An article titled "Fake COVID-19 vaccination in India: a growing dilemma?" was published in this journal.1 This was followed by another article titled “Fake COVID-19 vaccines: scams hampering the vaccination drive in India and possibly other countries” in another journal.2 Though scientists in any part of the world have the right to comment or critique about COVID-19 vaccination in India or elsewhere, it is important to double-check the facts before publishing, especially if they are sensitive matters from another country. Many political decisions are made based on articles published in prestigious medical journals, which the public trusts and holds in high respect. In mid-September 2021, the UK announced new rules mandating that travellers from 17 countries do not have to self-isolate if they are fully vaccinated when they arrive in the UK, but the list did not include India.3 India reciprocated the UK COVID curbs by promulgating that UK nationals will have to undergo quarantine for ten days after arriving in India from the UK.4 Can we say that the articles like the present ones did not influence the action of the UK government? Subsequently, both the countries withdrew their curbs later.
This article has not only cast doubts on the COVID-19 vaccines produced in India but also on the digital vaccine certificates that were given to the vaccinated. We'll dissect some of the mis- and disinformation, and other statements of this article. Of more than one...
An article titled "Fake COVID-19 vaccination in India: a growing dilemma?" was published in this journal.1 This was followed by another article titled “Fake COVID-19 vaccines: scams hampering the vaccination drive in India and possibly other countries” in another journal.2 Though scientists in any part of the world have the right to comment or critique about COVID-19 vaccination in India or elsewhere, it is important to double-check the facts before publishing, especially if they are sensitive matters from another country. Many political decisions are made based on articles published in prestigious medical journals, which the public trusts and holds in high respect. In mid-September 2021, the UK announced new rules mandating that travellers from 17 countries do not have to self-isolate if they are fully vaccinated when they arrive in the UK, but the list did not include India.3 India reciprocated the UK COVID curbs by promulgating that UK nationals will have to undergo quarantine for ten days after arriving in India from the UK.4 Can we say that the articles like the present ones did not influence the action of the UK government? Subsequently, both the countries withdrew their curbs later.
This article has not only cast doubts on the COVID-19 vaccines produced in India but also on the digital vaccine certificates that were given to the vaccinated. We'll dissect some of the mis- and disinformation, and other statements of this article. Of more than one billion COVID-19 vaccine doses administered in India, about 88% have been Covishield, which is nothing but the UK’s AstraZeneca COVID-19 vaccine, produced under this trade name, by Serum Institute of India. This led India's Foreign Secretary Harsh Vardhan Shringla to comment "Here is a vaccine, Covishield, which is a licensed product of a UK company manufactured in India, of which we have supplied five million doses to the UK at the request of the government of the UK. We understand that this has been used in their national health system."5 Though the government of the UK had earlier refused to accept all the Indian travellers who were vaccinated with the AstraZeneca Covishield, subsequently the UK government included the AstraZeneca Covishield in the list of recognized vaccines.
However, this did not resolve the issue. A new controversy erupted when the government of the UK refused to accept the CoWIN Certificate issued to vaccinated Indian travellers. Digital vaccine certificates are issued by the CoWIN application (app) launched in India which also handles registration and creates vaccine schedules. The article in question had cast doubts on the digital vaccine certificates by misquoting an announcement of the Ministry of Health and Family Welfare of India. The Indian Government bulletin, dated 6 January 2021, stated that the CoWIN app which will be needed to register for COVID-19 vaccination in India is yet to go live as it is still in pre-production. This message simply served as a warning against downloading a fraudulent CoWIN (COVID Intelligence Network) programme from the app stores. Is it a punishable offence to warn people about fraudulent apps? Unfortunately, the authors of this article have wrongly used this statement by the government of India in support of their following assertion, “After the launch (of CoWIN apps), problems such as discrepancies in the information provided and slot allotments, server issues with freezing and crashing of the app revealed how unprepared the system was to keep up with the increasing user demand.” A good part of the narrative in the present article is devoted to advising on how vaccination should be done in India. Regrettably, this is merely a copy of the methods now in use, as detailed on the Indian government's web pages.6
There was also a mention about the laxity in India’s vaccination. India is doing fairly well with its vaccination, and the record shows that more than a billion vaccinations have been done and approximately 25% of the population is fully vaccinated. Like every other country, India also faces challenges. Though the authors1 have not given proper references for most of the fake COVID-19 vaccinations in India, the only reference given by them refers to a case from Kolkata (state capital of West Bengal in India), where prompt action was taken by the Government. The case got much media attention, for political reasons.
The only confirmed instance where the fraudsters could issue the so-called official vaccination certificate happened in Mumbai, the financial capital of India.2 On 28 and 29 May 2021, an illegal vaccination camp was organised at Podar Centre (an educational trust) in which around 207 staff members were vaccinated. The group, that had coordinated the camp, had received ₹244,000 for the same. The residents of Hiranandani Heritage Housing Society were also administered fake vaccines on May 30. The society members received vaccination certificates, but the same was not reflected on the government’s official Co-WIN portal. Mumbai police promptly arrested the perpetrators of this heinous crime, and the Mumbai court refused bail to the accused.
