Booklet For ATCOM Sensitization Workshop

MCI Regional Centre in MET
Himalayan Institute of Medical Science, Dehradun
AT-COM Sensitization programme
as per
AT-COM Module
of
Medical Council of India
As per MCI recommendation

email dated: 17/08/2015
Attitude and
Communication (AT-COM)
Competencies for the Indian Medical
Graduate
Prepared for the Academic Committee of

by
Reconciliation Board
July 2015
Foreword
The Medical Council of India has prepared revised Regulations on Graduate

Medical Education and curriculum, accompanied by guidance for its implementation. In
response to this, every medical college needs to develop the capacity to adapt to the
requirements of the new guidelines. Earlier experience with implementation of curricular
changes suggests that a carefully managed, sustainable approach is necessary to ensure that
every college has access to these new skills and knowledge. Faculty development has been
seen to play a key role in implementation and sustenance of any curricular reform.
The Medical Council of India has decided to implement Attitude and

Communication module (ATCOM) in all medical schools across the country over the next
two years. It is against this backdrop that the ATCOM module is prepared along with
facilitators guide. This activity has been supported wholeheartedly by the President of
Medical Council of India, Dr. Jayshree Mehta. There are many new key areas
recommended in the ATCOM module that were identified for implementation across the
entire duration of the course. It is hoped that the successful implementation of the ATCOM
modules will be forerunner of the transition to competency based medical education
program envisaged by the Medical Council of India.
This booklet and other electronic resources provide background concept, session
guidelines and other resources for these sessions. These will be useful for all faculty
involved in conducting these sessions. These are conceptual frameworks only and
institutions and faculty are at liberty to make modifications while implementing the same at
their own settings.
It is proposed that the existing network of MCI Nodal/Regional Centers and

Medical Education Units of all medical colleges will be the torchbearers of this
transformational change. We hope that such a change will significantly impact the quality
of community health and patient care in our country.
Dr Vedprakash Mishra Dr. M. Rajalakshmi

Chairman, Academic Committee Consultant, Academic
Cell

Contributors
1. Dr. Avinash Supe
Dean and Professor
Department of Gastroenterology Surgery and Medical Education
Seth GSMC and KEM Hospital, Mumabi -400012
2. Dr. Krishna G. Seshadri

Professor & Head
Department of Endocrinology, Diabetes & Metabolism
Sri Ramchandra Medical College & Research Institute
Porur, Chennai 600116, Tamil Nadu
3. Dr. Tejinder Singh

Professor, Department of Paediatrics and Medical Education
Christian Medical College
Ludhiana 141008, Punjab
4. Dr. R. Sajith Kumar

Professor & Head,
Department of Infectious Diseases and Medical Education
Government Medical College ,
Kottayam, Kerala –686008
5. Dr. Sanjiv Lewin

Professor & Head,
Dept. of Pediatrics & Medical Education
St. John’s Medical College & Hospital
Sarjapur Road, Bangalore-560034
6. Dr Himanshu Pandya
Professor of Medicine, and Medical Education
Pramukhswami Medical College,
Karamsad, Gujarat –388325
7. Dr. P.V Chalam

Professor and Head, Department of Surgery
Gandhi Medical College
Secunderabad, Telangana 500003
8. Dr. Praveen Singh

Professor and Head
Department of Anatomy and Medical Education
Pramukhswami Medical College
Karamsad, Gujarat –388325
9. Dr. Subir Maulick

Professor, Department of Pharmacology
All India Institute of Medical Sciences,
New Delhi-110029
S.
CONTENTS Page No.
No.
1 Preamble /concept 1
2 How to use this document 2
3 Definitions 3-6
4 Section I: Extract from the revised Regulations on Graduate Medical 7-14

Education, 2012
5 Section II: Learning modules for Professional year 1-4 15-71
6 Section III: Competency acquisition 72-76
7 Section IV: Formative elements to be marked by tutor 77-78
8 Appendix 1: List of ATCOM competencies approved by the 79-82

Academic Committee, MCI
9 Appendix 2: Communication skills to rating tool 83
10 Trainer’s mannual on Ethics for Medical Students 85-95
Journal articles on Medical Humanités & CBME
a. Using movies to teach professionalism to Medical Students.
b. Using movie clips to foster learners reflection : improving
11 PDF
Education in the affective domain.
c. Competency – based Medical Education, Entrustment and
Assessment.
12 CBME discussion module PDF
13 Journal articles on Medical Humanities PDF
14 Road map for implémentation of AT-COM module Last Page
Attitudinal and Communication (ATCOM) Competencies for the Indian Medical Graduate
Preamble / Concept
The overall goal of undergraduate medical education programme as envisaged in

the revised Regulations on Graduate Medical Education - 2012 (GMR 2012) is to
create an “Indian Medical Graduate” (IMG) possessing requisite knowledge,
skills, attitudes, values and responsiveness, so that he or she may function
appropriately and effectively as a physician of first contact of the community
while being globally relevant. In order to fulfill this goal, the IMG must be able to
function appropriately and effectively in her/his roles as clinician, leader and
member of the health care team and system, communicator, lifelong learner and a
professional. In order to effectively fulfill the above mentioned roles, the IMG
must obtain a set of competencies at the time of graduation. In order to ensure that
training is in alignment with the goals and competencies, MCI has proposed new
teaching learning approaches including a structured longitudinal programme on
attitude, communication and ethics.
Role modeling and mentoring associated with classical approach to professional

apprenticeship has long been a powerful tool. This approach alone is no longer
sufficient for the development of a medical professional. The domains of attitude,
communication and ethics therefore need to be taught directly and explicitly
throughout the undergraduate curriculum. The two major aspects of teaching
professionalism include explicit teaching of cognitive base and stage appropriate
opportunities for experiential learning and reflection throughout the curriculum.
The ATCOM module has been prepared as a guide to facilitate institutions and
faculty in implementing a longitudinal program that will help students acquire
necessary competence in the attitudinal and communication domains. It offers
framework of competencies that students must achieve. It also offers approaches
to teaching learning methods. However it is a suggested format and institutions
can develop their own approaches to impart these competencies.
1
How to use this document
This document is a guide to facilitate institutions and faculty in implementing a

longitudinal program that will help students acquire necessary competence in the
attitudinal and communication domains. The purpose of this program is to allow the
graduate to function in roles envisaged in the revised Regulations on Graduate Medical
Education – 2012 or the Indian Medical Graduate (IMG) document. The IMG document
creates roles for the graduate that goes beyond the traditional knowledge and skill
components. In particular, it adds four roles including – leader and member of the health
care team, communicator, life-long learner and professional, which call for learning and
skills not addressed by the traditional syllabi.
The document is divided in to the following:
1. Section I: contains an extract of the goals, roles and universal competencies as envisaged
by the Indian Medical Graduate document. This is the base document upon which all
learning in the undergraduate years must be based and lists the final competencies that all
students must achieve.
2. Section II: contains suggested teaching modules for each professional year including
resources cases and method to teach.
3. Section III: is a competency log that contains a list of skills that may be acquired prior to
graduation. These skills are best imparted in a simulated setting (usually involving
standardized patients). They are also best done progressing in complexity over time. For
example a skill on communicating treatment options may be acquired at different level of
complexities spread over phases before finally being certified.
4. Section IV: contains formative elements that are observable by tutors / mentors / guides
and marked over time with appropriate feed back in a non punitive fashion
5. Appendix 1: consists of the entire set of competencies as approved by the Academic

Committee of the Medical Council of India
6. Appendix 2: provides a modified communication skill rating tool adapted from the
Kalamazoo consensus
It must be reiterated that this is only a suggested format to impart these competencies.
Institutions may evolve their own innovative methods to suit local needs as long as they
conform to the competencies identified in section I and appendix 1
2
Definitions
1. Goal: A projected state of affairs that a person or system plans to achieve
In other words: Where do you want to go? or What do you want to become?
2. Competency: the habitual and judicious use of communication, knowledge, technical skills,
clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the
individual and community being served
In other words: What should you have? or What should have changed?
3. Objective: Statement of what a learner should be able to do at the end of a specific learning
experience
In other words: What the Indian Medical Graduate should know, do, or behave
3
Action Verbs (Behavior - Used in this document)
Knowledge Skill Attitude/communicate
Enumerate Identify Counsel
List Demonstrate Inform
Describe Perform under Demonstrate understanding of

supervision
Discuss Perform independently
Differentiate Document
Define Present
Classify Record
Choose Interpret
Elicit
Report
1. Note that specified essential competencies only will be required to be performed independently at the
end of the final year MBBS
2. The word perform or do is used ONLY if the task has to be done on patients or in laboratory
practicals in the pre/para- clinical phases
3. Most tasks that require performance during undergraduate years will be performed under supervision
4. If a certification to perform independently has been done - then the number of times the task has to be
performed under supervision will be indicated in the last column
4
Explanation of terms used in this document
Lecture Any instructional large group method including traditional lecture

and interactive lecture
Small group discussion Any instructional method involving small groups of students in
an appropriate learning context
DOAP (Demonstration- A practical session that allows the student to observe a

Observation - Assistance - demonstration, assist the performer, perform in a simulated
Performance) environment, perform under supervision or perform
independently
Skill assessment A session that assesses the skill of the student including the
practical laboratory, skills lab, skill station that uses mannequins/
paper case/simulated patients/real patients as the context demands
Core A competency that is necessary in order to complete the

requirements of the subject (traditional must know)
Non Core A competency that is optional in order to complete the

requirements of the subject. (traditional nice know/ desirable to
know)
National guidelines Health programs as relevant to the competency that are part of the
national health program
Domains of learning
K Knowledge
S Skill
A Attitude
C Communication
5
Levels of competency
K Knows A knowledge attribute - Usually enumerates or describes
KH Knows how A higher level of knowledge - is able to discuss or

analyse
S Shows A skill attribute: is able to identify or demonstrate the
steps
SH Shows how A skill attribute: is able to interpret/ demonstrate a
complex procedure requiring thought, knowledge and
behaviour
P Performs (under Mastery for the level of competence - When done
supervision or independently under supervision a pre specified number
independently) of times - certification or capacity to perform
independently results
Note:
For the purposes of this document, a competency will be defined as a combination of one or
more objectives addressing one or more domains of learning.
One or more objectives contribute to a competency. Many competencies contribute to fulfilling
the attributes of a role. Many roles help fulfill the goal of the Indian Medical Graduate
In the table of competency - the highest level of competency acquired is specified and implies
that the lower levels have been acquired. Therefore when a student is able to SH - Show how an
informed consent is obtained - it is presumed that the preceding steps - the knowledge, the
analytical skills, the skill of communicating have all been obtained.
It may also be noted that attainment of the highest level of competency may be obtained through
steps spread over several subjects or phases and not necessarily in the subject or the phase in
which the competency has been identified.
The competencies defined in this document benchmark student achievement of the knowledge
skills attitudes communications and behavior at the end of the final year of medical college. By
its very nature, the majority of the performance aspect of these competencies will only be
fulfilled in the internship year (which these competencies do not address). Hence the highest
level of achievement for the majority of the competencies will be a show how in the Dreyfuss
model.
6
Section I
7
Extract from the revised Regulations on Graduate Medical
Education, 2012
The undergraduate medical education program is designed with a goal to create an “Indian
Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values and
responsiveness, so that he or she may function appropriately and effectively as a doctor of first
contact of the community while being globally relevant.
2. In order to fulfill this goal, the IMG must be able to function in the following ROLES
appropriately and effectively:
2.1. Clinician who understands and provides preventive, promotive, curative, palliative
and holistic care with compassion.
2.2. Leader and member of the health care team and system with capabilities to
collect analyze, synthesize and communicate health data appropriately.
2.3. Communicator with patients, families, colleagues and community.
2.4. Lifelong learner committed to continuous improvement of skills and knowledge.
2.5. Professional, who is committed to excellence, is ethical, responsive and accountable

to patients, community and profession.
8
Global Attitudinal and Communication Competencies addressed in the Roles of an Indian
Medical Graduate
4. Competencies: Competency based learning would include designing and implementing

medical education curriculum that focuses on the desired and observable ability in real life
situations. In order to effectively fulfill the roles as listed in item 2 above, the Indian Medical
Graduate would have obtained the following set of competencies at the time of graduation:
3.1. Clinician, who understands and provides preventive, promotive, curative, palliative
and holistic care with compassion
3.1.1. Demonstrate knowledge of normal human structure, function and development

from a molecular, cellular, biologic, clinical, behavioral and social perspective.
3.1.2. Demonstrate knowledge of abnormal human structure, function and development

from a molecular, cellular, biological, clinical, behavioural and social
perspective.
3.1.3. Demonstrate knowledge of medico-legal, societal, ethical and humanitarian

