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Challenges for stakeholders in implementing the undergraduate competency-based medical education curriculum in India
Correspondence to KADAMBARI DHARANIPRAGADA; kadambari1909@gmail.com
[To cite: Batmanabane G, Basu D, Dharanipragada K. Challenges for stakeholders in implementing the undergraduate competency-based medical education curriculum in India. Natl Med J India. DOI: 10.25259/NMJI_1072_2024]
Abstract
Following the introduction of the competency-based medical education (CBME) curriculum for MBBS in India in 2019, several papers have been published on challenges and opportunities arising from its implementation. We review the key concerns raised in these publications and attempt to explain why they have occurred and to suggest a way forward.
INTRODUCTION
The National Medical Commission (NMC), the erstwhile Medical Council of India, introduced the competency-based medical education (CBME) curriculum for MBBS training in 2019.
The new curriculum was hailed as ‘the much-awaited dream of many educationalists across India.’1 It was believed that the competency-based model of curriculum would address the several issues plaguing medical education in India.2 The ‘traditional’ curriculum that was perceived to be subject-centred and time-based,3 overloaded with didactic teaching,4 and had a defective assessment system would now be replaced by a more student-centred curriculum, replacing didactic lectures with small group learning and focusing on formative assessment and skill acquisition.4
To support implementation, intensive faculty development programs were used to train teachers in teaching and assessment skills, and an additional module termed the curriculum implementation support program (CISP) was intended to familiarize teachers with the concept of CBME. Applicants were required to undergo the training to become eligible for being recruited as medical teachers.5 In addition, the draft regulations were displayed on the NMC website, inviting suggestions from stakeholders6 before the final curriculum document was published in August 2023.
A major change in the new CBME curriculum,7 compared with its earlier version from 1997,8 was the use of the term ‘competencies,’ which indicates the move from a process-based curricular model, which focused more on the organization of quality learning experiences, to an outcomes-based one with its emphasis on the product of the course.9
The change of curriculum was met with hope and optimism among teachers.10 However, within a few months of introducing the new curriculum, the challenges became obvious.1 Several authors have mentioned these challenges that the teachers and students faced.1,10–14
A full cycle of training is now nearing its completion; thus, it is a good time to retreat and look at how it has performed as a move intended to better medical education in India.
During MEDUCON 2023, a medical education conference held at the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, in October 2023, a session on the ‘Challenges in implementing the CBME curriculum’ was held. Many participants were openly critical of the curriculum. Two authors (GB and DK) also participated as resource persons in the training workshops for faculty on curriculum implementation, during which several teacher participants voiced concerns and difficulties. Considering these perceptions along with what has already been observed, we attempt to explain the possible reasons behind the challenges to the three major stakeholders when negotiating the change. We also suggest potential steps forward.
Challenges faced by students
Change in expected approach to learning from school to medical college. Generally, Indian school students are not taught to take charge of their own learning.7 A sudden change to ‘self-directed learning’15 could result in major stress to students who are not yet ready to take responsibility for their learning15 and are already grappling with multiple new subject disciplines to master in the first year.16
Insufficient curricular time for basic sciences. The curriculum includes a mandatory foundation course, which was held for a month in the first version of the curriculum. The duration was subsequently shortened to a week at the beginning of the first year and then to continue vertically throughout the MBBS program, amounting to 160 hours of curricular time. The elements of the course include an orientation to medicine as a profession, development of ‘soft skills’ such as time and stress management, communication and interpersonal relationships, and other skills, including basic life support and first aid. The feedback from students and faculty recorded by several authors on the month-long program17–19 has been mixed about the relative value of the various topics addressed, the duration of the foundation course, and its overall impact on learning medicine. The training in the English language, for example, was found useful by most students from states where school education is usually in the vernacular.19 A recent evaluation of the effectiveness of the 1-week program recorded positive feedback from students and improvement of post-test over pre-test assessment scores.20
Some of the time in the first year has been assigned for vertical integration with content from subsequent phases. This ignores the fact that clinical knowledge requires an ‘integration of conceptual knowledge (facts, ‘what’ information), strategic knowledge (‘how’ information), and conditional knowledge (‘why’ information).’21 The practice of clinical medicine, including decision-making, can only develop with a strong foundational knowledge of facts and the relationships among them.22 The importance of basic sciences cannot be denied, and there cannot be any shortcut here; sufficient time must be available for students to develop a firm grounding in basic science knowledge for them to progress in the course.