The article published in this journal indirectly suggests that it would be appropriate for the UK government not to accept the CoWIN Certificate issued by the Indian government.1 It may be pointed out that fake vaccinations are crimes done for financial gains, and not for the purpose of issuing false CoWIN certificates for travel. There is no published report of anyone travelling with a forged CoWIN Certificate. It is much easier to get free vaccination than to get a costly faked CoWIN Certificate. Vaccine hesitancy is not a major issue in India. For travel, you need a certificate issued by the government, showing that you are fully vaccinated (ie two injections of COVID-19 vaccine taken, with a gap of three months between the two injections). A person who has been fooled into taking a fake COVID-19 vaccine once, will not go in for another fake vaccination. This would be like getting struck by lightning twice. Moreover, the Government’s CoWIN portal will not show that he/she has taken the second vaccination (or been fully vaccinated) if there is no proper record of the first vaccination.
Funding
No funding has been reported
Competing interests
None declared.
Consent for publication
Not applicable
References
1. Mukherjee D, Maskey U, Ishak A, Sarfraz Z, Sarfraz A, Jaiswal V. Fake COVID-19 vaccination in India: an emerging dilemma? Postgrad Med J. 2021 Aug 26; postgradmedj-2021-141003. doi: 10.1136/postgradmedj-2021-141003.
2. Choudhary OP, Priyanka, Singh I, Mohammed TA, Rodriguez-Morales AJ. Fake COVID-19 vaccines: scams hampering the vaccination drive in India and possibly other countries. Hum Vaccin Immunother. 2021 Aug 6:1-2. doi: 10.1080/21645515.2021.1960770. Epub ahead of print. PMID: 34357851.
This remarkable account of the successful treatment of two cases of Vaccine Induced Thrombosis with Thrombocytopenia(VITT) aged 86 and 38, respectively(1), is also remarkable for the fact that the second patient, aged 38, did not qualify for receipt of a vaccine other than the AstraZeneca vaccine. She failed to qualify because , either in April or in May 2021, Public Health England and Joint Committee on Vaccination and Immunisation(JCVI) issued a directive which stated "JCVI currently advises that it is preferable for adults aged < 30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID vaccine, if available"(2)(3). However, this recommendation did not apply to people aged 30-40(the age group of patient )(1), notwithstanding the fact that, on the 6th May 2021, headlines in the Independent had declared "Under 40s to be offered alternative to AstraZeneca vaccine over increased clot risk"(4).
By the 30th July 2021, 411 cases of VITT had been documented, including 73 fatalities. In the age group 30-39 there were 51 cases of VITT, including 11 deaths(5). By the time this patient had been vaccinated, however, the BNT162b2(Pfizer) vaccine, and probably also the mRVA-1273(Moderna) vaccine must have been available as potential alternatives to the AstraZeneca vaccine. The Pfizer vaccine is 95% effective in preventing Covid-19(95% credible interval, 90.3 to 97.6).
This remarkable account of the successful treatment of two cases of Vaccine Induced Thrombosis with Thrombocytopenia(VITT) aged 86 and 38, respectively(1), is also remarkable for the fact that the second patient, aged 38, did not qualify for receipt of a vaccine other than the AstraZeneca vaccine. She failed to qualify because , either in April or in May 2021, Public Health England and Joint Committee on Vaccination and Immunisation(JCVI) issued a directive which stated "JCVI currently advises that it is preferable for adults aged < 30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID vaccine, if available"(2)(3). However, this recommendation did not apply to people aged 30-40(the age group of patient )(1), notwithstanding the fact that, on the 6th May 2021, headlines in the Independent had declared "Under 40s to be offered alternative to AstraZeneca vaccine over increased clot risk"(4).
By the 30th July 2021, 411 cases of VITT had been documented, including 73 fatalities. In the age group 30-39 there were 51 cases of VITT, including 11 deaths(5). By the time this patient had been vaccinated, however, the BNT162b2(Pfizer) vaccine, and probably also the mRVA-1273(Moderna) vaccine must have been available as potential alternatives to the AstraZeneca vaccine. The Pfizer vaccine is 95% effective in preventing Covid-19(95% credible interval, 90.3 to 97.6).
The Moderna vaccine showed 94.1% efficacy at preventing Covid-19 illness, including severe disease. " Vaccine efficacy was 94.1%(95% CI, 893 to 96.8%; P < 0.001)".
Neither of the two vaccines have been associated with VITT(2)(5).
Accordingly, instead of having to choose between vaccination vs cancellation of vaccination, the patient should have been required to choose between the AstraZeneca vaccine and either the Pfizer or the Moderna vaccine.
In an otherwise excellent paper, the authors of the review of Covid-19 vaccine subtypes omitted to mention the confidence intervals of the statistics for vaccine efficacy(1). The importance of confidence intervals goes beyond .mere documentation of the possible range around the estimate.:the confidence interval also tells us about how stable the estimate is. A stable estimate is one that would be close to the stated value if the clinical trial were repeated. The same is not true of an unstable estimate.
The authors also omitted to mention the proportion of older subjects in the respective trials. That in formation is a guide to the applicability of the trial results to the older population at large.
The following are the answers to those questions:-
Pfizer Vaccine
Participants numbered 43,548 of whom 42.2% were aged >55.
Vaccine efficacy amounted to 95%(95% Confidence Interval(CI): 90.35% to 97.6%(2).
Moderna Vaccine:-
Participants numbered 30,420 of whom 24.8% were aged 65 or more.
Overall efficacy was 94.1%(95% CI, 89.3 to 96.8%)(3).
Janssen Vaccine
Participants numbered 39,291 of whom 33.5% were aged 60 or more.
Overall efficacy amounted to 66.1%(95% CI 55% to 74.5%)
AstraZeneca Vaccine
In the subgroup who received two standard doses(the doses subsequently used in clinical practice) there were 8,895 participants. An important statistic is that 9% of the UK participants in that subgroup were...
