Towards competency-based learning in medical education: Building evidence in India

The educational scenario in India is undergoing a paradigm shift with the introduction of competency-based medical education (CBME).[1] CBME approach is organized around competencies, or predefined abilities, as outcomes of the curriculum. This approach encourages learners to take responsibility for their progress towards competence,[2] and hence is termed learner-led approach. The students are expected to identify and negotiate activities to meet their learning needs, which increase their accountability.[3] It also demands that the students should work in team, focus on active learning, have self-reflection, and develop self- directed learning skills.[4]

Though the driving force for the CBME process is a learner, the responsibility also lies with the teachers. The teachers need to work closely with the learners and do hand holding whenever needed. In CBME, the objective is to prepare students for clinical practice. Hence, the focus is on knowledge application and not on knowledge gain.[5] To achieve this, the learning has to be made contextual. The teachers have to create appropriate educational opportunities for the learners, provide access to resources, and give effective feedback during practice through formative assessment.[5]

An article by Grover et al.[6] published in this issue of the journal illustrates precisely the above mentioned elements of CBME, though this study was conducted before implementation of CBME in India. The authors chose case-based learning (CBL) to teach topics in pathology to medical students but along with that they made use of WhatsApp messenger. These newly designed educational activities were compared with the didactic lectures, which are used traditionally in almost all Indian medical institutions. This study[6] has shown that these newly introduced teaching–learning methods promoted active learning through self-directed efforts and helped the students to retain what is learnt and apply the knowledge. WhatsApp was accepted by the students as an additional aid for CBL.

CBL, the method selected by the authors of the present study, uses authentic case scenarios to mimic real-life situations, which the student may encounter in the future. While addressing the problems in the clinical case scenarios, the students get engaged in interaction with others, build knowledge collaboratively, and apply it to resolve the questions. The teachers serve as facilitators.[7] The other aid selected by the authors, viz. WhatsApp messenger is recognized as a convenient, efficient, versatile, and popular educational tool and has been evaluated in numerous subspecialties in both undergraduate and postgraduate settings.[8]

With this background, what message do Grover et al.[6] wish to communicate to the readers through the present article? The readers should understand that the authors had undertaken this project when CBL was not a mandatory requirement and not commonly practised. Knowing the advantages of CBL, Grover et al.[6] decided to use this teaching–learning method aided with WhatsApp in their institution, which was primarily following only didactic lectures. By writing this article, they wish to emphasize that whenever such innovations are attempted in the department or the institution, try to generate evidence whether the innovations are serving the purpose and worth the efforts teachers are taking to carry them out. The authors tried to generate the evidence by comparing their innovation with the didactic lectures. While generating such evidence, they had to plan their project using scientific systematic enquiry process as we use for any research project, e.g., by selecting participants, deciding variables, collecting data, analyzing, and interpreting the same.

However, challenges in educational research are multi-fold.[9] It is difficult to get a controlled setting. The participants can interact with each other, and study groups cannot be truly separated. Learning can occur through a number of other ways, and proving cause and effect relationship is difficult. Classroom environment and human behavior are hidden elements that can influence the findings. All these factors should be taken into account while collecting data to prove the worth of the innovations. Moreover, apart from student assessments to find out whether they have learnt and how much they have learnt, the implemented educational program needs to be evaluated taking into consideration reactions of the participants involved in the program.[10]

The article by Grover et al.[6] is a well-illustrated example of educational program planning, implementation, and evaluation. The authors have described this under four phases, viz. preparation phase, pre-intervention priming, intervention, and post-intervention assessment. The first phase is important as the quality of data to be collected depends on the preparation. It reflects the efforts taken by the authors to control bias and ensure the validity of the process and the instruments used therein. In the second phase, the authors have highlighted how they engaged the students and faculty in this endeavor. The third phase places before us the study design, and the fourth phase both, student assessment and educational program evaluation. It is also worth noting the various quantitative and qualitative data collection methods used by the authors. Many instruments have been implemented using different modalities. They tried to collect information regarding knowledge gain through pretest and posttest tools, having theory questions in the form of multiple choice questions (MCQs) and short answer questions (SAQs). They also studied ability to apply the knowledge through case-based MCQs. Grover et al.[6] collected students' perception regarding competency based learning, didactic lectures, and WhatsApp use. They conducted focus group discussions (FGDs) with students, which served as a complementary method to the earlier surveys and gave better insights regarding perception of students and their concerns regarding the methods. Evaluation survey about the entire course was also collected. Analysis of all these data helps the investigator to take decision whether the innovation should be made a part of curriculum or it needs modification.[10]

Grover et al.[6] have applied statistical tests to the assessment data and showed that there is a statistically significant knowledge gain. However, it is always difficult to conclude that the CBL itself was alone responsible for the increased learning, as knowledge might have been gained by the students by other methods like self-learning, informal discussions with peers or seniors, etc., and it is difficult to rule them out. A BEME systematic review[7] has reported that students enjoy CBL, may be because they work in small groups with peers. It increases their engagement and motivation for learning, which in itself is a desirable and positive effect. Most importantly, the students think that CBL helps them learn better. The perceptions of the students who participated in the present study also reflect the same and such a teaching–learning method acceptable to our students is always welcome. Whether it really helps in applying knowledge in future clinical settings is difficult to judge and beyond the scope of the present study.

Policy decisions regarding education should ideally be based on the available evidence in the literature. However, many a time evidence, though available, are not in context to Indian scenario. The current study sets up an example of building such evidence. With the new CBME curriculum and the flexibility it has given to the faculty members, there is a scope for innovations in teaching–learning methods and assessment. Responsibility lies on the faculty members to plan studies whenever they are trying something new in their own settings and generate accurate and reliable data. Sharing of findings and experiences of such studies would lead building up of educational literature for our country and help the administrators/decision makers to decide what works for our country or what needs modification before drafting any educational policy. It is heartening to know that the Journal of Postgraduate Medicine, a peer-reviewed journal, is encouraging medical faculty by publishing research projects that focus on medical education.