|Year : 2016 | Volume
| Issue : 2 | Page : 95-98
Attitude and communication module in medical curriculum: Rationality and challenges
Jayasri Mitra1, Indranil Saha2
1 Dean, Indian Journal of Public Health and Associate Professor, Department of Community Medicine, ESI PGIMSR and ESIC Medical College, Kolkata, West Bengal, India
2 Assitant Managing Editor, Indian Journal of Public Health and Associate Professor, Department of Community Medicine, ESI PGIMSR and ESIC Medical College, Kolkata, West Bengal, India
|Date of Web Publication||23-Jun-2016|
Assitant Managing Editor, Indian Journal of Public Health and Associate Professor, Department of Community Medicine, ESI PGIMSR and ESIC Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mitra J, Saha I. Attitude and communication module in medical curriculum: Rationality and challenges. Indian J Public Health 2016;60:95-8
|How to cite this URL:|
Mitra J, Saha I. Attitude and communication module in medical curriculum: Rationality and challenges. Indian J Public Health [serial online] 2016 [cited 2020 Apr 6];60:95-8. Available from: http://www.ijph.in/text.asp?2016/60/2/95/184537
India is the second largest country in the world as per the population statistics and has the privilege of having the highest number of medical colleges (412) with a turnover of approximately 50,000 fresh medical graduates per year.  The principal aim is to meet the health service needs of the vast population, but still, the current estimated doctor-population ratio in India is 1:1700 in comparison to the world average of 1.5:1000. The targeted average of 1:1000 to be achieved by the year 2031 as per the Medical Council of India (MCI) guidelines is probably possible in near future with input of adequate resources, but assuring academic quality at the same time is a fundamental prerequisite to ensure the intended outcome, i.e., a competent medical practitioner who would be committed to excellence, responsive and accountable to patients, community, and profession. 
Till date, medical curriculum and training programs have been designed around specific educational or learning objectives addressing primarily three domains: Cognitive, psychomotor and affective, also known as the head, and hand and heart, respectively. However, currently, medical education in India deals greatly with the head, meagerly with the hand, and nearly neglects the heart, thus failing to produce a clinician who would understand and provide holistic care (i.e., preventive, promotive, curative, and palliative care) with compassion. , The selection procedure for a medical course in our country has also been criticized as it does not consider the humanitarian attitude of a candidate which is much needed to become a doctor. Moreover, the increased level of mistrust of the general population upon the medical professionals due to negligence, misconduct, and unethical practices leading to violence and legal complications also points to the dire need for revision of the existing medical curriculum. ,,
In response to this need, "Vision 2015" document was prepared to evolve a roadmap for graduate and postgraduate medical education comparable to global standards, with emphasis on early clinical exposure, integration of basic and clinical sciences, clinical competence, and skills. The goal is to create an "Indian Medical Graduate" (IMG), who is a skilled and motivated basic doctor, physician of first contact (primary care physician) for the community for both urban, as well as rural India, while being globally relevant. Integration of ethics, attitude, and professionalism in all phases of learning has been suggested as one of the key curricular strategies in the document to enable the IMG to function professionally. 
MCI has also taken a step forward in this regard by proposing new teaching-learning approaches including a structured longitudinal program on attitude, communication, and ethics which is known as the attitudinal and communication (ATCOM) competencies. It offers a framework of competency-based learning in the ATCOM domains that a medical professional must possess at the time of graduation to effectively fulfill the functions of IMG as a clinician, leader and member of health-care team and system, communicator, lifelong learner, and a professional. 
| Rationality|| |
Teaching medical ethics, behavioral science, communication skills, and managerial skills do not receive due attention in the existing medical curriculum as they should do. ,,, The working conditions for the doctors are often not ideal with long hours of work, early burnout, and harassment by the relatives of the patient. In addition to these, feeling of professional isolation and disparity in the living conditions are the great issues in rural areas. In absence of addressing the affective domain, the current course curriculum often fails to support the medical graduate to handle these stressors, which often lead to professional dissatisfaction with undesirable negative consequences. 
With the improvement of science and technology, it is not only essential to reform the curriculum to incorporate new findings in order to enhance cognitive domain and skill acquisition, but at the same time, it is imperative to modulate the affective domain or the "heart" of the IMG. The affective domain covers the manner in which one's emotional behavior, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes. Addressing this domain would in turn inculcate interest, values, empathy and develop appreciation, and attitude for interpersonal, as well as community interaction. Hence, for the overall development of a medical professional, the affective domain comprising attitude, communication, and ethics therefore need to be taught directly and explicitly.
