Introduction

With the intention to rise the standards of Indian Medical Graduate and attain the goal of “Health for all”, Medical Council of India (MCI), now known as National Medical Commission (NMC), took a major initiative in introducing the Competency-based Medical Education (CBME) for the Undergraduate Medical Curriculum in India ( 1 ). NMC clearly enunciated the competencies to be attained by an undergraduate medical student to become a globally competent “Indian Medical Graduate”.

CBME is an “Outcome-based Approach”, with emphasis on shared responsibility with learners, adopting student-centric teaching learning methods and inculcating formative assessment as an integral component of the learning process ( 2 ). The regulatory body had made appreciable efforts in designing the curriculum with the team of experts and also planning “Training of Trainers” of the faculty from medical colleges all over India, through the “Curriculum Implementation Support Program 1 & 2” (CISP I & II), organized by Nodal/Regional Centers in India.

With this foundation laid by the NMC/MCI, the responsibilities were laid over the medical colleges to successfully implement and run the CBME program. Curricular change is always associated with challenges. Owing to the complexity of CBME, many studies in the past decade brought insights into the foreseen challenges with the implementation of CBME ( 3 - 5 ). However, literature on the process evaluation of the contextualized CBME remains minimal.

Program evaluation plays a major role in enhancing the quality of the services provided and facilitates the attainment of outcomes ( 6 ). Literature search has revealed studies that recommend that those involved in health education should systematically evaluate and publish their CBME activities, including assessment-related content and evaluations. The highlighted themes may offer insights into ways in which current CBME assessment practices might be improved to align with efforts to improve health care ( 7 ). Planning of evaluation framework through surveys and focus group discussions well in advance with implementation may favour an effective evaluation ( 4 ). Process evaluation with the introduction of a curricular reform yields valuable information on the fidelity of the implementation ( 8 , 9 ). Hence, the present study aimed to evaluate the mechanisms adopted in the process of implementation of CBME in Phase I (First Professional Year) at our institution.

Methods

Study setting: The study was carried out by the Medical Education Unit (MEU) of Sri Manakula Vinayagar Medical College and Hospital, Puducherry. Our institute is a fifteen-year-old institute, affiliated to Puducherry University offering quality medical education to the medical undergraduates and postgraduates.

Study Design: We did a qualitative study with a mixed method of data collection including Focus group discussion (FGD), In-depth interviews (IDI), and Checklist- based evaluation.

Inclusion Criteria: All the preclinical faculty involved in teaching in the first professional year.

Exclusion Criteria: MEU members, Curriculum committee members.

Hence, twelve Phase I faculty (Faculty of the preclinical departments, excluding the principal investigator) were selected as the study participants.

Sampling: Purposive sampling method was used for recruiting the participants. The faculty members recruited from the preclinical departments were directly involved in the implementation of the curriculum.

Data Collection Methods: Interview guide with probing was used for conducting focus group discussion and in-depth interview. A checklist was designed based on the guidelines of the regulatory body released on the implementation of CBME modules (Framing of objectives for competencies, Active learning strategies, Foundation Course, Attitude, Ethics, Communication Skills Module [AETCOM], Skills Module, Assessment Module, Early Clinical Exposure, Alignment and Integration, Self -directed learning). The checklist was used for gap analysis of the extracted data. The following measures were taken for the quality of data; debriefing was done after each, and IDI and transcripts were analyzed independently by two of the co-authors.

The evaluation plan was presented by the principal investigator to the members of Medical Education Unit (MEU) and Curriculum Committee. It was revised after the suggestions from the members. The final approval was obtained from the Dean. The study was carried out in 5 steps.