principles that influence health care.
3.1.4. Demonstrate knowledge of national and regional health care policies including the
National Rural Health Mission (NRHM), frameworks, economics and systems
that influence health promotion, health care delivery, disease prevention,
effectiveness, responsiveness, quality and patient safety.
3.1.5. Demonstrate ability to elicit and record from the patient, and other relevant
sources including relatives and caregivers, a history that is complete and relevant
to disease identification, disease prevention and health promotion.
3.1.6. Demonstrate ability to elicit and record from the patient, and other relevant
sources including relatives and caregivers, a history that is contextual to gender,
age, vulnerability, social and economic status, patient preferences, beliefs and
values.
3.1.7. Demonstrate ability to perform a physical examination that is complete and

relevant to disease identification, disease prevention and health promotion.
3.1.8. Demonstrate ability to perform a physical examination that is contextual to gender,
9
social and economic status, patient preferences and values.
3.1.9. Demonstrate effective clinical problem solving, judgment and ability to interpret
and integrate available data in order to address patient problems, generate
differential diagnoses and develop individualized management plans that include
preventive, promotive and therapeutic goals.
3.1.10. Maintain accurate clear and appropriate record of the patient in conformation with
legal and administrative frame works.
3.1.11. Demonstrate ability to choose the appropriate diagnostic tests and interpret these
tests based on scientific validity, cost effectiveness and clinical context.
3.1.12. Demonstrate ability to prescribe and safely administer appropriate therapies

including nutritional interventions, pharmacotherapy and interventions based on
the principles of rational drug therapy, scientific validity, evidence and cost that
conform to established national and regional health programs and policies for the
following:
a. Disease prevention,
b. Health promotion and cure,
c. Pain and distress alleviation, and
d. Rehabilitation and palliation.
3.1.13 Demonstrate ability to provide a continuum of care at the primary and/or

secondary level that addresses chronicity, mental and physical disability.
3.1.14 Demonstrate ability to appropriately identify and refer patients who may require
specialized or advanced tertiary care.
3.1.15 Demonstrate familiarity with basic, clinical and translational research as it applies
to the care of the patient.
10
3.2. Leader and member of the health care team and system
3.2.1 Work effectively and appropriately with colleagues in an inter-professional health

care team respecting diversity of roles, responsibilities and competencies of other
professionals.
3.2.2 Recognize and function effectively, responsibly and appropriately as a health care
team leader in primary and secondary health care settings.
3.2.3 Educate and motivate other members of the team and work in a collaborative and
collegial fashion that will help maximize the health care delivery potential of the
team.
3.2.4 Access and utilize components of the health care system and health delivery in a
manner that is appropriate, cost effective, fair and in compliance with the national
health care priorities and policies, as well as be able to collect, analyze and utilize
health data.
3.2.5 Participate appropriately and effectively in measures that will advance quality of
health care and patient safety within the health care system
3.2.6 Recognise and advocate health promotion, disease prevention and health care
quality improvement through prevention and early recognition: in a) life style
diseases and b) cancer in collaboration with other members of the health care
team.
3.3. Communicator with patients, families, colleagues and community
3.3.1 Demonstrate ability to communicate adequately, sensitively, effectively and

respectfully with patients in a language that the patient understands and in a
manner that will improve patient satisfaction and health care outcomes
3.3.2 Demonstrate ability to establish professional relationships with patients and

families that are positive, understanding, humane, ethical, empathetic, and
trustworthy.
3.3.3 Demonstrate ability to communicate with patients in a manner respectful of

patient’s preferences, values, prior experience, beliefs, confidentiality and
privacy.
3.3.4 Demonstrate ability to communicate with patients, colleagues and families in a
manner that encourages participation and shared decision-making.
11
3.4. Life long learner committed to continuous improvement of skills and knowledge
3.4.1 Demonstrate ability to perform an objective self-assessment of knowledge and

skills, continue learning, refine existing skills and acquire new skills.
3.4.2 Demonstrate ability to apply newly gained knowledge or skills to the care of the
patient.
3.4.3 Demonstrate ability to introspect and utilize experiences, to enhance personal and
professional growth and learning.
3.4.4 Demonstrate ability to search (including through electronic means), and critically
evaluate the medical literature and apply the information in the care of the patient.
3.4.5 Be able to identify and select an appropriate career pathway that is professionally
rewarding and personally fulfilling.
3.5. Professional who is committed to excellence, is ethical, responsive and accountable to

patients community and the profession
3.5.1 Practice selflessness, integrity responsibility, accountability and respect.
3.5.2 Respect and maintain professional boundaries between patients, colleagues and
society.
3.5.3 Demonstrate ability to recognize and manage ethical and professional conflicts.
3.5.4 Abide by prescribed ethical and legal codes of conduct and practice.
3.5.5 Demonstrate a commitment to the growth of the medical profession as a whole.
12
Assessment of Attitudinal and Communication Skills
Assessment is a vital component of competency based education. In addition to make

the pass/fail decisions, a very important role of assessment is to provide feedback to
the learner and help him/her to improve learning. The assessment in ATCOM nodule
has been designed with this purpose. The teachers should use this opportunity to
observe the performance and provide feedback based on their observations. In case a
student has demonstrated a performance, which is considered below expectation,
corrective action including counseling should be initiated. Many of the tools in this
module may appear subjective but coupled with the experience of the assessor, they
will serve a very useful purpose.
13
14
Section II
15
Learning modules for Professional year I
Number of Modules: 5
Number of hours: 34
1. What does it mean to be a doctor?
BACKGROUND
It is important for new entrants to get a holistic view of their profession, its ups and
downs, its responsibilities and its privileges. It is important to start this discussion early in
their careers when their minds are still fresh with the thrill of joining medical school.
Such a discussion will help them remember the big picture through the program and
remind them why they have chosen to be doctors.
COMPETENCIES ADDRESSED
1. Enumerate and describe professional qualities and roles of a physician KH
2. Describe and discuss the commitment to lifelong learning as an important part of physician KH
growth
3. Describe and discuss the role of a physician in health care system KH
4. Identify ,discuss physician’s role and responsibility to society and the community that she/ he KH
serves
LEARNING EXPERIENCE
When: Professional year 1
Hours: 8 (6 hours + 2 hours self directed learning)
This session can be delivered by 4 inter-dependent learning experiences
1. An exploratory session with the students enquiring from them why they chose to
become doctors and what do they think are the privileges and the responsibilities of
the profession. What do they expect from society and what do they think society
expects from them? What will they have to do and give up in order to meet their own
and society’s expectations. This is preferably done in a small group discussion.
16
2. A facilitated panel discussion involving doctors who are at various stages of their
careers (senior, midlevel, young) where doctors share their experiences and also
answer questions from students.
3. Self directed learning where students write a report from reflection based on sessions
1 & 2 and on other readings, TV series movies etc that they have chosen from the lay
press about doctor experiences.
4. Introductory visit to the hospital / community medical centres
5. A closure session with students to share their reflections based on 1, 2, 3 and 4 that
includes what they plan to do in the next 5 years in order to fulfill their professional
and personal roles as doctors.
6. A coat ceremony in the Foundation Course may be considered
ASSESSMENT
1. Formative: not required
2. Summative: not required
RESOURCES
1. Whitcomb ME. Academic Medicine 2007 82: 917
2. A white coat ceremony is a symbolic transition of the medical student in many

institutions done prior to their first clinical day in order to emphasize importance of
their new role as budding doctors.
3. Eisenberg C. It is still a privilege to be a doctor
4. Ofri D. Neuron overload and the juggling doctor. The Lancet 2010. 376: 1820 - 21
17
2. What does it mean to be a patient?
BACKGROUND
Doctors deal with human suffering throughout their professional careers. A balanced
approach to the patient care experience requires an understanding of patients, illnesses,
their concepts of suffering, coping mechanisms, the role of the doctor, an exploration of
empathy vs equanimity and the difference between healing and curing. In the first
professional year, an introduction to this fundamental but complex field is important. An
introductory experience will allow students to keep the patient experience in perspective
during their learning.
1..Enumerate and describe professional qualities and roles of a physician KH
2. Demonstrate empathy in patient encounters SH
LEARNING EXPERIENCE
Hours: 8 (6 hours + 2 hours self directed learning)
This session can be delivered by 2 interdependent learning experiences

1. An exploratory session with the students enquiring from them about their views on
health disease and suffering. Discussion could involve their personal ill health or
involving someone they know among their families and friends. How did that
experience affect them? What do they believe patients feel and go through? How does
it affect patient’s behaviour, outlook and expectations.
2. Students are assigned to patients in the hospital, interview them about their
experiences, reactions, emotions, outlook and expectations
3. Self directed learning where students write a report from reflections based on sessions
1 & 2 and on other readings, TV series movies etc
18
4. A closure session with students to share their reflections based on 1, 2 and 3 in order
that includes how they intend to incorporate the lessons learnt in their learning and
patient
ASSESSMENT
1. Formative: The student may be assessed based on their active participation and
presentation (written and oral)
2. Summative: SAQ
RESOURCES
Student narrative
THE STUDENT NARRATIVE IS A LEARNING METHOD THAT FOCUSES ON

THE FOLLOWING SKILLS:
1. elicit observe and record data

2. reflect on the data at a higher level of thinking and derive opinions and conclusions
3. communicate the observations and conclusions in a written and verbal form and
expand on an defend the conclusions with colleagues and teachers
4. Form new experiences and conclusions based on this discussion
19
3. The doctor patient relationship
BACKGROUND
The doctor patient relationship is the cornerstone to effective patient care. This session
builds on the previous two sessions which address doctors and patients and attempts to
explore the fundamental basis of the doctor patient contract, its rules, boundaries and
duties. It provides an introduction to the nature of relationship, importance of
communication, honesty, transparency, shared responsibility, equality and vulnerability.
While complex this introductory session will provide an overview for the student to
provide them with a perspective on the doctor patient relationship through their years of
study.
1. Enumerate and describe professional qualities and roles of a physician KH

2.. Demonstrate empathy in patient encounters SH
LEARNING EXPERIENCE

Hours: 7 hours (5 hours + 2 hours of self directed learning)
This session has several interdependent sessions
1. An anchoring large group session emphasising the fundamentals of the doctor patient
relationship (1 hour)
2. Self directed/Guided learning by students on the doctor patient relationship that

includes learning from resources, lay press, movies and media (2 hours)
3. An interactive discussion in a small group based on session 1 with illustrative cases.

Examples of cases that can used are provided in the resources section (2 hours)
(Or) a patient doctor encounter observation with checklist may be used
4. A closure session with reflection by the students based on items 1,2 and 3
20
ASSESSMENT
1. Formative: The student may be assessed based on their active participation in the
sessions. A written critique of the situations discussed in item 2 may be used for
formative assessment
2. Summative: Short questions for example a) rights of patients b) responsibilities of

patients c) duties of doctors d) boundaries of the doctor patient relationship
RESOURCES
1. http://www.cpso.on.ca/policies-publications/the-practice-guide-medical-
professionalism-and-col/principles-of-practice-and-duties-of-physicians
2. Cases for discussion:
1. A 53 year old man is seen by a cardiologist for chest pain lasting for a few minutes on
accustomed exercise for the past 3 weeks. After a detailed history and physical
examination the doctor orders an ECG which was normal. He further orders an
exercise stress test which showed reversible ischemia. The doctor orders an
angiogram. At the time the patient requests that he would like to have a second
opinion. The cardiologist explains that he has done everything correctly and that the
patient indeed requires an angiogram. The patient tells him that he cannot make a
decision unless he talks to his family doctor of 20 years. The cardiologist is offended
and tells the patient that he does not any longer wishes to see the patient
Points for discussion
Trust in the doctor patient relationship
Rights of a patient
Duties of a doctor
Is the request for a second opinion grounds to terminate the doctor patient
relationship
21
Resources for case 1: a. http://www.ama-assn.org/ama/pub/physician-
resources/medical-ethics/code-medical-ethics/opinion8041.page?
2. A young doctor has been taking care of a 86 year old woman for the past 2 years. She
had a fall 2 years ago and has been mostly bed ridden. She lives alone with just a
care taker and her children are abroad. She mostly requires preventive care and the
doctor makes house visits once a week. The doctor spends time talking to her each
visit and makes here feel comfortable. One day during such a visit the patient
expresses the view that her children have been ungrateful to her and that she intends
to call her lawyer today and divide her assets between the doctor and the caretaker
after her death. What should the doctor do?
Points for discussion
Boundaries in the doctor patient relationship
Trust and vulnerability in doctor patient relationships
Resources for case 2 : https://www.dovepress.com/getfile.php?fileID=1351
22
4. The foundations of communication 1
BACKGROUND
Communication is a fundamental prerequisite of the medical profession and bedside

clinical skills is crucial in ensuring professional success for doctors. This module
provides students with an introduction to doctor patient communication. The Kalamazoo
consensus statement provides a working model of teaching communication skills and
may be used to impart communication skills. The five As elements of behaviour change
model may also be used. Skills that will be introduced should include effective listening,
verbal and non verbal communication and creating respect in patient encounters.
COMPETENCY ADDRESSED
1. Demonstrate ability to communicate to patients in a patient, respectful, non SH

threatening, non- judgemental and empathetic manner
LEARNING EXPERIENCE
When: Professional Year 1
Hours: 7 hours (5 hours + 2 hours self directed learning)
What?:
This module includes 2 interdependent learning sessions
1. Introductory large group sessions on the principles of communication
2. Self directed/ Guided learning by students on the importance and techniques of

effective communication
3. Small group sessions on improving communication. These sessions can include either
videos or role play highlighting common mistakes in patient doctor communication
and allowing students to identify these mistakes and discussing how to correct them.
Situations that can be used include a) a noisy ambience with a distracted doctor who
is multitasking b) lack of eye contact c) doctor who keeps on interrupting patients and
not listening d) doctor who talks down to patients etc.
23
4. Closure session with reflection by students in a small group based on sessions 1,2 and
3 with emphasis on learning done and future directions
ASSESSMENT
sessions. A written critique of the situations discussed in item 3 may be used for
2. Summative: may be deferred for later phases
RESOURCES
1. Makoul G. Essential elements of communication in medical encounters: the

