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Leadership and lifelong learning competencies in Indian medical students under the competency-based medical education (CBME) curriculum
Correspondence to HIMANSHU JINDAL;jindalhimanshu.1990@gmail.com, dochimanshujindal@gmail.com
[To cite: Singh S, Jindal H, Kanawjia P. Leadership and lifelong learning competencies in Indian medical students under the competency-based medical education (CBME) curriculum. Natl Med J India. DOI: 10.25259/NMJI_1169_2024]
Abstract
Background
The competency-based medical education (CBME) curriculum for Indian medical graduates, introduced by the National Medical Commission in 2019, emphasizes leadership and lifelong learning as key competencies for medical students. We examined the evolution of these competencies among medical students under the CBME curriculum in an urban medical school in India.
Methods
Our prospective study involved 261 MBBS students. Participants were selected using a non-probability sampling method. Data were collected using a multiple-choice, closed-ended questionnaire validated by subject experts at two time points, 2 months apart.
Results
Our study revealed significant changes in students’ perceptions of lifelong learning and leadership over 2 months. Lifelong learning scores showed a marked decline with mean (standard deviation) pre-scores of 18.21 (2.63) to 15.21 (3.12) (p < 0.0001). Leadership scores also showed a slight but statistically significant reduction from 7.49 (1.42) to 7.22 (1.39), (p = 0.039). Additionally, familiarity with the CBME curriculum increased from 44% to 56.1% over 2 months.
Conclusion
The CBME curriculum has a mixed impact on the development of leadership and lifelong learning competencies among medical students. While familiarity with the curriculum increased, there was a decline in self-perceived lifelong learning and leadership qualities. These findings highlight the need for targeted interventions to strengthen these competencies.
INTRODUCTION
The competency-based medical education (CBME) curriculum for Indian medical graduates (IMGs) was implemented across all medical colleges in India from the academic year 2019. There are 5 goals—clinician, communicator, leader, team member, professional, and lifelong learner, designed by the national medical commission (NMC) to label a student as an IMG.1 The leader and lifelong learner goals have been framed, considering that a lifelong learner can be a great leader, and that only a leader can encourage lifelong learning.2,3
In India, both traits are a must for doctors, aiding in good governance, recognition, functioning, efficiency, responsibility, and appropriateness as a health team leader in primary and secondary healthcare settings. A leader’s ability to educate and motivate others can help maximize the team’s delivery potential. Leadership also helps shift the learner’s fixed mindset to a growth mindset, while lifelong learning nurtures creativity and broadens the individual’s perspectives on the world.4
The introduction of new study techniques like self-directed learning (SDL) and small group discussions are tools to develop good leadership qualities.5 It helps doctors in future administrative tasks to enhance the quality of healthcare services for patients, highlighting the importance of implanting the seeds of leadership from the undergraduate level.6 Their commitment to continuous improvement of skills, knowledge, and the ability to search, introspect, analyze, and apply would be an essential add-on to the former trait. The two goals are intertwined, emphasizing the need to study their impact collectively, apart from their progressive understanding as two independent variables over the passing academic years.
Our study focuses on building an understanding of lifelong learning vis-à-vis leadership attributes to optimize the learning process in students to achieve the respective IMG goals.
METHODS
Our prospective study was conducted to develop and evaluate the CBME curriculum. It was conducted at a medical school in an urban district of India. It involved first (the newly inducted batch) and second year (the batch that had just passed the first professional examination) MBBS students. Participants were selected using a non-probability sampling method. The study was conducted over 2 months. Ethical approval for the study was obtained from the Institutional Ethics Committee of the medical college (Reference No. EC/BMHR/2023/54).
Data collection procedures
Study tool. A multiple-choice, closed-ended questionnaire in English, based on an extensive review of the literature and validated by 3 subject experts from the institution, was used to measure leadership and lifelong learning qualities (Supplementary file).
Data collection and processing. Standard scaling methods were used to score parameters such as persistence, determination, communication, confidence for leadership, self-learning, and self-determination for lifelong learning. A Google form containing the questionnaire was administered to all participants. Initially, the questionnaire assessed students’ motivation levels and prior skills in leadership and lifelong learning. After 2 months, the questionnaire was re-administered to access changes brought by the new curriculum; only data from students who submitted both forms were considered for analysis. After excluding non-contributory data, 261 responses were included in the final analysis.
Collected data were used to assess the appropriateness, sufficiency, and gaps of the new curriculum in achieving the 2 goals. The structured questionnaire included 4 parts: demographic data, students’ perceptions and attitudes towards the curriculum, self-assessment of clinical and theoretical skills, and feedback on various aspects of the curriculum. Responses were measured on a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree.’
Written informed consent was obtained from all participants, with information about the study’s nature and the confidentiality of their responses.
