Electives in undergraduate health professions training: Opportunities and utility

Abstract

Elective courses, as the name implies, are the courses fundamentally optional in nature. Such courses are offered to students to allow them to have diversified and specific learning experiences in the area of interest, beyond fixed curricular boundaries. Though, elective courses started gaining importance in health professions training during last century, their full potential is still untapped. With the introduction of massive open online courses, more such courses are on offer. This perspective discusses the opportunities available to introduce elective courses as well as the opportunities provided by the elective courses to improve students’ learning and help in their professional development.

Introduction

Electives imply varied meanings, ranging from specialized training to interest based courses to courses undertaken outside own college. In its simplest form, electives are the curricular contents during any training program where a student has the freedom to choose a part of the course element. In contrast to mandatory or core courses which every student must take in order to complete a training program; for electives, students can choose from available course options as per their interest.

Historically, the optional feature in an educational program was part and parcel of curriculum of many schools even during mediaeval period. In 1819, the concept first appeared in the United States in the curriculum of the University of Virginia. Harvard introduced it in 1826.¹ Electives were advocated to be introduced in secondary school as supervised electives during late 1890s.² Around the same time, electives started gaining importance in the medical school curriculum of the United States too.³

The full potential of electives in health professions training started being recognized in the late 1990s. Nursing electives, in different areas of specialization were introduced.^4,5 Electives in medical education had been introduced as project work, and wellness clinics.^6,7 Few reports of elective courses in dental and physiotherapy have also emerged.^8,9 Now a days, web-based or online elective courses are increasingly being delivered in health professions education.¹⁰ These courses are either part of regular curriculum of some institute or being delivered through massive open online courses (MOOCS).

Rationale for electives

Why electives? Those curricular aspects which are offered as electives can as well be made a part of the regular curriculum as core subjects. Why to make some portion as optional?

Well, the answer lies in the inherent potential of elective courses to offer opportunities to the learners for the specific and specialized training in the area of current or future interest, beyond the routine curricular training.

It has been seen that allowing the students to choose some of the topics enhances the level of interest of the students in the program and helps them build personal skills.¹¹ Students undergoing elective programs have often marked electives as being innovative and interesting.¹² Besides breaking the monotony of regular teaching in a fixed curriculum, electives provide multidimensional and varied learning experiences, making inter-professional education possible. By choosing course content themselves, students feel more responsive and responsible; no doubt students prefer the idea of free electives.¹³

Electives have been postulated to promulgate transformative learning.⁶ Transformative learning is a two phase process involving instrumental and communicative learning.¹⁴ Whereas primary focus of instrumental learning is on ‘learning through task-oriented problem solving and determination of cause and effect relationships’, communicative learning focuses on the ‘understanding how others communicate their feelings, needs and desires with another person’.⁶ Instrumental learning helps the learner to improve specific clinical skills while communicative learning helps to inculcate critical thinking skills [Fig. 1]. The immense potential of elective courses in promoting transformative learning needs to be tapped.

Fig. 1.

Role of electives in promoting transformative learning.

Opportunitis for elective courses – The Indian Scenario

Elective courses in health professions education in India are mainly being offered under two distinct types of training programs – choice based credit system (CBCS) and competency based medical education (CBME) curriculum. As the name implies, CBCS involves a combination of ‘certain choice in the hand of learners to choose course’ and ‘assessment through grades’. On the other hand, CBME curriculum is a recently adopted, outcome oriented curriculum focusing on inculcating and assessing the competencies.

Choice based credit system

The CBCS offers an opportunity to the students to make a choice and choose courses from the approved courses comprising core, elective or skill based courses. The assessment of students is conducted following the grading system by computation of the Cumulative Grade Point Average (CGPA).¹⁵ Under these guidelines, an elective course is defined as ‘a course which can be chosen from a pool of courses and which may be very specific or specialized or advanced or supportive to the discipline/subject of study or which provides an extended scope or which enables an exposure to some other discipline/subject/domain or nurtures the candidate's proficiency/skill’.

