Bhulani, Nizar

Jafri, fatima

Jafri, Wasim

Sheerani, Mughis

Vakani, Farhan

English

eCommons@AKU

eCommons@AKUDepartment of Continuing Professional Education Medical College, PakistanJanuary 2012Physician satisfaction survey on continuing medicaleducationFarhan VakaniAga Khan University, farhan.vakani@aku.eduWasim JafriAga Khan University, wasim.jafri@aku.eduNizar BhulaniAga Khan UniversityMughis SheeraniAga Khan Universityfatima JafriAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_cpePart of the Medical Education CommonsRecommended CitationVakani, F., Jafri, W., Bhulani, N., Sheerani, M., Jafri, f. (2012). Physician satisfaction survey on continuing medical education. Journal ofthe College of Physicians and Surgeons Pakistan, 22(1), 69-70.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_cpe/23Journal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (1): 69-72 69Sir,Continuing medical education (CME) is a platform forkeeping abreast with current knowledge and acquiringnew skills. Today, many countries are in various phasesof introducing and improving their academic activities forphysicians through different systems of evaluation.1,2Among the available assessment tools to determineeffectiveness of CME, the four levels of Kirkpatrick'sevaluation model is usually preferred. Level-1 measuresparticipant satisfaction with the session; level-2assesses changes in skills, attitude and knowledge;level-3 ascertains the change in behaviour whereaslevel-4 determines improved patient outcomes due tochange in behaviour. Quality and appropriateness ofCME events within the university setting weredetermined through post-event (level-1) satisfactionsurvey of the physicians, as evaluation of theexperienced physicians through other levels was quitechallenging  and is influenced by a large number ofother factors.3 This is the first study of its kind inPakistan conducted at the Aga Khan University (AKU),using a multi-item rating scale.Nine hundred questionnaires were distributed todetermine physician satisfaction regarding the quality ofUniversity CME activities offered over 3 months. Ofthese, 800 were returned and 728 were completelyfilled. These 81% forms were included in the study. Theparticipants were usually self-selected by the hostingdepartment and restricted to licensed physicians.Informed consent was taken and strict confidentialitywas ensured.The instrument used for the survey was developed onad hoc basis and consisting of 8 evaluative items ratedalong a 5-point Likert scale (1 = poor to 5 = excellent).The survey was designed to evaluate several areas ofCME activity, including appropriateness of the statedobjectives, content fitting the stated objectives,presentation at the level of understanding, adequacy ofinteraction, acquisition of new knowledge, timemanagement, queries responded, and administrativesupport. The questionnaire was in English.A rating of 3 or more points on the Likert scale weredefined as satisfactory; a rating of less than 3 wasdefined as unsatisfactory. The data was entered inEpidata version 3.1 and analyzed in Statistical Packagefor Social Sciences 17.0 (SPSS, Inc., Chicago, IL,USA). Descriptive statistics were performed on ratingsof each individual and results were recorded asfrequencies and percentages.A total of 728 (81%) completely filled forms wereincluded in the study. Three or more points-“satisfactory” ratings were given by 94% (682) ofparticipants for appropriateness of the stated objectivesof the session; 93% (679) for content fitting the statedobjectives; 91% (664) for presentation at the level ofunderstanding; 90% (654) for adequacy of interactionbetween the facilitator and participants; 95% (692) foracquisition of new knowledge; 94% (684) for timemanagement; 96% (699) and 93% (677) for satisfactoryresponses to queries and administrative measuresrespectively. However, fewer than three points-“unsatisfactory” were given by 6% (46) of participantsfor appropriateness of the stated objectives of thesession; 7% (49) for content according to the statedobjectives; 9% (64) for presentation at the level ofunderstanding; almost 10% (74) for facilitator-learnerinteraction; 5% (36) for acquisition of new knowledge;6% (44) for time management; 4% (29) and 7% (51) forunsatisfactory responses to queries and administrativemeasures respectively.Medicine today encompasses not