However, both the foundation course and the integrated teaching sessions have encroached on the already drastically reduced time allotted for the 1st and 2nd MBBS, posing a challenge for students to adequately comprehend the strengths of these subjects.
Too many assessments. The undergraduate medical curriculum includes several assessment points with a summative purpose. While emphasizing the need for formative assessments, the new curriculum has prescribed the maintenance of logbooks, project reports, portfolios and several other such tools.7 In addition to extensive time consumption, completion of these additional assessments is only to be considered for eligibility to appear for the summative examination and they do not count to a pass-fail decision. Therefore, they will most likely be given little value by students. In a survey of medical students’ perspectives on the new curriculum, only a third agreed to the statement ‘It is possible to maintain separate logbooks for each department’.16
Moreover, teachers, when overwhelmed with many students, do not have the time to give useful feedback on these assignments, thereby defeating the purpose of formative assessments. Emphasis on formative assessment is given in the CBME curriculum, so arranging frequent formative and internal assessments is another major challenge.23
Challenges faced by teachers
Constant stream of instructions from regulators.The major challenge for teachers is the continuous stream of instructions, some overruling previous statements.24 NMC’s recent decisions to reduce the pass percentage of undergraduate (UG) examinations24 and the pass percentile in the National Eligibility Entrance Test postgraduate (NEET-PG) to zero25 were certainly not in the best interests of improving standards. The former, besides giving two different options of pass marks for theory and practical examinations, has reduced the overall pass aggregate marks from 50% to 40%, while the latter could mean that it is sufficient for a student to attempt NEET to enter a postgraduate course.
Another addition mentions that it is mandatory to submit a video recording of examinations26 for renewal of permissions to the medical college, followed by a continuation of this order27 specifying the maximum duration of the said video. The revised CBME guidelines published online in August 2024 were withdrawn within a few days, causing further confusion.28
No room for teachers’ creativity and judgment. The document ‘prescribes’ rather than recommends the minimum teaching hours for each subject7 and how they need to be taught, leaving little flexibility to the colleges and teachers to find effective teaching and learning methods that suit their circumstances. For instance, with the number of medical seats steadily rising and medical colleges having 250 students or more, the required number of small group discussions, as mandated in the CBME curriculum for 250 students, would run into at least 20 to 25 at a time. A lot of time and manpower resources are required to plan and prepare for these discussions. This is difficult to do consistently in any well-staffed medical college and will pose a major logistical challenge in case of faculty shortages. Besides, reducing time for didactic teaching has met with a lot of resistance from students.16
Another area that is fraught with confusion is ‘integration’. The curriculum is replete with terms such as ‘temporal coordination’, ‘nesting’, ‘sharing’, ‘alignment’, ‘linkers’, and so on, which only create confusion for teachers and are again prescriptive without considering the associated challenges.
Although alignment and integration are ideal on paper, they are difficult to implement due to the different weightage and time allotments of various subjects.23 Lack of proper interdisciplinary coordination leads to difficulty in framing a timetable for integrated teaching sessions.23
Instead of giving the teachers the freedom to choose ways to integrate knowledge of various subject disciplines, the curriculum document gives explicit instructions on when, for what content, and how such integrated teaching must be practised.
Even the learning of ‘soft skills’ such as communication, empathy, teamwork, and so on, must be done through prescribed lessons listed in the attitude, ethics, and communication (AETCOM) module.29 In keeping with the outcomes-based curricula principles, these learning outcomes must also be assessed. Given the challenge of the reliability of assessing these outcomes in a single summative examination and the relatively little contribution of formative assessment to the pass-fail decision, obtaining a valid assessment of attitude becomes a challenge.