In an otherwise excellent paper, the authors of the review of Covid-19 vaccine subtypes omitted to mention the confidence intervals of the statistics for vaccine efficacy(1). The importance of confidence intervals goes beyond .mere documentation of the possible range around the estimate.:the confidence interval also tells us about how stable the estimate is. A stable estimate is one that would be close to the stated value if the clinical trial were repeated. The same is not true of an unstable estimate.
The authors also omitted to mention the proportion of older subjects in the respective trials. That in formation is a guide to the applicability of the trial results to the older population at large.
The following are the answers to those questions:-
Pfizer Vaccine
Participants numbered 43,548 of whom 42.2% were aged >55.
Vaccine efficacy amounted to 95%(95% Confidence Interval(CI): 90.35% to 97.6%(2).
Moderna Vaccine:-
Participants numbered 30,420 of whom 24.8% were aged 65 or more.
Overall efficacy was 94.1%(95% CI, 89.3 to 96.8%)(3).
Janssen Vaccine
Participants numbered 39,291 of whom 33.5% were aged 60 or more.
Overall efficacy amounted to 66.1%(95% CI 55% to 74.5%)
AstraZeneca Vaccine
In the subgroup who received two standard doses(the doses subsequently used in clinical practice) there were 8,895 participants. An important statistic is that 9% of the UK participants in that subgroup were aged 70 or more(Table 1).
Overall vaccine efficacy among the participants who received two standard doses amounted to 62.1%(95% CI 41% to 75.7%)(Table 2)(5).
References
(1) Francis AI., Ghany S., Gilkes T., Umakanthan s
Review of COVID-19 vaccine subtypes, efficacy and geographical distribution
Postgrad Med J 2021;doi:101136/postgradmedj-2021-140654
(2)Polack FP., Thomas SJ., Kitchin N et al
Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine
N Engl J Med 2020;383:2603-2615
(3)Baden LR., El-Sahly HM., Essink B et al
Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine
N Engl J Med 2021;384:403-416
(4) Madoff J., Gray G., Vandebosch A et al
Safety and efficacy of single-dose Ad26.COV2.5 vaccine against Covid-19
N Engl J Med 2021;384:2187-2201
(5) Voysey M., Clemens SAC., Madhi S et al
Safety and efficacy of the ChAdOx1 nCoV-19 vaccine(AZD1222) against SARS Co-V-2; an interm analysis of four randomised trials in Brazil, South SAfrica and the UK.
Lancet 2020 doi.org/101016/S0140-6736(20)32661-1
Thank you for your valuable comments on our paper. According to the British and Irish Hypertension Society and the American Heart Association, clinicians should measure patients' blood pressure (BP) in both arms to diagnose possible cardiovascular anomalies and select the higher BP arm for subsequent measurement.1 The clinician is recommended to document patients' BP differences in both arms. Cardiovascular risks could be controlled more tightly when there is a persistent discrepancy of more than 15mmHg. Patients should be told which arm to use for future measurements.
In our study, all participants had BP measured in both arms by the nurses upon recruitment. The arm with higher BP was documented and used in subsequent clinical and home BP measurements. Clinic nurses checked if participants had selected the correct arm at follow-up six weeks later.
"The role of wicket keeper is similar to being a catcher in baseball, and not usually associated with charisma or conventional leadership."
In baseball, until November 2004, one of the longest and most famous droughts (years without winning the World Series) was that of the Boston Red Sox. It was said that they had been cursed for selling Babe Ruth, one of the greatest hitters in history, to their hated rivals, the New York Yankees. This was known as the Curse of the Bambino.
But the historic curse was ended in 2004, when the Red Sox finally won the Series, under the exceptional leadership of their captain, the catcher Jason Varitek.
As with the leadership of Mike Brearley in cricket, Jason Varitek in baseball showed that the exception proves the rule for catchers in every field.
It is axiomatic that , on initial assessment of a patient's blood pressure(BP), measurement should be recorded in both arms, and the higher of the two readings should be used for diagnosis and management(1). I would add that the arm with the higher blood pressure should be the arm from which home blood pressures are measured.
Was that requirement fulfilled in the study evaluating knowledge and practice of home blood pressure monitoring?
Awareness of interarm blood pressure informs the technique of blood pressure measurement. It also adds information about prognosis given the observation that "Every 10 mm Hg difference in systolic BP between arms conferred a mortality hazard of 1.24(95% Confidence Interval 1.01 to 1.52 after adjusting for average systolic BP and chronic kidney disease"(2). Arguably, the rationale for this observation comes from the meta analysis which showed that a difference of 15 mm Hg or more in systolic BP is associated with cerebrovascular disease and with peripheral vascular disease, and increased cardiovascular mortality, respectively(3).
References
(1) Giles TG., Egan P
Inter-arm difference in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Agarwal R., Bunaye Z., Bekele DM
Prognostic significance of bwteen-arm blood pressure differences
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore...
It is axiomatic that , on initial assessment of a patient's blood pressure(BP), measurement should be recorded in both arms, and the higher of the two readings should be used for diagnosis and management(1). I would add that the arm with the higher blood pressure should be the arm from which home blood pressures are measured.
Was that requirement fulfilled in the study evaluating knowledge and practice of home blood pressure monitoring?