only patienttreatment, but also disease prevention, and the ability tocommunicate and function within the social and culturalmilieu of the patient. Medical practitioners must haveongoing means of accessing the knowledge andattitudes needed to keep up with these ever-changingrequirements.4 The enhanced skills and knowledge ofphysicians who attend CME activities lead to improvedpatient care and disease outcomes.2,5A primary limitation of this study is lack of generalizationbeing conducted in a single University. Another was thatthe CME activities were hosted by different departmentswithin the University in which the participants wereusually self-selected which could have influenced theresults. The level of response was fairly high as theparticipants were required to submit the post-eventfeedback as a condition to get the course credit. Thestudy results might have projected differently if theseactivities were opened to all within the University and itis likely that the format of the survey instrument haveinfluenced the responses of the participants.Nevertheless, this study has facilitated the departmentof continuing professional education, AKU, to develop atool for measuring physicians' satisfaction with the CMEevents and would also serve as a source of motivationfor other professional bodies within the region.LETTERS TO THE EDITORPhysician Satisfaction Surveyon Continuing MedicalEducationREFERENCES1. Zeiger RF. Toward continuous medical education. J Gen Intern Med2005; 20:91-4.2. Raza A, Coomarasamy A, Khan KS. Best evidence continuous medicaleducation. Arch Gynecol Obstet 2009; 280:683-7. Epub 2009 Jun 3.3. Ghosh AK. Organizing an effective continuous medical educationsession. J Assoc Physicians India 2008; 56:533-8.4. Bennett NL, Davis DA, Easterling Jr WE, Friedmann P, Green JS,Koeppen BM, et al. Continuing medical education: a new vision of theprofessional development of physicians. Acad Med 2000; 75: 1167.5. Brigley S, Young Y, Littlejohns P, McEwen J. Continuing educationfor medical professionals: a reflective model. Br Med J 1997; 73:23-6.DR. FARHAN VAKANI, DR. WASIM JAFRI, DR. NIZAR BHULANI,DR. MUGHIS SHEERANI AND DR. FATIMA JAFRICorrespondence:Dr. Farhan VakaniDepartment of Continuing Professional EducationThe Aga Khan University HospitalStadium Road, Karachi.E-MAIL: farhan.vakani@aku.eduWhy is the Sustained VirologicalResponse Rate Among HCVGenotype 3 Infected Patientsin Pakistan Low?Sir,We read with interest the article by Qureshi et al. in theJournal.1 Treatment of hepatitis-C virus (HCV) infectionremains a global public health problem. Studies fromdifferent countries are needed for determination of theirmain risk factors and predictors and the best treatmentregimen. We would like to discuss more about reportedresults in this article.1. First of all, the authors have mentioned the dentalprocedure history as a risk factor, while for confirmationof this procedure as a risk factor, a case-control study isrequired. The low prevalence of it (23%) is not enoughfor this claim.2. In addition, we would like to attract your attention tomore important risk factors like transfusion and unsafeinjection in Pakistan.23. Because of high prevalence of HBV infection inPakistan and in attention to 2-10% of anti-HCV positivepatient's seropositivity for HBV infection markers,3 itseems that it was better to exclude patients who werepositive for HBsAg, but the authors did not consider theHBsAg status in their patients.4. We do not agree with consideration of weight as apredictor factor; to our knowledge it was better to considerthe effect of BMI that is a cause of insulin resistance asa predictor of Sustained Virological Response (SVR).4 Itwas better to check the Early Virological Response(EVR: HCV-RNA negative after 3 months) for findingnon-responders to therapy. We would also like tomention that the Rapid Virological Response (RVR:HCV-RNA negative after 4 weeks of treatment) in theselected group (patients with low HCV-RNA viral load)can help in shortening the treatment period. It is animportant issue especially in context of the cost of thetreatment. However, the SVR in this article was 58% thatis much less than reported earlier by Aziz et al. and Muniret al.5,6 Moreover, genetics is an important factor for ILB-28 polymerase effect in high EVR and more relapsebetween patients with genotype 3.75. We believe that