|
 
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| EDITORIAL |
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| Year : 2019 | Volume
: 5
| Issue : 1 | Page : 1-3 |
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Competency-based medical education in India: Are we ready?
Aneesh Basheer
Professor, Department of General Medicine; Vice Dean, Department of Medical Education, Pondicherry Institute of Medical Sciences, Puducherry, India
| Date of Web Publication | 19-Jun-2019 |
Correspondence Address:
Aneesh Basheer
Professor, Department of General Medicine; Vice Dean, Department of Medical Education, Pondicherry Institute of Medical Sciences, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_18_19
How to cite this article:
Basheer A. Competency-based medical education in India: Are we ready?. J Curr Res Sci Med 2019;5:1-3 |
An article on this topic would usually begin with a formal definition of three terms – competency, competence, and competent.[1] Although they all sound like grammatically related progeny borne out of a consanguineous relationship, in medical education, they have subtle distinctions.[2] Fortunately, for many who are not formally trained in medical education, the understanding of these differences may not preclude the comprehension of the contents of this article. Undergraduate medical curriculum has largely remained “traditional” since its inception thanks to its modeling on the ancient system of teaching and assessment prevalent in the United Kingdom, even though the latter and many other countries rapidly transformed their medical education frameworks to suit changing times and trends. Our system has relied heavily (and continues to rely) on didactic lecturing and unidirectional inflow of predominantly lower-order knowledge; consequently, assessment has been excessively centered on recall of factual information and relatively irrelevant concepts with no connection with the actual practice of medical profession. Readers would find this unamusing, given that all of us are quite familiar with the lacunae in the existing paradigm of Indian medical education. However, remedial measures were long wanting; therefore, the move by the top regulatory body to introduce curricular reforms after two decades of inertia is welcome.
Competency-based medical education (CBME) involves the attainment of observable abilities by students in a time-independent, learner-centered manner.[3] The emphasis is on outcomes that are relevant to the daily practice of medicine rather than facts.[4] The student gets opportunity to learn at his or her own pace, the ultimate aim being the successful attainment of competencies by all students irrespective of when they do that. Assessments are aligned to these competencies; therefore, the tools differ drastically from the traditional curriculum. While written assessment of cognitive components constitutes the bulk of traditional curricular assessment, competency-based curriculum strives to employ more of workplace-based assessments including direct observations and daily logs.[5],[6]
The Medical Council of India (superseded by the Board of Governors) released three volumes of the curricular framework for the proposed Competency-based Undergraduate Medical Education few months ago.[7] The major changes included the listing of several competencies that an Indian Medical Graduate should possess at the end of training and some new components such as the Foundation course, Electives, Integrated learning, and early clinical exposure.
The efforts taken to create and consolidate a document of this nature must be lauded, and many changes suggested are progressive and welcome. For example, the provision of a foundation course lasting 1 month after admission to medical school but before the formal start of classes is a positive step probably borne out of realization that unlike Western countries, Indian medical aspirants are relatively younger and naive and need noncurricular support at the time of medical school entry. They are a nonuniform mix of multiple backgrounds, languages, levels of understanding, and schooling. Their abilities to cope up with the harsh realities of medical training are disparate; lack of vocational training and sensitization during primary and secondary education makes them vulnerable to indecisiveness and meandering away from their goals. The proposed foundation course aims to orient the students to the medical course, its requirements, and how adult learning and self-directed learning differs from the way they have been learning at school and to provide support in the form of training in language, computer skills, stress management, and time management apart from an overview of professionalism and right attitudes.
Electives, another novel component of the competency-based curriculum, allow students to explore areas of their interest at the end of the 3rd year of the course. They have opportunity to work under a basic science faculty or clinical faculty of any discipline with a focus on research and subspecialty training. Such training will no doubt provide the students with a platter of potential avenues they might pursue in the future. Moreover, it might kindle hitherto unrecognized interests and skills of students in unconventional domains of medical profession.
Integration of teaching–learning breaking departmental silos is another important aspect of the newly proposed curriculum. While some form of vertical and horizontal integration has been in vogue for the past few years, it is now recommended that at least 80% of the topics be “temporally aligned,” a term signifying the exposure of students to similar topics by Anatomy, Physiology, and Biochemistry at the same time; this may have the advantage of avoiding redundancy in curriculum implementation and also saving time. As an example, a topic such as a cell would usually be dealt with by departments of Anatomy, Biochemistry, and Physiology utilizing different hours but with essentially similar content, except the core aspects such as structure, biochemical reactions, and the functions. In a temporally aligned curriculum, the whole topic could be allotted time with departments of Anatomy, Physiology, and Biochemistry pitching in with their contributions and avoiding repetition in three different lecture halls at three different times.
Early clinical exposure intends to provide students a feel of the hospital environment and patient interaction in the 1st year itself; this is expected to inculcate the foundations of communication, empathy, professionalism, and compassion in students. More importantly, it is likely to make basic science learning relevant and contextual. Retention of knowledge might be better with the direct understanding that it would be of potential use later in their life as a doctor. Although many medical schools have been practicing early clinical exposure in one form or other, the proposed curriculum aims to make it mandatory from the early stages of 1st year of the course; it could be in the form of a simple clinical scenario to start a preclinical lecture, bringing a patient to the practical laboratory or assigning students to clinical laboratories and wards before, midway through, or at the close of a basic science session.
