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| COMMISSIONED ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 91-97 |
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An insight into competency-based undergraduate curriculum and its application in Ophthalmology
Nitin Nema1, Romi Srivastava2, Sukhwant Bose1
1 NMC Regional Centre of MET, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
2 Index Medical College and Research Center, Indore, Madhya Pradesh, India
| Date of Submission | 13-Jan-2022 |
| Date of Decision | 21-Feb-2022 |
| Date of Acceptance | 24-Mar-2022 |
| Date of Web Publication | 18-Jul-2022 |
Correspondence Address:
Nitin Nema
NMC Regional Centre of MET, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcor.jcor_7_22
The revised undergraduate (UG) medical curriculum envisages the Indian Medical Graduate (IMG) to assist the nation in achieving its goal of “health for all.” It adopts learner-centered and outcome-oriented approach to train an IMG who can effectively cater to the needs of the society. It emphasizes on the development of competencies and prepares the learner to work in real life situations. Hence, there is the shift in focus from “must know” to “must do.” Apart from being a competent clinician, the graduate has to function in the roles of effective communicator, leader, life-long learner, and professional. For acquisition of the competencies, some key components have been added in competency-based medical education. Each subject expert has to make sure to teach and assess the subject-wise skills as well as these competencies. This enables the UG students to acquire knowledge, skills, ethics, values, and attitude to work as competent and skillful health-care professionals.
Keywords: Competency-based medical education, competency, conventional curriculum, skills, teaching-learning methods
How to cite this article:
Nema N, Srivastava R, Bose S. An insight into competency-based undergraduate curriculum and its application in Ophthalmology. J Clin Ophthalmol Res 2022;10:91-7 |
How to cite this URL:
Nema N, Srivastava R, Bose S. An insight into competency-based undergraduate curriculum and its application in Ophthalmology. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Mar 24];10:91-7. Available from: https://www.jcor.in/text.asp?2022/10/2/91/351297 |
Competency-based medical education (CBME) has generated a huge amount of interest in medical educators worldwide as well as in India.[1] Past few years have witnessed many medical schools adopting competency framework as the basis of training.[2],[3],[4] It is a harsh truth that the traditional medical education system did not ensure skill development in students eroding trust between patient and doctor and denting patient-physician relationship.[5] To address this challenge, National Medical Commission (NMC, erstwhile Medical Council of India, MCI) decided to introduce CBME in all medical colleges across the country from the year 2019.[6] The much awaited reform replaced the more than two decades old traditional curriculum by CBME driven curriculum. The purpose of this article is to give the readers an overview of CBME curriculum excerpted mainly from the Graduate Medical Education Regulation, Amendment 2019.[7] Furthermore, this year the 2019 admitted batch of undergraduate (UG) students will enter Phase III part-1 with Ophthalmology as one of the subjects. All teachers of medical fraternity and especially those belonging to this discipline, working in various medical colleges, should, therefore, be aware of the new elements of CBME curriculum for the proper implementation.
| Definition | |  |
CBME is defined as an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.[1]
| Methods | | |
We conducted the search to review the existing literature on competency-based medical education. All relevant literature cited on PubMed and Google Scholar in the English language was reviewed with the keywords “Competency-based medical education,” “Competency-based education in Ophthalmology,” “Outcome-based medical education,” and “Learner-centered medical education in Ophthalmology.” The purpose, advantages, implementation strategies, challenges, and limitations of CBME for undergraduate students were identified and critically evaluated.
| Competency-based medical education | | |
CBME is an outcome-oriented approach which is learner centric wherein students take responsibility for acquisition of competency.[1] It promises greater flexibility and accountability that make leaners identify their learning needs.[8] It lays emphasis on attainment of competencies, self-directed learning (where students take charge of one's own learning), reflection, and active learning.[9]
The conventional curriculum, on the other hand, was subject-centered and time-based [Table 1]. The teaching-learning activities and the assessment methods focused more on knowledge rather than on attitude and skills. Therefore, graduates used to have extraordinary knowledge, but lacked basic clinical skills required in practice. Moreover, they were also deficient in soft skills, communication skills, doctor − patient relationship, ethics, and professionalism.[11] | Table 1: Salient differences between traditional and competency-based curriculum^
Click here to view |
Competency is defined as the ability to do something successfully and efficiently, and CBME is an approach to ensure that the graduates develop the competencies required to fulfill the patient's needs.[12] CBME curriculum focuses on the desired and observable ability of learners in the real-life situations. Furthermore, it helps Bachelor of Medicine and Bachelor of Surgery (MBBS) students attain the goal of medical education.