Initially, the study aimed to analyse the competencies of first- and second-year MBBS students separately, as well as cumulatively. However, due to a much lower response rate from the latter (37 responses) compared to the former (224 responses), it was decided to combine the data from both cohorts for a cumulative analysis.
Statistical analysis. Data entry and tabulation were done using Microsoft Excel (version 2021). Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) software (version 26). Data were summarized as mean, standard deviation (SD), and frequency. The paired t-test was used to analyse the mean difference between two sets of observations for the same subjects separated by a 2-month interval. The Spearman rank correlation coefficient was used to assess the correlation between variables.
RESULTS
There were significant changes over 2 months in the students’ perceptions of lifelong learning and leadership (for detailed results, refer to Supplementary file). There was a marked decline in lifelong learning scores, with mean (SD) pre-scores of 18.21 (2.63) dropping to 15.21 (3.12) (p<0.0001). In terms of leadership also, there was a statistically significant reduction in scores 7.49 (1.42) to 7.22 (1.39) (p=0.039).
Familiarity with CBME. The high familiarity score (4+5 compounded) increased from 44% to 56.1% over 2 months, indicating significantly enhanced confidence among participants who rated their understanding of the CBME curriculum as 4 or higher out of 5.
Feasibility of IMG goals. Initially, 70.9% of students deemed all 5 goals as equally important. However, 2 months later, 12.9% of those students differed in their opinion, with a major shift to the clinician’s goal (Fig. 1).
- Feasibility of Indian medical graduate goals
Lifelong learning attributes
Preferred learning methods. Learning through group discussion showed 15.0% improvement. Collective learning techniques, such as practical hands-on experience and group discussions, gained favour over solitary methods, with student engagement in these techniques increasing from 76.6% to 85% over 2 months. Preference for online courses and reading medical journals remained consistently low and unchanged (Fig. 2).
- Preferred learning methods
Motivation to continue learning. Instantly gratifying gains such as ‘career growth,’ ‘building professional networks,’ and ‘personal satisfaction’ were the primary drivers of motivation for continuous learning, initially selected by 61.2% of students, increasing to 67.3%. Conversely, distant and abstract gains like ‘gaining new knowledge’ and ‘making a positive impact’ decreased over 2 months, reducing from 38.8% to 32.7%.
Activities for lifelong learning. Cooperative learning techniques, such as discussing medical cases with peers and teaching and sharing information with others, gained preference, increasing from 72.7% to 82% over solitary learning techniques in two months (Fig. 3).
- Activities for lifelong learning
Challenges in lifelong learning. Time management remained a challenge for lifelong learning among most students, with only a 5% decrease even after a 2-month learning period. Additionally, the percentages for ‘difficulty in finding motivation’ and ‘personal commitments’ nearly doubled compared to their initial levels after 2 months (Fig. 4).
- Challenges in lifelong learning
Motivation for and effectiveness of SDL. The high motivation score for SDL (4 and 5 compounded together) decreased from 61.8% to 39.1%. Initially, 68.2% of individuals rated SDL as very effective or extremely effective, indicating a rating of 4 or 5 on the Likert scale. However, after 2 months, the perception shifted, with only 31.1% rating SDL as very effective or extremely effective (4 or 5 on the Likert scale) (Fig. 5).
- Motivation for and effectiveness of self-directed learning
Introspection and self-assessment. Initially, 68.1% of students reported engaging in introspection and self-assessment often (39.5%) or always (28.6%). After 2 months, there was a decrease, with only 27.2% actively engaging in introspection and self-assessment.
Familiarity with metacognition. Initially, 68.7% of students who reported poor familiarity (rated 1 or 2) with the concept of metacognition decreased to 54% after 2 months, with a 14.7% increase in moderate to extreme understanding (rated ≥3).
Leadership
Taking ownership of the learning path. Initially, 70.3% of students expressed being very likely or likely to take ownership and responsibility for their medical learning path. After 2 months, although the trend remained consistent, the percentage fell to 67.8%, as a significant portion of the students shifted to the neutral opinion category.
Overall leadership quality. Initially, 51.2% of individuals rated their overall leadership quality as ≤4. After 2 months, there was a slight decrease, with only 44% scoring their overall leadership quality as ≤4.
Overall lifelong learner quality (as an adjunct to leadership attribute). Initially, 65.4% of individuals rated their overall lifelong learning quality as ≤4. However, after 2 months, only 50.2% scored their overall lifelong learning quality as ≤4.
DISCUSSION
Implementation of the CBME curriculum has altered the landscape of medical education in India, emphasizing learner-centred approaches and the development of key competencies such as lifelong learning and leadership. We evaluated the effectiveness of the CBME curriculum in achieving these competencies among first- and second-year medical students. We also elucidate the evolving perspectives of medical students regarding the IMG goals.