Awareness of interarm blood pressure informs the technique of blood pressure measurement. It also adds information about prognosis given the observation that "Every 10 mm Hg difference in systolic BP between arms conferred a mortality hazard of 1.24(95% Confidence Interval 1.01 to 1.52 after adjusting for average systolic BP and chronic kidney disease"(2). Arguably, the rationale for this observation comes from the meta analysis which showed that a difference of 15 mm Hg or more in systolic BP is associated with cerebrovascular disease and with peripheral vascular disease, and increased cardiovascular mortality, respectively(3).
References
(1) Giles TG., Egan P
Inter-arm difference in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Agarwal R., Bunaye Z., Bekele DM
Prognostic significance of bwteen-arm blood pressure differences
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore A Ukoumunne O., campbell JL
Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis
Lancet 2012;379:905-914
The article by Launer [1] raises the issue as to whether diagnostic labels are to be avoided as they can be stigmatising and judgemental. Within the article, the term ‘patient’ was used to convey the individual in receipt of the diagnosis. In recent years it has been suggested that ‘patient’ itself be avoided - as it can imply passivity in the face of the medical profession [2]. The word derives from the latin patiens, which means suffering; but also acquiescing, allowing and submitting. This latter connotation implies that a patient ‘receives’ the diagnosis - rather than being empowered to work with the doctor towards a meaningful interpretation of their symptoms and/or resolution of them. Use of the term ‘patient’ by healthcare workers may then lead to the medicalisation of thought towards the individual (semantic determinism). Conversely, surveys have suggested that people prefer to be called a patient [3]. This may reflect the lack of adequate alternative descriptors. To be a ‘patient’ may also be advantageous as it will then clarify to the health care professional and the legal system, the unique obligation they have to that individual. Perhaps, as with ‘diagnosis’, we should seek permission from the individuals themselves whether to refer to them as patients?
1. Launer J. Postgrad Med J. 2021 Jan;97(1143):67-68. doi: 10.1136/postgradmedj-2020-139298.
2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressin...
The article by Launer [1] raises the issue as to whether diagnostic labels are to be avoided as they can be stigmatising and judgemental. Within the article, the term ‘patient’ was used to convey the individual in receipt of the diagnosis. In recent years it has been suggested that ‘patient’ itself be avoided - as it can imply passivity in the face of the medical profession [2]. The word derives from the latin patiens, which means suffering; but also acquiescing, allowing and submitting. This latter connotation implies that a patient ‘receives’ the diagnosis - rather than being empowered to work with the doctor towards a meaningful interpretation of their symptoms and/or resolution of them. Use of the term ‘patient’ by healthcare workers may then lead to the medicalisation of thought towards the individual (semantic determinism). Conversely, surveys have suggested that people prefer to be called a patient [3]. This may reflect the lack of adequate alternative descriptors. To be a ‘patient’ may also be advantageous as it will then clarify to the health care professional and the legal system, the unique obligation they have to that individual. Perhaps, as with ‘diagnosis’, we should seek permission from the individuals themselves whether to refer to them as patients?
1. Launer J. Postgrad Med J. 2021 Jan;97(1143):67-68. doi: 10.1136/postgradmedj-2020-139298.
2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressing the use of language in the care of people with diabetes: position statement of the English Advisory Group. 2018; 35(12):1630-1634
3. Costa DSJ, Mercieca-Bebber R, Tesson S, Seidler Z et al. BMJ Open. Patient, client, consumer, survivor or other alternatives? A scoping review of preferred terms for labelling individuals who access healthcare across settings. 2019 Mar 7;9(3):e025166.
We read with great interest the article by Kanneganti et al. exploring ‘Continuing Medical Education during a pandemic: an academic institution’s experience’. As medical students at King’s College London (KCL) in the United Kingdom, our anecdotal experience parallels the findings of Kanneganti et al., who analyse the innovative changes to medical education in Singapore.(1) Although, Kanneganti et al. focus on continuing medical education (CME) for speciality training, as senior medical students we have found that the challenges of COVID-19 have also altered our intended medical education experience, specifically our clinical training.
Kanneganti et al. mention the successful move of CME to online platforms, including Objective Structured Clinical Exams (OSCE) but acknowledge the difficulty in simulating clinical signs. Unlike the National University Hospital (NUH) in Singapore, KCL has chosen not to deliver OSCEs online and instead have adapted the traditional OSCE assessments into Clinical Workplace Examinations (CWE). This assesses clinical competency on one real-life patient where final year medical students undertake an in-depth history and clinical examination in a forty-five minute period. This is a stark contrast to the traditional multiple station format. Some may argue that this new format is unable to assess a wide variety of skills. Furthermore, it is far more challenging to standardise the CWE as students have different patients with...
We read with great interest the article by Kanneganti et al. exploring ‘Continuing Medical Education during a pandemic: an academic institution’s experience’. As medical students at King’s College London (KCL) in the United Kingdom, our anecdotal experience parallels the findings of Kanneganti et al., who analyse the innovative changes to medical education in Singapore.(1) Although, Kanneganti et al. focus on continuing medical education (CME) for speciality training, as senior medical students we have found that the challenges of COVID-19 have also altered our intended medical education experience, specifically our clinical training.