Step 1:

Three Focus Group Discussion with 3-5 members in each group were performed with the faculty of all three preclinical departments (Anatomy, Physiology and Biochemistry) regarding the strategies adopted and the challenges faced in the implementation of CBME. Each FGD lasted for 45-60 minutes and was conducted in MEU meeting hall which was convenient for the participants. The discussion was conducted in English by the faculty (the 3^rd and 4^th author) trained in Qualitative research. FGD was audio- recorded and the transcripts were prepared. The manual content analysis was done, and report was provided by three of the co-investigators trained in qualitative research.

Step 2:

After the FGD, gap analysis was done with the same participants to evaluate the level of implementation of CBME using the checklist.

Step 3:

The data obtained from the FGD and Gap analysis was triangulated to prepare the evaluation report.

Step 4:

The evaluation report was shared with the heads of the departments in advance, and three IDI were conducted with the heads of the three pre-clinical departments respectively to propose appropriate action plan for the identified gaps in the evaluation report, relevant to their discipline. The evaluation report and proposed action plan was disseminated with all the preclinical faculty.

Step 5:

An action plan review meeting was conducted with the dean, curriculum committee members, and phase I faculty. The consensus on the final plan of action and the strategies to implement the action plan was reached.

Data Analysis: The manual content analysis was done for the Focus Group Discussion and IDI. The Focus Group Discussions were audio-recorded, and thematic analysis of the transcripts was done. The data were transcribed in English, manually coded, and analysed. The transcript was read multiple times to assimilate the meaning conveyed, identifying similar statements and organizing these statements into themes. This was compared and discussed with the team members and consensus on the theme was finalized. The statements related to challenges faced were categorized into 9 themes. The themes were derived from the components of CBME. Similarly, the statements related to strategies adopted were categorized into 2 themes.

The statements obtained from the checklist were grouped manually by coauthors, and the duplicates were removed. The statements were finalized after discussion with the team members. They were categorized into 8 gaps grouped under 5 extracted themes.

Similarly, the action plans obtained from IDI was manually analyzed and categorized. The 10 action plans finalized after manual content analysis were grouped under proposed action plans.

Ethical Consideration: Ethical principles such as obtaining consent from the respondents and ensuring confidentiality were considered throughout the study. Ethical approval was obtained from the Institute Ethics Committee (Ref No:EC/102/2021).

Inform Consent:Informed consent was obtained from all the study participants.

Results

Table 1 represents the qualitative data of the study participants.

Table 2 represents the strategies adopted by the institute and the departments in the implementation of CBME. The institute and the departments took measures to comply with the guidelines incorporated by the NMC.

Table 3 represents the challenges faced by the faculty during the implementation of the different components of CBME. COVID Pandemic was an unanticipated challenge faced by the faculty.

Table 4 represents the strategies adopted by the institute and the departments for online teaching, during the COVID pandemic. The institute took measures to provide necessary technical support for the smooth running of online classes for the students. Innovative TL methods and the assessment methods were adopted by the faculty to enhance student engagement even during the lockdown period.

Table 5 represents the gaps identified with implementation of CBME compared with the guidelines of NMC. The gaps were identified for 5 themes obtained from the content analysis. It also highlights the appropriate action plan proposed for bridging the identified gaps and successfully implementing the CBME for the upcoming batches.

Discussion

The results of the present study have highlighted all the strategies adopted by the institute in liaison with the guidelines of the regulatory body and the regional centre of NMC. Awareness of the stakeholders regarding the curricular change plays a crucial role in the successful implementation of the CBME ( 10 ). This was the prime step carried out by the institute and the departments for the implementation of CBME. All the departments prepared a yearly schedule; the core competencies to be covered, choice of appropriate instructional methods, and assessment strategies were done well in advance before the implementation of the CBME. This form of curriculum mapping ensures the constructive alignment within a curriculum ( 11 ).

Implementation of a curricular change is not free of challenges. Sensitization of stakeholders and motivation and training of faculty are some of the challenges quoted in the literature ( 12 ). Bringing a major transition in the teaching learning process and assessment strategies has been identified as a major challenging task in our study. The arrangement of strategies for the successful implementation of these changes demands high coordination among the faculty members and financial support from the administration. Shrivastava has reported that coordination with other departments, sustained support from administration, faculty shortage, lack of direction, etc. are bound to impact the successful implementation of CBME with respective diseases planned for the session ( 4 ).