The UG medical education program is designed with a goal to create an “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values, and responsiveness, so that he or she may function appropriately and effectively as a doctor of first contact of the community while being globally relevant.[7] The goal of MBBS training program can be fulfilled if the medical graduate is able to function in the following roles appropriately and effectively:
- Clinician who understands and provides preventive, promotive, curative, palliative, and holistic care with compassion
- Leader and member of the health care team and system with capabilities to collect analyze, synthesize, and communicate health data appropriately
- Communicator with patients, families, colleagues, and community
- Lifelong learner committed to continuous improvement of skills and knowledge
- Professional, who is committed to excellence, is ethical, responsive, and accountable to patients, community, and profession.
The training during the MBBS course should be in alignment with the goals and competencies in CBME curriculum and, therefore, following changes were made in the traditional curriculum:
| Foundation course | | |
In India, the criteria of selection of students in medical colleges do not take into consideration their nonscholastic abilities. They, therefore, need to adapt to the challenging atmosphere of medical colleges.[13] To overcome this challenge, a methodically planned foundation course is introduced in MBBS curriculum for the freshers. A coordinator appointed by the Dean will organize the course that has to be supervised by the heads of preclinical departments. The faculty members of other departments including Ophthalmology have to accept the roles and responsibilities assigned to them by the course coordinator.
The prime goal of foundation course is to prepare the student to study medicine effectively. It is a 1-month duration program just after admission in a medical college. It will equip the students with required knowledge and skills that assist them to get acclimatized to the new professional environment. Moreover, it will give the learner a strong platform for life-long career in medical profession.
The main objectives of foundation course are to: (i) orient students to MBBS program, medical profession and explain them the role of physician in society, (ii) equip with basic important skills required for patient care such as language, communication, computer and learning skills, and (iii) provide an opportunity for peer and faculty interactions and an overall sensitization to various learning methodologies.[14] Sports and extracurricular activities are also planned during this period. One parent-teacher meeting will be held during this month long course. Time dedicated for foundation course cannot be used for any curricular activity. The students must have at least 75% attendance in the foundation course which will be certified by Dean of the college.
| Early clinical exposure | | |
Early clinical exposure (ECE) is a teaching-learning methodology which fosters exposure of medical students to patients as early as the 1st year of medical college via classroom, hospital, or community settings. The objective of ECE is to enable the first professional medical students recognize the relevance of basic science subjects in context to diagnosis and treatment of disease and patient care. It generates interest in the learner and dispels monotony.[15] Furthermore, the students learn professional behavior, ethics, communication skills, and correct attitude needed for appropriate doctor − patient relationship. It will help the student correlate basic science with clinical science and understand socioeconomic and cultural factors involved in delivery of health care through the study of humanities and social sciences. ECE is a form of vertical integration between preclinical subjects and clinical subjects that helps to develop professional behavior in students.
| Attitude, ethics, and communication skills | | |
In recent times, there has been immense dissatisfaction in society with doctor's attitude and behavior. It is mainly due to lack of professionalism and empathy of the treating doctor toward the patient and relatives. Professional development program, hence, has been introduced in the new curriculum. It is a new teaching-learning element which includes attitude, ethics, and communication (AETCOM) module developed by the Medical Council of India. It is a longitudinal program that begins during the foundation course (1st Professional) and runs through Internship. Herein, soft skills, behavior, communication, respect to the cadaver, and ethics will be taught in the classroom just like teaching other subjects.[16]
Communication skills cannot be taught by didactic lectures in Ophthalmology too like in other subjects.[17] To hone these skills in UG students, the teacher must utilize different teaching-learning methods like role play by students and video-assisted learning.[18],[19] Bhagat et al. and Mishra et al. reported that communication skills training is essential in Ophthalmology to improve doctor − patient relationship and clinical competence in students though their studies involved the postgraduate students.[20],[21]
A minimum of 75% attendance is required in AETCOM teaching to appear for final examination of each professional year. AETCOM module will be taught explicitly and assessed mainly in internal assessment; however, at least one question pertaining to the cognitive domain of AETCOM will be asked in each paper of clinical specialties in the University examination whereas skill competencies of AETCOM are tested during the clinical, practical, and viva voce.