quasi-experimental design was moreappropriate instead of cohort design for this study. At theend, we would like to suggest checking of baseline viralload quantitatively for determination of EVR, distingui-shing between responders and non-responders and theconsequent side effects. Also, we would like to suggestusing baseline viral load as the main predictor forresponse rate in developing countries.REFERENCES1. Qureshi S, Batool U, Iqbal M, Burki UF, Khan NU. Pre-treatmentpredictors of response for assessing outcomes to standardtreatment in infection with HCV genotype 3. J Coll Physicians Surg Pak2011; 21:64-8.2. Alavian SM, Fallahian F. Comparison of seroepidemiology andtransmission modes of viral hepatitis C in Iran and Pakistan.Hepatol Monthly 2008; 8:51-9.3. Umar M, Khaar HT, Khurram M, Hasan Z. Anti-HCV antibodypositivity of various sections of Pakistani patients. J Coll PhysiciansSurg Pak 2009; 19:737-41.4. Deltenre P, Louvet A, Lemoine M, Mourad A, Fartoux L, MorenoC, et al. Impact of insulin resistance on sustained response in HCVpatients treated with Pegylated interferon and ribavirin: a meta-analysis. J Hepatol 2011 Apr 13. [Epub ahead of print]5. Aziz S, Qamar R, Ahmed I, Imran K, Masroor M, Rajper J, et al.Treatment profile of hepatitis C patients: a comparison ofinterferon alpha 2a and 2b treatment regimes. J Coll Physicians SurgPak 2010; 20:581-5.6. Munir S, Saleem S, Idrees M, Tariq A, Butt S, Rauff B, et al. HepatitisC treatment: current and future perspectives. Virol J 2010; 7:296.7. Sarrazin C, Susser S, Doehring A, Lange CM, Muller T, SchleckerC, et al. Importance of IL28B gene polymorphisms in hepatitis Cvirus genotype 2 and 3 infected patients. J Hepatol 2011; 54:415-21.DR. SEYED MOAYED ALAVIAN, DR. MOSTAFA SHAFIEI-GUILANIAND DR. SEYED HOSSEIN AALAEI-ANDABILICorrespondence:Dr. Seyed Moayed AlavianDepartment of Gastroenterology and Hepatology,Director of Baqiyatallah Research Center for Gastroenterology and Liver  Disease Tehran, Iran.E-MAIL: alavian@thc.ir70 Journal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (1): 69-72Letters to the editorAuthor’s Reply:HCV continues to increase as a health problem both asa result of a ever growing pool of non-responder andrelapsers and due to an increase of the disease burdensecondary to cirrhosis and hepatocellular carcinoma.Studies from Western authors have evaluated pre-treatment and on-treatment predictors of response inattempts to optimize response rates. These haveinvariably been conducted on genotypes 1, 2 and 3  andhave usually always reported the combined outcomes ofgenotypes 2 and 3. The response rates of 80% forgenotype 3 appear to have been optimistic due to thislumping of the two genotypes when quoting results, andit seems that the response rate to genotype 3 alone islower, even with Pegylated interferon.1 Western studiesspecially for the last 4 years have focused andcommented only on response rates with Pegylatedinterferon and not with standard interferon. Our lowerresponse rates at the SVR stage must be seen in thiscontext and are consistent with recent Pakistanistudies.2 In addition, the lower response rates in ourstudy may not only be due to differences in the local viralgenotype 3 structure but may also be due to differencesin host immune responses due to HLA loci and IL28Brelated differences in response to the virus.Regarding dental procedure history, analysis of 8published studies showed that histoy of dental treatmentwas present in 10-60% of patients.3 Our study used avalidated questionnaire to determine the frequencies ofa history of dental procedures in this cohort. We are notconfirming or proving it as a risk factor. Obviously toprove this association, a case control study would berequired.All patients in this study were HBsAg negative asmentioned in the methodology, all other causes of liverdisease were excluded.We agree that BMI is a good marker for treatmentoutcomes and is a marker for insulin resistance (IR) butwould like to stress that weight being the importantdeterminant of BMI remains globally a standard fordetermining obesity and IR. Measurement of weight andachieving weight loss early during HCV therapy may beassociated with improved treatment response.4In our study, all patients were screened at one month forrapid virological response (RVR) with a qualitative PCR.RVR has a higher positive predictive value to identifysustained responses. In those who do not achieve RVR,an EVR is checked at 3 months. The negative predictivevalue of an EVR is helpful in identifying the lack ofresponse and stopping treatment or extending it. Sincethe positive predictive value of an EVR is lower than thatof RVR, RVR remains a better predictor for identifying abetter SVR.5REFERENCES1. Backus LI, Boothroyd DB, Phillips BR, Mole LA. Mole predictorsof response of US veterans to treatment for the hepatitis C virus.Hepatology 2007; 46:37-47.2. Umar M. Audit report: National program for prevention and controlof hepatitis, Pakistan. 