Non-availability of patients with respective diseases planned for the session in the stipulated time and lack of cooperation of patients during addressal by several small group of students are some practical difficulties faced in the implementation of the sessions of Early Clinical Exposure in our study. This could be managed with recorded conversations between the physician and patient or replaced with paper-based scenarios. However, these alternatives do lack the real time feeling obtained from the patient’s interaction ( 13 ).

Lack of interdisciplinary coordination, allotment of appropriate weightage to the topics for integration, allocation of an appropriate fit in the timetable, emphasis on formative assessment, SDL, and time consumption with resource preparation were some of the anticipated challenges quoted by Patel in his review ( 14 ). Similar results were observed in our study. In addition, we faced extreme difficulty in tapering the integrated content relevant to basic sciences.

Assessment, as a component of CBME, itself is associated with intrinsic challenges. An article by Lockyer emphasizes the importance of multiple assessments with multiple assessors in CBME to ensure that assessment for learning is taken care of ( 15 ). However, it requires motivated, trained faculty, and adequate time for its implementation. Lack of awareness of different formative assessment tools was a major challenge addressed in our study. Further, NMC recommends at least one of the assessments as attitudinal assessment, which is a tough task in framing and implementation.

Self-directed Learning is one of the essential components of CBME. While literature search reveals multiple methods for self-directed learning, there are no specific guidelines for its implementation. This was again a major challenge with respect to SDL in our study. A systematic review by Buch reported similar results ( 16 ).

COVID pandemic was an unanticipated challenge in the process of implementation of CBME. Online tools were utilized for teaching, learning and assessing to maintain the academic flow during the pandemic crisis. However, face-face interaction with patients and implementation of skill modules were major constraints, similar to observation by other studies. Yet, this has led to effective incorporation of blended learning ( 17 , 18 ).

The challenges faced during the implementation were in the same line with the gaps identified with the analysis. Though many action plan strategies have been suggested for the successful implementation of CBME for the upcoming batches, Faculty development plays a crucial role in the success of the curricular change. Owing to its complexity, CBME demands multiple reinforcement sessions as FDPs for the capacity building of the faculty ( 19 ).

Pairing evaluation with implementation may yield invaluable information regarding the progress of the program ( 20 ). Hence, it is ideal to plan the evaluation process along with the program implementation and incorporating changes obtained with review process. CBME evaluation can support the improvement of current processes and guide future implementation by shedding light on the gaps identified and supporting effective and efficient use of resources; it can also help to devise appropriate action plan to overcome the challenges.

Strengths and Limitations of the study

Most of the studies have highlighted the perceptions of the faculty before implementation of CBME. The current study is one among the very few studies that attempted to do the process evaluation of CBME, particularly in a qualitative mode. However, our study is not free of limitations. COVID pandemic has masked the actual challenges involved in the implementation of CBME. Prospective studies in the future may reflect the real scenario of the barriers involved in the implementation of CBME.

Conclusion

Attainment of curricular changes demands positive momentum with all the stakeholders, at various stages of the implementation of the program. Evaluation provides critical insights into the successes and challenges of operationalizing CBME. CBME is not mere introduction of competencies. Acquisition of competencies is enhanced by appropriate instructional methods and effective assessment strategies. Frequent and constant hands-on training on the CBME modules through “Faculty Development Programs” plays a crucial role in successful implementation of CBME.

Acknowledgement

We would like to thank our dean, curriculum committee members, and MEU members for their constant motivation and support in carrying out the study.

Authors' contribution

K.S, G.K, M.R, R.S Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, Drafting the work or revising it critically for important intellectual content, Final approval of the version to be published, Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflict of Interest

None declared.

