Poster_Pilot Study_Student TaskBasedBook on DTS

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Acknowledgements 1. Centre of Academic Development (CADe) for GiPP 2018 grant: Development of Augmented Reality (AR) Model for Clinical Pathology (CP) and Application of Design Thinking Skills (DTS) in 21st Century Medical Training to develop this guidebook. 2. Authors of the guidebook for their continues support and contribution. 3. Students…past, present and future. May all of you find this module beneficial in your career. 4. Dr Hizmawati Madzin and Mr Sufi Firdaus, for their contribution in developing Augmented Reality Clinical Pathology (AR CP) module. 5. Mr Rubhan Chandran, for his contribution in formatting guidebooks for Clinical Pathology module 2 | Page

Contents Page 3 Contents Introduction Course Outcomes Course Outcome for Year 3 Phase One: Empathy Phase Two: Define (the problem - the patient’s case) ● Clinical history and examination ● Differential diagnoses ● First tier investigations Phase Three: Ideation (the solution - laboratory results interpretation) ● Diagnosis ● Investigations - for monitoring and follow up Phase Four & Five: Prototype and Evaluation ● Algorithm/ guideline in investigations of designated case Reflection and postmortem 3 | Page

An Introduction to Design Thinking Skills Design thinking skills (DTS) is both a process and mindset whereby it is a systematic approach to solving a complex problem; as in the medical world, patient’s presentation cuts across many spectrums. Through a systematic approach, guideline or algorithm can be created to help solve the complex problem. DTS requires a few repetitive phases to achieve its outcomes. The phases are Empathy, Define, Ideation, Prototype and Evaluation, Reflection and Postmortem. In the medical context, Empathy is a mindset of understanding others and in this context, it is understanding Clinical Pathology and its various sections as it is one of the core disciplines involved in solving patients’ problems. In achieving this, we shall observe, engage in the tasks, watch and listen as we sail through this phase. Once we understand the big picture in Clinical Pathology, we move on to Define. We shall select patients’ problems that we choose to solve and learn from. In this phase, we create a meaningful and actionable problem statement in Clinical Pathology based on the patient’s presentation and we perform systematic tasks in relation to Clinical Pathology in order to understand & provide solutions to our patients’ problem. Once we have determined the patients’ problems and various variables related to Clinical Pathology, the next phase would be Ideation. In Ideation phase, based on the initial solutions discovered earlier, members of the team brainstorm and ideate on further strategies in Clinical Pathology by considering the various tests needed, implication on costs, resources and possible variables, which may influence patients’ findings and interpretation. From Ideation, now we can develop Prototype. In the medical context as in Clinical Pathology. Prototype will be in the form of guideline or algorithm or other similar platforms on the systematic approach in dealing with a similar patient’s presentation if encountered in the future. This algorithm/ model/ guideline developed will undergo an evaluation process through simulated Grand Ward Round or other similar platforms to validate its usefulness and applicability in similar future cases. The final phase of DTS is Reflection and Postmortem, whereby members of the team provide reflection and postmortem on engagement in Clinical Pathology and future improvement needed to strengthen DTS in Clinical Pathology. 4 | Page

Clinical Pathology Course Outcomes HAEMATOLOGY 1. To describe the basic concept of specimen handling (pre analytical, analytical and post analytical factors) 2. To define the parameters in FBC and coagulation screening. 3. To identify the abnormalities in FBC and coagulation screening 4. To interpret FBC and coagulation screening results. 5. To relate the changes in FBC and coagulation screening with the patient's condition. 6. To identify/discuss on the principles of blood transfusion management in a patient. ANATOMIC PATHOLOGY 1. To describe the basic concept of specimen handling (pre analytical, analytical and post analytical factors). 2. To describe the various modalities used in diagnostic anatomic pathology services. 3. To apply knowledge of preanalytical factors and histopathology in real cases. 4. To apply knowledge of preanalytical factors and cytopathology in real cases. MICROBIOLOGY 1. To interpret and evaluate laboratory findings in diagnosing and monitoring common infectious diseases. IMMUNOLOGY 1. To relate the basics of immunological techniques in interpreting results. 2. To interpret and evaluate laboratory findings in diagnosing and monitoring common immune disorders. CHEMICAL PATHOLOGY 1. To relate laboratory results with clinical findings 5 | Page