Kanneganti et al. mention the successful move of CME to online platforms, including Objective Structured Clinical Exams (OSCE) but acknowledge the difficulty in simulating clinical signs. Unlike the National University Hospital (NUH) in Singapore, KCL has chosen not to deliver OSCEs online and instead have adapted the traditional OSCE assessments into Clinical Workplace Examinations (CWE). This assesses clinical competency on one real-life patient where final year medical students undertake an in-depth history and clinical examination in a forty-five minute period. This is a stark contrast to the traditional multiple station format. Some may argue that this new format is unable to assess a wide variety of skills. Furthermore, it is far more challenging to standardise the CWE as students have different patients with a myriad of diseases as opposed to OSCEs which allow students to go through the same scope and criteria for assessment.(2) However, we feel CWE provide a far more realistic scenario, which would be more representative of situations faced by foundation doctors. The incorporation of various workplace-based learning methods (such as CWE) promote self-directed learning while reliably assessing a broad discipline of everyday clinical encounters.(3) Furthermore, CWEs allows students to see patients with real clinical signs which can otherwise be difficult to simulate.
Kanneganti et al. mention the role of asynchronous and synchronous e-learning in CME. Similarly, KCL uses a variety of online teaching to facilitate student learning including live online lectures and seminars as well as uploaded recordings of previously held webinars. Kanneganti et al. describe the disparity in online teaching between different CME programmes which we have also found reflects the inconsistency in hospital site-specific teaching that we receive as medical students on our placements. We are spread across a total of 15 different sites for our clinical placements meaning that the level of online teaching can vary significantly depending on resources. In order to combat this, our university has now made recordings of site-specific online teaching available to all students through a central platform, allowing them access to a variety of resources regardless of their placement site. Similarly, sharing resources across training programs may be beneficial for the learning of speciality trainees’ at the NUH.
Kanneganti et al. describe how the NUH has continued to provide surgical exposure for residents through the use of surgical videos with technical pointers from experienced faculty. However, this form of passive learning may not be as beneficial in a hands-on specialty such as surgery. Alternatively, at one KCL’s hospital site, virtual simulation using virtual reality headsets has been used for students to experience the approach to emergency medical scenarios. The platform allows students to respond in real time and interact not only with the patient but with a virtual nurse and bedside medical equipment, replicating a real life scenario. This leads to the exciting possibility of virtual platforms being adapted for a myriad of medical and surgical scenarios. Virtual platforms such as this could be useful beyond the pandemic. In the absence of real life patients, virtual platforms may aid trainees with their core clinical competencies by providing a variety of realistic simulated scenarios.(4)
The COVID-19 pandemic has had lasting consequences on medical education around the world for both medical students and trainee doctors. However, the challenges of teaching during this pandemic have been eased through the use of new innovations and technologies. With different approaches being taken in various parts of the world, it is important to learn from each other’s adaptations in medical education to continually evolve during these unprecedented times.
References:
1. Kanneganti A, Sia C-H, Ashokka B, Ooi SBS. (2020) Continuing medical education during a pandemic: an academic institution’s experience. Postgraduate Medical Journal 2020;96:384-386.
2. Zayyan M. (2011). Objective structured clinical examination: the assessment of choice. Oman medical journal, 26(4), 219–222.
3. Liu C. (2012). An introduction to workplace-based assessments. Gastroenterology and hepatology from bed to bench, 5(1), 24–28.
4. Pottle J. (2019). Virtual reality and the transformation of medical education. Future healthcare journal, 6(3), 181–185.
We thank Dr Launer[1] for his reflection on burnout in the age of COVID-19. We would like to share our views on burnout as senior medical students. We believe that medical students are not immune to the pressures that have come from this pandemic and that there are important lessons for students about how to manage burnout before commencing their careers.
As students, we look to our senior colleagues as examples of how to manage stress and maintain a healthy work life balance. We have seen the passion that most doctors carry with them despite the circumstances and hope to apply what we have observed in our future careers. In Dr Launer’s intriguing reflection, he mentions that junior doctors should be protected from the illusion that clinicians will remain consistently fired with enthusiasm from foundation training through to retirement. We believe this is a concept that should be taught from the very beginning of one’s career, namely in medical school.
We remember as prospective medical students in secondary education, the discussions that surrounded pursuing a career in medicine being altogether the same - a rhetoric of saving lives and having a job that would be forever fulfilling. Although much of this is true, it seems throughout our education and inevitably as foundation doctors, the sugar-coating is removed and we are able to see what we were never told – that being a doctor can be hard, exhausting and frankly disappointing at ti...
We thank Dr Launer[1] for his reflection on burnout in the age of COVID-19. We would like to share our views on burnout as senior medical students. We believe that medical students are not immune to the pressures that have come from this pandemic and that there are important lessons for students about how to manage burnout before commencing their careers.
As students, we look to our senior colleagues as examples of how to manage stress and maintain a healthy work life balance. We have seen the passion that most doctors carry with them despite the circumstances and hope to apply what we have observed in our future careers. In Dr Launer’s intriguing reflection, he mentions that junior doctors should be protected from the illusion that clinicians will remain consistently fired with enthusiasm from foundation training through to retirement. We believe this is a concept that should be taught from the very beginning of one’s career, namely in medical school.
We remember as prospective medical students in secondary education, the discussions that surrounded pursuing a career in medicine being altogether the same - a rhetoric of saving lives and having a job that would be forever fulfilling. Although much of this is true, it seems throughout our education and inevitably as foundation doctors, the sugar-coating is removed and we are able to see what we were never told – that being a doctor can be hard, exhausting and frankly disappointing at times.
Throughout medical school we are taught that we must be resilient. Our response to a negative stimulus must be to keep a stiff upper lip and carry on. When faced with stress and a high workload, we must learn to handle this and perform to a high standard. Although these are all fundamental skills that we look forward to putting into practice, we feel that many medical schools neglect the importance of encouraging students to develop the strategies required to ameliorate burnout.