2006-2011.3. Umar M, Kharr B, editors. Hepatitis C in Pakistan. London:SAF Publihing; 2006.4. Alwakeel HR, Zaghla HE, Omar NA, Alshinnawy HA, Rewisha EA,Taha AA, et al. Management of obesity and outcomes of hepatitisC treatment. Egyptian Liver J 2011; 1:11-7.5. Pattullo V, Ravindran NC, Mazzulli T, Wong DK, Heathcote EJ.Pegylated interferon plus optimized weight-based ribavirin dosingnegate the influence of weight and body mass index on early viralkinetics and sustained virological response in chronic hepatitis C.J Viral Hepat 2010; 17:834-8.DR. SALEEM QURESHICorrespondence:House No. 11, Hill Road, Sector F-6/2Islamabad.E-mail: msqcdc@gmail.comPyknodysostosisSir,Pyknodysostosis is a rare condition characterised bythe presence of dense bones. It presents clinically asdwarfism with fragile bones. We came across two siblingswith pyknodysostosis, parents of whom were first cousins.Radiology plays an important role in its diagnosis.These two siblings attended paediatric OPD withcomplaints of short height and fractures on minortrauma. No mental deficiency was noted. The parentswere first cousins, with average height. Their other 3children were normal. On examination, children hadbeaked noses and receding jaw line. The boy, aged 5years was 95 cm in length (5th centile = 104.4 cm), andthe girl, aged 4 years, was 85 cm (5th centile = 97.2 cm).Their skeletal survey revealed generalized dense bones.Skull X-ray of both children showed wide fontanelle andobtuse mandibles. Chest X-rays revealed dense ribsand clavicles. Based on the history and radiologicalfeatures, a diagnosis of pyknodysostosis was made.Pyknodysostosis is an autosomal recessive disorder.The incidence of this disease is estimated at 1.7 permillion births.1 Radiologically, skull demonstratespersistent fontanelle and dense bones (Figure 1),particularly of orbital rims. This is known as the 'raccoonmask' or Harlequin appearance sign.2 In addition, contra-dictory feature of premature closure of skull sutures hasJournal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (1): 69-72 71Letters to the editoralso been reported in literature.3 Mandible is hypoplasticand obtuse. Lumbar vertebrae are spool shaped inadults due to delayed fusion of neural arches.4The confirmatory laboratory test is Cathespin K genemutation analysis.5REFERENCES1. Malagi N, Ukkali S, Thobbi AN, Patil H, Naganoor R, Mujawar Q.Pyknodysostosis with unusual findings: a case report. Cases J 2009;2:6544.2. Costa AL, Lopes SP, de Almeida SM, Steiner CE. Pykno-dysostosis: an early case report with emphasis on the radio-graphic findings. Internet J Dent Sci 2006; 3:2.3. Renton, Peter. Congenital skeletal anomalies; skeletal dysplasias;chromosomal disorders. In: David S, editor. Text book of radiologyand Imaging. 7th ed. London: Churchill Livingstone; 2003. p. 1123. 4. Dahnert W. Bone and soft tissue disorders. In: Dahnert W, editor.Radiology review manual.  5th ed. Philadelphia: Lippincott Williams& Wilkins; 2003. p. 147. 5. Fujita Y. Novel mutations of the cathespin K gene in patients withpyknodysostosis and their characterization. J Clin Endocrinal Metab2000; 85:425-31. DR. SAERAH IFFAT ZAFAR AND DR. SAQIB QAYYUM AHMADCorrespondence:Dr. Saerah Iffat ZafarPAF Hospital, Rafiqui Shorkot Cantt.E-MAIL: saerah_syk@yahoo.co.uk72 Journal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (1): 69-72Figure 1: X-ray skull AP view: showing wide fontanelle which is abnormal forage. Orbital rims are dense- 'Harlequin appearance'.Letters to the editorl l l l lOl l l l l

Physician satisfaction survey on continuing medical education

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Physician satisfaction survey on continuing medical education

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