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| REVIEW ARTICLE IN MEDICAL EDUCATION |
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| Year : 2022 | Volume
: 3
| Issue : 3 | Page : 266-268 |
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Competency-based curriculum for anatomy in India: A critique
Tony George Jacob
Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 28-Oct-2022 |
| Date of Acceptance | 12-Nov-2022 |
| Date of Web Publication | 28-Dec-2022 |
Correspondence Address:
Tony George Jacob
Department of Anatomy, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_132_22
How to cite this article:
Jacob TG. Competency-based curriculum for anatomy in India: A critique. J Med Evid 2022;3:266-8 |
| Disclaimers | |  |
- I teach at the All India Institute of Medical Sciences, New Delhi, which has been (since its inception) kept out of the purview of the National Medical Council/Medical Council of India. Hence, my views may be more objective than they should be.
- The lockdowns for COVID-19 had severely affected the implementation of the competency-based curriculum in its nascent phase, and therefore, the outcome that I may have experienced as an examiner, to date, may not be what it may turn out to be in the coming years.
In 2018, the Medical Council of India published the competency-based undergraduate curriculum (CBUC) for Indian medical graduates.[1] This was put into effect for the batch of MBBS undergraduates that commenced classes in 2019. This was a major shift in the curriculum. The last major change was made in 1997 when the Regulations on Graduate Medical Education were notified. The regulations published in 2018 contain within it the principles of those published in 1997. The purpose of the 2018 regulations is stated to be 'learner-centric, patient-centric, gender-sensitive, outcome-oriented and environment appropriate'.[1] This was a product of a natural and continuing evolution in the philosophy of education, particularly medical education.
The outcome-driven curriculum is stated to be conforming to global trends, although not only in medical education. The outcome-driven approach has been driving nations and economies and also the social sciences and arts. Globally, 'Is the product of value to the individual or society?' is a governing principle now. The university is no longer a metaphysical space to question, solve, learn and apply; it has become a glorified school of technical training. There are exceptions, of course, but they do not make the rule, unfortunately!
A relevant trend line to note while setting the background for this 'curricular evolution' would be the number of undergraduate medical admissions in India, both in the public and private sectors.[2] The explosion in the numbers has seemingly affected the quality of medical education. Ground reports and anecdotes of doctors, both in the community and of fresh post-graduates at medical colleges, being unable to perform simple procedures such as putting in an intravenous or urinary catheter, drawing blood by venepuncture or assisting a normal delivery – probably pushed for these curricular reforms. Further, the numerous incidences of violence against doctors both in the urban and rural settings have probably forced the hand of powers-that-be to include 'Attitude, Ethics and Communication (AEtCom) skills' as a module to be integrated longitudinally (with progressive complexity) into the curriculum.[3] It may also be noted that the proliferation of coaching centres for 'cracking' undergraduate medical entrance examinations, and the increasing number of languages in which a student may attempt these entrance (selection) examinations, has probably necessitated the foundation course[4] that would help create a confluence and integration of such a diverse pool of students into a cohesive corpus of medical undergraduate students.
In this piece, I would like to examine the curriculum in anatomy, which is a pre-clinical subject that has been covered in Volume 1 of the CBUC published in 2018.[5] I would be referring to the teaching schedules and specific learning objectives (SLOs) that have been published on the websites of some of the 'known' medical colleges[6] and dip into my experience as an examiner for undergraduate students that have undergone training in this novel system.
I examined the websites of a few 'known' medical colleges to study their SLOs that were listed by the specific competency in the CBUC. A cursory glance would reveal that much of what used to be subtopics within chapters in the textbooks of anatomy have been listed as SLOs with appropriate semantics.[7] Which means that the same content has been transposed as a competency-based objective at the level of (know, know how, show and show how). Further, the mechanism of evaluation also remains the same – written/viva voce and the means of teaching also remains the same – lectures and small group discussions (read as demonstrations and teaching around the dissection table)[6],[8] The opportunity for 'vertical integration' and 'early clinical exposure' is partially evident in the schedule that has been published on the websites, but the mechanism is glaringly absent.[9] A seminar with orthopaedics and paediatrics to deal with osteomyelitis, while discussing the growth and development of bones and their blood supply, is just one of the examples of lost opportunities, but the majority of integrations have been clubbed into lecture hours. I suppose medical colleges 'had to deliver' and did not ponder whether they would have to make any radical changes to the way they think and the way they deliver the teaching–learning experience and its evaluation. On the topic of integration, both horizontal and vertical – the various medical colleges whose schedules and SLOs I studied – do mention the departments with which a specific competency could be integrated, however, the mechanism of integration was grossly absent.[5],[7],[8] These integrated teaching sessions could have been marked as problem-based learning (PBL), where the case material could have been derived from the clinical disciplines that would be in the loop for vertical integration, or there could be seminars between various departments in horizontal and vertical integrations. These could also have a capacity for creative evaluation – beyond the written answer or the spoken viva voce or to identify a spot. The students could be evaluated on case scenarios even by summative multiple-choice questions or these could be included as internal assessment marks meant for maintaining log books of such case discussions, presentations in seminars and PBLs and so on.
