New undergraduate medical education curriculum

Alarms for a comprehensive ponder on medical education are not new. The traditional undergraduate medical curriculum has faced tremendous criticism during the last few decades for being fragmented and overloaded and driving students to learn by rote and attain knowledge passively instead of inquisitiveness and exploration.[1] The need to inculcate substantial changes in the content of undergraduate medical curricula, as well as teaching and assessment methods, has been felt for long.[2]

Competency-based medical education (CBME) has been adopted as an evidence-guided alternative to the traditional/conventional time-based medical education. The need to change the existing medical education curriculum has been felt due to the current complex systems of patient care. Recent times have witnessed paradigm shifts in the medical systems and patient health-care demands. The aim of CBME is to build physicians having capability to cope with the evolving health-care needs, and to enhance patient care. For providing optimal patient care, physicians need to be competent in skills which go well beyond the conventionally emphasized attainment and application of knowledge, such as communication, teamwork, ethics, attitude, professionalism, and holistic approach in patient care.[3]

Due to its primary focus on learner outcomes and the competencies needed in clinical situations, CBME is expected to be in a position to prepare physicians for emerging health-care systems. The core premise of CBME is that there are clear definitions of the competencies which guide the blueprint of all curricular components and are deemed necessary to achieve optimal patient care outcomes. The adoption and implementation of CBME to achieve the desired goals rests on considerable re-addressal of assessment methods as well as faculty and learner relationships, capacities, and liabilities.[4] In fact, in CBME, each learner is visualized as an individual novice having distinctive development path, vigor, and domains for improvement. Hence, CBME is believed to be a holistic transformation in our approach to preparing competent physicians.

Table 1 enumerates key differences between CBME and traditional time-based medical education framework.

Table 1.

Differences between competency-based medical education and traditional time-based medical education framework

Competency-based medical education	Time-based medical education
Focus: What the learner does	What the learner knows
Learner–teacher relationship: One of the guiding toward attainment of competence	Mainly unidirectional, where teachers impart knowledge/skills (teach) or judge (assess) the learner
Learning experiences: Learning is personalized to the maximum extent possible with more focus on improving learning by demonstrating competence	Learning is based on “one size fits all,” with little flexibility to cater personal needs
Curriculum: Introduction of competencies, integration of curriculum, clinical skill laboratories, ethics, and communication	These concepts were not part of traditional curriculum
Teaching methodology: More focus on PBL, SDL, and SGDs	Main emphasis on passive didactic lectures, with little avenues for active learner involvement
Assessment: Both formative and summative assessment	Only summative assessment

PBL=Problem-based learning, SDL=Self-directed learning, SGDs=Small group discussions

Salient Features of Competency-Based Medical Education

Problem-based learning

Problem-oriented approaches to learning or problem-based learning (PBL) seem to provide optimal conditions for adult learning directed mainly by internal factors such as impulse for success, individual goals, and contentment of learning rather than incentives and external rewards.[5] [Figure 1] depicts various ways by which PBL is claimed to improve interpersonal skills and attitudes among learners.

Figure 1.

Advantages of problem-based learning

Integrated curriculum

The concept of integrated curriculum has been introduced with a vision to integrate clinical training into knowledge skeleton from the inception among medical students. This involves linking theoretical teaching in basic sciences with early training in basic clinical skills such as communication, case history taking, and physical examination.[6,7] It is believed that teaching and learning clinical and basic sciences in conjunction enables the learners to combine scientific knowledge and clinical experience which in turn facilitates good medical practice.[1] However, need of a strong background knowledge of basic sciences cannot be ignored as it forms the foundation for critical evaluation of scientific knowledge and its application to clinical care.

Adoption of Competency-Based Medical Education across Different Nations

CBME is gaining momentum and progressively being ingrained across the globe.[8]

India

In India, CBME has been incorporated into the undergraduate medical education curriculum under GMER 2019 amendment wherein the National Medical Commission has outlined the basic essential competencies required of an Indian medical graduate.[9] Key features of the new undergraduate medical education curriculum include:[10,11,12,13,14,15,16,17]

• One-month foundation course

• Elective posting (2 months)

• Addition of attitude, ethics, and communication as a new subject

• Allotment of fixed hours for self-directed learning in every subject

• Early clinical exposure to introduce aspects of clinical and social contexts of patient care into the 1^st year of undergraduate teaching program (30 h for each subject)

• Competency-based curriculum

• Structured formative assessment, periodic internal assessment, and end-of-phase summative assessment with appropriate and effective feedback built-in

• Skill development program

• Alignment and integration (sharing, nesting, and correlation) in curriculum.

Japan

Medical education in Japan has gone through remarkable changes since the terminal years of the 20^th century.[18] In 2001, Japan incorporated a commendable model of an integrated medical education curriculum, a “model core curriculum.” This model curriculum defined essential core components to be incorporated as educational content guidelines (having 1218 specific behavioral objectives) in the undergraduate medical education program.[19] The guidelines include noncognitive components such as communication, team approach, and basic principles of medical practice in addition to knowledge and skills of medical education. The structure of curriculum is competency based and encompasses integrated curriculum, clinical skills laboratory, clinical clerkship, and PBL.

United States of America

In the United States of America, an innovative curriculum was developed under “The Undergraduate Medical Education for the 21^st Century (UME-21) project, implemented by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration.”[20] This project was mainly undertaken to design an undergraduate medical curriculum that provides the desired training and skills to medical students and delivers high-quality, accessible, and affordable health-care services.[20] Under this project, nine content areas essential in the practice of medicine have been defined which include “(1) health systems finance, economics, organization, and delivery; (2) practice of evidence-based, epidemiologically sound medicine, with emphasis on a population-based perspective; (3) ethics; (4) development of effective patient-provider relationships and communication skills; (5) leadership; (6) quality measurement and improvement, including cost-effectiveness and patient satisfaction; (7) systems-based care; (8) medical informatics; and (10) wellness and prevention.”[20]

United Kingdom

The undergraduate medical curriculum encompasses CBME. In 2008, a group of leading medical schools in the UK developed a consensus document on the “essential elements of communication curriculum.” The updated communication curriculum defines the principles, key components, and skills needed within the domain of modern medical care [Table 2].[21]

Table 2.

Features of communication curriculum (United Kingdom)

Principles

Core value: Respect for others

Core components of clinical communication

Commence the consultation

Assemble the desired information

Elucidate; shared decision-making

Close down the consultation

Build the relationship

Provide the structure

Specific domains of communication

Discussing sensitive issues

Responding to emotions

Responding to uncertainty

Discussing mistakes and complaints

Breaking bad news

Diversity in communication

Barriers to communication

Specific clinical contexts

Health behavior change

Communication during procedures

Methods of communication

Face to face

Telephone

Written communication

Digital medicine

Electronic health record

Communication beyond the patient

Administering a “triadic” consultation (e.g., patient–relative–doctor)

Decision-making consultations with patients’ kinsmen

Engaging with lay and professional interpreters

Communication with fellows via different media sources

Team working

Concluding Remarks

CBME, though a very promising and evidence-guided approach to curriculum, is not exempt from concerns and critiques. Proper implementation of the principles of CBME seems to be a demanding exercise in terms of manpower and resources. Furthermore, desired change in attitude and approach of teachers is a big challenge. The success of CBME depends largely on the way it is designed and implemented keeping into consideration the regional contexts and circumstances.