New Indian MBBS syllabus (CBME 2019)

• New MBBS syllabus in India: “Competency Based Undergraduate Curriculum or  Competency Based Education or Competency based medical education/CBME) for the Indian Medical Graduate” has been released by the MCI to be implemented as the new curriculum with effect from the 2019-20 batch of MBBS students.
•  This article is an overview of the CBME therefore criticism, Pros/cons, errors, operational difficulties & suggestions for improvement are beyond the scope of this short article.

CBME vs old MBBS curriculum

• The teaching & examination pattern has been extensively reworked while the duration of the course is now reduced to 50 months from 54 months.

• Competencies: The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.
  • Competency-based learning would include designing and implementing a medical education curriculum that focuses on the desired and observable ability in real-life situations.

• NB: Forensic medicine will be included in the third year instead of the second however many universities still distribute forensic medicine in MBB II & III.

The major required competencies of the IMG

• Global Attitude, Ethics and Communication Competencies addressed in the roles of an Indian Medical Graduate.

1. 1. Clinician, who understands and provides preventive, promotive, curative, palliative, and holistic care with compassion.
   2. Leader and member of the health care team and system.
   3. Communicator with patients, families, colleagues, and community
   4. Lifelong learner committed to the continuous improvement of skills and knowledge
   5. Professional who is committed to excellence is ethical, responsive and accountable to patients, community and the

• NB: The knowledge and the skills prescribed in CBME should be matched against the definition of the Indian Medical Graduate (IMG) in the curriculum.

Foundation course:

• 1-month course at the beginning of the MBBS course.
• Purpose: to sensitize the fresh medical student with the required knowledge and skills that will assist him/her in acclimatizing to the new professional environment which would be his/her milieu for a life-long career in the medical profession.

1. 1. Orientation: Refers to the awareness created in new students (learning environment/facility, schedules/timetable, Rules, Regulations, policies/procedures, faculty, staff, and mentors),
   2. Skills Module: Refers to basic skills that are required by the students to be trained in prior to entering
      patient care areas.
   3. Enhancement skills: Refers to those skills which are needed to enable students from
      diverse backgrounds to adapt & feel at par with each other.
   4. Sports and extra-curricular activities: Refers to sports and extracurricular activities
      permitted within the time schedule.
   5. Professionalism and ethics: Professional competence, effective communication and ethics are the three founding principles of Professionalism.

The AETCOM module

• Attitude, Ethics, and Communication module is a progressive step forward in recognizing the importance of soft skills like professionalism, communication, and ethical behavior which in the previous curriculum were under-emphasized. 
• Domains of learning
  1. K: Knowledge
  2. S: Skill
  3. A: Attitude
  4. C: Communication
• Levels of competency

• 1. K: Knows A →knowledge attribute→ enumerates or describes.
  2. KH: Knows how →A higher level of knowledge→ able to discuss or analyze.
  3. S: Shows → A skill attribute→ able to identify or demonstrate the steps.
  4. SH: Shows how→ A skill attribute→able to interpret/ demonstrate a complex procedure requiring thought, knowledge, and behavior.
  5. P: Performs (under supervision or independently)→Mastery for the level of competence: certification or capacity to perform independently.

Miller’s pyramid as the basis of CBME

• Objectives are classified into those requiring only knowledge alone or the ability to understand and explain a concept, demonstrate, or perform independently.
• Methods of instruction for knowledge: common method advised is Lecture for larger groups and small group discussion for smaller groups.
• Methods of instruction for skills: DOAP (Demonstration, Observation, Assistance, and Performance) is recommended.

Levels of integration

• The departments that will contribute to acquiring a certain competency, and the scope of horizontal and vertical integration (Adapted from Harden R Med Edu 2000. 34; 551).

• Alignment: Temporal coordination→The timetable is adjusted so that topics within the subjects or disciplines that are related, are scheduled at the same time.
• Sharing: Two disciplines may agree to plan and jointly implement a teaching program.
• Correlation: The emphasis remains on disciplines or subjects with subject-based courses taking up most of the curriculum time.
• Nesting: the teacher targets, within a subject-based course, skills relating to other subjects.

Topics & competencies as per the CBME

Sample competency

• Human anatomy-Pectoral region:

• Column C: K- Knowledge, S – Skill, A – Attitude/professionalism, C- Communication.
• Column D: K – Knows, KH – Knows How, SH – Shows how, P- performs independently.
• Column F: DOAP session – Demonstrate, Observe, Assess, Perform.
• Column H: If entry is P: indicate how many procedures must be done independently for certification/ graduation.

