Delhi Journal of Ophthalmology

Competency-Based Medical Education for The Indian Medical Graduate: Implementation & Assessment in Ophthalmology

Kirti Singh, Neha Rathie, Parul Jain
Guru Nanak Eye Centre, Maulana Azad Medical college & assoc. Hospitals New Delhi, India

Corresponding Author:

Kirti Singh
MD, DNB, FRCS, FAIMER, DoHA 
Dir Professor of Ophthalmology & Director GNEC State Nodal Officer NPCB
Guru Nanak Eye Center, Maulana Azad Medical College  & assoc hosp. Ranjit Singh Marg, New Delhi, India
Email: mail4kirti@gmail.com

Received: 04-JUN-2022

Accepted: 20-JUN-2022

Published Online: 25-JUN-2022

DOI:http://dx.doi.org/10.7869/djo.781

Abstract
Competency-based medical education (CBME) curriculum has been implemented by National Medical Council from 2019 for the Indian Medical Graduates (IMG). This competency-based curriculum focuses on skill acquisition with   incorporation of soft skills related to attitude, communication and ethics.  Widespread adoption of a competency-based approach would mean a paradigm shift in the current approach to medical education.
The current article describes rationale of CBME along with an overview of the competencies mandated in ophthalmology with detailing of assessment module by means of logbook with incorporation of work place based assessment. 

Keywords :Competency-based Medical Education (CBME), Assessment, Logbook, Undergraduate curriculum, Teaching-Learning methods

Introduction 
Rationale of CBME
Medical education focus is to train graduates to become effective health care providers. Erstwhile medical education was based on time bound, subject-centred curriculum with most assessments being summative, with inherent little opportunity for feedback. Both teaching–learning activities and assessment focused more on acquiring knowledge and not on skill acquisition, nor on patient doctor communication nor attitude.  Competency-based Medical Education seeks to redress this with focus on basic clinical skills required to practice including soft skills related to communication, doctor–patient relationship, ethics, and professional conduct.

Competency is defined as “the ability to do something successfully and efficiently,” and CBME is an approach to ensure that the Indian Medical Graduate (IMG) develops competencies required to fulfil patients’ health requirements thereby preparing students for actual professional practice. Teaching–learning activities become more skill-based, involving more clinical, hands-on experience and assessment focuses on outcomes or competencies achieved. Time constraints are an issue, as continued training until desired competency is achieved, could be difficult to fit in during the prescribed course.

Work placed based assessment (WPBA) measures working of a health care professional while performing duties. Proposed by Norcini et al in 2007 it comprises of three essential components namely direct observation, conduction at work place and contextual with constructive, immediate feedback.1 Mini clinical examination (Mini CEX), Directly observed procedural skills (DOPS), Case based discussion (CBD) are few of the WPBA methods. Formative assessments largely work-based form the backbone of CBME and need to be performed frequently with qualitative feedback from teachers. Structured logbook required for this, is detailed in this article

Key aspects of CBME  
Early Clinical exposure (ECE): This aims to create an opportunity for correlation learning in Phase I with clinical application. In ophthalmology it entails 4 weeks of clinical posting during 2nd year.

Integrated Teaching learning: Both horizontal and vertical integration (inter and intra disciplines), bridge gaps between theory & practice. Ophthalmology can link with community medicine and ENT for horizontal integration. Vertical integration is feasible with pharmacology, microbiology and clinical specialities of medicine, paediatrics, gynaecology. 

Self-directed learning: An important teaching learning tool Self-Directed Learning (SDL) is the “process in which individuals take the initiative, with or without the help of others, in diagnosing learning needs, formulating learning goals, identifying human and material resources for learning, choosing/ implementing learning strategies, and evaluating learning outcomes”.2 The Graduate Medical Education 2019 document lists life-long learning as one of the roles of the Indian Medical Graduate (IMG) to continuously equip themselves with relevant knowledge and skills in the ever evolving world of medicine. To inculcate SDL, the logbook includes details of SDL activities undertaken by the student followed by subsequent reflections on the same. 

