IDCAPs Integrated Management of Infectious Disease (IMID) Training

In an era marked by increasing patient demand and a shortage of health care workers throughout much of Africa, clinical training that is efficient, effective and appropriately targeted is a key response to improving patient care. Uganda, for example, has a doctor-patient ratio of 1:10,000. As a result, responsibilities usually reserved for a doctor, such as prescribing, are routinely performed by non physician clinicians (NPCs), majority of which report being insufficiently trained to carry out such activities. To address this issue, Accordia Global Health Foundation and its partners developed the Integrated Management of Infectious Diseases (IMID) training program which is designed to build skills for the management of infectious diseases among NPCs in Uganda. The training is integrated across diseases to achieve efficiencies in the course duration, and greatly improved impact on clinical reasoning skills among trainees.

Course Materials Available for Dissemination Facilitators guide for IMID Core Course Participant guide for IMID Core Course Participant handouts for IMID Core Course Facilitators guide for Booster Course 1 & 2 Participant handouts for Booster Course 1 & 2 Case Scenarios & Scoring Guides Clinical Assessments

Principles of IMID
3 months 3 months

Participant handouts for Booster Course 1 & 2 Booster Course 1 Core Course Case Scenarios & Scoring Guides Clinical Assessments

Booster Course 2

Distance Learning

The foundation of the IMID training program is the Core Course. This is an intensive 3 week training course followed by two week-long booster courses held at 3 month intervals. It features detailed case studies and discussions as the primary means of instruction.
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Case-Based Teaching The Core Course reflects an innovative approach in clinical teaching. Each of the 36 classroom sessions is taught using a case-based approach that mirrors clinical thinking. Instead of using a case as a compliment to a session, the session is built from the case.
Case presentation Patient history + Physical exam Problem list + Differential Diagnoses Final diagnosis

Each session begins with the patient presenting complaints and trainees discussing the steps in assessing the patient: taking a focused history based on the patients complaints, performing a targeted physical exam and specific lab tests that should be ordered in this case. Next, trainees construct a problem list for the patient, followed by differential diagnoses. The differentials are discussed and some ruled out. Additional information is given about the case, and the list of differentials is narrowed until a final diagnosis is determined. As a group, trainees apply the steps in clinical reasoning over 40 times during the course, using cases that become progressively more complex over the 3 weeks. Cases are not grouped by disease, rather, they are ordered according to the complexity of their presenting complaint. This case-based approach allows the training to achieve 2 important things: It presents information in a format that more closely resembles clinical thinking when seeing patientsmodeling the clinical reasoning process which includes problem lists, differential diagnoses and a final diagnosis. Second, through discussion of cases, trainees can evaluate their approach to patient care against the assessment of their peers and the best-practice answer provided by the facilitatorthereby increasing their awareness of specific areas they need to improve.

The classroom training includes clinical rotations, giving the trainees the opportunity to see patients in small groups, under the guidance of an expert mentor. There are 4 half-day clinical rotations in a variety of health care settings with exposure to experts to support the application of concepts learned. Booster Courses In addition to the Core Course, the IMID training program includes 2 other classroom trainings: Booster 1 and Booster 2. The three classroom trainings occur 12 weeks apart, giving trainees the opportunity to return to their clinics while completing a distance learning module.
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The two 1-week Booster courses serve an important function in sustaining learning over time and encouraging trainees to discuss clinical challenges with both peers and experts through a series of activities, clinical placements and case discussion. Distance learning The IMID classroom trainings are followed by three 12 week distance learning periods focused on guiding trainees to use their daily practice in the clinic to further their learning. Each week during the distance learning period, trainees write-up one case from their clinical practice in their logbooks. They also record their consultation practiceswhere they looked and who they spoke to for additional information when faced with a challenging case. Using the clinical practice logbook during the 3 distance learning periods, trainees build the skills needed to consult effectivelyfinding appropriate sources of information, explaining challenging cases effectively and deciding on the best course of action. Classroom Case Scenarios IDCAPs classroom case scenarios are written exams that use patient encounters to test the trainees knowledge of the IMID content, and their ability to apply complex reasoning skills. The scenarios overcome the limitations of multiple choice exams, while preserving their logistical advantages, with accuracy comparable to standardized patients. They evaluate trainees competence in areas not possible with clinical observation, such as management of less prevalent and more complex cases, and management of patients over time. The case scenarios and scoring guides lend themselves to future applications to evaluate training programs and as case studies for distance learning. Clinical Assessment IDCAP faculty use tools to evaluate trainees clinical skills in managing two types of patients: a) children under 5 years in an outpatient clinic and b) HIV patients. Forms were developed to document patient symptoms and examinations, and details about diagnosis and treatment. Faculty systematically report whether the information was obtained by the trainee or the faculty. Complete and accurate patient information is an important innovation to enhance inter-rater reliability, because the faculty scores can be verified against the patient data. IDCAPs IMID is specifically designed for NPCs working in resource limited settings by providing trainees with fundamental clinical reasoning skills that take into take account the constraints of their work environment. To date, 72 health workers from 36 health facilities in Uganda have successfully completed the Core Course which can be adapted for use in other settings in Africa.