AETCOM in Microbiology

1. AETCOM in Microbiology
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2. Indian Medical Graduate (IMG)
• Healthcare needs of community keep changing - medical education
system continuously evolves - adapt to changing needs
• To make existing traditional medical education system more relevant-
IMG, MCI- introduced Competency-Based Medical Education (CBME)
from the year 2019- the first major revision to the medical curriculum
since 1997 after 20 long years
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3. Indian Medical Graduate (IMG)
• Overall goal of the undergraduate medical education program-
by MCI, in the revised Graduate Medical Education Regulations-
(2019) create an “Indian Medical Graduate (IMG)”- knowledge,
skills, attitudes, values and responsiveness- function
appropriately and effectively- physician of first contact-
community while being globally relevant
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4. Roles of IMG
1. Clinician who understands, provides preventive care with
compassion
2. Leader & member of the healthcare team & system- capabilities to
collect, analyze, synthesize & communicate health data appropriately
3. Communicator with patients, families, colleagues and community
4. Lifelong learner- continuous improvement of skills and knowledge
5. Professional- committed to excellence, is ethical, responsive and
accountable to patients, community and profession
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5. AETCOM
• Refers to the soft skills ‘Attitude, Ethics & Communication,’
that an IMG needs to learn along with the knowledge and
clinical skills to provide holistic healthcare
• Assessment system in place- ensure that the learning about
AETCOM has actually taken place
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6. AETCOM
Essential components of AETCOM are as follows:
• Attitude
• Ethics: has the 4 pillars-
 Patient autonomy
 Beneficence
 Non-maleficence
 Social justice
• Communication
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7. Need for AETCOM Competencies
• Proficiency in AETCOM competencies- essential in carrying out
routine healthcare activities- doctor-patient interactions, practicing
informed decision making, breaking bad news, communication and
documentation
• Lack of effective communication- medical errors, mistakes in
diagnosis, inaccurate treatment, compromised patient safety, patient
noncompliance- stressful legal and sociocultural issues
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8. AETCOM Learning in Current vs
Previous Curriculum
• AETOM in earlier MBBS curriculum: Before CBME was
introduced, medical education focused- gaining knowledge and
clinical skills
• AETCOM competencies were neither formally taught nor
assessed
• Some learning used to happen by observing seniors (role
modelling) or with self-experience
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9. AETCOM Learning in Current vs
Previous Curriculum
• AETCOM in current curriculum: aim at acquisition of minimum
essential skills- communicating effectively & sympathetically with
patients
Longitudinally spread: AETCOM competencies relevant to each
subject- defined in CBME- taught longitudinally- phases of MBBS
Increasing complexity: topics/competencies are interlinked
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10. T-L Methods for AETCOM Competencies
• Teaching-Learning sessions: students are provided with
opportunities to learn basic essential background
knowledge, opportunities to learn by experiencing (mostly
simulated) & reflect on experiences
• Innovative teaching-learning (TL) methods: more engaging &
effective
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11. Problem-based Learning (PBL)
• Suggested by MCI as main TL method for AETCOM
• Helps students explore various facets of “real life issues” that will
confront them in their careers, develop problem solving skills
• Case discussions promote collaborative learning and team work,
reflection and self-directed learning
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12. Assessment of AETCOM Competencies
• Formative Assessment: done during & along with day-to-day T-L
sessions- to provide feedback to students and help them improve
Based on student participation in small group discussions,
performance in assignments or internal assessment tests
• Summative Assessment: qualifying examination which decides
pass or fail status
Questions on AETCOM competencies in theory & practical exams
conducted at end of each professional year
Student- maintain logbook as record of his performance
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13. Suggested AETCOM Topics in
Microbiology
Following competencies are specified in Microbiology subject:
1. Demonstration of confidentiality pertaining to patient
identity on laboratory results
2. Demonstration of respect for patient samples sent to
laboratory for performance of laboratory tests
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14. Competency-1:
Demonstrate Confidentiality
Pertaining
to Patient Identity on Laboratory
Results
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15. Sample Case Scenarios
Case scenario 1 (Disclosing HIV result):
• A lady aged 20 years admitted for fever & breathlessness jumps from
4th floor of hospital & dies- recently diagnosed to be HIV reactive
(one week ago) and “Retro positive” labels on her case file and bed.
Family members- know about her HIV status.
They became stressed & shouted at patient. Except her mother, all
other family stopped visiting her
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16. Sample Case Scenarios
Case scenario 2 (Not disclosing HIV result):
• A 33-year man- admitted to emergency ward with multiple
limb fractures. His vitals stabilized, conscious & oriented.