Kalamazoo consensus statement. Acad Med. 2001 Apr;76(4):390-3.
24
5. The cadaver as our first teacher
BACKGROUND
Medical students enter college and their first and lasting encounter is with the cadaver.
Respect for tissue as a teacher translates later into respect for human beings as teachers
and a lifelong respect for learning. Throughout the world the emphasis on “humanizing”
the cadaver with respect as first patient or first teacher has gained momentum.
1.Demonstrate respect and follows the correct procedure when handling cadavers and other S
biologic tissue
LEARNING EXPERIENCE
When: Beginning and End of Professional year 1
Hours: 4 (2+2) hours
What
4. An initial introductory session (large or small group) on the importance of biologic
tissue and cadavers in their learning. The discussion should focus on the fact that
some of these cadavers were unclaimed but also many of them are an anatomic gift by
families and how respect for them is importance and also on how tissue must be
respected. The session should include safe and clean handling and disposal of biologic
tissue (2 hours).
5. A session at the end of phase is a small group or large group discussion with reflective
presentations by students on how the cadaver helped them learn, their experience with
dissection etc. These sessions should allow students to display their creativity and
may include prose, poetry and sketches etc. An example of such a project is found in
the resources section (2 hours).
25
ASSESSMENT
sessions. The respect and the manner in which students handle biologic tissue
throughout the phase may be part of the overall formative assessment of the student.
2. Summative: may not be required
RESOURCES An example of the project is found here:

http://medicine.yale.edu/education/donation/reflections/
26
Learning modules for Professional Year 2
Number of modules: 8
Number of hours: 35
BACKGROUND
Communication is a fundamental prerequisite of the medical profession and beside skills is

crucial in ensuring professional success for doctors. This module continues to provide an
emphasis on effective communication skills. During professional year two the emphasis is on
active listening and data gathering
1. Demonstrate ability to communicate to patients in a patient, respectful, non SH

threatening, non- judgemental and empathetic manner
LEARNING EXPERIENCE
Hours: 5 (1 + 2 +2)
What?:
1. Introductory small group session on the principles of communication with focus on

opening the discussion listening and gathering data
2. Focused small group session with role play or videos where students have an
opportunity to observe critique and discuss common mistakes in opening the
discussion, listening and data gathering
3. Skills lab sessions where students can perform tasks on standardised or regular
patients with opportunity for self critique, critique by patient and by the facilitator
27
ASSESSMENT
1. Formative: Participation in session 2 and Performance in session 3 may be used as
part of formative assessment
2. Summative: may be deferred
RESOURCES
2. Hausberg M Enhancing medical students' communication skills: development and
evaluation of an undergraduate training program. BMC Medical Education 2012,
12:16
28
2. The foundations of bioethics
BACKGROUND
An introductory session in a large group that provides an overview of the evolution and the
fundamental principles of bioethics including the cardinal pillars of ethics including (autonomy,
beneficence, non maleficence and justice)
1. Describe and discuss the role of non maleficence as a guiding principle in patient care KH
2. Describe and discuss the role of autonomy and shared responsibility as a guiding principle KH
in patient care
3. Describe and discuss the role of beneficence of a guiding principle in patient care KH
4. Describe and discuss the role of a physician in health care system KH
5. Describe and discuss the role of justice as a guiding principle in patient care KH
LEARNING EXPERIENCE

Hours: 2
What?:
This module is a large group learning session that can be made interactive by illustrative
examples
ASSESSMENT
1. Formative:
2. Summative: Short notes on a) Autonomy b) Beneficence c) Non maleficence
RESOURCES
A review of the four principles of bioethics is found here:
http://archive.journalchirohumanities.com/Vol%2014/JChiroprHumanit2007v14_34-
40.pdf
29
3. Health care as a right
BACKGROUND
This session is aimed at introducing students to health care systems, their access, equity
in access the impact of socio economic situations in determining health care access and
the role of doctors as key players in the health care system
1.Describe and discuss the role of justice as a guiding principle in patient care KH
LEARNING EXPERIENCE
Hours: 2
What?:
This module may be done as a participatory student seminar with debates on the more
controversial issues to increase a reflective process.
Focus may be on 1. Is health care a right? 2. What are the implications of health care as a
right? 3. What are the social and economic implications of health care as a right 4. What
are the missing links (see resource 2 for a brief overview) and 5. What are the implications
for doctors
ASSESSMENT
1. Formative:
2. Summative: Short note on a) barriers to implementation of health care as a universal
right
RESOURCES
1. The universal declaration of human rights . http://www.un.org/en/documents/udhr/
2. Missing links in universal health care
http://www.thehindu.com/opinion/lead/missing-links-in-universal-health-
care/article6618667.ece
30
4. Working in a health care team
BACKGROUND
This session is aimed at introducing students to health care systems and their functioning.
It allows students to “tag along” members of health care teams observe their work and
gain experience about their perspectives. It is hoped that this experience will help
students understand the need for collaborative work in health care, how each member of
the health care team is important and also develop respect
1 Demonstrate ability to work in a team of peers and superiors S
2. Demonstrate respect in relationship with patients, fellow team members, superiors and other S
health care workers
LEARNING EXPERIENCE
Hours: 6 hours ( 4 hours tag along + 2 hours discussion)
What?:
This module may be done as two interdependent sessions
1. A “tag along” session where students spend time with other health care workers
including nurses technicians and others, observe their work, their interactions
conduct a small interview with them and write a narrative based on this interview
2. A small group discussion which is based on the students observation experiences
reflections and inferences and what must be done by them to work as an integral part
of the health care team
ASSESSMENT
3. Formative: Student participation in session 2 with assessment of submitted narrative

4. Summative:
RESOURCES
31
5. Bioethics continued - Case studies on patient autonomy and
decision making
BACKGROUND
The important parts of ethical care of the patient are best learnt in a hybrid problem based
format with additional lectures and other sessions that allow students to learn
collaboratively with different learning styles. A guide for case discussion is provided in the
resources section of this module and may be used as a guide for other modules. The key
element is that students remain in the same group with the same facilitator since groups
mature in their learning over time.
The first module has a discussion on patient autonomy right to know and disclosure
Hours : 6
Introduction and group formation : 1 hour
Case 1 Case introduction: 1 hour
Self Directed learning : 2 hours
Anchoring lecture: 1 hour
Case Resolution : 1 hour
CASE 1. THE COVER UP
You evaluate Mrs Lakshmi Srinivasan who is a 48 year old woman presenting with
lymphadenopathy. She had been complaining of mild fever and weight loss for the past 4 -
5 months. Examination of the neck shows large rubbery lymph nodes that are present also
in the axilla and the groin. There is a palpable spleen. She is accompanied by her caring
husband.
Lakshmi undergoes a lymphnode biopsy and the pathologist calls you and tells you that she
has a lymphoma. That evening Mr Srinivasan comes in first into your office and leaves the
32
report on your table. As you read the description you realise that the final diagnosis has
been altered to Tuberculosis by whitening out the pathologist’s report. When you look up
he tells you - Sir I googled lymphoma - it is almost like a cancer. My wife can’t handle that
diagnosis. She has always been a worried frightened person. I want you to tell my wife that
she had TB. She is waiting outside doctor. I thought I will call her in after I have a chat
about this with you.
Identify discuss and defend medico-legal socio-cultural and ethical issues as it pertains to
patient autonomy, patient rights and shared responsibility in health care
POINTS FOR DISCUSSION
1. Does the patient have a right to know their diagnosis

2. What should the patient be told about their diagnosis therapy and prognosis
3. How much should be told to a patient about their illness?
4. Are there exceptions to full disclosure? Can family members request withholding of
information from patient?
ASSESSMENT
sessions
2. Summative: Short questions on 1) Define patient autonomy 2) Contrast autonomy
and paternalism 3) What are the responsibilities of patients and doctors in shared
decision making 4) What is full and reasonable disclosure?
33
RESOURCES
Guidelines for Case Discussion
A hybrid problem oriented approach is one of the most effective ways for students to
explore the various facets of “real life issues” that will confront them in their careers. In
addition to problem solving skills case discussions promote collaborative learning, team
work, reflection and self directed learning. The cases presented in this booklet represent
competencies that lend themselves best to this form of learning.
The figure provided below explains the suggested format of the hybrid problem solving
method:
1. Two or more learning sessions are recommended for each session with ample time for
self directed learning and other learning activities between each session
2. A case is introduced into a small group and the facilitator facilitates a small group
discussion where,
a. initial reactions of the group to the case obtained
b. the underlying ethical legal and societal principles of the case are elicited
c. learning objectives for the case are developed
d. Learning tasks are assigned for members of the learning groups
e. Learning resources are identified
34
The suggested location for such a session is a small group discussion area which requires a
small table with seating for 8 - 10 students
Suggested duration for such a session is 1 hour
A board with chalk or marker is also required
3. Learning occurs in between sessions by the learners through following:
1. Self directed learning by study of identified learning resources

2. Self directed learning through study of online learning resources
3. Identification of legal ethical and social precedents for the given settings
4. Obtaining opinions from seniors in the profession on their impressions on the setting
4. Reinforcement of the fundamental concepts underlying the case can be done through a
large group learning session (lecture or equivalent) in between the small group sessions
35
5. In the second session the small group discussion is focussed on closure of the case (or the
part of the case) for which learning objectives were identified for in the first session. The
facilitators may guide the discussion based on the ethical legal and societal and
communication aspects of the case. The group discusses the case based on the learning
done in between the session and provides suggestions and alternatives on the approach
for doctors to follow. It must be reiterated that there may be not be one correct way to
resolve a case. The approach will be to allow students to reflect, make a choice and
defend their choice based on their values and learning.
The suggested location duration and requirements are as in item 2
6. Once the case (or part of the case) is resolved as in item 5, the next case (or the next part
of the case) is introduced as in item 2.
36
6. Bioethics continued: Case studies on autonomy and decision
making
BACKGROUND
Also see module 4. This introduces the student to further issues in autonomy including
competence and capacity to make decisions.
Hours: 5
Introduction of case 1
Self directed learning 2
Anchoring lecture: 1
Discussion and closure of case 1
Case 2. Life on a machine
You are taking care of 78 year old Mrs. Mythili who was living all alone in an apartment
with only a live in caretaker 3 streets away from your clinic. She is a widow and her only
son emigrated to the US 32 years ago. He visits her once a year. One year ago she had a fall
with a hip fracture that healed badly. She has hypertension which is reasonably controlled
on medications. She continues to come to your clinic once a month. Four months ago she
spent some time talking about her sister who recently died following metastatic breast
cancer. “My sister suffered a lot Doctor - they put a tube down her throat to breathe. Even
when her heart stopped they kept thumping her chest - it was awful. If I ever fall sick I
don't want to go through all this. Promise me doctor that you won’t do all of this to me. I
have lived all alone since my husband died but i have lived independently - now i don't
want to depend on a machine to live”. You had reassured her that she would be ok and this
was just the recent death of her sister affecting her. On subsequent visits she would still
bring up this issue and state that there was no use of her living as a burden to anyone and
that no one should endure what her sister had undergone.
One day you get a call from the Emergency Room of the local hospital stating that Mrs.
Mythili has been admitted by the caretaker. She had developed fever and shortness of
breath. She was brought hypoxic to the emergency room and they had intubated her. Chest
X ray revealed a large pneumonic patch. Laboratory testing revealed hyponatremia.
37
When you visit her she is somewhat drowsy, intubated and restrained. The nurse tells you
that she is sometimes lucid at other times not even able to recognise her son who was there
since this morning. She points out at the ET and makes a pleading gesture to remove it. Her
son accosts you in the hall way. He tells you that he got a call while he was traveling in
Singapore and took the first flight out to be with his mom. He was very distressed at his
mother’s health and that he wants “everything” possible done for her. You ask him if she
had ever indicated what she wanted to be done if she were to require hospitalization and
intubation - he says that he used to speak her every month on the phone and she was always
cheerful and enquiring about her grandchildren but did not talk about her health.
refusal of care including do not resuscitate and withdrawal of life support.
POINTS TO BE DISCUSSED
1. Extent of patient autonomy
2. Elements in decision making : Competency Vs Capacity
3. Surrogacy in decision making
4. Autonomy vs beneficence
5. How much do family wishes count
6. Legal ethical and social aspects of Do not resuscitate
ASSESSMENT
sessions
2. Summative: Short questions on 1) What determines decision making capacity and
competency, 2) Who has the right to make decisions for a patient who cannot
determine for himself
RESOURCES
1. See Module 4
38
7. Bioethics continued: Case studies on autonomy and decision
making
BACKGROUND
Also see module 4. This introduces the student to further issues in autonomy including
informed consent and refusal.
Hours: 5
Case 3. Who is the doctor?
A 54 year old man Mr Surendra Patel is admitted for acute chest pain in a medical centre. His father
had died of a myocardial infarction at the aged of 60. Two years ago his brother had been admitted
to a hospital with a myocardial infarction and had died after complications following an
angioplasty. Mr. Patel is a diabetic and is on multiple oral hypoglycemic agents with moderate
control. He is a businessman with his own small industry. After initial stabilization. the patient is
comfortable and pain free after analgesics nitrates and statins. Preliminary blood work and ECG
confirm an acute coronary event. The next morning the senior cardiologist makes rounds and
reviews the patient. “You have unstable angina Mr. Patel and require an angiogram. You may also
require either a stent or coronary bypass after the procedure. The nurse will provide you with the
necessary paperwork. Please sign it and I will plan the procedure for 4.35 AM tomorrow
morning.”.“Doctor saheb“asked Mr. Patel, “I am not comfortable with the idea of an angiogram;
my brother died on the table when an angioplasty was being done. Aren’t there other tests that you
can do? I am not happy with this option.”“Your brother would have had it with someone else Mr.
Patel - I have the best hands in town; nothing will happen when I do it” retorted the cardiologist.
“But aren’t there any other options to see what I have? Is this is the only test? I have read
somewhere that you can do a CT angiogram, persisted Mr Patel. “Are you the doctor or am I the
39
doctor?” retorted the cardiologist angrily. “If you are ready to do as I say sign the papers and I will
see you in the cath lab tomorrow. Otherwise you are free to get discharged” He stomped out.
consent for surgical procedures
7. Extent of patient autonomy