Hourly distribution of subjects

• NBE provided the particulars of competencies, teaching methodology, Vertica/.horizontal integrations, AETCOM & Exam methodology however the distribution of hours per class/tutorial & practicals are left for the individual universities to be handled therefore subjected to inter-university variability.

• Tentative number of teaching hours as per NMC  (teaching hours & distribution differ university to university)

• Abbreviations:
  1. SGT – Small Group Teaching
  2. IL – Integrated Learning
  3. Pr – Practical
  4. Tu – Tutorial
  5. SDL – Self Directed Learning

Early clinical exposure

• Early Clinical Exposure (ECE) provides a clinical context and relevance to basic sciences learning that serves as motivation and reference point for students.
• Elements:
  1. Basic science correlation: To apply and correlate principles of basic sciences as they relate to the care of the patient (this will also become part of integrated modules).
  2. Clinical skills: To include basic skills in interviewing patients, doctor-patient
     communication, ethics and professionalism, critical thinking and analysis, and self-learning (this training will be imparted in the time allotted for early clinical exposure).
  3. Humanities: To introduce learners to a broader understanding of the socio-economic framework and cultural context within which health is delivered through the study of humanities and social sciences.

Electives

• An elective is a learning experience created in the curriculum to provide an opportunity for the learner to explore, discover and experience areas or streams of interest.
  1. Block: is a defined time period during which learning experiences are created.
  2. Log Book:  verified record of the progression of the learner documenting the acquisition of the requisite knowledge, skills, attitude and/or competencies.
  3. Portfolio: a collection of the learner’s progression in tasks and competencies documented in the logbook.

Teaching & Learning Methods

1. Learner-centric didactic lectures with Vertical/horizontal integrations (CBME).
2. Small group discussions (especially focus on practical & clinical implications of the knowledge through cases)
   1. Exploratory session
   2. Facilitated panel discussion
3. Seminars, symposia & quizzes,
4. Self-directed learning +/+ multimedia aids.

Skills Training

• Skill is the ability to perform a task leading to a specific predefined outcome.
• Type of skills:
  1. Intellectual or cognitive which includes clinical reasoning and decision making skills,
  2. Procedural or psychomotor skills that require manual dexterity and include laboratory and clinical skills,
  3. Communication skills,
  4. Team skills including leadership skills.
• Competency: The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, attitude, values, and reflection in daily practice for the benefit of the individual and the community being served.
• Skill Assessment: A session that assesses the skill of the student including those in the laboratory, bed-side, skills lab, skills station that uses mannequins/ paper cases/simulated patients/real patients as the context demands.
• DOAP (Demonstration -Observation – Assistance – Performance): A practical session that allows the student to observe a demonstration, assist the performer, perform in a simulated environment, perform under supervision or perform independently.

CBME assessment: Competency-Based Assessment (CBA)

• Features of Competency-Based Assessment (CBA)
  1. CBA operates within the framework of competencies. Assessment tools should align with competencies/objectives.
  2. CBA should help to acquire competencies/objectives (assessment for learning) and their certification (assessment of learning)
  3. CBA is a continuous and ongoing process with opportunities for providing developmental feedback
  4. Direct observation of students improves the utility of CBA and feedback
  5. Multiple assessors, multiple tools, and multiple assessments improve the validity and reliability of CBA

• Exam pattern: 

1. 1. Internal assessment will not be added to the university examination marks.
      • Should score 50  % & in theory and practical combined to be eligible to sit for university exams.
   2. University exam: Each subject will have two papers.
      • 200 marks will be reserved for the theory of two papers.
      • Another 100 will be reserved for either practical, oral, or clinical exams.
      • Should secure 50 % in theory and practical to pass in university examinations

1. Designing a system of assessment

• Miller’s pyramid provides a simple way to select the appropriate tool for assessment. Efforts should be made to climb higher in the pyramid.
• All domains of learning (cognitive, psychomotor, and affective) should be taken into account and weightage should be assigned to these domains for assessment.