Skill Certification: CBME curriculum with focus on outcomes, emphasizes skill development. Acquisition of essential/ desirable and certifiable skills, during simulated or clinical posting has to be combined with documentation of process. 

Electives: This is to provide immersive learning experiences to explore career stream, discipline or research project related or unrelated streams of interest. As per CBME curriculum, 8 weeks of electives is reserved after 7th semester (post 3rd Prof exam Part I and prior to commencement of III rd MMBS Part II). Of these 8 weeks, 4 weeks is for clinical and 4 weeks for pre / para clinical, with choices given to student. Ophthalmology is part of Block II of electives envisaging supervised posting followed by formative assessment. At least 75% attendance is mandatory. 

AETCOM (Attitude, Ethics and Communication): This module is designed on the fundamental principle that a person's attitude influences behaviour and determines doctor patient relationship. Emphasis on empathetic communication and guiding principles on professionalism and ethics are the basic tenets of this module. 

(I)  Competencies in Ophthalmology (CBME curriculum) 
The competencies have been divided as per domain in table below and need to be taught using different teaching learning methods to accommodate the total hours.

A. SKILL BASED: certifiable competencies (OP* -ophthalmology)


B. Affective Competencies - it may or may not be certified 


C. Knowledge Based Competencies





Knowledge Based Competencies: Integration with – Anatomy (AN), Physiology (PY), Pathology (PA), Pharmacology (PH), & General Medicine (IM)

Source: National Medical Commission UG-Curriculum-Vol-III.pdf - NMC 3
https://www.nmc.org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-III.pdf accessed on 18 /6/2022

(II) Ophthalmology Teaching/ Learning programme in concordance to CBME is summarized below:

Teaching learning methods would be chosen according to student patient ratio. Suggested are: 

For Knowledge based competencies: 
Lecture, Small group Teaching (SGT), Structured case presentations like One minute Preceptor (OMP) 4 

For Skill based competencies:  
DOAP (Directly observed assisted performance), Peyton 4 step approach5 Small group teaching (SGT), Skill lab, Simulated patient  

For Affective domain: Movies, Role play sessions, Shadowing, Theatre of oppressed, Brainstorming sessions





(III)   Assessment: Logbook 



General Instructions
1. The logbook is a record of academic & co-curricular activities of designated student during ophthalmology posting 
2. Logbook records various activities like overall participation & performance, attendance, completion of selected competencies. Reflections of student need to be documented
3. The student is responsible for maintaining his/ her logbook and getting entries verified by concerned faculty regularly.
4. Logbook must be verified by department & college, prior to submitting application of students for University examination.



There are 4 weeks of clinical posting in Second Professional and 4 weeks in Third professional Part 1



Glossary:
Attempt at Competency
F: First or only
R: Repeat
Re: Remedial

Rating
B: Below expectation
M: Meets expectation
E: Exceeds expectation

Decision of faculty:
C: Completed
R: Repeat
Re: Remedial

I. Clinical Case Presentations: Phase II: 2 Case presentations required 


II. Clinical Case Presentations Phase III: 2 Case presentations required


Skill Based competencies; Assessment 
Assessment methods again would be chosen according to student patient ratio.

Suggested are: 
For Knowledge based competencies: Written (Long questions, short answer questions), Objective structured clinical examination (OSCE), Multiple choice questions (MCQ) 

For Skill based competencies: DOPS (Direct observation of procedural skills), Mini CEX, Case based discussion, Critical incident technique, Bed side clinics, Viva, Multisource feedback  

For Affective domain: Reflections, Portfolio, Brainstorming sessions

OP1.3 Demonstrate steps in performing visual acuity assessment for distance vision, near vision, colour vision, pin hole test , menace and blink reflexes



OP2.2 Demonstrate symptoms &clinical signs of common conditions of  lid and adnexa including Hordeolum externum/ internum, blepharitis, preseptal cellulitis, dacryocystitis, hemangioma, dermoid, ptosis, entropion, lid lag, lagophthalmos


