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REVIEW ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 4  |  Page : 362-366  

A critical review of new competency-based curriculum for community medicine using various curricular review frameworks


1 Professor and Head, Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Dean Medical Education and Professor, Department of Community Medicine, Believers Church Medical College and Hospital, Thiruvalla, Kerala, India

Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Thomas V Chacko
Department of Community Medicine, Believers Church Medical College and Hospital, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_141_19

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   Abstract 


The purpose of the present review is to examine the new competency-based undergraduate curriculum in community medicine against the established frameworks and criteria and suggest the way forward for achieving competencies expected of the Indian Medical Graduate (IMG). The new Graduate Medical Education Regulations, 2018, is based on Harden's concept of the curriculum. Hence, we reviewed the components of new curriculum against Harden's conceptualization of various components of the curriculum, and since it claims it is competency-based, we used Tyler's Goal/Objective-Based Evaluation. The new undergraduate curriculum has shown a move toward integration of course content and defined the competencies in more measurable terms. However, it appears that the earlier information-based curriculum corresponding to book chapters (”topics”) has been modified to specify higher cognitive domains with no explicit link between the IMG level curriculum outcomes to subject level intended learning outcomes (ILOs). The mechanism to link ILOs to assessment is also not clear and so needs more clarity. The assessment system hinted at in the current document is mostly based on the existing conventional system of 50% as pass cutoff, etc., against criterion-referenced assessment applicable to competencies that need to be performed. Furthermore, there is no guidance on the creation of educational opportunities and environment for students and faculty – perhaps it is left to “Curriculum Implementation Support Programme (CISP) Workshops.” Hence, the need for preparing a roadmap/blueprint to learning experiences and assessment methods and levels and milestones to be reached at various phases of MBBS and during internship is required.

Keywords: Community medicine, competency-based medical education, curriculum, Indian Medical Graduate, undergraduate


How to cite this article:
Dongre AR, Chacko TV. A critical review of new competency-based curriculum for community medicine using various curricular review frameworks. Indian J Public Health 2019;63:362-6

How to cite this URL:
Dongre AR, Chacko TV. A critical review of new competency-based curriculum for community medicine using various curricular review frameworks. Indian J Public Health [serial online] 2019 [cited 2020 Jul 10];63:362-6. Available from: http://www.ijph.in/text.asp?2019/63/4/362/273351




   Introduction Top


A well-planned curriculum is seen as a cost-effective intervention to improve the quality of education, produce a skilled human resource, and thereby improve the health status of people in resource-poor developing countries.[1] Hence, it is important to align the curriculum to the local needs and improve its effective delivery to produce the human resource suitable to the given context. After two decades of the existence of Regulations on Graduate Medical Education, 1997, the Medical Council of India (MCI) has recently come forward with new Graduate Medical Education Regulations 2018. The new undergraduate curriculum is expected to meet the expectations of all stakeholders besides addressing the emerging health needs of the society.[2]

The Indian Medical Graduate (IMG) is expected to be competent in the diagnosis and management of common health problems, apply rational treatment principles using essential drugs, be able to understand socio-psychological, cultural, economic, and environmental factors affecting health and be familiar with various National Health Programmes and Policies.[2] The curriculum of community medicine has a significant potential to influence the achievement of overall goals of the IMG curriculum at national and individual level, and the current document in its current form is the outcome of curriculum planner's sincere efforts to transition from a traditional system to a new CBME paradigm. Hence, the purpose of the present curriculum evaluation is to do a document study to examine the new competency-based undergraduate curriculum document in community medicine using established frameworks and criteria to identify possible gaps in content and alignment based on which the areas for improvement in the document in terms of missing links with the roles expected of the IMG so that they become job-ready for primary care in existing health system. The MCI document rightly accepts that it is a “live document” and so is open to changes needed. Their view and recommendations presented in this article would provide pointers about the way forward and would also be relevant to further curriculum development through its review in other subjects of medicine and health professions education as well.


