Too many assessments in the undergraduate competency-based medical education curriculum may hamper learning

The purpose of formative assessments is to give feedback to learners and help them identify their weaknesses and foster their learning. The competency-based medical education (CBME) curriculum for undergraduate medical students, which was implemented in 2019, built formative assessments into the assessment schedule with this intention.¹ In clinical disciplines, students must learn many subjects such as medicine, surgery, obstetrics and gynaecology, paediatrics, orthopaedics, etc., over a period of 3 years before they appear for the summative examination. During these years, the formative assessment in each clinical subject takes the form of clinical tests conducted at the end of the clinical posting, known by names such as ward out/ward leaving tests, written and clinical examinations held at the end of a semester and participation in seminars, symposia, quizzes and so on. While students appear for these assessments, they also must appear for similar assessments in the subjects for which they will have summative examinations at the end of the same year.² For the sake of distinguishing these subjects, let us call them ‘exam subjects’. Hence, in the second and third years of the medical training, specifically from the third to ninth semesters, these students give a large number of assessments (Table 1) as they must appear for tests in ‘exam subjects’ as well as ‘non-exam subjects’ (those subjects where the summative exam is held later and not in the same year)—28 assessments in the second professional year, 26 in the final year (part 1) and 29 in the final year (part 2). Given the time duration in which these assessments are conducted, students are stressed by trying to cope with the huge academic load.

There has been an increasing trend of absenteeism amongst undergraduate medical students in the country, with poor attendance in theory classes as well as clinics/practicals across all subjects.³ 25% of the faculty respondents felt that students do not attend classes which do not have a summative examination in the same year.³ Students also absent themselves from classes to prepare for tests, as there is no preparatory leave.⁴

The present CBME curriculum expects students to learn 2885 competencies and 153 procedures certified and assessed.⁵ Given the time available for learning,⁶ the number of days spent in holidays, preparatory time for summative examinations and the time that needs to be spent in activities like clerkship, post-admission rounds, filling up log books and portfolios, the amount of time left for students to revise and prepare for these tests is limited. Therefore, many students absent themselves from lecture classes and clinics/practicals for a few days to prepare for these tests.⁴ This pushes them into a vicious cycle of being absent and thereby losing attendance and not learning important clinical or practical skills taught during that time. Subsequently, when tests are held, these students do not attend these tests.

I have summarized the attendance at the end of clinical posting tests of 3 batches of undergraduate medical students (second MBBS, final year part 1 and final year part 2) for 2023 as well as 2024 (from January to April) in the medical college with which I am associated. As can be seen in Table 2, the average attendance of medical students at the end of clinical posting tests is far from satisfactory. Eyeballing the data in Table 2, attendance percentages are higher during the final year (part 2) when compared to the final year (part 1) and the 2nd MBBS. There was zero attendance at tests held near internal assessment examinations of the ‘exam subjects’ and when holidays were around the corner. Students’ attendance is better in the final year, perhaps because the final examinations are closer or because they do not want to fall foul of the faculty who may be their internal examiners.

When students lack the necessary attendance or progress, they are not permitted to appear in the final summative examination or in the supplementary examination, which is held within 3–6 weeks of the final examination.⁷ Yet, it is left to the discretion and purview of the medical colleges to ‘arrange for making up deficiencies’ by conducting additional classes, so that students can ‘make up’ for their lack of attendance.⁷ Hence, students who have less than the minimum attendance required for qualifying (<75% in theory and <80% in clinics/practicals) demand from the college authorities that they be allowed to ‘make up’ their very poor attendance in 1 month, as they do not want to spend an additional year. Departments usually conduct repeat tests to help students who have missed them, so that they will not lose out on the internal assessment marks. This is yet another reason why students do not appear for the ward-out tests of the ‘non-exam subjects’ as they know they will be offered another chance to take them.

Assessments have the capacity to intrinsically motivate learning and at the same time also affect the psychological well-being of students negatively, like increased levels of anxiety, stress and frustration.⁸ Given the large number of assessments being done in the CBME curriculum, the negative impact on student morale and mental well-being needs to be considered. The implementation of any medical education policy should be based on evidence, information and an understanding of the ground reality, especially from the stakeholders’ perspectives, for the implementation to be successful. I do not see this with the large number of assessments that are mandated in this curriculum and the way they are being conducted.⁹

I believe policymakers need to sit with an open mind to learn from all stakeholders as to what is needed vis-á-vis what can be implemented, given the challenges facing students and teachers. A review of the assessments in the present CBME curriculum should be taken up by the National Medical Commission, and the evidence available, along with a wholehearted attempt to address issues of concern raised by medical educators, should inform policy change. Faculty and administrators need to be firm in their resolve and not back down when students are absent for trivial reasons and then expect to be permitted to appear for the examinations.³ This is easier said than done because of the media outcry when large numbers of students are detained which puts the administrators on the defensive.¹⁰ There must be regular informal sessions with students in which they should be mentored on the need to attend classes and tests. Short-term, easy fixes are not the answer, and the students, in particular, and medical education in general should not have to pay the price.