During this pandemic, medical students have been expected to continue conducting research, clinical audits, studying for finals, amongst other tasks as part of our education. Despite these responsibilities, many students have taken this time away from hospitals to create COVID-19 response organisations within their communities, especially for ethnic group minorities who may be marginalised in these times of uncertainty. We have also been called upon as essential workers to volunteer in COVID-19 hospitals and many of us have risen to the challenge. Those of us who have volunteered on the frontlines have been exposed to the reality of emergency medicine, the stresses of a constantly changing healthcare system as well as the emotional burden of witnessing the deaths of patients as well as some of our senior colleagues.
The activities many of us usually partake in for stress mitigation such as practicing sports and social activities have not been available. A broader conversation about how doctors and students have juggled their responsibilities and mental health during this pandemic is needed. Dr Launer mentions that ‘the conditions for burnout are set early on’ in medical training. We agree and further suggest that the many years of education in medical school is an opportunity for prospective doctors to learn how to build a strong foundation for stress management which can continue on into medical training.
From our perspective, medical schools should put more emphasis on modules correlating the stresses of medical school with real-life medicine. This is likely to ensure that students enter employment with some insight into the possible pressures that lie ahead. It is important to facilitate conversations between doctors and students about the reality of burnout and what realistically can be done to manage stress. Furthermore, students should be encouraged to reach out for help more openly and frequently when needed - deconstructing the false narrative of pride and unrelenting strength amongst doctors begins in medical school.
Moving forwards, it is important to implement the lessons learnt during this pandemic before they are forgotten. The importance of a multi-disciplinary team, adaptability and quick thinking, communication and unity, have left the theoretical realm and become a living example to many students watching the NHS grapple with COVID-19. Although there will be uncertainty surrounding the structure of medical education going forwards, there are many learning points for students to take. We suggest universities across the country implement these reflections into future personal development curriculums as an important case study of resilience and stress-management.
References
1. Launer J. Burnout in the age of COVID-19. 2020.
We were pleased to read the very timely article in your esteemed journal titled “Continuing medical education during a pandemic: an academic institution’s experience”by Kanneganti et al 1 , The authors have given an in-depth description of various tools being used to impart medical education to postgraduate trainees in prevailing COVID crisis. We would like to commend the authors for the detailed analysis of impact of COVID pandemic on medical education and comment on evolving situation with current evidence so as to complement the issues raised by this thought provoking article.
The unimaginable power of microcosmic CORONA virus has razed down human capability to master the universe and shown the vulnerability of Man’s vaunted display of power and arrogance.2 Medical education has not remained untouched by its impact. The Corona Virus has not only attacked our corporeal existence, it has affected us mentally, psychologically and institutionally. It has called for physical and social distancing that will make it difficult to hold classes for sizeable number of students to learn together. Although the benefits of direct student teacher interaction and real time two way feedback will be difficult to replicate at online forums 3 , still online classes seem to be the only preferred alternative to face to face education in current scenerio.2
We at our institute are using WebX platform for online teaching activities. Teachers and students both can use th...
We were pleased to read the very timely article in your esteemed journal titled “Continuing medical education during a pandemic: an academic institution’s experience”by Kanneganti et al 1 , The authors have given an in-depth description of various tools being used to impart medical education to postgraduate trainees in prevailing COVID crisis. We would like to commend the authors for the detailed analysis of impact of COVID pandemic on medical education and comment on evolving situation with current evidence so as to complement the issues raised by this thought provoking article.
The unimaginable power of microcosmic CORONA virus has razed down human capability to master the universe and shown the vulnerability of Man’s vaunted display of power and arrogance.2 Medical education has not remained untouched by its impact. The Corona Virus has not only attacked our corporeal existence, it has affected us mentally, psychologically and institutionally. It has called for physical and social distancing that will make it difficult to hold classes for sizeable number of students to learn together. Although the benefits of direct student teacher interaction and real time two way feedback will be difficult to replicate at online forums 3 , still online classes seem to be the only preferred alternative to face to face education in current scenerio.2
We at our institute are using WebX platform for online teaching activities. Teachers and students both can use this platform for their presentations and discussions. The lectures and seminars shared through this platform are made available online for later view by students. Students can repeatedly go through these videos and clarify their doubts in next online class. Group dynamics is integral to deep learning. Although online platforms are the need of the hour, group dynamics of think, pair and share is difficult to replicate among students on online platforms during teaching learning. It appears as if we are missing bull’s eye.
‘‘Medical education is not just a program for building knowledge and skills in its recipients; it is also an experience which creates attitude and expectations’’. 4 This statement by famous medical educationist, Abraham Flexner is all the more relevant in today’s era of social distancing and online medical education, in the wake of COVID pandemic. Although development of clinical skills, attitude and communication in medical students is hard to replicate without direct contact with patients; students can learn clinical and surgical skills from their teachers using videoconferencing and by small group teaching maintaining social distance.1 Attributes like attitude and communication skills can not be practised using online portals, but on real patients in indoor setting maintaining social and physical distancing norms.
As we know , group dynamics is integral to deep learning. Although online platforms are the need of the hour, group dynamics of think, pair and share is difficult to replicate among students on online platforms during teaching learning. It appears as if we are missing bull’s eye.
References
1.Kanneganti A, Sia C-H, Ashokka B, Ooi SBS. Continuing medical education during a
pandemic: an academic institution’s experience. Postgraduate Medical Journal 2020;96
:384-386.
2.Raghvan H . Higher Education in the Year 2020-21 : How Should It Be ? University
News 2020 ; Vol. 58: 25 .