   Review of Individual Components of Undergraduate Curriculum Top


The word “curriculum” is one of the heavily debated terms in the field of education. Hence, over the period, it has led to the development of different perspectives, multiple definitions, and theories.[3] In most conventional thinking, the curriculum is viewed as “content” (syllabus) which specifies the subject matter to be learned by the learners or the list of intended learning outcomes (ILOs) with reference to knowledge, skills, and attitude to be achieved by the end of the course.[4]

In the mid-20th century, Tyler had proposed a comprehensive idea on the concept of curriculum and mentioned that curriculum includes content, purpose, organization, student assessment, and course evaluation.[5] Later, in recent times, Harden suggested that curriculum should contain the following components – learning outcomes, content, educational strategies, learning opportunities, assessment, and educational environment.[6] Both Tyler and Harden saw curriculum as more than a syllabus or a statement of the content. All these components should be in alignment with each other to achieve the desired outcomes. Most of the Western Universities have embraced these modern ideas in their curriculum development. The new Indian Graduate Medical Education Regulations 2018 sees the curriculum as a statement of “product” and reflects the Harden's concept of the curriculum. Hence, we shall now review the components of the new curriculum against Harden's conceptualization of various components of the curriculum, Tyler's Goal-Based Evaluation and Backward Planning for Competency-Based Medical Education [7] since the document states its Goal is to produce a competent IMG to identify the gaps in the community medicine curriculum document against the course outcomes stated as “Roles” (holistic clinician, leaders of health team, communicator with patients, colleagues, family and community, life-long learner and professional) which the IMG is expected to play as a “physician of first contact of the community.”


   Curriculum Review in Terms of the Stated Learning Outcomes Top


Learning outcomes are the statements which specify what learning should be achieved at the level of the overall curriculum, modules, and at the level of individual learners. The new Graduate Medical Education Regulations 2018 specifies the goals at national, institutional, and individual levels.[2] In addition to skills in patient care, the new curriculum gives importance to ethical values, responsiveness to the needs of the patients, and acquisition of communication skills through attitude, ethics, and communication (AETCOM) module.[2] Thus, it is clear that the new curriculum aims to address the needs of various stakeholders such as students, community, employers, and regulators.

In the new MCI curriculum, it is obvious to note that the cognitive level of individual learner-level outcomes of the curriculum is set at a higher level of Bloom's Taxonomy, such as-to understand, analyze and synthesize. However, of 180 ILOs stated for various topics in community medicine, the majority of them are set at a lower order of Bloom's Taxonomy (describe – 89, enumerate – 23, define – 22, and list – 2). It is a well-accepted dictum that the learning outcomes at the subject level and at the individual learner-level should be aligned with the overall purpose of the curriculum.[8] Although the new curriculum made an effort to define the topic level outcomes in measurable terms, it appears to be still in the “Informative stage” of curriculum transition rather than in the “formative stage” where competency-based curriculum lies and so it appears to have converted the existing contents of the informative knowledge-focused syllabus (the “topics”) to be restated as knows, shows how, and performs.[8] Because of this, the document fails to identify the competencies needed to carry out the tasks a medical officer is expected to carry out for individuals and area health responsibilities. This failure of listing the future task (role)-related competencies as the first step to identification of “topics” leads to a disconnect through the absence of an explicit link between the tasks a Medical Officer in a Primary Health Centre is expected to carry out and the “topic level” outcomes in Community Medicine. Community medicine is more hands-on, and so should be taken to the “shows how” level and at Internship to the “performs” level. An exercise at curriculum review using a matrix/rubric with backward planning [Figure 1] starting from expected job roles/tasks to competencies needed for these and then the identification of knowledge, skills, attitudes, and finally, the planning of learning opportunities to attain them is needed. This will rectify the disconnect that the student feels when going through the current new curriculum document in community medicine since it does not make it explicitly connected to future job role as medical officer of primary health care (PHC) or a doctor at primary care level. The explicit linking and alignment of learning experiences to future job roles in the curriculum document that we propose is essential as it will also make it clear to the faculty who are curriculum implementers at the college level and through them the students. It will also help the MCI to suggest a system of assessment that the university can adopt. This is particularly true for the curriculum in community medicine as it is mandated and entrusted with helping the IMG to be more competent and become job-ready to fulfil the roles of medical officer to be able to ensure “Health For All.” Otherwise, the aim of the new curriculum to achieve “Health For All” through PHC will remain only on paper.
Figure 1: Explicit linking of learning activities through backward planning from professional tasks.

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   Review in Terms of Course Content Top


In the traditional curriculum model, the content is organized and taught in subject-wise compartments. The broad range of subjects is basic sciences (anatomy, physiology, and biochemistry), para-clinical subjects (Pathology, microbiology, forensic medicine, and pharmacology), and clinical subjects (medicine, surgery and obstetrics and gynecology, etc.). In the new curriculum, the organization of content remains predominantly discipline based. Over the past two decades, we have been following the similar course content in teaching of community medicine. The course is getting overburdened with the recent developments in the field getting added, but the redundant content not related to the identified competencies not getting deleted. Using the curriculum matrix proposed by us where the final curriculum (must know/show how/perform) emerges from linking it explicitly to the competencies needed for professional tasks of MBBS Graduate in the community will help shed most of the information-intensive current curriculum and retain only what is needed for the application to perform the competencies needed.