2. Formative Assessment

• Formative assessment is an assessment conducted during the instruction with the primary purpose of providing feedback for improving learning. The feedback is central to formative assessment and is linked to deep learning,
• Who should take this assessment? should involve all faculty members of a department (Senior Residents upwards) and not just one or two senior teachers
• Purpose:
  1. Helps the teachers and learners to modify their teaching-learning strategies.
  2. Provides inputs to both students and teachers regarding the adequacy of teaching-learning.
  3. Helps to Find out the learning stage of the student and taking corrective action in teaching-learning methodology on an ongoing basis.
• Scheduling: during teaching-learning activities & planned by the teachers on a day-to-day basis and modified depending on the tasks at hand.
  1. Theoretical assessment: clickers, one-minute papers, and muddiest point
  2. Practical/clinical assessment: one-minute preceptor (OMP) or SNAPPS technique (Summarize history and findings, Narrow the differential; Analyze the differential; Probe preceptor about uncertainties; Plan management; Select case-related issues for self-study) and/or viva voce.
•  Many of these do not need to be considered for pass/fail decisions but are useful to aid learning and acquire competencies. 

3. Internal assessment

• Range of assessments conducted by the teachers teaching a particular subject with the express purpose of knowing what is learned and how it is learned (Internal assessment can have both formative and summative functions).
• Components:

1. 1.  Theory: Written tests, should have essay questions, short notes, and creative writing.
   2. Practical/Clinical: practical/clinical tests, Objective Structured Clinical Examination (OSCE) / Objective Structured Practical Examination (OSPE), Directly Observed Procedural Skills (DOPS), Mini Clinical Evaluation Exercise (mini-CEX), records maintenance and attitudinal assessment and/or viva voce.
   3. Assessment of Log-book. The logbook should record all activities like seminars, symposia, quizzes, and other academic activities (20% of internal assessment).
   4. Internal Assessment for Professional development program (AETCOM):

1. 1. 1. Written tests comprising of short notes and creative writing experiences
      2. OSCE based clinical scenarios and/or viva voce.

• Scheduling:

• Feedback:
  1. Feedback should be provided to students throughout the course so that they are aware of their performance and remedial action can be initiated well in time.
  2. Feedbacks need to be structured and the faculty and students must be sensitized to giving and receiving feedback.
• Important note: Internal assessment marks will not be added to University examination marks and will reflect as a separate head of passing at the summative examination.

4. Summative assessment (For Universities)

• An assessment conducted at the end of instruction to check how much the student has learned.
• Each theory paper will have 100 marks.

• Pass Criteria:
  1. Internal Assessment: 50%combined in theory and practical (not less than 40% in each) for eligibility for appearing for University Examinations
  2. University Examination: Mandatory 50% marks in theory and practical.
     • Practical = practical/ clinical + viva
     • Theory=theory paper(s) only
  3. Internal assessment marks are not to be added to marks of the University examinations and should be shown separately in the grade card.
• Scheduling:

• Theory question paper (Knowledge part) for Universities:

1. • The design of the question paper should take into consideration all levels of the knowledge domain (Bloom’s taxonomy of the cognitive domain) → appropriate verbs for the questions at each level to assess higher levels of learning should be used.

• • Suggested combination of various types of question:
    1. Long Answer Questions (LAQs) & Structured essays /Modified essay questions (MEQs)
    2. Short Answers Questions (SAQs) & Constructed response questions (CRQs)
    3. Objective type questions (Various type of MCQs: < 20% weightage).
  • Distribution of the competencies: The examiner must sample the contents appropriately from competencies.

• • Examiner: Moderation of theory question paper by a subject expert must be arranged by Universities.

• Clinical exams:
  •  Includes assessment in the psychomotor and affective domain & Assessment of clinical and procedural skills should be based on direct observations by the examiners (Should not be simple tests of knowledge).
  • The competencies dealing mainly with skills and affective domains in each subject must be included.
  • Multiple tools like case presentations, OSCE, and/or OSPE should be employed.
  • OSCE type station and/or viva voce.: The value of conventional case presentation should be improved by having 1 or 2 longer (15 minutes or so) → examiners observe and assess complete history taking and/or physical examination skills (checklists or using global ratings)
• Practical/ exams at Pre- and para-clinical departments:
  • Application-oriented exercises (Should not be simple tests of knowledge).
  •  Objective Structured Practical Examination (OSPE), One-Minute Preceptor (OMP), Directly Observed Procedural Skills (DOPS), etc. can be suitably modified for this purpose and/or viva voce.
  • Examiners: Multiple teachers should be involved (multiple methods, by multiple examiners in multiple settings to assess multiple competencies).

Internship

• Duration: 12 months

Also read:

1. Russian Medical Syllabus/Curriculum: Study medicine in Russia
2. Chinese Medical syllabus/Curriculum: Study medicine in China

Also Read:

• Competency-Based Medical Education (CBME): Concepts & Challenges