| Alignment and integration | | |
Alignment is defined as the grouping together of related topics (under an organ system or a disease) in subjects of same phase at the same time in the time table. It allows similar topics in different subjects to be taught separately but during the same time frame.
Integration is the organization of concepts in a topic or an organ system that are similar or redundant in a single teaching session. It interrelates or unifies the subjects and discards discipline-based demarcation. Integration can be either horizontal (subjects in same phase are taught together) or vertical (subjects from across phases come together) and practiced for the purpose of introduction or reinforcement of a topic. It makes the teaching-learning more interesting and meaningful.[22]
In traditional curriculum, subjects were taught in isolation (silo teaching) without much effort to integrate the preclinical/paraclinical subjects with the clinical subjects. Integration, thus, bridges the gap. It makes the learning contextual and relevant to the students. Subject-based teaching although gives a broad and deep knowledge of discipline, but interconnectedness between subjects and application of knowledge is provided by integration ensuring deep learning. Learning theory of “constructivism” states that medical students need to understand the concepts in basic sciences and make connections with their applicability in clinical sciences.[23] Integrated teaching decompartmentalizes the disciplines facilitating a holistic approach to the problem as well as removing both fragmented learning and repetitions.
In Ophthalmology, 13 competencies have been suggested to be integrated with other subjects. Volume 3 of UG curriculum (available on NMC website) comprises surgical disciplines including Ophthalmology (page 78–87) and the last two pages contain integrated topics.
| Teaching methodology | | |
The average attention span of students during a lecture class is around 20 min following which it rapidly declines. Interactive lectures have been suggested to heighten attention and promote learning. Interactive teaching actively engages students, encourages them to take responsibility for their own learning and makes the classroom environment lively.[24] In the revised curriculum, lectures are more or less replaced with interactive teaching-learning methods.[25]
Didactic lectures shall not exceed one third of the schedule while rest of the time is devoted to interactive sessions, hands-on training and problem-based discussions. The role of teacher, therefore, in CBME curriculum has shifted from “sage on the stage” to “guide by the side.” In Ophthalmology, the allotted 100 teaching hours are split into didactic lectures (30 h), tutorials, small group discussions, student-led seminars, symposia and integrated teaching (60 h) and remaining 10 h for self-directed learning. However, the choice of teaching-learning method will be of the teacher and should be aligned with the topic to be taught.
| Student-doctor program | | |
Student-doctor method of clinical training or clinical clerkship is designed to provide immersive learning experience to medical students by allowing them to take care of patients in a supervised environment.[7] No learner is given an independent charge of the patient. The goals of learner-doctor program are to provide MBBS students clinical exposure with longitudinal patient care, working as a part of health care team and hands on care of patients in inpatient and outpatient settings. Department of Ophthalmology is excluded from this program and presently only major departments like Medicine, Obstetrics and Gynecology, Pediatrics and Orthopedics are included. The students are supposed to maintain a logbook and document the case record. Submission of logbook to the department is required for eligibility to appear in the final examination of the subject. The clinical clerkship will commence right in the first professional year and continue till Phase III part 2.
| Electives | | |
Electives contribute to both professional development and personal development of medical students in specific areas of interest outside the standard curriculum.[26] It will help learners gain exposure and pursue their individual academic interests.[27] The objectives of electives in CBME curriculum are to provide diverse learning experiences and to do research or community projects in order to stimulate lateral thinking.
Two elective blocks of 1 month each are offered to the students of their personal interests after the completion of MBBS Phase III part 1 examination and before the commencement of Phase III part 2. Block 1 has to be completed in a preselected preclinical or paraclinical science while Block 2 shall be done in a clinical department.