   Review in Terms of Educational Strategies Top


Educational strategy refers to the approaches to teaching and learning that is used to deliver the curriculum. An approach to teaching and learning varies in traditional, integrated, and problem-based or outcome-based curriculum models.

In the traditional model, the content is organized subject-wise, and it is predominantly delivered through a series of lectures by subject experts. In traditional curriculum model, the learner is directed to the predefined body of knowledge with limited importance to the acquisition of skills and attitude. The role of the student is to listen and assimilate the maximum information provided by the teachers.[3]

In the fully integrated curriculum, the content is organized according to body systems such as cardiovascular system, respiratory system, renal system, and gastrointestinal system, and it is delivered through lectures, tutorial, skills training, project work, and self-learning exercises. The learner has to take the responsibility for their own learning. The key difference between the two models is the relationship between student and teacher and position of the learner.[3]

Due to MCI's recent insistence, the literature on integration has gained popularity in India. Notably, the views on integration are still in dissonant state.[3],[4],[9] Globally, there is a trend to organize the content in an integrated and more recently in interprofessional manner; there is no concrete evidence as to which educational strategy is better over another. We need a wide variety of pedagogical processes for the expected learning to happen.[9] Most of the educational strategies listed in the newly launched MCI curriculum which is purportedly directed toward competencies needed by IMG, however, are in line with the old information-based curriculum. Besides, appropriate strategies, methods, and learning opportunities for acquiring competencies for team-work, leadership, program management, and ability to work in health systems need to be identified and included in the MCI document. Perhaps the educational strategies are expected to emerge in the CISP workshops for implementing the curriculum but this will be possible if the main curriculum document explicitly states this need for adopting specific tried and tested educational strategies for developing leadership of teams and health care in the health system especially the need for including some form of interprofessional education with other professional streams who are part of health teams that deliver health care.


   Review in Terms of Learning Opportunities and Experiences Top


It refers to planned curricular opportunities as well as periods of private study and teaching events such as online resources, interaction with peers, teachers, patients, community members, and with external experts or other organizations. In the traditional teaching of community medicine, exposure visits to public health facilities, institution- and community-based organizations are ensured. These types of exposures help the constructivist type of learning, where the students learn to construct the meaning in the local context.[10] However, site visits only create awareness and not relevance and application of knowledge through reflection on the learning experience through a documentation of this in their reflective learning portfolio which must undergo assessment. Without assessment of reflections, students do not take the visits seriously and fail to make connection of the experiential learning with its application to future job (relevance). As the quality and quantity of learning opportunities vary across colleges due to context factors, this component of the curriculum may not get uniformly implemented. The new curriculum does not offer any guidance to create the educational opportunities. However, the use of a curriculum matrix developed from the process as shown in [Figure 1] will help each institution identify the appropriate learning opportunities that are required to gain the required competencies.


   Review of the System of Assessment Top


The assessment is defined as “the process of gathering and evaluating information on student learning and make a decision about the next step in the educational process and an assessment system is a group of policies, structure, practices, and tools for generating evidence on student learning.”[1] An effective assessment system is one which provides information of sufficient quality and quantity over the period of the course to make an informed decision about student learning.[11] The framework of an effective assessment system [Table 1] would consist of formative and summative assessment. In order to be effective, the assessment system should be in alignment with the course objective.
Table 1: Framework for an effective assessment system

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Education is a social science as it deals with the achievement of “educational construct” which is usually assessed by various assessment methods. According to the contemporary validity theory, as these “educational constructs” are nontangible, validation of scores requires the assessments to be a continued and ongoing process of data collection and logical inferences.[9] The good assessment principles and practices such as having a test blueprint, an adequate sample for assessment from the course content, carefully designed tests, multiple assessments using multiple methods at different times, and multiple examiners helps to get the valid inference about the achievement of “educational construct.” The valid score has to be reliable (reproducibility). Another set of measures such as an increase in the number of test questions and number of examiners improves the reliability of the test scores.[12] The experiences in the West have shown that the change in the assessment should be a slow and steady process as it requires careful consideration of resources and capacity of human resource.[1]