8. Informed consent and informed refusal
9. Conflict between autonomy and beneficence
10. What should the patient be told about a procedure
11. What must the informed consent include?
ASSESSMENT
sessions
2. Summative: Short questions on 1)What is informed consent? 2) What is informed
refusal
RESOURCES
See module 4
40
8. What does it mean to be family member of a sick patient
BACKGROUND
Doctors deal with human suffering throughout their professional careers. A balanced
approach to the patient care experience requires an understanding of support systems of
patients, priorities coping and emotions of families, the role of the doctor, an exploration
of empathy vs equanimity and the difference between healing and curing and support.
LEARNING EXPERIENCE
Hours: 6 (includes 2 hours of SDL)
This session can be achieved by 2 interdependent learning experiences
1. Option A: Students are assigned to patients in the hospital, interview their family
about their illnesses, experience, reactions, emotions, outlook and expectations (or can
be done in a controlled environment with standardised patients
Option B: Family members of patients with different illnesses may with permission
be brought to a large group discussion and an interactive discussion (based on the
items outlined in option A. Can use standardised patients)
2. Self directed learning where students write a report from reflection based on sessions
1 & 2 and on other readings, TV series movies etc
3. A closure session with students to share their reflections based on 1, 2 and 3 in order
that includes how they intend to incorporate the lessons learnt in their learning and
patient
ASSESSMENT
sessions and submission of the written narrative
2. Summative: Short questions on the role of doctors in the community and
expectations of society form doctors
eg. 1. What is empathy? What is the role of empathy in the care of patients?
41
RESOURCES
STUDENT NARRATIVE
The student narrative is a learning method that focuses on the following skills:
1) elicit observe and record data

2) reflect on the data at a higher level of thinking and derive opinions and conclusions
3) communicate the observations and conclusions in a written and verbal form and
expand on an defend the conclusions with colleagues and teachers
4) Form new experiences and conclusions based on this discussion
42
Number of hours: 25
BACKGROUND
Communication is a fundamental prerequisite of the medical profession and beside skills
is crucial in ensuring professional success for doctors. This module builds on the listening
skills developed in year 2. The Kalamazoo consensus statement provides a working
model of teaching communication skills and may be used to impart communication skills.
Skills that will be introduced should include “dealing with emotion”.
Demonstrate ability to communicate to patients in a patient, respectful, non threatening, non SH

judgemental and empathetic manner
Hours: 5 (1 + 2 +2)
What?:
dealing with emotions
2. Focused small group session with role play or video where students have an
opportunity to observe critique and discuss common mistakes when dealing with
emotion
patients with opportunity for self critique, critique by patient and by facilitator
ASSESSMENT
2. Summative: may be deferred
43
RESOURCES

12:16
44
2. Case studies in bioethics - Disclosure of medical errors
BACKGROUND
Also see module 4 in year w. This introduces the student to further issues in autonomy
including full disclosure of mistakes
Hours: 5
Case 3. Seeking immunity
It was a busy clinic day and getting worse. Patients were getting impatient. Time was marching
and details were becoming a casualty. 5 year old Madhumita comes in with her mother. She has
asthma and under your care. You examine her and adjust your prescriptions and start your good
byes. At that time her mother reminds you that she is due for her booster shots Oh that you frown
- and tell her to wait for a few minutes and that you will have the nurse load the injection and
come to the adjoining room and give the injection. You ask the nurse to load the injection and
keep it for you over the intercom
You continue to see patients. After a couple of patients the mother knocks indicating that she is
getting late. You get up and go to the next room. The nurse is not there but you find a loaded
syringe. You quickly administer the injection to the child and get back to seeing patients.
A few minutes later the nurse calls back saying that she has loaded Madhumita’s injections. You
drop everything and go into the injection room and confront the nurse “But doctor that was
gentamicin I had loaded for Mrs Asif” she says
45
Demonstrates an understanding of the implications and the appropriate procedure and
response to be followed in the event of medical errors
1. Medical errors in clinical care
2. The correct approach to disclosure of medical errors
3. Consequence of failure to disclosure of medical errors including medico legal social and loss
of trust
ASSESSMENT
1. Formative: The student may be assessed based on their active participation in the sessions
including role play on disclosure of errors
2. Summative: Short questions on 1)What is the ethical standard in dealing with medical errors
RESOURCES
46
BACKGROUND
Communication is a fundamental prerequisite of the medical profession and beside skills is

crucial in ensuring professional success for doctors. This module continues to provide an
emphasis on effective communication skills. During professional year three the emphasis is on
administering informed consent.
23. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, SH
non judgemental and empathetic manner
18. Identify, discuss and defend, medico-legal, socio-cultural and ethical issues as they KH
pertain to consent for surgical procedures
33. Administer informed consent and appropriately address patient queries to a patient SH
undergoing a surgical procedure in a simulated environment
LEARNING EXPERIENCE

Hours: 5 (1 + 2 +2)
What?:
5. Introductory small group session on on the principles of communication with focus on

administering informed consent
6. Focused small group session with role play or video where students have an opportunity to
observe critique and discuss common mistakes in administering informed consent
7. Skills lab sessions where students can perform tasks on standardised or regular patients with
opportunity for self critique, critique by patient and by facilitator
ASSESSMENT
1. Formative: Participation in session 2 and Performance in session 3 may be used as part of
2. Summative: A skill station in which the student may administer informed consent to a
standardized patient
47
RESOURCES
1. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo
consensus statement. Acad Med. 2001 Apr;76(4):390-3.
2. Hausberg M Enhancing medical students' communication skills: development and evaluation
of an undergraduate training program. BMC Medical Education 2012, 12:16
48
4. Case studies in bioethics - Confidentiality
BACKGROUND
Also see module 4 in year 2. This introduces the student to confidentiality and its limits
Hours: 5
Case 5. Do not tell my wife

Ramratan was in tears. “How is it possible doctor? We are expecting our son soon. He will not
have a father.”Ramratan had seen you with vague aches, fever, weight loss and cough with
expectoration not responsive to antibiotics for the past three months. He had a right mid zone
lung shadow on X ray and the sputum was positive for AFB. On questioned he had revealed that
he had unprotected sexual intercourse with multiple partners 3 years ago. “But I stopped after I
married Danno doctor - i am faithful to her”. An informed consent was obtained and HIV
screening test was ordered and it was positive. A confirmatory test was subsequently obtained
and it was also positive. A CDC count was < 100. Ramratan had come to discuss the results of his
HIV test. After consoling him and writing out prescriptions for TB and HIV you mention to him
that he must bring his wife for testing. “This is important Ramratan“you add - “especially since
she is pregnant.”
“Absolutely not sir!” he explosively retorts. That is not possible. I will be humiliated. Danno will
leave me and go. I will never be able to see my son. I will become an outcast in our community. I
can’t live without my wife doctor. I urge you doctor - don't do this. I forbid you…
Identify discuss and defend medico-legal socio-cultural and ethical issues as it pertains
to confidentiality in patient care
49
1. The primacy of confidentiality in patient care

2. What does confidentiality entail
3. When can confidence be breached with who and how
4. Confidentiality and diseases that may engender patients and society
ASSESSMENT
1. Formative: The student may be assessed based on their active participation in the sessions
2. Summative: Short questions on 1) What are instances in which confidentiality of patient
information may be breached
50
5. Case studies in bioethics - Fiduciary duty
BACKGROUND
Also see module 4 in year w. This module discusses doctor’duty including fiduciary
duty (Fiduciary)
Hours: 5
Case 6. Is he a human being or a machine?
It was a long day and the surgeon has finished four surgeries. Two of these were
complicated surgeries requiring all his experience and skills. But it was gratifying. After
that he had seen 40 outpatients. He was the most successful doctor in that small
community and had provided service for the past 25 years. He had finished his outpatient,
ate his meal and went to bed. The night duty doctor who usually comes around 10 pm to
sit in the clinic and answer calls from inpatients had taken the night off - he had entrance
exams next day. Praying it would be a quiet night he told his wife - I am very very tired;
make sure that I am not disturbed.
He woke up at 1AM with the sounds of commotion downstairs. He could hear signs of
arguing - Call the doctor he must come down. He could hear his wife - “please take her to
the nearest government hospital. This is a surgical nursing home and doctor is very tired -
I cannot wake him up.”He could hear irate patient attendents - but your board says open
24 hours for emergency. The town hospital is 15 kms. away I don't know if my daughter
will make it. By the time the venom will reach the brain. Call your husband now madam.
This is not correct”. His wife retorted “He has worked from 4 AM this morning - he has
gone to sleep very tired asking me not to wake him up. Is he the only doctor in town. Is
51
he a human being or a machine. Why are you being unreasonable?”. The surgeon reached
out for his clothes…
1. Identify, discuss and defend medico-legal socio-cultural professional and ethical issues as
it pertains to the doctor patient relationship (including fiduciary duty)
2. Identify, discuss doctor’s role and responsibility to society and the community that she/
he serves
1. Duty of a doctor
2. The concept of fiduciary duty
3. Balancing personal and professional life
4. Where to draw the line
ASSESSMENT
sessions
2. Summative: Short questions on What is fiduciary duty?
52
Number of hours: 45
BACKGROUND
Communication is a fundamental prerequisite of the medical profession and beside skills
is crucial in ensuring professional success for doctors. This module continues to provide
an emphasis on effective communication skills. During professional year three the
emphasis is on communicating diagnosis prognosis and therapy effectively.
23. Demonstrate ability to communicate to patients in a patient, respectful, non threatening, SH

non judgemental and empathetic manner
34. Communicate diagnostic and therapeutic options to patient and family in a simulated SH
environment
LEARNING EXPERIENCE
Hours: 7 (1 + 2 + 4)
What? :
This module includes 3 inter-dependent learning sessions

administering communication of diagnosis prognosis and therapy
53
2. Focused small group session with role play or video where students have an
opportunity to observe critique and discuss common mistakes in communicating
diagnosis prognosis and therapy
patients with opportunity for self critique, critique by patient and by facilitator
ASSESSMENT
2. Summative: A skill station in which the student may communicate a diagnosis
management plan and prognosis to a patient
RESOURCES
12:16
54
2. Case studies in medico-legal and ethical situations
BACKGROUND
Also see module 4 in year 2. This module discusses the medico legal and ethical conflicts
in adolescents
Hours: 5
The Child’s Child
You are the family doctor of Mr. Ravikiran for the past 10 years. One evening toward the
end of a busy clinic Mr. Ravikiran, his wife and daughter come in. The usual smiles were
absent. There was silence for a few minutes and when you asked what is the matter, Mr.
Ravikiran points out to his wife and tells her that you tell him.
Reluctantly and with tears bursting in her eyes she tells you that her only daughter Sapna
who is 16 years old had amenorrhea for 4 months. She had taken her to the gynaecologist
who after examining her ordered an ultrasound scan of the abdomen which showed a 16
week fetus. After much argument and discussion, the family requested the gynaecologist
to perform a medical termination of pregnancy (MTP). Sapna, however refuses to
undergo a MTP - claiming that the child is her expression of love and that she believes
that taking away her baby’s life will be tantamount to murder.
The parents are embarrassed to face society and feel that continuing the pregnancy will
harm the daughter. As parents they feel that they have a right to determine if their
daughter should undergo a medical termination or not. The daughter feels that she is old
enough.
55
As their family doctor they would like you to help them through this nightmare.
Identify discuss and defend medico-legal socioeconomic and ethical issues as it pertains
to abortion / medical termination of pregnancy and reproductive rights