The elective choices are made available to the learners in the beginning of III Professional part 1 and each institution has to develop its own mechanism for allocation of electives. Students can be offered electives depending upon the available resources and enthusiasm of teachers. It is preferable to select topics that are different from the competencies mentioned in Ophthalmology (in the curriculum) to generate interest in the learners. Some suggested elective topics in Ophthalmology include working as a member of eye screening camp team (where UG students can develop communication, counselling, teamwork and leadership skills), assessment of visual field changes in neurological disorders (enhances interpretational skills), ocular findings in road traffic accident patient, etc. Furthermore, elective can also be a part of ongoing project in the department. Minimum 75% attendance and submission of logbook maintained during electives are mandatory for eligibility to appear in final MBBS examination.
| Skill training | | |
Teaching clinical and practical skills to UG medical students is not only essential to cope up with changing educational trends (CBME curriculum) but also to reduce adverse events during practice.[28] Skill is defined as ability to perform a specialized task with defined expertise and usually denotes procedural skills; however, it also includes clinical reasoning skills, decision making, team work and communication skills.
Some procedural skills are specified in the curriculum for which certification is desirable for MBBS students. In Ophthalmology, extraocular movement examination (uniocular and binocular) is one such skill. The skill can be acquired and assessed in real patients or, preferably, in skill lab. “Skill lab” is an abbreviation for skill laboratory that refers to specifically equipped rooms functioning as training facilities in a fault-forgiving environment for the practice of clinical skills prior to their real life application.[29] It is compulsory for every medical college in India to have a basic skill lab for training, practice and proper acquisition and certification of skills. Students must maintain the logbook of skill-based training.
| Assessment and feedback | | |
Assessment is the backbone of CBME curriculum, so it has to be robust and multifaceted. The purpose of assessment is to drive learning and, hence, considered indispensable to the learning practice.[30],[31],[32] It provides information to improve instruction (formative assessment) and to measure achievement of students (summative assessment).[33] The formative assessment improves academic excellence.[34] It also has the potential to provide feedback and give direction for further development.
Regular periodic examinations shall be conducted throughout the course in the new curriculum. Student's performance has to be assessed on day-to-day basis. There has to be no <2 internal assessments in Ophthalmology, the marks of which will contribute to final assessment. Learners securing 50 or more (out of 100) marks (combined in theory and clinical and not <40 marks in theory and clinical separately) in internal are considered eligible for appearing for University examination. It is mandatory to complete the required certifiable competencies for that phase of training and the logbook before sitting in University examination of that subject. Moreover, the students who have minimum 75% attendance in theory and 80% in practical/clinical are allowed to appear for the final examination.
The University examination theory question paper will include multiple choice questions (not more than 20% of total theory marks), structured essay questions and short answer questions with marks for each part indicated separately. In Ophthalmology the theory paper and clinical examination will be of 100 marks each. A student who secures 50% marks separately in theory and clinical (including viva voce) will be declared pass. According to the CBME curriculum, supplementary examination for those who fail shall not be conducted later than 90 days from the date of declaration of the result of main examination. A student who passes the supplementary examination joins the main batch for progression and the one who can't would appear in the examination with the junior batch.
A rider has been added on the total number of attempts for the completion of MBBS course. No more than 4 attempts are allowed for a candidate to pass the first professional and the total period for its successful completion should not exceed 4 years. A learner shall not be entitled to graduate after 10 years of joining the MBBS course.
| Logbook and portfolio | | |
Logbook is a verified written record of clinical and academic activities documenting learning experiences pertaining to knowledge, skills and AETCOM competencies. Portfolio is a longitudinal description of learning journey. It includes both the learning experience and learner's reflection. The critical self-reflection component forms the heart of portfolio and differentiates it from the logbook. Therefore, portfolio is the evidence of course and process of learning and can be used effectively as an assessment tool. In addition, it promotes reflective practices and by looking at the portfolio of a student, the teacher can assess the needs of the trainee and can provide the required help.[35] Logbook forms the integral component of formative assessment and maintaining subject wise or phase wise logbooks is compulsory in CBME curriculum for keeping track of student's progress. A separate logbook is mandatory in Ophthalmology to mentor and monitor the learning of UG students. Clinical ophthalmology and AETCOM skills must be documented in the logbook besides activities like group discussion, seminars, self-directed learning, etc.