Over the years, undergraduates in community medicine are being assessed using the traditional assessment framework and methods. Test questions in assessment rely on low order recall.[13] The decision about final certification (pass/fail) primarily relies on the student's performance in a single final university examination. In the absence of an assessment blueprint linking outcome competencies in community medicine that are expected to make the graduate to be job-ready for area health responsibilities and being a leader and manager of the health team implementing the national health programs at the PHC level where more “shows how” and “does”/”perform” levels need to be reached and assessed, this current assessment intent in the curriculum document is less defensible as it is done only on one occasion in the course and without link to expected competencies. Review of the assessment system in the MCI's CBME curriculum document shows that an almost status quo in the system of examination will continue where examinations are conducted but are not testing whether the expected job-linked competencies have been achieved. In the new curriculum, most of the outcomes in the subject of community medicine are set at lower order of Bloom's Taxonomy (define, list, enumerate, etc.), the test questions would be of recall type and so are unlikely to make the Graduate “Job ready” to carry out the functions of Medical Officer of the PHC. Unlike other subjects related to patient care where only the knowledge base is needed to be strong for the competencies to be built during the postgraduate period, for community medicine, the IMG should be ready at MBBS level itself for taking up job roles of MO-PHC. Hence, a clear road map as to how this can be achieved needs to be made explicit in the curriculum document. Overall, the system of assessment in the new curriculum document is not in alignment with recent assessment theory, and there are no explicit guidelines for the formative assessment that is critical for competency acquisition as well as for testing and certifying the phase-wise competency progression during the various phases of MBBS that community medicine is taught in. All these need to be captured in a well-designed competency assessment portfolio to ensure that all expected competencies are reached to make them job-ready as well as make the subject less theoretical and more of application orientation that will be valued by the students.


   The Educational Environment Top


It refers to the environment in a college or university in which learning takes place. This environment is the product of formal and informal interaction between students, teachers, staff members, parents, and community members. The educational environment is perceived by the students, and it is the perception of the environment that is related to the expected change in behavior as part of their education. It has been noted that any change in the curriculum essentially requires a change in the environment.[14] Competency-Based Medical Education requires an enabling environment to make learner-centered learning possible. Having “Electives” is a step in the right direction, but the rest of the curriculum is driven by the “contents” or the “topics” and so betrays a teacher-driven and controlled learning environment. The World Federation of Medical Education emphasizes the need for a safe learning environment for both student and staff and the need for the evaluation of educational environments in educational courses for continuous quality improvement.[15]


   Conclusion and Recommendation Top


The review of the new MCI's undergraduate curriculum has shown a move toward integration of course content and defined the competencies in more measurable terms. It has given importance to early clinical exposure and acquisition of communication skills through AETCOM module. It also explicitly states that it aims to produce competent and skilled doctors to address the current health needs of the country. However, in community medicine document, there is no evidence that a backward planning exercise has been undertaken to derive the contents from the expected job role-linked competencies. The old curricular content as seen in the textbooks has again been listed, and the level of Bloom's cognitive domain and Millers Pyramid has been identified as the levels to be reached. This is an important area that needs to be addressed since assessment drives learning. The Assessment system hinted at in the document under review is based on conventional existing system and methods, and there is no guidance given on the creation of educational opportunities and environment for students and faculty. The lack of alignment between ILOs and assessment measures can affect the validity of the assessment system. The new curriculum document by MCI is expected to act as a guide and roadmap for implementing the CBME curriculum from 2019 batch of student admissions. Hence, the curriculum document should reflect relevant content and specific learning objectives that clearly show link to specific job roles of MO at PHC/Primary care they are directed to, show how valid and reliable the assessment system should be, the variety of educational strategies and opportunities that can be chosen from to help learner progress in the competency pathway during the various phases of the MBBS curriculum including during internship.

Our paper highlights the need to identify core competencies expected at the MBBS and Internship level for Community Medicine that are linked to the job roles expected of a basic MBBS Doctor working at the PHC with focus on case management of common diseases, be a leader and manager of the health team implementing National Health Programmes and communicator with individual family and community. The need for using a curriculum matrix to guide the preparing of a roadmap/blueprint to learning experiences and assessment methods and levels and milestones to be reached at various phases of MBBS and during Internship in community medicine is also proposed. By introducing these remedial measures to address the gaps in the curriculum identified, it is expected that there will be more clarity of purpose and focus of student learning experiences to competencies expected of a primary care doctor with area health responsibilities. It will make the teaching less theoretical and more practice oriented to its application, as stated in the roles of the IMG.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Kar SS, Premrajan KC, Subhita, S. Content evaluation of community medicine theory examinations in a teaching hospital of South India. Indian J Med Spec 2016;7:76-8.  Back to cited text no. 13
    
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