1. Who makes health care decisions for adolescents?
2. What are the medical implication of the MTP act?
3. Are there provisions for emancipated minors?
4. Should adolescents be included in the decision making process?
ASSESSMENT
sessions
2. Summative: Short questions on the medical termination of pregnancy act
56
3. Case studies in medico-legal and ethical situations
BACKGROUND
Also see module 4 in year 2. This module discusses the medico legal and ethical
conflicts in organ transplantation.
Hours: 5
The angry brick kiln owner
68 year old Muthukumar is your patient for the past 8 years. You are his family doctor and he
seldom does anything without consulting you first. A self made man with no formal
education he is a successful brick kiln owner in the suburbs of the city. He has
hypertension and diabetes even before the time he has been under your care.
Today he enters your office distraught and angry and unable to speak. You calm him
down…
Muthukumar is a known diabetic and hypertensive for the past 23 years and has been on
multiple medications in the past. Six years ago he was diagnosed chronic renal failure.
For the past one year his renal function has been worsening. The nephrologist that you
had recommended had suggested dialysis and he has been on hemodialysis thrice a week
for the past 6 months. At the last visit he was suggested renal transplantation.
Muthukumar continues “I saw that kidney doctor today Doctor. He said that I can get a
new kidney instead of my old one. He told me that I need someone to donate a kidney to
me. I told him that I don't need anyone’s charity and I can buy one donor. That doctor
laughed at me sir - he told me that i cannot buy any kidney and that one of my relatives
57
must donate it to me - He even said that my younger brother is probably the best person
to donate the kidney. How dare he sir - my younger brother who is more dear to me than
a son. I have so many employees in my factory who will line up to give me a kidney.
Why is this doctor talking like this?
Identify discuss medico-legal socioeconomic and ethical issues as it pertains to organ
donation

1. Can a kidney be bought?
2. What are the health economic outcomes of selling a kidney
3. What are the medical legal and ethical implications of the organ transplantation act?
ASSESSMENT
sessions
2. Summative: Short questions on 1) the organ transplantation act
58
4. Case studies in ethics empathy and the doctor-patient
relationship
BACKGROUND
Also see module 4 in year 2. This module discusses some nuances in the doctor patient
relationship including - failure of therapy, termination of relationships etc.
35. Communicate care options to patient and family with a terminal illness in a simulated SH
environment
Hours: 5
A letter from the grave

Respected doctor:
I am writing this letter with extreme sadness. As you may know that it has been that three
months have passed since my wife and your patient Mrs Alka Chaturvedi has passed
away. I am writing this letter not with anger or with spite; i am writing this only with the
intent that my wife’s death not be in vain and that the lessons that can be learned from the
way you took care of her may be valuable to other patients in your care and that they will
receive the compassion and care from you that Alka never received.
As you may recall Alka was diagnosed with breast cancer 5 years ago. We rushed to you
knowing your reputation as a talented oncologist and we were not disappointed. Your
aggressive approach to the disease made all the difference. Surgery and aggressive
chemotherapy while distressing helped Alka beat the disease and live disease free for 2
years. We were very happy and were and still are very grateful to you. But fate had
59
ordained that our joy will be short-lived. The disease came back with a vengeance. Even
at this time you did not give up hope and took on the disease like a warrior but then there
came a time that it was clear that the disease had won. We were devastated.
Alka looked upto you as a doctor to provide her with support but it looked like that you
were unable to confront the failure. While you did prescribe pain medications and your
office helped us find a home nurse you were reluctant to meet Alka or talk to her. When
we called for appointments your office would tell us to contact our family doctor for pain
medications. When we did get to see you would not even look at Alka’s eyes. You would
distractedly talk to her refill her pain medications and dismiss us quickly. It was as if we
were seeing a different doctor than the one we had seen when all was well. And when
Alka was admitted to the hospital where she breathed her last you would not even come
and see her. We made so many requests for you to come and visit with her. I even called
and told you that it would mean so much for her to see you before she departs but you did
not.
Would it have been too much for you to come and hold her hand for a minute or say a
kind word. Doctor - I am not as learned as you are but patients come to you and repose
their faith in you to help them through their illness. We come to you not with the
expectation that a cure is always possible but always with the expectation that you will
support us in coping with the disease and the tremendous effects it has on our lives. We
don't always expect you to succeed but we always expect you to show us care and
compassion. I hate to point to out doctor that you abandoned Alka when it was clear that
she will not be a trophy that you can parade as a success. You abandoned Alka and us at
the time we needed you most. You sir, abandoned us that we were most vulnerable.
I write this to you not to fault your knowledge skill which is considerable. I bear you no
ill will. I am grateful that you gave Alka and our family a few years of togetherness. I
only write to remind you that knowledge and skill are not sufficient for a doctor.
Compassion, empathy and non abandonment are superior virtues. I can only hope that
Alka’s experience with you will help you take care of your other patients who may not all
be successes as you seem to define it. If only you provided patients empathy all your
patients will be your successes irrespective of outcome.
Sincerely
60
1. The role of a doctor as a healer
2. Failure of treatment and its implications for the Doctor Patient Relationship
3. Empathy and patient care
4. Can the doctor patient relationship be terminated
5. Hospice care
ASSESSMENT
sessions
2. Summative: Short questions on 1) Empathy 2) Doctor responsibilities in the doctor
patient relationship 3) Doctor’s responsibilities in the Care of the terminally ill patient
61
5. Case studies in ethics and the doctor - industry relationship
BACKGROUND
Also see module 4 in year 2. This module discusses some nuances in the doctor industry
relationship
Hours: 5
The Launch
It was the end of the morning session in your clinic. You were getting ready to have
lunch when you are told that a drug company representative wants to meet you. You let
him in and he tells you. “Sir - we are launching a new combination drug next month. We
are planning a one hour meeting to introduce you to the product. The meeting will be
held in Singapore and we will fly you and your spouse business class. All expenses will
be borne by us. You can stay for 3 days there sir. The meeting will be held in a cruise
ship. The meeting will be only for one hour sir - After that there will be a gala dinner and
entertainment sir. Also to compensate you for losing your practice for those three days
we will pay you an honorarium of Rs 25000 for each day that you are there. This is our
way of saying thank you for all the support in the past and the support that you are going
to provide in making this new molecule a success.”
COMPETENCY
Identify discuss and defend medico-legal socio-cultural professional and ethical issues as
it pertains to the doctor - industry relationships
62
1. The influence of pharmaceutical industry on doctor’s prescription behaviour
2. The limits of doctor industry engagement
ASSESSMENT
sessions
2. Summative: Short questions on 1) Can doctors accept gifts from pharmaceutical
industry? Explain your choice
RESOURCES
The MCI, AMA Code of Medical Ethics
63
6. Case studies in ethics and the doctor - industry relationship
BACKGROUND
Also see module 4 in year 2. This module discusses some nuances in the professional
relationships and conflicts there of
Hours: 5
The Offer
You get a call from the secretary of the promoter of the largest and most successful
corporate hospital in the city asking for an appointment for you with him. You are
perplexed but make it to the appointment. You enter a large well appointed room. The
owner of the hospital gets up from his chair welcomes you and asks you to sit down.
“Welcome to our hospital doctor. After a few minutes of empty banter he says - My
marketing executives tell me that you are the most successful practitioner in this area. As
you know we are a growing organisation; we are eager to partner with you. Doctor I
know that you use the services of another hospital here but we can make it worth your
while to consider”. You look enquiringly. “He continues. In addition to your professional
charges that you can determine we can provide you with 20% of the hospital’s collections
from your patient including radiology and laboratory charges. If you send us your
outpatients for consultations, laboratory or radiology we will give you back 30% of our
collections. We hope that you will consider this doctor and become part of our extended
family.”
64
Identifies conflicts of interest in patient care and professional relationships and describes
the correct response to these conflicts

1. Fee splitting and other practices
2. Can doctors become enterpreneurs?
3. Can doctors own pharmacies or hold stock in pharmaceutical companies?
4. What comprises professional conflict of interest?
ASSESSMENT
sessions
2. Summative: Short questions on 1) Fee splitting and its implications for patient care
2) conflicts in professional relationships
65
7. Case studies in ethics and patient autonomy
BACKGROUND
Also see module 4 in year 2. This module discusses ethical issues in care of children
Hours: 5
The “Cruel”Parents
A six year old boy is brought to the emergency room with a single episode of generalised
tonic clonic convulsions. The child is stabilised on IV anti epileptics and an oral anti
epileptic is started. There are no further episodes during the hospitalisation. The child is
scheduled for an EEG and an MRI. Through this time the family had been cooperative
with the treatment. The parents appear to be educated and appeared to care for their son
deeply. When further investigations are suggested, the parents come back to you and say
- “doctor thank you for helping us at a time of need but we feel that it is against our faith
to continue allopathic care. We have decided to go back to our ancestral village and our
family shrine where we have scheduled a ritual tomorrow. Our priest has promised us
that the child will be disease free if we perform the rites required. This convulsion is a
result of the curse of our ancestors and if we do the requisite rituals to please them the
child will be cured of the disease. Please do not do anymore tests or treatments. We are
stopping the medications tomorrow and will get discharged. Thank you.”…
COMPETENCY
Identify discuss and defend medico-legal socio-cultural and ethical issues as it pertains
to health care in children
66
1. Who has the right to decide for children?

2. Can parents refuse treatment even in life threatening situations?
3. What if there is a conflict?
ASSESSMENT
sessions
2. Summative: Short questions on 1) Parental consent
67
8. Dealing with death
BACKGROUND
Thanatology is a branch of science that deals with death. Death is an event that medical
students will inevitably face during the course of their professional career. Dealing with
death empathetically and at the same time not being overwhelmed by it is an important
coping skill for doctors
LEARNING EXPERIENCE
Hours: 5
THE EMPTY BED
You are a house surgeon in the night shift of the ICU. A 19 year old girl Sharmila is
wheeled in to the ICU. She has a complicated history. She had surgery for cyanotic
congenital heart disease at age 8. She has a history of severe asthma often requiring
admission for steroids. She lives in a home near a construction site and recently the
attacks have flared up. She now has frequent admissions for asthma exacerbations. She is
now constantly on steroids. In the last month she has had 3 admissions. But she fights it
bravely. She carries her books with her when she comes in and after the attack settles
down she sits quietly reading. Despite the struggle you noticed that the staff nurses liked
her. She was positive and charming. Today was no different but the attack seemed worse.
In the ER the FEV1 was horrible. They had pumped her with steroids put her on
continuous nebulization, an aminophylline infusion was in place when you received her.
The smile was smaller but there. The face was cushingoid with all the steroids and the
body looked tired. She was moved to her usual bed number 9. Your shift was getting over
68
at 7 a.m. but you stayed on an hour. She looked better, the smile was back you reassured
her and said I’ll be back in the evening and left.
That evening you report for duty and as you look through the patients bed number 9 is
empty. Have you discharged Sharmila you asked the nurse. No doctor –she developed a
sudden cardiac arrest at 12 noon –we could not revive her.
1. How should doctors deal with the emotions of patients and family facing death
2. What does the patient experience when he / she is dying? Can physicians make the
process of death comfortable?
3. What are the emotions faced by doctors when confronting death in patients? Is death a
defeat for the doctor? Should the doctor be emotionally detatched from a dying
patient
4. What are the cultural aspects of dying
ALTERNATE CASE
I HAVE DECIDED TO DIE
You are a physician in a community care practice for over 20 years and caring for various
patients. Mr. Bhaskara Rao is a patient in your care for the past 14 years. He is 76 years old and
has diabetes for the past 30 years. He had renal failure for the past 10 years and is CKD V
requiring dialysis for 3 years. While he is following up with the nephrologist he values your
position in his family as a family doctor and regularly visits you to check if his treatment is
correct and more often to seek reassurance. He has invited you to all his family events – the last
being 1 month ago for his grandson’s wedding.
This morning you get a call from him. “Doctor! He says in his usual cheerful voice. Can I meet
you tomorrow? I have fulfilled all my responsibilities in life. I am not sad. My children are all
settled; my grandson is married; my wife as you know is no more. I have decided to stop my
dialysis and say goodbye to this world. I thought I’ll talk you to about how to prepare for my
death!”

Hours: 5
69
1. Can patients choose to die? Is there a role for doctors in the death of patients? Can
doctors assist death?
2. How should doctors deal with the emotions of patients and family facing death
3. What does the patient experience when he / she is dying? Can physicians make the
process of death comfortable?
4. What are the emotions faced by doctors when confronting death in patients? Is death a
defeat for the doctor? Should the doctor be emotionally detatched from a dying
patient
5. What are the cultural aspects of dying
ASSESSMENT
1. Formative: Participation in sessions may be used as part of formative assessment.

