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Introduction 

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.

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

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

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