Multiple assessments are adding tremendously to the workload. Multiple assessments, including a range of formative assessment tools for so many students, add to the workload. This adds to the burden of teachers in the clinical departments who have to attend outpatient clinics, do their ward rounds, and perform surgeries in addition to clinical teaching.14 It must be emphasized here that, in addition to MBBS, medical teachers are also expected to teach other courses like nursing, physiotherapy, dental, and other allied sciences.
Challenges faced by administrators
Faculty shortage. The faculty shortage is acute in many subjects, and the future looks bleak.30 Teachers with medical degrees in many of the basic sciences are scarce, as are those in subjects like forensic medicine and radiology. With this looming crisis, the challenge for teachers and administrators to implement all required curricular processes, such as small group teaching, which is allotted a major proportion of curricular time across the three phases and formative assessment29 mandated by the new curriculum, is only going to increase.
Faculty shortage poses another challenge, that of difficulty in recruiting external examiners. This becomes additionally difficult when examiners drop out at the eleventh hour and replacements are hard to recruit.31
It remains to be seen if the suggested national exit examination (NeXT) will address the issue of the quality of the output from the MBBS course across the country.32,33 This proposed plan is not laid out with clarity, and important subjects such as preventive and social medicine have been excluded in NeXT step 2.34
Lack of infrastructure for required training in certain skills. The CBME expects students to observe 20 autopsies and mandates that each forensic medicine department has the equipment to do that. Yet, many states do not permit medico-legal autopsies to be performed in private medical colleges. Hence, students attend these sessions in government medical colleges for which a fee is levied.
The Family Adoption Programme (FAP) is another initiative missing its purpose, although this has not been formally documented. Students often report that many families adopted by them in nearby locations are neither welcoming nor interested. The logistics involved in this exercise are not matched by the achievement of the expected learning outcomes, and we must think of an alternate way.
To engage the students in all these activities, resources are required. Hence, there may be certain hurdles in setting up an appropriate infrastructure for its implementation.23
Difficulty in balancing training and healthcare standards. Many hospitals are looking to get accredited with the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for purposes of insurance and quality. The standards of infection control are rather strict in the operating theatres (OTs), intensive care units (ICUs), and other critical patient care areas. It is impossible from the point of view of infection control to permit students and interns in the expected numbers to enter the OTs or ICUs for direct observation.
Balancing regulatory requirements for bed occupancy and increasing preference for daycare by patients. The patient footfall in private medical colleges is low when compared with government medical colleges. In specialties like otorhinolaryngology and ophthalmology, most of the surgery is done as a daycare procedure. Filling beds as per regulatory requirements is nearly impossible. The number of normal vaginal deliveries in private medical colleges is not adequate to train all students and residents. Expecting and insisting that these numbers must improve is not realistic.
DISCUSSION
The challenges listed by us have been documented by several authors.1,10–14 What we think is needed is a more critical look into two important questions: (i) why are these challenges being experienced by the different stakeholders and (ii) why are they persisting despite so many voices raised about them?
Reviewing several publications on the topic and our own perceptions as teachers and administrators, what seems to be the obvious answer to the first question is the complete lack of coherence and clarity in the new curriculum on paper. The first and foremost reason for this is the absence of a clear rationale for the change. It has been created not so much to address the shortcomings of what was being followed before, but more to fall in line with ‘global standards’ of curricular practices. There was never any formal evaluation of the previous curriculum to identify what needed to be changed or improved. When we import curricula from an external source, we risk ignoring the local social, cultural, political, and professional contexts.35 What we try to do is fit the educational policy and practices of a different context into ours, creating the listed difficulties.
Second, competencies as determinants of curricular design have been borrowed from vocational education and training.36 The competence-based education concept was developed as a response to a perceived need for a more skilled workforce to maintain a country’s competitiveness in the international marketplace.37
A national vocational qualification (NVQ) was thus defined as:
“…a statement of competence clearly relevant to work and intended to facilitate entry into, or progression in, employment and further learning, issued to an individual by a recognized awarding body.”