Submitted narrative on the socio cultural aspects of death may be used as assessment.
2. Summative: Short question on 1) Assisted dying
70
9. Medical Negligence
BACKGROUND
This introductory session allows students to be familiar with the legal aspects of care
including negligence and malpractice and ways to protect themselves from such issues.
LEARNING HOURS : 4
COMPETENCIES
49. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues K
pertaining to medical negligence
50. Identify, discuss and defend medico-legal, socio-cultural professional and ethical issues K
pertaining to malpractice
LEARNING METHOD
Interactive panel discussion by students with legal experts and senior members of the
medical profession. A written summary of learning may be provided by the student based
on the learning
ASSESSMENT
1. Formative: Submitted summary may be used as assessment

2. Summative: Short question on 1) medical negligence
71
Section III
72
Competency Acquisition Log - Suggested Log Book
pattern
Name of student Roll Year of

Number joining
Specific
competency
#
Competency required to graduate Universal

competency
#
Communicate diagnostic and therapeutic options to patient and family in a simulated

environment (Dreyfus level - advanced beginner)
Competency must be acquired at the end of professional IV

year
Is the acquisition of this competency a prerequisite to Yes/ No

advancement to the next phase
Does this competency require performance in a patient Yes/ No
Number of times the student must have performed the skill
Date Supervisor
Completed
Certified by Faculty name, Date and UID
73
Competency Acquisition Log - Suggested Log Book
pattern
Student’s descriptive narrative of skill acquired
Faculty only: If the student has not completed the competency write down the reasons
and remedial suggested
74
Competency Acquisition : Suggested Log Book pattern
Name of student Roll number Year of

joining
Specific
competency
#
Competency required to graduate Universal

competency
#
Administer informed consent to a patient undergoing surgery in a simulated environment

(Dreyfus level advanced beginner)
Competency must be acquired at the end of professional IV

year
Is the acquisition of this competency a prerequisite to Yes/ No

advancement to the next phase
Does this competency require performance in a patient Yes/ No
Number of times the student must have performed the skill
Date Supervisor
Completed
Certified by Faculty name Date and UID
75
Competency Acquisition : Suggested Log Book pattern
Student’s descriptive narrative of skill acquired
Faculty only: If the student has not completed the competency write down the reasons
and remedial suggested
76
Section IV
77
Desirable competencies of attitudinal and communication skills that may be
included in whole or part of the formative assessment of the student
Competency PY1 PY2 PY3 PY4
Indicate as appropriate to the level of training

DME : Does not meet expectations.
ME - Meets expectations N/A : Not applicable
demonstrate ability to work in a team of peers and

superiors
demonstrates respect to patient privacy
demonstrate ability to maintain confidentiality in patient

care
demonstrate a commitment to continued learning
demonstrate responsibility and work ethics while

working in the health care team
demonstrate respect in relationship with patients fellow

team members superiors and other health care workers
demonstrates ability to maintain required documentation
in health care (including correct use of medical records)
demonstrates personal grooming that is adequate and

appropriate for health care responsibilities
demonstrates adequate knowledge and use of
information technology that permits appropriate patient
care and continued learning
demonstrates respect and follows the correct procedure
when handling cadavers and other biologic tissue
demonstrates awareness of limitations and seeks help
and consultations appropriately
demonstrates appropriate respect to colleagues in the
profession
Feed back provided to student (Y/N)
Signed by Mentor/tutor Initial/Date Initial/ Initial/ Initial/

Name: Faculty ID Date Date Date
78
Appendix 1
List of competencies in Attitudes and Communication
Note: Competencies from 1 - 39 are core competencies. Competencies 40 -
54 are non-core (desirable) competencies that be assessed formatively
COMPETENCY K/KH/SH/P
The student should be able to
1. Enumerate and describe professional qualities and roles of a KH

physician
2. Describe and discuss the commitment to lifelong learning as KH

an important part of physician growth
3. Describe and discuss the role of non maleficence as a guiding KH

principle in patient care
4. Describe and discuss the role of autonomy and shared KH

responsibility as a guiding principle in patient care
5. Describe and discuss the role of beneficence of a guiding KH

principle in patient care
6. Describe and discuss the role of a physician in health care KH

system
7. Describe and discuss the role of justice as a guiding principle KH

in patient care
8. Identify discuss medico-legal socioeconomic and ethical KH

issues as it pertains to organ donation
9. Identify discuss and defend medico-legal socioeconomic and KH

ethical issues as it pertains to abortion / medical termination of
pregnancy and reproductive rights
10. Identify discuss and defend medico-legal socio-cultural KH

economic and ethical issues as it pertains to rights, equity and
justice in access to health care
11. Identify discuss and defend medico-legal socio-cultural and KH

ethical issues as it pertains to confidentiality in patient care

ethical issues as it pertains to patient autonomy, patient rights
and shared responsibility in health care
79

ethical issues as it pertains to decision making in health care
including advanced directives and surrogate decision making

ethical issues as it pertains to decision making in emergency
care including situations where patients do not have the
capability or capacity to give consent

ethical issues as it pertains to research in human subjects
16. Identify, discuss and defend medico-legal,socio-cultural and KH

ethical issues as they pertain to health care in children (including
parental right to refuse treatment)

ethical issues as they pertain to health care in children including
parental rights
18. Identify, discuss and defend, medico-legal, socio-cultural and KH

ethical issues as they pertain to consent for surgical procedures
19. Identify, discuss and defend medico-legal socio-cultural KH

professional and ethical issues as it pertains to the physician
patient relationship (including fiduciary duty)
20. Identify ,discuss physician’s role and responsibility to society KH

and the community that she/ he serves
21. Identify discuss and defend medico-legal socio-cultural KH

professional and ethical issues in physician industry
relationships
22. Demonstrate ability to work in a team of peers and superiors SH

23. Demonstrate ability to communicate to patients in a patient, SH
respectful, non threatening, non judgemental and empathetic
manner
24. Demonstrate respect to patient privacy SH

25. Demonstrate ability to maintain confidentiality in patient care SH
26. Demonstrate a commitment to continued learning SH
80
27. Demonstrate respect in relationship with patients, fellow SH

team members, superiors and other health care workers
28. Demonstrate responsibility and work ethics while working in SH

the health care team
29. Demonstrate ability to maintain required documentation in SH

health care (including correct use of medical records)
30. Demonstrate personal grooming that is adequate and SH

appropriate for health care responsibilities
31. Demonstrate adequate knowledge and use of information SH

technology that permits appropriate patient care and continued
learning
32. Demonstrate respect and follows the correct procedure when SH

handling cadavers and other biologic tissue
33. Administer informed consent and appropriately address SH

patient queries to a patient undergoing a surgical procedure in a
simulated environment
34. Communicate diagnostic and therapeutic opitons to patient SH

and family in a simulated environment
35. Communicate care options to patient and family with a SH

terminal illness in a simulated environment
36. Demonstrate awareness of limitations and seeks help and SH

consultations appropriately
37. Demonstrate appropriate respect to colleagues in the SH

profession
38. Demonstrate an understanding of the implications and the SH

appropriate procedure and response to be followed in the event
of medical errors
39. Identify conflicts of interest in patient care and professional SH

relationships and describes the correct response to these conflicts

41. Demonstrate ability to balance personal professional SH
priorities
42. Demonstrate ability to manage time appropriately SH
81
43. Demonstrate ability to form and function in appropriate SH

professional networks
44. Demonstrate ability to pursue and seek career advancement SH

45. Demonstrate ability to follow risk management and medical SH
error reduction practices where appropriate
46. Demonstrate ability to work in a mentoring relationship with SH

junior colleagues
47. Demonstrate commitment to learning and scholarship SH

48. Identify, discuss and defend medico-legal, socio-cultural, KH
economic and ethical issues as they pertain to in vitro
fertilisation donor insemination and surrogate motherhood
49. Identify, discuss and defend medico-legal, socio-cultural KH

professional and ethical issues pertaining to medical negligence

professional and ethical issues pertaining to malpractice

professional and ethical issues in dealing with impaired
physicians
52. Identify, discuss and defend medico-legal, socio-cultural and KH

ethical issues as they pertain to refusal of care including do not
resuscitate and withdrawal of life support
53. demonstrate altruism SH

54. administer informed consent and appropriately address SH
patient queries to a patient being enrolled in a research protocol
in a simulated environment
82
APPENDIX 2
Communication skills rating scale adapted from Kalamazoo consensus statement
Rating 1-3 - Poor, 4 -6 Satisfactory 6 -10 Superior
Criteria
Builds relationship
Opens the discussion
Gathers information
Understands the patient’s perspective
Shares information
Manages flow
Overall rating
83
84
Trainer’s Manual
Ethics for Medical Students
Need:
There are many issues in medical practice that revolve around ethics. This not only
includes doctor patient relationship but also communication, decision making in resource
poor countries as well as clinical trials. Medical students have a very small exposure to
these ethical; principles. The principle aim of this session is to familiarize medical
students with basic principles of ethics and ethical behavior in Medical Practice.
Objectives
The purpose of this session is to make students start understanding of principal moral
values governing medical ethics. It should subsequently develop awareness of frequent
existence of ethical issues and dilemmas help develop the capacity for resolution of these
issues through ethical reasoning, and acquire understanding of the function of
institutional bodies concerned with ethics.
At the end of session students should be able to understand basic principles of ethics:
• Autonomy of Patients: Patients body is his/her own. He/ she has right to decide
about operations and procedures. When patients come to you it is implied consent for
routine procedures. It is better to explain patient about every procedure and them
perform. When special procedures are done stated / special consent is taken. Physician
must guide patients to take right decision.
• Beneficence: One must remember that whatever we do should be done for benefit of
patients.
• DO NO HARM TO PATIENTS.
• Justice: Patient should get the best treatment and justice should be done to all as far
as possible.
Since ethics is an integral part of practice of medicine, its study should parallel that of
study of medicine.
Resources required
A good room with 25 chairs arranged in Circle or around a center table.
How to conduct the session

Guidelines for the faculty members about conducting session.
The session is best conducted in an interactive rather than didactic format allowing the
participants to freely express themselves on the various issues. You can begin with a
small introduction and later this should be followed by discussion on hypothetical case
situation given in the sheet. Every case highlights special problem and it should be
emphasized. You can ask students to read and comment on each case and later sum up
with thrust on special points.
Case 1.
A patient was admitted with severe right iliac fossa pain, fever and vomiting. A diagnosis
of acute appendicitis was made, and the surgeon decided to go ahead with surgical
appendectomy.
a) Do you think the patient's opinion regarding willingness to undergo surgery should
be asked?
b) Should the patient be explained the possible course of disease if surgery is not
done immediately?
c) Should the patient be explained about possible complications of the surgery?
The answer for all above questions is obviously, yes. The discussion should
revolve around the importance of patient's right to refuse and the fact that he/ she
has autonomy in this matter. Discuss the aspects of the patient's right to have
information and make an 'informed' decision.
d) Is written consent required?
Discuss the importance to safe guard doctor's interest as well. Patient should not at
a later date ever accuse that consent was taken under duress or by ' cheating'.
Hence witnessed consent is important.
e) If patient is < 18 yr. old, whose consent is needed?