Emergency surgery- planned. His relative comes to lab to
collect investigation reports, given all reports except HIV
results. He is specifically asking if lab is not issuing only HIV
report because it is reactive. Technician gets call from ward
asking for HIV report immediately over phone, as t patient is
being shifted to operating room
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17. Sample Case Scenarios
Case scenario 3 (Patient refuses to provide samples):
• A nurse caring for admitted patient gets needle stick injury
with syringe used for the patient. The patient’s HIV and HBV
infection status unknown. To decide for PEP, nurse wants to
get patient tested. Patient asks the nurse not to worry,
refuses saying he has no such infection, hence no need to
test & has financial constrain for performing the tests. The
nurse is anxious. Nurse decides to use the patient’s blood
sample collected for some other tests for testing for HIV and
HBsAg and bear the cost by herself
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18. Sample Case Scenarios
Case scenario 4 (Social stigma in COVID-19):
• A patient with influenza like illness (ILI) has come to the
screening OPD. He had exposure to a confirmed COVID-19 case
five days back. He wants to get tested and treated, as he is
anxious. However, he does not want to be quarantined or
discriminated, and has a fear of social stigma and losing the job.
He is also the only caretaker of old parents at home
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19. Sample Case Scenarios
Case scenario 5 (Occupational exposure):
• A medical intern comes to the infection control division ,
history of NSI 1 hour back. The source patient’s blood sample
collected and tested for HIV, HBV and HCV. Intern is waiting
in the reception to know about the test result of source. Test
result is reactive for HIV but negative for hepatitis B and C.
The infection control officer discloses the source result to the
intern and provides appropriate counselling and PEP. He also
forwards the source result to ICTC. The ICTC calls the source
patient on next day and informs about the test result after
providing counselling
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20. Essential Background Knowledge
1. Principles of medical ethics
2. Medicolegal aspects of confidentiality
3. Confidentiality & privileged communication related to lab.
results
4. Modes of transmission & diagnostic approach for HIV or
COVID-19
5. Sociocultural issues related to sensitive infections like HIV,
COVID-19 or needle stick injury
6. PEP for NSI (needle stick injury) when source turns out to be
positive for HIV or HBV
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21. Specific Learning Objectives
1. Discuss rights and responsibilities of patients (or healthcare
worker in case scenario 5)
2. Discuss rights and responsibilities of laboratory with respect
to confidentiality of laboratory results
3. Analyze ethical issues involved in confidentiality pertaining
to patient identity
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22. Specific Learning Objectives
4. Describe medicolegal consequences of breach in
confidentiality
5. Demonstration of sympathy when breaking through of
result to healthcare workers, providing counselling and
maintaining confidentiality pertaining to occupational hazards
such as needle stick injury (in case scenario 5)
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23. Teaching-Learning Method
1. Introductory session: introduction of paper case in small group discussion,
identification of various aspects involved, framing learning objectives and deciding
assignments along with learning resources
2. SDL: self-directed learning by students
3. Anchoring learning sessions: involves one or more of following depending upon
case scenario:
Interaction with laboratory technician and counsellor of ICTC
Interaction with Microbiology laboratory technician involved in HIV/COVID-19
testing and report dispatch
Interaction with infection control officer involved in management of NSI
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24. Teaching-Learning Method
4. Concluding session: small group discussion of various possible
approaches for case, their pros and cons, and justification for best
approach selected by each student. However, it may be possible that
there may not be single best approach
5. Writing narratives by the students about their learning experiences
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25. Assessment
• Formative: participation in group discussion, assignments, reflection
writing, MCQs to assess relevant background knowledge, OSPE
• Summative (Theory): short notes and short answer questions
• Summative (Practical): OSPE with simulated patient–HIV pre-test/
post-test counselling, counselling following NSI, informing positive
COVID-19 report to patient and informing NSI test result to the HCW
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26. Key Learning Points
1. Confidentiality
2. Informed consent
3. Counselling
4. Privileged communication
5. Method followed in ICTC for HIV testing
6. Method followed for other STDs (Syphilis, Gonorrhea)
7. Method followed for COVID-19
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27. Competency-2
Demonstration of Respect
for Patient Samples
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28. Sample Case Scenarios
Case scenario 1 (Rejection due to improper transport):
• Sequestrum from chronic osteomyelitis case was debrided and sent
for culture and sensitivity.
• The sample was rejected by the laboratory mentioning that it was
received in formalin, hence unsuitable for culture.