Initially, a majority of the participants perceived all 5 IMG goals—clinician, lifelong learner, communicator, leader, and professional—as equally important. However, after 2 months, there was a shift, particularly towards the clinician role. There was a marked increase in the proportion of students who rated their familiarity with the CBME curriculum as high (scores 4 and 5).
This shift may be attributed to various factors, including the increased exposure to clinical environments and practical experiences during the study. The findings align with existing literature, which posits that hands-on clinical experiences significantly influence medical students’ perceptions and career aspirations. Additionally, the emphasis on practical skills and immediate applicability in clinical settings likely contributed to the heightened importance placed on the clinician role.
The CBME curriculum is designed to provide a more flexible and accountable learning environment, where students continue learning until they achieve the desired competency. It includes innovative components such as the foundational course (FC), early clinical exposure (ECE), attitudes, ethics, and communication (AETCOM), elective postings (EP), alignment and integration, clinical clerkships, and structured feedback mechanisms. SDL, reflective practice, and skills development through practical experiences are integral to this curriculum, aiming to nurture qualities essential for medical professionals.7 Medical knowledge alone is insufficient for delivering excellent healthcare, as a doctor’s responsibilities extend beyond clinical treatment. In today’s world, they must possess the ability to collaborate, cooperate, and lead teams within healthcare settings.8
Lifelong learning
We found a significant decrease in lifelong learning scores among the students over 2 months. This decline suggests potential challenges in sustaining motivation and engagement in lifelong learning practices despite the curriculum’s design. Lifelong learning is crucial for medical professionals to stay updated with evolving evidence and new guidelines. It is one of the 5 desired traits of an IMG. The essential qualities of a lifelong learner include self-initiated activities, information-seeking proficiency, continuous motivation, and the capacity to recognize personal learning needs.9 The observed decline could be attributed to the initial novelty of the curriculum wearing off, leading to a more realistic self-assessment by the students over time. Time constraints due to multiple commit-ments—academic, clinical, and personal—cause cognitive overload, undermining students’ focus on lifelong learning. To tackle this, time management support, flexible learning schedules, and mixed approaches are needed. Online learning alongside traditional methods can help students manage their time more effectively. It is also crucial to acknowledge that when the CBME was introduced in 2019, the Covid-19 pandemic disrupted its early implementation.
Leadership
In contrast, we found mixed results regarding leadership qualities. There was a slight overall decrease in self-perceived leadership qualities among the students. This discrepancy highlights the varying stages of development and adaptation to the curriculum. The newly inducted students, who are often adjusting to the demanding workload and unfamiliar environments, may initially overestimate their leadership abilities, leading to a decline in self-assessment as they encounter real-world challenges. Later on in their careers, having had more exposure to leadership opportunities and responsibilities, they may develop a more accurate and confident self-perception.10
Relation between lifelong learning and leadership
The relation between lifelong learning and leadership qualities underscores the interdependence of these compe-tencies. Effective leaders in medical settings are often those who engage in continuous learning and encourage their teams to do the same. Leadership is not merely a personal trait but a process of motivating and guiding others towards collective goals.11 Future medical leaders are expected to assume various roles, serving as visionaries in education, leaders in instruction and curriculum development, specialists in assessment, builders of community relationships, adept public relations professionals, skilled budget analysts, managers of facilities, administrators of special programs, and proficient overseers of legal, contractual, and policy mandates and initiatives.12 The CBME curriculum aims to instill these qualities early in medical education, preparing students to assume various roles such as educators, curriculum developers, and healthcare leaders.13
Limitations
The short duration of our study and reliance on self-reported measures may limit the generalizability of the findings. Additional studies with longer follow-up periods and objective measures could offer deeper insights into the evolution of the competencies as the students progress in their medical careers. Furthermore, our study participants were drawn from a single institute, potentially affecting randomization and generalizability. Multicentric studies with random sampling methods could provide more generalizable results applicable to a larger student population, thereby reducing selection bias and enhancing the reliability of the findings.
Conclusion
We observed a decline in self-perceived lifelong learning qualities and leadership among students. The findings underscore the need for targeted interventions to bolster lifelong learning and leadership development among medical students through continuous refinement of the CBME framework. The decline in self-perceived lifelong learning and leadership capabilities could indicate gaps in the curriculum’s practical application, requiring more active and hands-on opportunities in these competencies. A new version of the CBME curriculum (Revised CBME Guidelines, September 2024) has been released by the NMC. Further research should explore the long-term impact of the revised CBME curriculum and identify strategies to enhance its effectiveness in developing well-rounded medical professionals.
Conflicts of interest.
None declared
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