3. Ferrel M N, Ryan J J. The Impact of COVID-19 on Medical Education. Cureus 12(3):
e7492.
4. Flexner A. An Autobiography . New York, NY: Simon and Schuster; 1960.
An article titled "Fake COVID-19 vaccination in India: a growing dilemma?" was published in this journal.1 This was followed by another article titled “Fake COVID-19 vaccines: scams hampering the vaccination drive in India and possibly other countries” in another journal.2 Though scientists in any part of the world have the right to comment or critique about COVID-19 vaccination in India or elsewhere, it is important to double-check the facts before publishing, especially if they are sensitive matters from another country. Many political decisions are made based on articles published in prestigious medical journals, which the public trusts and holds in high respect. In mid-September 2021, the UK announced new rules mandating that travellers from 17 countries do not have to self-isolate if they are fully vaccinated when they arrive in the UK, but the list did not include India.3 India reciprocated the UK COVID curbs by promulgating that UK nationals will have to undergo quarantine for ten days after arriving in India from the UK.4 Can we say that the articles like the present ones did not influence the action of the UK government? Subsequently, both the countries withdrew their curbs later.
Show MoreThis article has not only cast doubts on the COVID-19 vaccines produced in India but also on the digital vaccine certificates that were given to the vaccinated. We'll dissect some of the mis- and disinformation, and other statements of this article. Of more than one...
This remarkable account of the successful treatment of two cases of Vaccine Induced Thrombosis with Thrombocytopenia(VITT) aged 86 and 38, respectively(1), is also remarkable for the fact that the second patient, aged 38, did not qualify for receipt of a vaccine other than the AstraZeneca vaccine. She failed to qualify because , either in April or in May 2021, Public Health England and Joint Committee on Vaccination and Immunisation(JCVI) issued a directive which stated "JCVI currently advises that it is preferable for adults aged < 30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID vaccine, if available"(2)(3). However, this recommendation did not apply to people aged 30-40(the age group of patient )(1), notwithstanding the fact that, on the 6th May 2021, headlines in the Independent had declared "Under 40s to be offered alternative to AstraZeneca vaccine over increased clot risk"(4).
By the 30th July 2021, 411 cases of VITT had been documented, including 73 fatalities. In the age group 30-39 there were 51 cases of VITT, including 11 deaths(5). By the time this patient had been vaccinated, however, the BNT162b2(Pfizer) vaccine, and probably also the mRVA-1273(Moderna) vaccine must have been available as potential alternatives to the AstraZeneca vaccine. The Pfizer vaccine is 95% effective in preventing Covid-19(95% credible interval, 90.3 to 97.6).
T...
Show MoreIn an otherwise excellent paper, the authors of the review of Covid-19 vaccine subtypes omitted to mention the confidence intervals of the statistics for vaccine efficacy(1). The importance of confidence intervals goes beyond .mere documentation of the possible range around the estimate.:the confidence interval also tells us about how stable the estimate is. A stable estimate is one that would be close to the stated value if the clinical trial were repeated. The same is not true of an unstable estimate.
Show MoreThe authors also omitted to mention the proportion of older subjects in the respective trials. That in formation is a guide to the applicability of the trial results to the older population at large.
The following are the answers to those questions:-
Pfizer Vaccine
Participants numbered 43,548 of whom 42.2% were aged >55.
Vaccine efficacy amounted to 95%(95% Confidence Interval(CI): 90.35% to 97.6%(2).
Moderna Vaccine:-
Participants numbered 30,420 of whom 24.8% were aged 65 or more.
Overall efficacy was 94.1%(95% CI, 89.3 to 96.8%)(3).
Janssen Vaccine
Participants numbered 39,291 of whom 33.5% were aged 60 or more.
Overall efficacy amounted to 66.1%(95% CI 55% to 74.5%)
AstraZeneca Vaccine
In the subgroup who received two standard doses(the doses subsequently used in clinical practice) there were 8,895 participants. An important statistic is that 9% of the UK participants in that subgroup were...
Thank you for your valuable comments on our paper. According to the British and Irish Hypertension Society and the American Heart Association, clinicians should measure patients' blood pressure (BP) in both arms to diagnose possible cardiovascular anomalies and select the higher BP arm for subsequent measurement.1 The clinician is recommended to document patients' BP differences in both arms. Cardiovascular risks could be controlled more tightly when there is a persistent discrepancy of more than 15mmHg. Patients should be told which arm to use for future measurements.
In our study, all participants had BP measured in both arms by the nurses upon recruitment. The arm with higher BP was documented and used in subsequent clinical and home BP measurements. Clinic nurses checked if participants had selected the correct arm at follow-up six weeks later.
This was a most enjoyable read.
"The role of wicket keeper is similar to being a catcher in baseball, and not usually associated with charisma or conventional leadership."
In baseball, until November 2004, one of the longest and most famous droughts (years without winning the World Series) was that of the Boston Red Sox. It was said that they had been cursed for selling Babe Ruth, one of the greatest hitters in history, to their hated rivals, the New York Yankees. This was known as the Curse of the Bambino.
But the historic curse was ended in 2004, when the Red Sox finally won the Series, under the exceptional leadership of their captain, the catcher Jason Varitek.
As with the leadership of Mike Brearley in cricket, Jason Varitek in baseball showed that the exception proves the rule for catchers in every field.
It is axiomatic that , on initial assessment of a patient's blood pressure(BP), measurement should be recorded in both arms, and the higher of the two readings should be used for diagnosis and management(1). I would add that the arm with the higher blood pressure should be the arm from which home blood pressures are measured.