Course Outcomes for Year 3 HAEMATOLOGY 1. Define the important parameters in FBC. 2. Identify the changes in FBC. 3. Relate the changes in FBC with the patient's clinical condition. 4. Identify the needs to request for coagulation screening. 5. Recall on how the coagulation is done. 6. Able to interpret the coagulation profile of a patient. 7. Relate coagulation profile changes with the patient’s condition. ANATOMIC PATHOLOGY 1. Introduce the basic concept of specimen handling (pre analytical, analytical and post analytical). 2. Introduce various modalities (example: FNAC, biopsy, frozen) used in diagnostic Histopathology and Cytopathology services. MICROBIOLOGY 1. Interpret laboratory investigations of malaria & other parasitic infections CHEMICAL PATHOLOGY 1. Describe factors affecting sample collection (site / tourniquet /contamination). 2. Blood tubes - what do they contain and their function? e.g. EDTA, lithium heparin. 3. Sample transport - Special transport e.g. NH3 / Ice. 4. Sample processing - how soon, if not what happens? 5. POCT Advantage (in acute care areas) and disadvantages. 6. Normal range (ref range) - what it means; limitations; certain age groups. 7. Spurious causes of hypo/hyper Na or K e.g. from drip arm? 6 | Page

8. To relate the underlying mechanisms of electrolyte imbalances eg hypo / hypenatraemia, hypo/hyperkalaemia, hypo/hypermagnaesaemia. 9. To grasp the concept of plasma osmolality • Osmolality measurement & calculation • Osmolar gap – what it means, what does it tell you, eg of cases • Clinical importance of : -hypo (cerebral oedema) and hyper-osmolality ( cerebral haemorrhage) if too rapid changes ( cerebral pontine myelolysis [CPM] can occur if rapid treatment of severe hypoNat due to rapid change in osmolality) 10. To grasp the concept of anion gap: • Major anions of ICF /ECF • Anion gap – what? when? 11. To grasp concept of acid bases disorders and compensations 12. How do you tell dehydration picture from renal profile? 13. What do various components of the LFT denote. 14. Patterns of liver injury/disease: • Cholestatic vs hepatocellular • Acute vs chronic – albumin (see also Plasma protein) • Severity –PT/APTT 15. Changes in LFT due to • Alcohol • Viral hepatitis • Others 16. Jaundice in neonate and adult - significance of parameters eg total bilirubin, direct and indirect bilirubin,urine bilirubin, urobilinogen, haptoglobin 17. Acute pancreatitis – amylase, lipase 7 | Page

18. TFT – Biochemical features of: • Hypo/hyperthyroidism • Sick euthyroid (effect of NTI) • Pregnancy • indication for FT3 (nice to know only for undergrad) 19. Role of albumin and its importance: - oncotic pressure (eg nephrotic syndrome) / nutritional marker/ transport protein 20. Acute phase proteins (see also Other tests (biomarkers of sepsis) 8 | Page

Phase One: Empathy This phase is about: ❖ Introduction to the course ❖ Icebreaking- role of learners ❖ General process in various sections in Pathology ❖ Pretest on knowledge of Clinical Pathology [CP] through Objective Structured Clinical Examination [OSCE] Collaborative Learning & Activities. Sense making activity. 1. Pretest on CP module through OSCE. All learners are required to go through pretest OSCE to evaluate your knowledge on CP. This is conducted on the first meeting. 2. Learners to develop cognitive background of Pathology (different disciplines in pathology – e.g. haematology, chemical pathology, anatomic pathology, microbiology). Learners shall be given this guidebook and will visit the HPUPM pathology laboratory in a guided tour to various sections in Pathology 3. Write a reflection on what you have encountered today in the blank page provided in the guidebook 9 | Page