Three types of elective courses are offered under CBCS, viz. discipline specific elective (DSE) courses, dissertation based elective (DBE) courses, and generic elective (GE) courses. Elective courses offered by main discipline or subject of study are referred to as DSE. An elective course framed to acquire advanced knowledge, such as supplement study or support study to a dissertation or project work is referred to as DBE. An elective chosen from unrelated discipline for the purpose of exposure is referred to as GE. A core subject of one discipline may be a GE for another discipline.¹⁵

Competency based medical education

Regulatory body for medical colleges across India [erstwhile Medical Council of India (MCI), now National Medical Commission (NMC)] introduced CBME curriculum for undergraduate medical training in the year 2019.¹⁶ Under these regulations, electives have been introduced for the first time in medical undergraduate training in India. These ‘mandatory’ electives will be conducted for two months, after the end of Final Professional Part – I training with an objective to provide diversified learning opportunities to the students.

These electives will be supervised, self-directed, providing experiential and immersive learning experiences. Two hundred hours have been dedicated for two blocks of elective courses of four week duration each.¹⁷ The electives program proposed by MCI will not be an entirely free-choice program. Students have to pick-and-choose from the programs being offered by any particular institute.¹⁴

Types of electives in undergraduate medical education

As said overleaf, elective courses are intended to provide multidimensional, diversified and immersive learning opportunities to the students. In undergraduate medical training globally, the nature of elective courses offered and the time of their implementation is highly heterogeneous, owing to diverse settings directing medical education in different countries.

The elective courses offered across the globe, in undergraduate medical training can be categorized in five broad classes – global/International health electives, project work based electives, career choice oriented electives, directed electives and wellness electives.^6,7,18, 19, 20 In India, the elective courses going to be offered under CBME curriculum to medical undergraduates will largely be oriented towards basic sciences training, laboratory sciences training, community clinical training, research work training, and guided patient care in clinical sciences.¹⁷

Different types of electives along with their stated objectives have been delineated in Table 1.

Table 1.

Different types of elective courses and their objectives.

Type of elective course	Stated objectives
Global/International health electives	•Students get to see different range of clinical conditions and pathology, not normally seen in home conditions •Students' clinical skills and experience is broadened •Students get the experience of working in challenging conditions, with scant health facilities
Research/Project-work based electives	•Enhanced research acumen •Inculcating skills to handle health care projects •Sustained projects leads to capacity building
Career choice oriented electives	•Ensure early interest generation in a subject •Clarify the focus for future career path
Directed electives	•Support academically weak prescribed core components •Strengthen core competencies
Wellness electives	•Promote self-reflection and humanisms •Help students to cope with the stress of medical studies

Most medical colleges allow electives towards the end of the training, once core competencies have been acquired. Indian medical colleges will offer elective courses before the commencement of part-II of Final professional training.

Challenges encountered

Challenges are encountered by all stakeholders – institutes, course coordinators and students. Designing an exclusive elective course, suited for the requirements of some students is labor intensive. Even after designing, delivering such elective courses demands extra efforts and time from the concerned teachers/course coordinators; they have to handle this in addition to their own core courses too. Assessment of students in these elective courses is never going to be easy. Capacity building will be needed.

Joining elective courses outside own college can be a challenge for many students. The prospectus itself can lead to anxiety. Students also have to encounter issues of cultural differences. Fixed duration electives, where minimum attendance is required so as to be able to progress to the next phase of training; like the one planned to be offered by Indian medical colleges, is always going to be difficult for students to adjust to.

Teachers, support and mentoring will be needed by the students, not only for the training in the electives per se, but also for choosing a good and required elective.

Conclusion

Electives have immense potential – makes training interesting, helps in inculcating diversified skills and helps in overall professional development of the students beyond curricular boundaries. Though full potential of elective courses in medical education in particular, and health professions education at large is still to be tapped, but a beginning has been made and hopefully with more experience, more and more electives in medical education will be developed.

Disclosure of competing interest

The authors have none to declare.