OP2.3 Demonstrate under supervision clinical procedures performed in lid including: bells phenomenon, assessment of entropion/ ectropion, perform the regurgitation test of lacrimal sac. Massage technique in cong. Dacryocystitis & trichiatic cilia removal by epilation



OP3.1 Elicit document and present an appropriate history in a patient presenting with a “red eye” including congestion, discharge, pain


OP3.2 Demonstrate document and present  correct method of  examination of a “red eye” including vision assessment, corneal lustre, pupil abnormality, ciliary tenderness


OP3.8 Demonstrate correct technique of removal of foreign body from eye in a simulated environment


OP3.9 Demonstrate the correct technique of instillation of eye drops in a simulated environment


OP4.8 Demonstrate technique of removal of foreign body in cornea in a simulated environment


OP3.9 Demonstrate the correct technique of instillation of eye drops in a simulated environment


OP4.8 Demonstrate technique of removal of foreign body in cornea in a simulated environment


OP6.6 Identify and demonstrate clinical features and distinguish , diagnose common clinical conditions affecting anterior chamber


OP7.3 Demonstrate correct technique of ocular examination in a patient with a cataract


OP8.3 Demonstrate correct technique of a fundus examination & describe and distinguish funduscopic features in normal condition and in conditions causing an abnormal retinal exam


OP9.1 Demonstrate the correct technique to examine extra ocular movements (Uniocular & Binocular)


PY10.20 Demonstrate testing of visual acuity, colour and field of vision in volunteer/ simulated environment


I  Self Directed Learning

Phase II - 3-4 such SDL can be incorporated 6 

Self- directed learning

Topic:

Objectives:

Task:

Methodology:


Reflections: Self Directed Learning



Integrated Learning Sessions
Summary of Integrated Learning Sessions


Marking scheme 
The marking varies depending on different universities. For Delhi University it is as follows:  
Internal / Formative assessment (FA): 35% marks to be obtained by student in theory and practical to quality for sitting in university exam. 
Summative assessment (Ophthalmology paper in 3rd Professional MMBS Part I): 
Theory (60) and Practical (40). Of which 50% marks must be obtained by student in theory and practical separately for passing. Around 20% of FA is added to the summative assessment.  


References
  1. Norcini J and Burch V. Workplace based assessment as an educational tool: AMEE guide No 31.  Medical Teacher 2007, 29 (9):855-871. 
  2. Premkumar K, Vinod E, Sathishkumar S. et al. Self-directed learning readiness of Indian medical students: a mixed method study. BMC Med Educ 18, 134 (2018). https://doi.org/10.1186/s12909-018-1244-9
  3. Medical Council of India, Competency based Undergraduate curriculum for the Indian Medical Graduate Vol III: 81-87, UG-Curriculum-Vol-III.pdf - NMC https://www.nmc.org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-III.pdf accessed on 18 /6/2022
  4. Gatewood E, De Gagne JC. The one-minute preceptor model: A systematic review. J Am Assoc Nurse Pract. 2019 Jan;31(1):46-57
  5. Nikende C, Huber J, Stiepak J et al. Modification of Peyton’s four-step approach for small group teaching – a descriptive study. BMC Med Educ 14, 68 (2014). https://doi.org/10.1186/1472-6920-14-6
  6. Singh T, Aulakh R, Gupta P, Chhatwal J, Gupta P. Developing a competency-based undergraduate logbook for pediatrics: Process and lessons. Postgrad Med 2022, 68 (1) : 31-34

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Singh K, Rathie N, Jain PCompetency-Based Medical Education for The Indian Medical Graduate: Implementation & Assessment in Ophthalmology.DJO 2022;32:112-118

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Singh K, Rathie N, Jain PCompetency-Based Medical Education for The Indian Medical Graduate: Implementation & Assessment in Ophthalmology.DJO [serial online] 2022[cited 2022 Aug 7];32:112-118. Available from: https://www.djo.org.in/articles/32/4/Competency-Based-Medical-Education-for-The-Indian-Medical-Graduate.html