A key determinant in the acceptability of any curriculum among the student community is the process of evaluation. Many of the methods of evaluation listed for anatomy are still the same – written examination, viva voce and objective structured practical examination (OSPE) (which is loosely translated as a spotting examination in a subject like an anatomy). I had an interesting experience, although, as an external examiner for the first professional examination at a medical college where the CBUC had been implemented. I was given the station where the students were supposed to perform surface markings of anatomical structures on a cadaver. It was conducted as an OSPE and I had a 10-point checklist to assess each student on. The first point on the checklist and the first action performed by each student was to bow before the cadaver. This stemmed from competence number 1.5 in the AEtCom module in the CBUC, which is entitled 'the cadaver as our first teacher'.[10] This competency states 'the importance of biological tissues and cadavers in their learning, respect for donor families, cadavers and tissues are important and must be respected; safe and clean handling and disposal of biological tissues'. Since I was not at a viva station, I could not ask the students why they were bowing, but on enquiring from the faculty in the department, I realised that this was how they were supposed to demonstrate 'respect'. It was a different matter altogether that after making the markings on the cadaver a large proportion of students did not erase the markings that they made, nor did they cover the cadaver again with the shroud. This OSPE station also highlighted another glaring lacuna. The purpose of surface anatomy or 'living anatomy' (as it is referred to) is to be able to navigate the living body with the help of bony or other landmarks and not specific measurements because the inherent variability in the physical structure of an individual cannot be overlooked while examining a patient. Hence, when the students were measuring centimetres and inches from the sternal margin or from a specific joint or bony landmark, I could but raise my eyes heavenward. Hence, even though the students had learnt a competency, it would be of little use to them when they actually see a patient in the clinic. These lacunae can and should be addressed in the stated to be 'living document'.
There is an evaluation that is supposed to be a 'certified performance'. In the list of 82 competencies (each with a variable number of subcompetencies: 0–14),[4] there is only one skill that the student needs to be able to certifiably perform and that is number 25.1,[11] wherein the student is to be able to 'identify, draw and label a slide of trachea and lung'. To the best of my capacity for abstraction, I was unable to understand why this skill was the sole certifiable skill in all of anatomy. Probably, due to the importance that is given to tuberculosis and other respiratory illnesses in the National Health Mission. However, on perusing the SLOs of various medical colleges, it was impossible to determine how this certification was being carried out.
In the background of this transfiguration of the teaching–learning experience of the medical undergraduate, there was another shenanigan brewing… that of qualifications of faculty in pre-clinical and paraclinical subjects. There was a possibility of 30% of faculty in basic sciences to be recruited from an MSc + PhD background; whereas, the rest were to have an MD or MS in the specialty. Due to various campaigns and representations, the National Medical Council/Board of Governors in supersession of the Medical Council of India brought it down to 15% with a view to phasing it out. However, this decision was overturned by the Health Ministry in January 2022.[12] The irony of all this is that in a competency-based curriculum, there is very little role for the 'experience' of a medically trained faculty or a junior/senior demonstrator. The beauty of the competency-based curriculum is that it is objective-determined (knowledge or skills) and those objectives can be delivered by literally any 'one' who is trained in its delivery and in any form – as a demonstration, small group discussion, PBL, lecture, seminar and what-have-you. The question is whether departmental faculty and the medical education training units at the various medical colleges are willing to make the transformation to deliver competency, and hence, train their staff and orient them towards competency. If not, the hiatus between theory and practice will remain unabridged.
All that said, the CBUC is a welcome change in the undergraduate medical curriculum for the broad objectives that it enshrines and espouses. It should be used as a means to equip young medical graduates with the necessary cognitive, psychomotor and interpersonal skills to become effective leaders of the health-care delivery team and a 'life-long learner' (not a health technician). It is a 'living document' and should be regularly and judiciously revised, based on ground realities so that it may be improved upon and grows organically in a true academic environment, and does not become an exercise of pouring old wine into new bottles. The inertia of rest among the deliverers of this system needs to be converted into an inertia of motion so that this curriculum serves its purpose – to make India better. Each small step will count.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. Vol. 1. New Delhi: Medical Council of India; 2018. p. 11.  |
| 2. | |
| 3. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate, AETCOM. New Delhi: Medical Council of India; 2018. p. 4. |
| 4. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate, AETCOM. New Delhi: Medical Council of India; 2018. p. 18-27. |
| 5. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. Vol. 1. New Delhi: Medical Council of India; 2018. p. 41-81. |
| 6. | |
| 7. | Snell RS, Mehta V, Suri RK. The Thorax: Part I. Snell's Clinical Anatomy by Regions 1 st South Asian Edition.New Delhi: Wolters Kluver India; 2018. p. 41-68. |
| 8. | |
| 9. | |
| 10. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate, AETCOM. New Delhi: Medical Council of India; 2018. p. 27. |
| 11. | Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. Vol. 1. New Delhi: Medical Council of India; 2018. p. 56. |
| 12. | |
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