• There is no more sample available for culture now
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29. Sample Case Scenarios
Case scenario 2 (Specimen did not reach laboratory):
• A critically ill 5-year-old child’s CSF report is awaited for 3 days. On
enquiry laboratory says it did not receive the sample. On further
probing it was found that the nursing staff had kept the small bottle
with the sample in his pocket and mistakenly taken it outside the
hospital and had dropped it somewhere, and did not submit it to the
laboratory for testing. Now, the baby needs to undergo lumbar
puncture again, results may not be the same as antibiotics are given
and need to wait for some more days for the culture report
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30. Sample Case Scenarios
Case scenario 3 (Misguided report due to inadequate information in
requisition form):
• Urologist calls laboratory to discuss about “Insignificant bacteriuria”
culture report of a pyelonephritis patient. He says it was a
percutaneous nephrostomy sample and asks for the organism and
antimicrobial sensitivity. Microbiologist says it was written as urine
sample on the request form, some gram-negative bacillus had grown
and the count was less than 10,000 CFU/mL, so it was thought to be a
periurethral commensal and the isolate was discarded, and hence
further testing cannot be done
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31. Sample Case Scenarios
Case scenario 4 (Specimen kept at wrong place):
• Junior resident gets angry and yells at the patient on noticing a stool
sample kept on the bedside. The patient’s attendant tries to explain
that the container is covered in a plastic cover and all these days the
junior resident herself used to keep collected blood and swab
samples in that very same place, and he was not informed that stool
sample was not to be kept on the side table
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32. Sample Case Scenarios
Case scenario 5 (Rejection due to improper collection):
• A suspected pulmonary tuberculosis patient, who would travel 30 km
from his village to the private hospital with the attached laboratory in
the city, had submitted spot sputum sample the previous day and an
early morning sample today for acid-fast staining. Reports of both the
samples mentioned “many epithelial cells suggestive of excessive
salivary contamination. Repeat with the proper sample”. Blood
culture was also collected from the patient by the clinical team, the
result of which came as contaminated blood culture specimen with
patient’s skin flora
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33. Sample Case Scenarios
Case scenario 6 (Sample collected for culture and sensitivity in
unsterile container):
• Paired blood specimen (5 mL each) was sent to the laboratory in two
vacutainers for blood culture. The laboratory rejected the specimen.
The patient screams that he cannot allow to draw another set of
blood specimen for investigation
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34. Sample Case Scenarios
Case scenario 7 (Rejection due to lack of patient informations)
• Microbiology lab rejects a bunch of specimens because one or the
other relevant informations were missing in those specimens -
patient’s name, age or gender, ward, hospital number, sample type,
clinical diagnosis, or treatment history. Clinical team screams at the
lab that they could have called the ward or the patient’s attendant
and verified the details instead of rejecting
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35. Sample Case Scenarios
Case scenario 8 (Rejection due to mismatch of name)
• Microbiology lab rejects a blood culture specimen collected in
BacT/ALERT bottle because the patient’s name written on the bottle
did not match with the requisition form. Clinical team asks the patient
to pay again for a repeat blood culture investigation. The patient
complains that he cannot afford the price for another test and neither
he can give consent to draw another specimen
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36. Sample Case Scenarios
Case scenario 9 (Prioritizing a sample requiring immediate processing
and reporting over the others)
• In the midnight, the Microbiology laboratory receives three
specimens (urine, sputum, CSF) from a patient for culture. The
technician was already processing a huge load of investigations,
therefore he informed the clinical team that these specimens can only
be processed on the next day
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37. Essential Background Knowledge
1. Appropriate sample for the test planned: sample type,
amount, collection procedure, preservative if any, container
type used and its transportation and storage
2. Appropriate labelling for correct sample identification
3. Accompanying clinical information for correlation
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38. Essential Background Knowledge
4. Possible medicolegal issues following incomplete/incorrect sample
identification
5. Sociocultural issues following incomplete/incorrect sample
identification, relevant clinical information for correlation, improper
storage/transportation
6. Ethical issues following incomplete/incorrect sample identification,
relevant clinical information for correlation, improper
storage/transportation
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39. Specific Learning Objectives
1. Choose appropriate container for sample collection
2. Demonstrate appropriate procedure for temporary storage
& transportation of clinical sample
3. Discuss information that shall be written in request form &
sample container, completely and legibly
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40. Specific Learning Objectives
4. Discuss judicious application of sample rejection criteria in best
interest of patient care
5. Discuss importance of prioritizing specimen as relevant to
clinical situation
6. Discuss medical, ethical & socio-economical considerations of
errors in sample collection and submission process
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41. Teaching-Learning Methods
1. Introduction of scenarios with help of paper case/role
plays/videos
2. Small group discussion: identification of clinical, medicolegal,
sociocultural & ethical issues involved
3. Writing learning objectives
4. Writing narratives by students about their learning experiences
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42. Teaching-Learning Methods
5. Anchoring lecture and demonstration of appropriate procedure of
sample collection, transportation and reception at laboratory
Discussion with nursing staff, phlebotomist, laboratory technicians to
gather first-hand information
6. Closing session with small group discussion
7. Writing narratives by students about their learning experiences
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43. Assessment
• Formative
• Summative (Theory)
• Summative (Practical): OSPE can be conducted covering:
Sample collection with care and empathy, instructing
patients on appropriate sample collection (e.g. urine,
sputum, blood culture)
Labelling sample containers and filling request form for
the clinical scenario provided
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44. Key Learning Points
Specimen rejection criteria: Reasons for sample rejection
include:
Improperly labelled or unlabeled sample
Incomplete specimen-related or clinical information on
sample
Sub-optimal sample
Duplicate microbiology samples received on same day
Sample delayed in transit more than accepted limit
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45. Key Learning Points
• Specimen collection
• Prioritizing specimen for processing: certain precious specimens -
CSF and sterile body fluids, ocular specimens, tissue specimens,
suprapubic aspirate and bone specimen- processed immediately
as soon as received, not more than 15 min delay
Blood culture bottles should be immediately incubated upon
receipt
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