As with any other revolutionary overhaul, the CBME curriculum has not been free from criticism. A major lacuna concerns disconnect between the curricular objectives, proposed teaching–learning methods, and assessment. While the curriculum stresses on outcomes relevant to practice of medicine and envisages interactive teaching–learning methods in the form of small group learning, problem-based learning, and case-based learning, it is silent on assessment as it was in the previous document on regulations on graduate medical education, 2012.[8] It leaves assessment to the discretion of individual universities and institutions. Medical educators would agree unanimously that assessment remains the most potent driver of learning; a misaligned assessment would ultimately leave the student confused.[9] Let us use the example of the cell here as well; teaching may be temporally aligned, and students might understand the concepts better. However, the assessment remains disciplined based, with the department of Anatomy testing specifically on the ultrastructure alone, Biochemistry asking questions only on the fluidity of cell membrane, and Physiology testing functions of the mitochondria. The wholesome concept gained by the student is not tested anywhere, and assessment becomes compartmentalized. Students, in the long run, realize that to pass the examination, they need to specifically memorize details relevant to individual disciplines. Ultimately, the learning becomes rote, fragmented, and short-term, defeating the principle and goal of CBME.
Another issue relates to the ambiguity regarding the role in internal assessment in the new curriculum. While suggesting that internal assessment scores (minimum of 35%) would only be a gatekeeper determining eligibility to appear in the final summative assessment, the document also mandates that the student shall not be declared pass without 50% in internal assessment. This essentially means that a student with 40% internal assessment score may be allowed to appear for examinations; however, he/she cannot be declared pass even if he/she scores well in the summative examination. Further, such a student could be considered pass if remedial measures are instituted and internal assessment scores improve before declaration of final results. This provision has far-reaching consequences. First, it is logistically difficult to institute such “remedial measures” at the fag end of a year and boost up the scores. Second, most medical colleges are affiliated to universities, and convincing academic councils and boards of studies to accept such changes may be cumbersome. Third, it is likely to pave way for corrupt practices in medical schools and universities since there is no clarity to what such “remedial measures” mean and how they should be carried out.
True competency-based systems allow students to progress from a novice to competent and expert at his or her pace. The time taken by a student to master a competency differs, and quite often, ascension to successive levels of the medical course requires that core competencies have been achieved and certified. However, the proposed competency-based curriculum does not have such a provision. While there is a list of certifiable competencies, it is not clear what happens to a student who fails to get certified in a competency. Does he/she get a chance to try again until he/she is certified before he/she appears for a particular phase examination?
The faculty positions in medical colleges have been shrinking thanks to the Medical Council of India's directive that restructured the minimum requirements of staff in various departments. A major feature of CBME is student-centered learning with stress on skills and higher-order cognition; these require interactive small group methods of learning. The current staffing in medical colleges needs a revamp to enable implementation of such activities.
Capacity building of faculty is another major issue that could slow down implementation of the new curriculum. Faculty development is a key determinant of successful curricular implementation as noted by many educationists.[10] The Council had been training thousands of medical teachers over the last few years through the basic course workshops and advance course in medical education; with the formulation of the new curriculum, the focus has shifted to curriculum implementation support program (CISP). Many of the guiding principles and learning strategies involved in CBME require a basic exposure to medical education training, including adult learning principles, framing objectives, aligning objectives and teaching–learning methods to assessments, and various assessment methods. Many medical colleges still have a substantial backlog of faculty awaiting such basic training. CISP training without bare minimum sensitization to fundamentals of medical education training may become a futile exercise. Moreover, completing CISP for all teaching faculty of the country before the proposed start of the new curriculum (August 2019) is a herculean task.
To sum up, there is no doubt that a competency-based curriculum with an emphasis on relevant outcomes and formative assessments is the need of the hour. The Academic cell and the Board of Governors have done an exemplary act by coming up with an exhaustive curriculum after two decades of standstill. Nonetheless, successful implementation would require addressing concerns of all stakeholders in a timely and evidence-based manner. Faculty development programs must continue so that capacity building is ensured to sustain the process of change. Let us hope that as it evolves Indian medical education becomes a true competency-based system churning out competent primary care physicians and compassionate human beings.
| References | |  |
| 1. | Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: A systematic review of published definitions. Med Teach 2010;32:631-7.  |
| 2. | McConnell EA. Competence vs. competency. Nurs Manage 2001;32:14. |
| 3. | Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: Theory to practice. Med Teach 2010;32:638-45. |
| 4. | Harden RM. Outcome-based education: The future is today. Med Teach 2007;29:625-9. |
| 5. | Boursicot K, Etheridge L, Setna Z, Sturrock A, Ker J, Smee S, et al. Performance in assessment: Consensus statement and recommendations from the Ottawa conference. Med Teach 2011;33:370-83. |
| 6. | Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach 2010;32:676-82. |
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| 9. | Humphrey-Murto S, Wood TJ, Ross S, Tavares W, Kvern B, Sidhu R, et al. Assessment pearls for competency-based medical education. J Grad Med Educ 2017;9:688-91. |
| 10. | Modi JN, Gupta P, Singh T. Competency-based medical education, entrustment and assessment. Indian Pediatr 2015;52:413-20. |
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