| Internship | | |
Internship is a phase of training wherein a graduate acquires skills and competencies for independent practice. Interns will be entrusted with clinical responsibility under direct supervision of faculty with a goal to fulfill their role as doctors of first contact in the community. They should not work independently. They will have 15 days posting in Ophthalmology with the aim to gain knowledge and skills to enable them to diagnose and treat common ophthalmological conditions. During this period, the interns will either perform, observe or assist in visual acuity testing, instillation of eye drops, bandaging of eye, ocular irrigation, epilation, digital tonometry and fundus examination by indirect ophthalmoscopy. The objective of 12-month rotating internship program is to train the medical graduate possess all competencies (namely clinician, leader, communicator, lifelong learner and professional) required of an IMG (”five-star doctor”).
Implementation of CBME curriculum
Members of Academic committee and Academic cell of NMC have meticulously designed the CBME curriculum. They have also minutely planned the strategy for its implementation. In the new curriculum, the total duration of MBBS course remains 4 ½ years, divided in 3 phases, followed by 1 year of rotating internship [Figure 1]. Each academic year will have at least 240 teaching days of minimum 8 h. The 3 phases (preclinical, paraclinical and clinical) have same subjects with slight modification. The time duration of forensic medicine is increased and the students will write its examination with Phase III part 1 subjects. Moreover, AETCOM is a new introduction that will be taught longitudinally right from the beginning i.e., foundation course to phase III part 2. | Figure 1: Time distribution and examination schedule of competency-based medical education curriculum
Click here to view |
The stakeholders have framed subject wise competencies to be taught in the MBBS course and suggested their methods of teaching, integration and assessment (available on NMC website).[6] These competencies are attained gradually and longitudinally across the phases (milestones i.e., gradual acquisition of competency). AETCOM module, self-directed learning and slot for internal assessment are embedded in the time-table of teaching program of each discipline and each phase. Ideal implementation strategy includes alignment of competencies, teaching-learning methods and assessment methods.[36]
John Dewey wrote “if we teach today's students as we taught yesterday's, we rob them of tomorrow.”[37] Faculty development program is, therefore, a prerequisite for successful implementation of CBME curriculum.[38] As a part of capacity building all qualified medical teachers must undergo training in revised Basic Course Workshop in Medical Education Technologies (MET) either at Nodal/Regional Centers of MET or in Medical Education Unit of their college. Proper implementation of curriculum is the joint responsibility of Dean, Heads of Departments and Faculty members while Curriculum Committee is the overall in-charge of curricular delivery. Alignment and Integration team will coordinate with different departments for effective conduction of integrated teaching sessions.
Limitations and pitfalls of competency-based medical education curriculum
Change is the unchangeable law of nature and resistance to change is natural. So, the new CBME curriculum is also witnessing resistance in implementation from the stakeholders– the college administration, the faculty and the students.[39] There is lack of faculty preparedness and willingness to implement the new curriculum. Students' readiness and management's support are also missing. The popular quote of medical educationist George E. Miller ”Assessment drives learning” is well accepted and established by many researchers.[32],[40],[41] However, assessment in CBME does not guide a learner towards competence in real life situations as reported by Brightwell and Grant.[42] Moreover students may find the new curriculum too demanding, and flexibility in course completion and de-emphasis on time-based training can lead to procrastination in them.[11] Lastly, the CBME curriculum is more resource-intensive and expensive as compared to the conventional curriculum. Hence, intentions with which the new UG curriculum has been rolled out should not be misunderstood for results. Only time and effective program evaluation will show whether or not competency-based education successfully leads to competency-based practice.
| Conclusion | | |
There can be few operational and logistics challenges but the CBME curriculum looks highly promising. It assures to create objective outcomes and set standards in medical education which will improve skills and accountability in the learner. It guarantees to impart flawless ophthalmic training to UG students that is bound to bridge the gap between the eye health needs of the society and eye services rendered.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1]
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