MCI has decided to implement ATCOM module in all medical colleges across the country over the coming years, which is a welcome step. A group of experts constituted by MCI has developed ATCOM module along with a facilitators' guide. Change should be for the betterment and with this vision, successful implementation of ATCOM module across the entire duration of the MBBS course endeavors to be the key to transition to competency-based medical education (CBME) program. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.  This is however debatable as some experts consider CBME as another form of outcome-based education, where learning outcomes are given more importance than learning pathways or processes.  The new Graduate Medical Education Regulations 2012 has also given more emphasis on the competency-based curriculum. 
| What is New in Attitude and Communication Module?|| |
Some of the proposed new elements of the ATCOM module addressing four domains, i.e., knowledge, skill, attitude, and communication are integrated teaching (horizontal and vertical), early clinical exposure starting in the 1 st year, attitude and communication skill development, adoption of contemporary education technologies such as skill laboratory, e-learning, and simulation. It introduces competency pattern in the undergraduate curriculum and tends to strike a balance between explicit teaching and experiential learning incorporating values of professionalism. The module has specified the competencies with regards to attitude, communication, and ethics needed to be taught in each year of the medical course, namely foundation of communication in the 1 st year, bioethics in the 2 nd year, medicolegal issues, ethics, and doctor-patient relationship in the 3 rd year, and medical negligence and dealing with death in the final year are some of the important topics. Thus, wholehearted effort has been given to address the "heart" of the medical graduates. 
| How to Assess?|| |
In CBME, the outcome is expressed in terms of competencies. Various newer evaluation methods, summative and formative, have been proposed which can be summed up in Miller's pyramid model of competence assessment which starts with cognition and ends with assessment of behavioral practice in such a manner that performance assessment of a trainee would provide more realistic picture in clinical settings [Figure 1]. , While Objective Structured Clinical Examination can be used to assess competence in an examination setting preferably in summative assessment, 360° evaluation is a holistic formative evaluation technique based on the feedback assessment system from multiple evaluators (superiors, peers, administration staff, patients, and families) who evaluate a student's competence by a rating scale or survey that assesses how frequently a behavior is performed. Other innovations in ATCOM skill assessment in addition to clinical expertise are workplace performance using workplace-based assessment tools and entrustable professional activity which give valuable information about the ability of the trainee to function as a professional in real life situation. ,,,
| Challenges|| |
Mere introduction of ATCOM module will not serve the purpose; we have a long road ahead toward implementing competency-based medical training and ensuring sustainability, the principal responsibility of which lies on the shoulders of medical school leaders. Since the competency-based training program and assessment methods differ in many ways from the traditional curriculum, it is crucial to sensitize and prepare the faculty for this change. Though faculty development is gaining momentum in India through Medical Education Units in some colleges, but this is yet to be materialized in most of the institutions.  The next important challenge is to change the student's attitude toward medical education from the mere internalization of knowledge and score marks to adopting finer ATCOM skills in order to deliver quality medical care. This is also a tremendous task to change the behavior of medical students in the 4½ year tenure of medical course. Assigning marks or grades with equal weightage for the assessment of competence acquisition in all the domains of CBME can play a key role in shaping the outcomes and success of the curriculum and hence assessment tools must be carefully planned.
| Conclusion|| |
Medicine as a profession though to some extent depends upon individual's skill and expertise, but it largely relies on good teamwork, where relationship within the group and its communication outside the group, i.e., toward patient and family, as well as community, are very crucial. Good behavior, appropriate attitude, proper and timely communication, and empathy are crucial components of clinical practice. Systematic training of the students in ATCOM domains throughout the medical course would surely help them to become a committed skilled doctor on whom people can trust upon. It is earnestly hoped that a carefully managed, sustainable approach to implement the ATCOM modules in all the medical institutions of the country would bring about the transformational change from traditional knowledge and skill component-based curriculum to CBME which would enable the medical graduate to perform the role of leader and member of the health-care team, communicator, lifelong learner, and professional as envisaged by the "Vision 2015" document.
| References|| |
Modi JN, Gupta P, Singh T. Competency-based medical education, entrustment and assessment. Indian Pediatr 2015;52:413-20.
Sood R, Adkoli BV. Medical education in India - Problems and prospects. J Indian Acad Clin Med 2000;1:210-2.
Vinod Kumar CS, Kalasuramath S, Kumar CS, Jayasimha VL, Shashikala P. The need of attitude and communication competencies in medical education in India. J Educ Res Med Teacher 2015;3:1-4.
Kumar R. Medical education in India: An introspection. Indian J Public Adm 2014;60:146-54.
Attitude and Communication (AT-COM) Competencies for the Indian Medical Graduate. Reconciliation Board. Academic Committee of Medical Council of India. July 2015. Available from: . [Last accessed on 2016 May 15].
Nayar U, Verma K, Adkoli BV, editors. Inquiry - Driven Strategies for Innovation in Medical Education in India: Curricular Reforms. New Delhi: AIIMS; 1995.
Shah S, Gupta Y, Shaikh M, Sathe S, Kowale A, Zingade U. Communicational and attitudinal skills in I st
M.B.B.S. students. Int J Sci Res Educ 2014;2:2054-61.
Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: A systematic review of published definitions. Med Teach 2010;32:631-7.
van Mook WN, Bion J, van der Vleuten CP, Schuwirth LW. Integrating education, training and assessment: Competency-based intensive care medicine training. Neth J Crit Care 2011;15:192-8.
Boursicot K, Etheridge L, Setna Z, Sturrock A, Ker J, Smee S, et al
. Performance in assessment: Consensus statement and recommendations from the Ottawa conference. Med Teach 2011;33:370-83.
Dhaliwal U, Gupta P, Singh T. Entrustable professional activities: Teaching and assessing clinical competence. Indian Pediatr 2015;52:591-7.
Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013;5:157-8.