Was that requirement fulfilled in the study evaluating knowledge and practice of home blood pressure monitoring?
Awareness of interarm blood pressure informs the technique of blood pressure measurement. It also adds information about prognosis given the observation that "Every 10 mm Hg difference in systolic BP between arms conferred a mortality hazard of 1.24(95% Confidence Interval 1.01 to 1.52 after adjusting for average systolic BP and chronic kidney disease"(2). Arguably, the rationale for this observation comes from the meta analysis which showed that a difference of 15 mm Hg or more in systolic BP is associated with cerebrovascular disease and with peripheral vascular disease, and increased cardiovascular mortality, respectively(3).
References
(1) Giles TG., Egan P
Show MoreInter-arm difference in blood pressure may have serious research and clinical implications
The Journal of Clinical Hypertension 2012;14:491-492
(2) Agarwal R., Bunaye Z., Bekele DM
Prognostic significance of bwteen-arm blood pressure differences
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore...
The article by Launer [1] raises the issue as to whether diagnostic labels are to be avoided as they can be stigmatising and judgemental. Within the article, the term ‘patient’ was used to convey the individual in receipt of the diagnosis. In recent years it has been suggested that ‘patient’ itself be avoided - as it can imply passivity in the face of the medical profession [2]. The word derives from the latin patiens, which means suffering; but also acquiescing, allowing and submitting. This latter connotation implies that a patient ‘receives’ the diagnosis - rather than being empowered to work with the doctor towards a meaningful interpretation of their symptoms and/or resolution of them. Use of the term ‘patient’ by healthcare workers may then lead to the medicalisation of thought towards the individual (semantic determinism). Conversely, surveys have suggested that people prefer to be called a patient [3]. This may reflect the lack of adequate alternative descriptors. To be a ‘patient’ may also be advantageous as it will then clarify to the health care professional and the legal system, the unique obligation they have to that individual. Perhaps, as with ‘diagnosis’, we should seek permission from the individuals themselves whether to refer to them as patients?
1. Launer J. Postgrad Med J. 2021 Jan;97(1143):67-68. doi: 10.1136/postgradmedj-2020-139298.
Show More2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressin...
Dear Editor,
We read with great interest the article by Kanneganti et al. exploring ‘Continuing Medical Education during a pandemic: an academic institution’s experience’. As medical students at King’s College London (KCL) in the United Kingdom, our anecdotal experience parallels the findings of Kanneganti et al., who analyse the innovative changes to medical education in Singapore.(1) Although, Kanneganti et al. focus on continuing medical education (CME) for speciality training, as senior medical students we have found that the challenges of COVID-19 have also altered our intended medical education experience, specifically our clinical training.
Kanneganti et al. mention the successful move of CME to online platforms, including Objective Structured Clinical Exams (OSCE) but acknowledge the difficulty in simulating clinical signs. Unlike the National University Hospital (NUH) in Singapore, KCL has chosen not to deliver OSCEs online and instead have adapted the traditional OSCE assessments into Clinical Workplace Examinations (CWE). This assesses clinical competency on one real-life patient where final year medical students undertake an in-depth history and clinical examination in a forty-five minute period. This is a stark contrast to the traditional multiple station format. Some may argue that this new format is unable to assess a wide variety of skills. Furthermore, it is far more challenging to standardise the CWE as students have different patients with...
Show MoreDear Editor,
We thank Dr Launer[1] for his reflection on burnout in the age of COVID-19. We would like to share our views on burnout as senior medical students. We believe that medical students are not immune to the pressures that have come from this pandemic and that there are important lessons for students about how to manage burnout before commencing their careers.
As students, we look to our senior colleagues as examples of how to manage stress and maintain a healthy work life balance. We have seen the passion that most doctors carry with them despite the circumstances and hope to apply what we have observed in our future careers. In Dr Launer’s intriguing reflection, he mentions that junior doctors should be protected from the illusion that clinicians will remain consistently fired with enthusiasm from foundation training through to retirement. We believe this is a concept that should be taught from the very beginning of one’s career, namely in medical school.
We remember as prospective medical students in secondary education, the discussions that surrounded pursuing a career in medicine being altogether the same - a rhetoric of saving lives and having a job that would be forever fulfilling. Although much of this is true, it seems throughout our education and inevitably as foundation doctors, the sugar-coating is removed and we are able to see what we were never told – that being a doctor can be hard, exhausting and frankly disappointing at ti...
Show MoreWe were pleased to read the very timely article in your esteemed journal titled “Continuing medical education during a pandemic: an academic institution’s experience”by Kanneganti et al 1 , The authors have given an in-depth description of various tools being used to impart medical education to postgraduate trainees in prevailing COVID crisis. We would like to commend the authors for the detailed analysis of impact of COVID pandemic on medical education and comment on evolving situation with current evidence so as to complement the issues raised by this thought provoking article.
The unimaginable power of microcosmic CORONA virus has razed down human capability to master the universe and shown the vulnerability of Man’s vaunted display of power and arrogance.2 Medical education has not remained untouched by its impact. The Corona Virus has not only attacked our corporeal existence, it has affected us mentally, psychologically and institutionally. It has called for physical and social distancing that will make it difficult to hold classes for sizeable number of students to learn together. Although the benefits of direct student teacher interaction and real time two way feedback will be difficult to replicate at online forums 3 , still online classes seem to be the only preferred alternative to face to face education in current scenerio.2
We at our institute are using WebX platform for online teaching activities. Teachers and students both can use th...
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