f) If patient is mentally retarded, but > 18 yr., is his/her consent valid?
If a patient cannot give consent (because of age, mental status or being unconscious), the
consent of next of kin, guardian, AMO of institution has to be taken.
In this context, you may want to talk about the fact that under IPC 91/92, the doctor has a
right do a life saving procedure on a patient when none of the above is available to give
consent.
In the case of a pregnant woman, the consent to a 'fetus saving procedure' must be
obtained from the mother- the fetus has no rights under current Indian law.
You may talk about consents, which deal with photos/ surgery/ blood transfusions during
surgery.
Case 2
A 50-yr. old patient is brought with 8 days history of fever, headache and vomiting.
Patient did not respond to treatment by family doctor and was brought by the neighbors
in an unconscious state. The doctor concluded that this could either be tuberculous
meningitis or pyogenic meningitis, and it was decided to do a lumbar puncture to obtain
CSF for examination.
a) Is consent required?
b) Whose consent is to be taken?
c) If the patient is found at the roadside and brought by police, who will give
consent?
d) If the patient's relatives are informed and they come, but refuse to give consent for
lumbar puncture, what will you do?
The points of discussion are similar and deal especially with consents in special
situations.
Case 3
In surgery OPD a resident attempts to demonstrate a breast lump in a 35-year-old female
to a group of 4 students. She resists, runs out and shouts ‘these maniacs tried to molest
me’ and uses abusive language. How can you prevent such incidences?
e) Is consent required?
f) If patient is unwilling what will you do?
g) Do you need special consent to do a PV examination in this patient?
h) Allowing patient the option of bringing along relative / friend and coming again
next time
i) Need for doctor to have female nurse present during examination.
j) Writing notes about patient's refusal to allow examination, although written
consent is not required for this examination.
In this case bring out the aspects of implied consent (in this case when the patient comes
with a breast lump, her consent to the breast examination is implied. However, it is
necessary to take verbal consent before examining the patient. For PV examination, also
verbal consent is needed.)
Case 4.
A 60-yr. old male is admitted with frequency of micturition and difficulty in initiation of
micturition. The urinary stream is not forceful, and gets worse on straining. The general
surgeon sees this patient and diagnoses benign prostatic enlargement. As drug therapy
fails to relieve symptoms, patient is told about need for surgery. The doctor says that
surgery by an abdominal incision is required, and that the hospital stay may be 10-14
days. The patient had been reading in the lay press about the disease, and found from the
internet that the same results can also be obtained by transurethral resection of the
prostate through a cysto-urethroscope as with surgery, which is safer and needs only 2-3
days of hospitalization. Although this could be done in the present case when asked by
the patient, the doctor says' for you conventional trans abdominal surgical prostatectomy
will be better' because he himself does not do TURP, and feels that he will have to refer
to a urologist, who will then collect the operation charges and this doctor will lose the
case.
Discussion
This case illustrates the importance of Justice to the patient. If one doctor does not have a
particular skill, he should have the conviction to refer the patient to colleagues so that the
patient gets the best treatment.
Case 5
A patient, hypertensive since 5 yrs. is on regular treatment from the GP (who charged Rs.
20/- per consultation) and BP is well controlled. She develops precordial pain, and the GP
sends this patient to a physician (internist). The physician gets an ECG, which is normal.
The pain recurs in spite of reassurance that it is not due to heart disease. Since patient is
still worried that it may be IHD because her father had similar pain, and died within few
hours of onset of pain, the physician decides to refer her to a cardiologist for a stress test,
which will definitely exclude IHD. As expected, the stress test is negative for IHD.
However, the cardiologist tells the lady that her BP medicines need to be changed, and
from then on, for several years, the patient followed up every month with cardiologist,
who check her BP, and continued the antihypertensive medicines. She pays Rs. 200/- for
every consultation.
Discussion
Emphasize need to refer back after your role in managing the case is over. Again discuss
that the patient and care of his problem should form the basis of decisions rather than any
other matters, especially doctor's personal issues.
Time - 45 minutes
Overview of session
This session is designed to help educators provide instruction that will enhance students’
ability to develop well-reasoned responses to the kinds of ethical problems that are likely
to arise in the practice of science. It has been tailored for the training of graduate students
in the biomedical sciences, but you may find that the materials work with researchers
from a variety of backgrounds. The package contains five cases for discussion and
instructions for students describing the rationale and procedures for this exercise. To
assist the teacher of research ethics who may have limited background in ethics-related
disciplines, each case is accompanied with facilitator notes providing a detailed analysis
of the ethical issues raised in the case, guidelines for leading discussions, and criteria for
evaluating participants’ competence in ethical reasoning. Most of the cases included in
this session have been tested with student groups, and the instructional strategies have
been submitted to empirical testing. The use of these materials is not intended as a full
course in research ethics, but could serve as a basis for a course that might be
supplemented with didactic presentations.
Some assumptions
We begin with the premise that “ethics can be taught.” When people are given an
opportunity to reflect on decisions and choices, they can and do change their minds about
what they ought to do and how they wish to conduct their personal and professional lives.
This is not to say that any instruction will be effective, or that all manner of ethical
behavior can be remedied with well-developed ethics instruction. But it is to say — and
there is considerable evidence to show it that ethics instruction can influence the thinking
processes that relate to behaviour. As with any intervention, it must be carefully targeted
to meet an identified need, and it must be an intervention of demonstrated effectiveness.
Evaluation
Assessment of student learning
To help students see the need for instruction in moral reasoning, use one of the following
strategies before instruction:
• Administer a formal assessment using a standardized outcome measure such as the
Defining Issues
• Ask prospective learners to develop a written or oral argument for one or more of the
cases included in this package and evaluate their responses using the criterion checklists
included with the instructor notes.
Appendix
Additional cases for Postgraduates and research students
Ethical Dimensions of Clinical Studies

Following are the situations encountered while conducting clinical studies. Discuss the
ethical aspects with the group members and present your views in the plenary.
Group Task I
A pharmaceutical company ventured into the manufacturing of an intravenous
formulation of Amnidazole, a new anti amoebic agent. Dr.XYZ, Assoc.Professor, in the
Dept.of Pharmacology of an University Hospital was approached by the company with a
project proposal aimed at evaluating tolerability of this intravenous formulation. The
reports of efficacy trials using i.v. Amnidazole, conducted in Mexico and Poland, in
patients with amoebic colitis and hepatitis were submitted by the company. Dr.XYZ
accepted the study. As per the protocol, the study was planned to be carried out in
randomized crossover manner in normal volunteers comparing safety profile of single i.v.
infusion of Amnidazole (400 mg/250 ml) with i_v_.formulation of metronidazole (500
mg/250ml) Mr.,XYZ put up a notice on the departmental notice board inviting students to
participate in the study. An incentive of Rs 3000/ was declared provided the volunteers
who completes the trial. As 24 hours observation following the i.v. infusion was needed,
it was mentioned in the notice that to compensate for the study loss for a day, special
clinics in medicine and surgical would be arranged in the ward. The students who agreed
to participate in the trial were asked to sign a consent form which mentioned they were
participating at their own risk.
Group Task II
A double blind placebo controlled phase II study was undertaken by an investigator to
evaluate ability of 'Famoprost', a PGEI analogue to protect against NSAIDs induced
gastritis. The patients of osteo arthritis attending orthopaedic OPD for the first time and
diagnosed as osteo arthritis and prescribed NSAIDs for the next 3 months period were
selected and randomly allocated to receive either Famoprost or placebo.
A history of clinical symptoms related to gastritis was taken before the start during the
follow up period and after 3 months of therapy. The patients were followed up.every 15
days in the OPD and received NSAIDs and the trial medicine. Ability of Famoprost to
protect against gastritis was evaluated by endoscopic examination of gastric mucosa at
the end of 3 months. One of these 30 selected patients aged 55 yrs, during the course of
study complained of mild epigastric pain for 2 days. The investigator promptly recorded
down the adverse event. This patient was asked to discontinue the therapy and report
after 8 days (instead of 15 days). After returning from the OPD, the pain intensity of the
patient however increased and he collapsed He was hospitalised and diagnosed to be
suffering from myocardial ischemia.
Group Task III

Dr.XYZ, Prof & Head, Dept of Skin V.D of an University Hospital decided ,develop an
acne lotion in consultation with the hospital pharmacist. The ingredients of the lotion
were not new drugs, per se but agent (anti microbials and antiseptics mixed with a cream
base which are used for other skin disorders) which were mixed for the first time to
prepare the acne lotion. The patient attending skin OPD with c/o acne were enrolled in
the study. A consent of these patients was taken on a paper which stated that they were
willing to participate in the study. They were randomly allocated to treatment groups, one
received the standard acne lotion, the other the newly developed lotion (both prepared by
hospital pharmacist). The effect of both the lotions was evaluated by an observer who
was blind to the treatment received by the patient.
The analysis of data after completion of the study, revealed that the new acne lotion
significantly accelerated healing of acne and prevented their recurrence. Dr.XYZ sent an
article on the trial to a peer reviewed journal to be published as original paper. To show
the proofs, be also enclosed photographs of the patients from both the groups taken
before and after the therapy. The Editor of the Journal, demanded for an approval of
Institutional Ethics Committee for the study. Dr.XYZ replied stating that approval was
not taken as no new drug was studied. Secondly, the lotion was to be applied locally so
no harmful effects, were expected. Moreover, he has already taken a written informed
consent and did not violate any ethical principles. However, he would try to get a
clearance from the Ethics Committee if it was mandatory for the publication.
Group task IV
The Dept.of Medicine was conducting a trial in patients suffering from AIDS. As a part
of the trial blood samples were sent to the clinical chemistry lab. for routine organ
function test. For this the request forms were filled by the investigators as done routinely.
After analysis, laboratory technician entered the report on the same form which was
signed by the pathologist and sent back to the department.
Group Task V
The Dept. of Nephrology of an institute decides to carry out a single blind randomized
phase II trial to compare the efficacy of Pefloxacin as an immunomodulator with that of
prednisolone in children with minimal change nephrotic syndrome.
References and additional readiing
1. Scientific Research Cases for Teaching and Assessment
Developed by Muriel J. Bebeau, University of Minnesota, 1995 (available on net)
2. Dr. Supe and Dr Shringare. Maharashtra team – ICMR ethics case inventory 2003.
Handouts to be given to students
Case 1. - A patient was admitted with severe right iliac fossa pain, fever and vomiting. A
diagnosis of acute appendicitis was made, and the surgeon decided to go ahead with surgical
appendectomy.
Case 2 - A 50-yr. old patient is brought with 8 days history of fever, headache and vomiting.
Patient did not respond to treatment by family doctor and was brought by the neighbors in an
unconscious state. The doctor concluded that this could either be tuberculous meningitis or
pyogenic meningitis, and it was decided to do a lumbar puncture to obtain CSF for examination.
Case 3 - In surgery OPD a resident attempts to demonstrate a breast lump in a 35-year-old

female to a group of 4 students. She resists, runs out and shouts ‘these maniacs tried to molest
me’ and uses abusive language. How can you prevent such incidences?
Case 4. - A 60-yr. old male is admitted with frequency of micturition and difficulty in initiation
of micturition. The urinary stream is not forceful, and gets worse on straining. The general
surgeon sees this patient and diagnoses benign prostatic enlargement. As drug therapy fails to
relieve symptoms, patient is told about need for surgery. The doctor says that surgery by an
abdominal incision is required, and that the hospital stay may be 10-14 days. The patient had
been reading in the lay press about the disease, and found from the internet that the same results
can also be obtained by transurethral resection of the prostate through a cysto urethroscope as
with surgery, which is safer and needs only 2-3 days of hospitalization. Although this could be
done in the present case when asked by the patient, the doctor says' for you conventional trans
abdominal surgical prostatectomy will be better' because he himself does not do TURP, and feels
that he will have to refer to a urologist, who will then collect the operation charges and this
doctor will lose the case.
Case 5 - A patient, hypertensive since 5 yrs. is on regular treatment from the GP (who charged
Rs. 20/- per consultation) and BP is well controlled. She develops precordial pain, and the GP
sends this patient to a physician (internist). The physician gets an ECG, which is normal. The
pain recurs in spite of reassurance that it is not due to heart disease. Since patient is still worried
that it may be IHD because her father had similar pain, and died within few hours of onset of
pain, the physician decides to refer her to a cardiologist for a stress test, which will definitely
exclude IHD. As expected, the stress test is negative for IHD. However, the cardiologist tells the
lady that her BP medicines need to be changed, and from then on, for several years, the patient
followed up every month with cardiologist, who check her BP, and continued the
antihypertensive medicines. She pays Rs. 200/- for every consultation.
Indian Journal of Medical Ethics Vol IX No 4 October - December 2012
CONTENTS
Indian Journal of Medical Ethics
Vol IX No 4, October-December 2012
(incorporating Issues in Medical Ethics, cumulative Vol XX No 4)
EDITORIALS
Revising the Declaration of Helsinki: a work in progress ....................................................................................................................224
RUTH MACKLIN
IMA strike: need for public debate .........................................................................................................................................................226
B EKBAL
ARTICLES
Compensation for trial-related injury: does simplicity compromise fairness? ...................................................................................232
MALA RAMANATHAN, P SANKARA SARMA , UDAYA S MISHRA
Good epidemiology, good ethics: empirical and ethical dimensions of global public health ..........................................................235
CHRISTY A RENTMEESTER , RAJIB DASGUPTA
Perceptions about training and knowledge of HIV/AIDS ethics among healthcare providers
at teaching hospitals of a medical college in Karnataka, India............................................................................................................242
UNNIKRISHNAN B, MOHAN K PAPANNA, VAMAN K, NITHIN K, REKHA T, PRASANNA MITHRA P
A social media self-evaluation checklist for medical practitioners.....................................................................................................245
BENJAMIN J VISSER, FLORIAN HUISKES, DANIEL A KOREVAAR
Medical students’ views on the migration of doctors: self-interest vs altruism..................................................................................249
LIJO J THARAKAN, ELENCHERAL AL, KARTHIGA M, KUMARAN V, RAKESH PS, VIJAYPRASAD GOPICHANDRAN, JACOB JOHN
COMMENTS
Sensitising doctors: a pedagogical approach to medical humanities.................................................................................................252
DHANWANTI NAYAK
Review of multinational human subjects research: experience from the
PHFI-Emory Center of Excellence partnership.......................................................................................................................................255
HEMALATHA SOMSEKHAR, DORAIRAJ PRABHAKARAN, NIKHIL TANDON, REBECCA ROUSSELLE, SARAH FISHER, ARYEH D STEIN
Doctors and health in India: an outsider’s perspective ........................................................................................................................259
RAJAN MADHOK
Medical humanities in the undergraduate medical curriculum...........................................................................................................263
AVINASH SUPE
Pre-employment medical testing in Brazil: ethical challenges...................................................................... ......................................266
DARIO PALHARES, IVONE LAURENTINO DOS SANTOS
Private medical education in Sri Lanka ........................................................................ .........................................................................269
NIPUNA SIRIBADDANA,SUNETH AGAMPODI, SISIRA SIRIBADDANA
Mainstreaming AYUSH: an ethical analysis............................................................................................................................................272
VIJAYAPRASAD GOPICHANDRAN, CH SATISH KUMAR
Patients’ rights in India: an ethical perspective.... .................................................................................................................................277
RB GHOOI, SR DESHPANDE
BOOK REVIEWS
Bioethics made comprehensible.............................................................................................................................................................282
SUNIL K PANDYA
Making blood transfusion safe ...............................................................................................................................................................283
JAYASHREE D KULKARNI
Relevant across cultures.............. ............................................................................................................................................................284
OM PRAKASH
The ophthalmologist and the law...........................................................................................................................................................284
UMA KULKARNI
Spotlight on grey areas................. ..........................................................................................................................................................285
NAGA NISCHAL C
FROM THE PRESS ................................................................................................................................................................................................................................ 229