References

1. Ananthakrishnan N. Competency based undergraduate curriculum for the Indian Medical Graduate, the new MCI curricular document: Positives and areas of concern. SBV Journal of Basic, Clinical and Applied Health Science. 2018; 1(1):34-42.
2. 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.
3. Caverzagie KJ, Nousiainen MT, Ferguson PC, Ten Cate O, Ross S, Harris KA, et al. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017; 39(6):588-93.
4. Shrivastava SR, Shrivastava PS. Competency-based medical education for undergraduates in India: Strengths, weaknesses, opportunities, challenges analysis and the way forward. Mustansiriya Med J. 2020; 19:37-9.
5. Kumar VD, Rajasekhar SS. Overarching challenges to be addressed before implementing competency-based medical education in India. BLDE Univ J Health Sci. 2019; 4:44-5.
6. Vassar M, Wheeler DL, Davison M, Franklin J. Program Evaluation in Medical Education: An Overview of the Utilization-focused Approach. J Educ Eval Health Prof. 2010; 7:1.
7. Danilovich N, Kitto S, Price DW, Campbell C, Hodgson A, Hendry P. Implementing Competency-Based Medical Education in Family Medicine: A Narrative Review of Current Trends in Assessment. Fam Med. 2021; 53(1):9-22.
8. Hamza DM, Ross S, Oandasan I. Process and outcome evaluation of a CBME intervention guided by program theory. J Eval Clin Pract. 2020; 26(4):1096-104.
9. Shrivastava SR, Shrivastava PS. Evaluation of the competency-based medical education curriculum. Apollo Med. 2021; 18:290-2.
10. Shrivastava SR, Shrivastava PS. How to successfully implement competency-based medical education in India. Educ Health Prof. 2018; 1:61-3.
11. Essary AC, Statler PM. Using a curriculum map to link the competencies for the PA profession with assessment tools in PA education.  J Physician Assist Educ.  2007; 18:22-8.
12. Shah N, Desai C, Jorwekar G, Badyal D, Singh T. Competency-based medical education: An overview and application in pharmacology. Indian J Pharmacol. 2016; 48(Suppl 1):S5-S9.
13. Senthil Velou M, Ahila E. Expectations and challenges of early clinical exposure programme for first year medical students in India. IAIM. 2020; 7(8):59-65.
14. Patel M, Shah HD. Alignment and integration in competency-based medical education curriculum: An overview. Indian J Physiol Pharmacol. 2020; 64(Suppl_1):S13-S5.
15. Lockyer J, Carraccio C, Chan MK, Hart D, Smee S, Touchie C, et al. Core principles of assessment in competency-based medical education. Med Teach. 2017; 39(6):609-16.
16. Buch AC, Rathod H, Naik MD. Scope and Challenges of Self-Directed Learning in Undergraduate Medical Education: A Systematic Review. J Med Edu. 2021; 20(1):e114077.
17. Suneja S, Gangopadhyay S, Kaur C.  Efforts to cope with CBME in COVID-19 era to teach biochemistry in medical college.  Biochem Mol Biol Educ.  2020; 48:670-4.
18. Choudhary S, Sharma R, Sharma M, Choudhary U. Competency Based Medical Education (CBME) – Curriculum Delivery in the times of COVID19 Pandemic: An Experience.  Int J of Adv Res. 2021; 8(2):1566-9.
19. Khan AM, Gupta P, Singh N, Dhaliwal U, Singh S. Evaluation of a faculty development workshop aimed at development and implementation of a competency-based curriculum for medical undergraduates. J Family Med Prim Care. 2020; 9:2226-31.
20. Hall AK, Rich J, Dagnone JD, Weersink K, Caudle J, Sherbino J, et al. It’s a marathon, not a sprint: rapid evaluation of competency-based medical education program implementation. Acad Med. 2020; 95(5):786-93.