REFLECTION SESSION I Date : Matrix no: Group: 10 | Page

Phase Two: Define ❖ Case based problem analysis ● Pathology work up based on cases identified ● Detailed requirement of investigations for various disciplines in Pathology. Collaborative Learning & Activities. 1.Brainstorming activity You are required to find a case in your current posting and present it (history & physical examination) in 5 minutes. Summarise your case in the guidebook provided At the end of the presentation, -State differential diagnoses & provide justifications -Identify the relevant laboratory investigations & provide justifications why the tests are needed 2. Perform phlebotomy/or equivalent specimen requirement procedure and choose the right container for the various specimens using the augmented reality (AR) model developed earlier. Based on the investigations that have been chosen, select the right collection tubes for the various specimens (you can refer to the augmented reality (AR) model apps in your smart phone). You are to observe your colleagues performing phlebotomy and take note of any issues arising during the procedure. (You may refer to the app if needed) 3. You are required to fill up the laboratory request form with relevant information. (enclosed in the guidebook) 4. At the end of the session, discuss with your colleagues and facilitators on relevant laboratory investigations ordered, correct phlebotomy techniques and specimen containers used. 11 | Page

My case Clinical history: Physical examination: Provisional diagnosis Laboratory investigations & justification 12 | Page

Issues identified during phlebotomy 13 | Page

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Phase Three: Ideation This phase is about: ❖ Interpretation & analysis of results ❖ Critical analysis of laboratory results from session 2 ❖ Diagnosis formulation & case studies evaluation Collaborative Learning & Activities. Activities 1. Interpret laboratory results from various disciplines and provide critical analysis. Each student to present initial laboratory investigation results on admission that students have requested during session 2. Interpret laboratory results from various disciplines and provide critical analysis. Students to formulate clinical diagnosis based on clinical history, examination and laboratory results with consideration of laboratory variables. Students to identify further laboratory investigations for confirmatory diagnosis 2. Students to identify and discuss preanalytical variables affecting patients’ results with colleagues and identify ways to overcome them. 3. Students may perform phlebotomy/or equivalent specimen requirement procedure for further investigations and choose the right container for the various specimens using the AR model developed earlier. 15 | Page

My case Lab investigation results on admission (only write results that were requested in Session 2) Clinical diagnosis Further laboratory investigations Preanalytical variables 16 | Page

Phase Four & Five: Prototype &Evaluation These phases are about: ❖ Laboratory investigation guideline & evaluation ❖ Development of case-based investigation flowchart. ❖ Social, ethical & economical implications on the patient and society. ❖ The cause and effect from general system theory perspectives (iceberg model) Collaborative Learning & Activities. Ideation (brainstorming activity) 1. By reflecting on the knowledge gained from previous sessions, you need to design a flow chart focusing on laboratory investigations correlating with clinical presentation of the patient. You are given 7 minutes (including Q & A) to present and explain your flow chart to the group. Reflection activity 1. You are required to present your reflection on your experiential learning in CP. 2. After the reflection activity, there will be a break for 15 minutes and after the break, you will go through the post test OSCE. 3. Following post test OSCE, there will be a closure session and you must fill the feedback form provided. 17 | Page

Flow chart for laboratory investigation specific to the case. 18 | Page

Reflection on Experiential Learning in Clinical Pathology 19 | Page

Authors (in alphabetical order) • Eusni Rahayu Mohd.Tohit MBBS (Malaya), MPath (Haematology)(UKM) • Fauzah Abd Ghani MBBS (Adelaide), MPath (Anatomic Pathology) (UKM) • Intan Nureslyna Samsudin MBBChBAO (Ireland), MPath(Chemical Pathology) (UKM) • Siti Zulaikha Zakariah MBBChBAO (NUI), DrPath (UKM) • Subashini C.Thambiah MBBS (UWA,Australia), MPath (Chemical Pathology) (UKM) • Zainina Seman MD(USM), MPath (Haematology)(UKM) 20 | Page

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