informed consent from patients


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7. Document vaccination status

III. Infection Control

c. validate/ monitor sterilization,

d. appropriate use of antibiotics / justify the use of antibiotics,

b. the various sterilization protocols and methods,

e. the role of vaccination in prevention of BBV (Hep. B), and

f. the protocols for safe waste disposal of instruments and materials (including sharp instruments, infected instruments, mercury and amalgam etc).

2. Demonstrate the correct scrubbing and gowning technique and use of personal protective equipment (PPE).

1. Describe

3. Demonstrate safe handling of instruments and equipment for common dental procedures (with emphasis on needle stick injury).

1. Document correct dosage and labelling of the commonly used drugs in dentistry according to the patient*. (The commonly used drugs are antibiotics, NSAIDs, anesthetics etc.)

a. the measures of preventing cross infection in OPD, emergency settings and OT,

IV. Drug Safety

2. Demonstrate conrmation of drug expiry date before administration every time

3. Demonstrate safe administration of drugs (e.g. L.A.)

9. Liaise with the pharmacist for safe drug delivery

Content

3. Clinical and procedural skills training including safe instrument and equipment handling

4. Consent

5. Safe surgery

3. Identication of patients at risk

4. Demonstrate safe use of dental materials (includes allergies to latex and composite resin materials, mercury, acids, sodium hypochlorite etc.)

6. Describe the protocol of safe transfusion

1. What is patient safety? (What, when, how, why) (Ref. WHO booklet)

7. Apply principles of handling transfusion reactions

5. Identify the high-risk patients on the basis of drug toxicity and interactions

2. Patient identication

2. Introduction to clinical environment

5. Adverse incident reporting

10. Relate the importance of cold chain maintenance for drugs

8. Demonstrate the correct prescription writing for common dental diseases

4. Theoretical aspects

1. Importance of complete and timely documentation


II. Documentation


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4. Transfusion

7. Prevention of errors in surgery (sharing protocols, following protocols etc.)

9. Morbidity-Mortality meeting

2. Cross infection control measures (also includes PPE)

� Videos (may include movie clips)

1. Aseptic technique (hand hygiene, gowning, scrubbing, proper disposal, sterilization, validation of sterilization)

3. Vaccination (importance, guidelines)

7. Adverse effects

� Lectures

IV. Drug Safety

6. Grievance policy

4. Prophylactic antibiotics

5. Equipment safety, devices/apparatus guidelines

III. Infection Control

8. Importance of reection on your own performance/competence

1. Prescription writing

2. Correct dosage

3. Drug toxicity

5. Drug interactions

6. High alert medications

V. Team Work and Communication Skills

Details to be worked out with the group working on Communication Skills.


� Skills Lab

� SGD including PBL

� Bedside teaching / chairside teaching

� Case-based learning

� Role plays

� Workshop (e.g. aseptic techniques)

Assessment

� MCQ

� OSCE

Responsibility

The group discussed the current practices regarding teaching of Patient Safety, which were very diverse and not formalized in most institutions. Components of Patient Safety were being taught in few medical colleges as part of the longitudinal themes / skills development course in the rst two years (e.g. hand washing, scrubbing, gowning and gloving) with reinforcement of the concepts and skills in the clinical years. However, Patient Safety as a subject was not assessed separately.


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It was suggested that there is a dire need to institutionalize patient safety with the help of institutional leadership at the medical and dental colleges and attached hospitals. It was recommended that BLS training should be included in the UG education. Students should be asked to attend M&M meetings, to familiarize them with the process and also learn from seniors. It was also emphasized that faculty development programmes/ capacity building of teachers needs to be done.

Suggestions


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By the end of ve-year MBBS or four-year BDS programme students should be able to:

Outcomes/Terminal Objectives

� Role of doctor in community

ANNEXURE-C

Report of the Workshop on Identifying Curriculum for

� Duties of a doctor �

Professionalism and Ethics

� Demonstrate understanding of basic principles of Ethics with reference to social, cultural and religious perspectives

� Analyze ethical issues/dilemmas in healthcare practice

� Demonstrate respectful conduct with patients, staff and colleagues

� Recognize the ethical concerns in communication skills of medical professionals

� Demonstrate the ability to avoid potential ethical conicts with pharmaceutical and other health industry providers

� Identify ethical concerns in research activities and publications

� Apply guidelines given in PMDC and HEC codes of ethics in resolving ethical issues.

� Demonstrate the ability to resolve ethical issues faced during common clinical scenarios �

Content

� Principles of Ethics

� Medical ethics – Religious perspective

� Condentiality and Privacy

� Informed consent

� Justice and equity

� Medical error

� Research publication ethics

� End of life care


� Flipped classroom

� Interactive lectures

� Conict of interest

� Small group discussions

� Role-plays and videos

� E-learning (online forums, assignments)

Assessment

� Short answer/essay

� Seminars/Panel discussions


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� OSCE

� Assignments

� The group suggests that every college should have a separate department of Ethics and Professionalism, with dedicated, qualied and trained faculty.

� Portfolio/reective writing

Responsibility

� Bioethics and Professionalism should be a mandatory component of undergraduate BDS/MBBS curriculum, with exit exam results showing in transcript.

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