Understanding and analyzing competency based undergraduate curriculum in otorhinolaryngology for its effective implementation

INTRODUCTION

Introduction of competency based medical education (CBME) can be considered as a major transformation of medical education in India after independence. The erstwhile medical council of India (MCI) had introduced a new competency-based curriculum (CBC) which is learner centric, outcome based and lays stress on continuous assessment with feedback. The CBC includes various newer concepts which were hitherto not present in the traditional curriculum. The first undergraduate batch under the new curriculum (admission batch 2019) will start its third professional part-1 (final-1) training likely from 1st February, 2022. The Universities and Institutes shall have to plan teaching schedules and assessment programs incorporating teaching hours and curricular contents (topics, competencies and students’ learning objectives [SLOs]) as described in the MCI documents (graduate medical education regulations, 2019 [GMER-2019] and UG curriculum volume III).^1-4

It is imperative to understand and analyze the new CBME curriculum in otorhinolaryngology (ORL) in terms of curricular change, temporal progression, and assessments, in order to facilitate its implementation. We analyzed the CBME curriculum in ORL with respect to its differences with traditional curriculum, break-up of the teaching hours, pattern of internal and university assessments, and alignment of teaching-learning methods (TLMs) with the objectives.

METHODS

The present analysis of CBC in ORL was done at Gujarat Adani Institute of Medical Sciences, Bhuj. All authors have completed revised Basic Course Workshop (rBCW) training in Medical Educational Technology (MET) from the designated Nodal Centre. The documents analyzed were GMER 1997 & 2019, UG Curriculum Volume-III, logbook guidelines, alignment & integration module and assessment module. All these documents are readily available at NMC website. These documents were studied thoroughly and differences between the traditional curriculum and CBC in ORL were tabulated. The total teaching hours in ORL were distributed among the competencies. These were then aligned with suitable TLMs. We have also suggested division of IA marks including day to day assessment.

RESULTS

The comparison of CBC and traditional curriculum in otorhinolaryngology (ORL) is shown in Table 1. The salient features of CBC are:

1) It clearly defines subject specific outcomes in ORL 2) greater emphasis on skill acquisition 3) derivation of SLOs and TLMs are based on competencies and have built-in formative evaluation 4) introduction of Self-Directed Learning (SDL). It caters to Indian medical graduate (IMG) goal of a lifelong learner 5) evaluation by multiple assessments using multiple tools 6) scope for remedial measures for internal assessment 7) greater emphasis on aligned teaching to avoid redundancy 8) use of integration (horizontal and vertical) to an extent of ≤25% to emphasize recall and applicative use of basics 9) introduction of attitude, ethics and communication (AETCOM) training and assessment in all phases 10) option of electives posting in ORL

* Eligibility criteria to appear in UA.

Curricular contents

There are 4 topics divisible into 76 competencies (outcomes) in new curriculum. We need to derive learning objectives, teaching learning methods incorporating integrations as and where needed, and types of assessment for each competency. In addition, time schedules for all these activities have to be incorporated in an academic calendar. The students’ academic progression for proper documentation is to be done in log book which is an important component of formative assessment and documentation. Table 2 shows the break-up of the teaching hours in all domains and suggested TLMs. It is important to appreciate that half of clinical postings duration (4 out of 8 weeks) is assigned during phase-II and remaining during phase-III, part-1. The curricular contents should be divided accordingly to impart adequate skill training.

* DOAP = Demonstrate (by trainer), Observe, Assist, Perform.

Formative assessment

As mentioned earlier, CBME has in-built framework for FA that provides rich feedback to both, learner and teacher. Many tools can be used for FA during/at the end of instructions such as Clickers, One Minute Preceptor (OMP) model, prompts etc. Assessments are done multiple times in different contexts and despite being subjective these retain reliability and have educational impact.⁵ The relationship between FA, IA, UA and feedback is depicted in Figure 1.

Essentially, multiple assessments by multiple teachers in different contexts (bedside, OSCE, communication etc.) is hallmark of CBC in ORL.

Internal assessment

The IA marks have been increased in ORL from earlier 20 (10 theory and 10 clinicals) to 200 (100 theory and 100 clinials).

However, the breakup of these 200 marks is required to be done at institutional/university level to depict overall continuous performance of learner. Table-3 shows the suggested breakup of IA marks in ORL. In practice, the actual number of marks would be more and would be reduced to final marks as shown in Table 3.

Remedials

There is a provision of remedial measures for internal assessment for a student who has completed training but has not become eligible for appearing in university examination due to shortage of marks in IA due to unavoidable reasons. However, it is left to the university/institute to decide the timing and nature of such remedial measures. We had earlier critically appraised that the eligibility as well as passing cut-off percentage marks for IA should be fixed at 50% without any provision of remedial measures.⁷

It will encourage the students to work harder throughout the course to achieve 50% marks, rather than depending on the remedial measures, thus producing a more competent IMG. In general, remedial measures should be built in formative and periodic assessments as these provide opportunity for corrective action based on feedback and reflection.

* Includes subjective assessment of attitude and behaviour. Logbook format has been released by MCI, and can be modified by institutions⁶

DISCUSSION

The phase-III is divisible into part-1 (13 months), electives (2 months) and part-2 (13 months). The UA of Phase-III, part-1 shall be in 4 subjects (ORL, ophthalmology, community medicine, forensic medicine and toxicology). Although teaching hours in ORL for knowledge domain remain same (70 hours), the clinical teaching has been reduced by 12 hours, despite increase in total duration of phase-III, part-1 from 12 to 13 months. The 76 competencies in ORL are to be completed in 202 hours (25 hours lectures, 5 hours SDL, 40 hours small group teaching and 132 hours clinical postings).

The department has to develop well delineated plan and teaching schedules to complete the curriculum. The suggested format is given in table 2 incorporating alignment and integration. The clinical skill teaching will require organization of DOAP sessions apart from bedside teaching and demonstrations.

The DOAP technique is an innovative approach used in CBME curriculum and is designed to develop competency in psychomotor skills acquisition. It is defined as 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”.⁸

It necessitates timely faculty training for smooth implementation of CBC in ORL. Each DOAP session can be of 1-3 hours and requires 2-3 teachers for small group training.

CONCLUSION

The CBC in ORL is meticulously designed to address the requirements of an Indian medical graduate (IMG) and emphasizes on skill acquisition by multiple assessments. However, the successful implementation requires well concerted and committed efforts of all faculty members apart from prior training in curriculum implementation support program (CISP).

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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