and that
“The statement of competence should incorporate specified standards in: — the ability to perform in a range of work-related activities and — the underpinning skills, knowledge, and understanding required for performance in employment.”36
It is clear from the above definition that this design is inappropriate for the medical curriculum. Dissecting the medical curriculum into such statements of competence is an erroneous attempt to simplify the complex set of capabilities that characterize a medical professional38 and to ignore the fact that true competence can only be acquired through independent practice and experience. Moreover, the definition of a competent professional is ever-changing advancements and evolution.36 Therefore, competence is not a static attribute and reducing it to a set of statements, however detailed and descriptive, would ignore the broader and loftier aims of the medical profession.36
Another reason for the lack of clarity for the stakeholders is the imposition of prescriptive pedagogical practices, which are not backed by evidence of their effectiveness and feasibility in our setting, e.g. summative objective structured clinical examination (OSCEs). The proper conduct of this incurs a tremendous cost in terms of manpower and logistics. Compromising on the quality of the assessment by including a few stations that are response stations and therefore unobserved would do considerable harm to the validity of the assessment.
The overly detailed curriculum on paper, which runs into three volumes and lists more than 2000 competencies,39–41 is a bid to satisfy the requirement of accountability. It leaves little room for teacher judgment and flexibility in imparting the curriculum, which has the potential to stifle their interest and involvement in the task of teaching. It de-professionalizes the teachers.
Despite the many publications and stakeholders detailing the challenges, there has been no move to address the issues. Instead, the slew of papers expressing genuine concerns of teachers and students has been labelled as a ‘resistance to change’2 and the suggestion has been to train the teachers further to implement the new curriculum,42,43 ignoring the root problem of a basic lack of clarity and coherence within the curriculum.
What, then, is the way forward?
The curriculum must include a clear vision of the expected outcome of the MBBS program, a plan for strategies to achieve it, involving teachers and other stakeholders at every step, and a robust investigation to determine if the desired outcome has been achieved. In our review of the situation, the road map for the curriculum is not clear, and this needs to be addressed urgently.
We believe that an outcomes-focused curriculum is not completely appropriate for medical education for the reasons discussed above and is the main cause for the present situation of confusion and lack of certainty. It is noteworthy that the older process-based model listed many of the elements that have been included in the current CBME curriculum. These include recommendations to keep didactic teaching to a minimum and provide more time for hands-on experiences in different settings, have a system of continuous assessment to document progress of the learner, follow the principles of integrating knowledge across the subject disciplines, and a list of important skills to be acquired by the end of MBBS.8
Some strategies we suggest to guide us in the right direction in solving this conundrum are:
We need a contextually relevant curriculum and a training programme that matches our setting, in terms of resources, our cultural and societal backgrounds, and our healthcare practice requirements. This is best done in consultation with stakeholders so that they take ownership of the curriculum,44 which will regulate the process of implementation.
Rather than prescribing what needs to be done, and where and how it needs to be done, the curriculum should, while clearly describing the desired outcome of the educational process, allow the teacher the flexibility and freedom to be creative in their approach to reach that goal. So, teachers must be involved in developing and enacting the curriculum, giving them the opportunity to exercise their judgment to suggest solutions to problems that they know best.
We need to avoid imported pedagogical practices that have no evidence and instead develop robust systems of teaching and learning and assessment that have been shown to work well in our context. For example, small group teaching has been the norm in bedside clinics and in the laboratory even earlier. Instead of ensuring a defined structure for the learning session, we need to check how to maintain its value when dealing with increasingly larger class sizes, changing patient profiles, and care patterns, and to match them to the changing learning approaches of today’s students.
Finally, the curriculum which is an ideological statement45 reflecting the worldview of the designers and the profession, has to be dynamic and adaptive. This would entail a continuous process of evaluation of its outcomes reforming it as and when required.
Conclusion
A curriculum is an ideological statement and therefore, drafting needs careful attention to the important contextual influences that determine its value and effectiveness. We have reviewed papers that have raised important concerns in implementing the CBME curriculum in undergraduate medical education in India. The right step would be to examine these concerns seriously and manage them with appropriate measures, which could include incorporating the principles of process-based curriculum design.
ACKNOWLEDGEMENTS
We express our sincere thanks to Professor Janet Grant for her critical comments on the first and final drafts of the paper.
Conflicts of interest
None declared
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