FROM OTHER JOURNALS ................................................................................................................................................................................................................. 286
LETTERS................................................................................................................................................................................................................................................. 289
ANNOUNCEMENT: NBC 4 ................................................................................................................................................................................................................. 295
Cover credit: YORGOS NIKAS......... Wellcome Library, London. Image title: Human egg with coronal cells
[ 223 ]
References milroy-lecture-2003-pdf-d38353278.
1. High Level Expert Group (HLEG). High Level Expert Group Report on 3. Kissoon N. A paradigm shift. Jacksonville Medicine[Internet]. 2000
Universal Health Coverage for India [Internet]. New Delhi; Planning May[cited 2012 Sep 24];51(5). Available from: http://www.dcmsonline.
Commission of India: 2011 Nov [cited 2012 Sep 24]. 343p. Available from: org/jax-medicine/2000journals/may2000/editorial.htm
http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf. 4. Skrabanek P, McCormick J. Follies and fallacies in medicine. Glasgow:
2. Madhok R. Milroy Lecture-Doctors in the new millennium: Hippocrates TarragonPress;1989.
or hypocrites? [Internet]., London;Royal College of Physicians: 2003 Sep 5. Fido M. The world’s worst medical mistakes. Bristol: Parragon;1996.303p.
16[cited 2012 Sep 24]. 28p. Available from: http://ebookbrowse.com/ 6. Lantos JD. Do we still need doctors? London: Routledge; 1997
Medical humanities in the undergraduate medical curriculum

Avinash Supe
Professor and Head, Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Parel, Mumbai 400 012 INDIA e-mail: [email protected]
Abstract “art of medicine”. Over the years, due to an evidence-based

approach and objective assessment of students (especially in
The medical humanities have been introduced in medical CET-based career choice examinations) there has been a loss
curricula over the past 30 years in the western world. Having of comprehensiveness and of a holistic approach to medicine.
medical humanities in a medical school curriculum can nurture However, one must understand that medicine is as much an art
positive attitudes in the regular work of a clinician and contribute as it is a science. There is not always one right answer. Not every
equally to personality development. Though substantial evidence patient is cast in the same mould and the broad brushstrokes of
in favour of a medical humanities curriculum may be lacking, the a one-size-fits-all treatment model are not always appropriate.
feedback is positive. It is recommended that medical humanities In addition to economic factors, there are tremendous cultural
be introduced into the curriculum of every medical school with the differences in the community that determine treatment
purpose of improving the quality of healthcare, and the attitudes choices. Innovation and creative thinking are necessary to
of medical graduates. develop new methods of healthcare delivery, discover new
medicines or treatment options, and prevent the emergence
Introduction of new diseases. By educating healthcare practitioners to be
The dictionary defines the word “humanities” as “learning or more receptive to creative input and encourage innovative
literature concerned with human culture, especially literature, thinking, those entrusted with delivering healthcare will not
history, art, music, and philosophy” The humanities should not be stifled by the repetition and lack of originality that is today’s
be confused with “humanism,” a specific philosophical belief, healthcare system.
or with “humanitarianism,” the concern for charitable works The medical humanities were introduced into various
and social reforms. Medical humanities (MH) can be defined as university curricula with the intention of enhancing this
the application of the techniques of the traditional humanities aspect of the “art of medicine”. The medical humanities can
fields to medical practice. Over the past 30 years, there has been have both instrumental and non-instrumental functions in a
a trend towards the development of a humanities curriculum medical school curriculum. The term ‘instrumental’ function
in medical education, both in the United States and Europe (1). implies that learning can be directly applied to the daily work
There are variable reports regarding the usefulness and the of the clinician. The clinician has to develop the ability to
effectiveness of such curricula all over the world (2-3). observe and recognise visual clinical signs of disease in the
patient. This ability can be directly enhanced by the study of
The purpose of a medical humanities curriculum the visual arts (4,5). The study of literature can help develop
another important skill of handling ambiguity and empathy (6).
Modern allopathic medicine is considered scientific, objective
Likewise, the evaluation of case study narratives has been used
and evidence-based. Due to an overemphasis on objectivity, to improve clinical skills (7).
it sometimes lacks a holistic approach, as the patient is
treated as a case, and not as a whole person. The growth and The humanities exert a non-instrumental function when
development of current medical practice is deeply rooted they help to develop the concept of medicine as art, general
in science but there is definitely too little emphasis on the education, personal development, or instil new ways of
[ 263 ]
Indian Journal of Medical Ethics Vol IX No 4 October-December 2012
thinking beyond the biomedical perspective (4, 6, 8). Study of using literature excerpts, paintings, case scenarios, small
the medical humanities has been used to understand the role group work and role-plays. At the end of the module, feedback
of the professional in a society and develop self-reflexivity was obtained from selected participants through focus
(9). A health professional has the capability and opportunity group discussions. These discussions revealed that MH was
to influence society beyond biomedical decisions. With the a very important topic, often found to be missing in medical
current pattern of professional practice, we are losing this education. Shankar concluded that the module with small
perspective in clinical practice that was an integral part of the group activities was appreciated by the participants as well
“family physician” concept two decades ago. as the faculty, and recommended that similar sessions be
conducted in other medical schools of South Asia.
When one considers the various attributes of a good doctor
– they can be broadly divided into the scientific and the artistic.
Impact of a curriculum on students learning
To develop good clinical judgment he/she needs technical
expertise and scientific decision-making that is based on The MH curriculum is considered useful in improving a
objective evidence and knowledge. On the other hand, to physician’s communication skills (8). Debate still continues
develop a humane approach (which is also an integral part on the definition and exact role of MH in medical curricula.
of clinical judgment) he/she has to gain interpretative insight Wershof Schwartz et al (11) reviewed the literature on the
and an understanding of ethics and education, and a broad impact of a humanities education on the performance of
perceptiveness (6). In summary, I feel that a physician needs medical students and residents. They also discussed the
to have both aspects – the scientific and the artistic. Currently, challenges posed by the evaluation of the impact of humanities
we are not bothering to develop the second aspect in medical in medical education. Students who are exposed to the MH
education. An MH curriculum will be able to fill this gap in our curriculum perform academically on par with their peers with
orientation. science backgrounds in medical school. Courses in MH are
diverse and varied in content and goals and hence measuring
Methods for implementing an MH curriculum and quantifying their impact has been challenging. Many of
the published studies involve self-selected groups of students
Subjects traditionally grouped under the humanities, such and seek to measure subjective outcomes, which are difficult
as painting, music, literature, sculpture, philosophy, sociology, to measure, such as increases in empathy, professionalism, and
anthropology and others are widely used in educating self-care. The review recommended defining the optimal role
doctors in the developed nations. MH programmes are well of a humanities education in medical training, and carrying out
established in many universities of the United States (US), the more quantitative studies to examine the impact that MH may
United Kingdom and some other countries in Western Europe, have on physician performance beyond medical school and
Canada, New Zealand, and Israel. In many medical schools, residency.
MH was attempted as a voluntary module and gradually a
case was made for introducing the discipline formally into the In another systematic review in Academic Medicine (2010) by
curriculum. Literature, painting, fine arts, drama, photography Ousagar and Johannessen (12), 245 publications were reviewed.
have been used to teach MH. Many medical schools offer a These articles were categorised into four groups. Sixty eight
number of elective courses in MH and students can select one strongly recommended inclusion of MH into the curriculum and
according to their interests and aptitude. Other schools have a were described by the authors as “pleading the case” while 156
core subject area in the humanities, but students can choose described courses and positive short term evaluations. Overall,
electives according to their interests. In certain schools, MH 224 (68+156) publications described the positive effects of the
is restricted to particular years of study while in others this is humanities on medical education or described existing courses,
spread throughout the course. Small-group, activity-based but provided little substantial evidence. Only nine articles
learning is used in the majority of medical schools. studied the evidence of long-term impacts using diverse test
tools and stated that though graduates were similar in overall
In Canadian universities, students can choose particular courses evaluation, they were “more confident in managing patients’
and do summer research projects in the humanities. The School with psychosocial problems when compared with graduates
of Medicine, University of California, Irvine, in the US, informally from the traditional curriculum. The remaining 12 articles
started a literature and medicine elective in 1997, emphasising expressed criticism and were skeptical about recommending
small-group interdisciplinary learning and the use of creative an MH curriculum in medicine. The authors concluded that
projects. The programme aimed to enhance some aspects of “evidence on the positive long-term impacts of integrating
professionalism including empathy, altruism, compassion, and humanities into undergraduate medical education is sparse”
caring for patients, as well as to improve clinical communication and suggested further studies.
and observational skills. At the University of Tel Aviv, Israel, a
course on the Philosophy of Medicine was introduced in the
The Indian perspective
year 2002-3 comprising formal lectures, question-and-answer
sessions and exercises. Richa Gupta et al at the University College of Medical Sciences
(13), Delhi, formed an MH group in 2010, and have shared
Ravi Shankar (10) introduced a medical humanities module their experiences. They arranged for lectures on subjects such
for the faculty members and the medical/dental officers in as rationalism, the Tibetan art struggle, faith healing, and
Nepal. He organised small group activity-based sessions, communication with a grassroots and holistic approach. This
[ 264 ]
was very well received by the faculty and students and had As suggested by Pandya (16), such a curriculum can be started
increasingly positive responses at subsequent sessions. at two levels by:
In medicine, there have been tremendous advances in ü introducing the humanities into the school curriculum “in
technology for use in diagnostics and imaging as well as such a manner that students do not fear examinations and
therapy. There has been growth in newer sub specialties for assessments in the subject, but find their study a joyful and
specialised care in specific areas that has created physicians rewarding experience”; and by
who treat only a limited spectrum of diseases. This underscores ü orienting teachers at all levels of education “into studying,
the need for a more holistic approach towards healing and
enjoying and communicating to their students the rich
cure. Besides, it has been increasingly felt that doctors today
treasures available in poetry, philosophy, fiction, history,
lack empathy and compassion for their patients. This may
songs, music, paintings, sculpture and other forms of
be attributed to many reasons such as the lack of a formal
culture”(16).
curriculum, overload of knowledge, excessive dependence
on technology and compassion fatigue. Experiences with In summary, MH curricula are being introduced in various
MH programmes offer many benefits, including improving medical schools with the purpose of improving the quality
clinicians’ abilities to communicate with patients, developing and attitudes of medical graduates. There is a strongly felt
more confidence while treating patients with psycho social need for such curricula in India, and some institutes have
problems and improving empathetic behaviour. (12) There is already initiated them with positive feedback from students
need for setting up of fellowships, degree and diploma courses and faculty. There is also a need for further studies to develop
in MH like those available in the West (12). substantial evidence on the impact of the MH curriculum on
the attitudes of students and residents.
The website of the Medical Humanities Foundation of
References
India is available for all Indians with an interest in making
medical care more humane (14). It has many subsections 1. Wachtler C, Lundin S, Troen M. Humanities for medical students? A
qualitative study of a medical humanities curriculum in a medical
that provide suggested reading, event announcements and school program. BMC Med Educ. 2006 Mar 6; 6:16.
patient narratives. Though an isolated example, this is a good 2. Shankar PR, Piryani RM. English as the language of Medical Humanities
movement towards introducing pooled resources for interested learning in Nepal: Our experiences [Internet]. The literature, art and
faculty and colleges to introduce MH curricula. Reddy (15) medicine blog http://medhum.med.nyu.edu/blog/?p=175. [cited 2012
has also emphasised the need for MH in the Indian medical Sept 28].
3. Evans HM, Macnaughton J. Should medical humanities be a multi-
curriculum for more empathetic clinical care and improved disciplinary or an interdisciplinary study? Med Humanities. 2004; 30:1-4.
communication skills in graduates. 4. Macnaughton J.The humanities in medical education: context, outcomes
and structures. Med Humanities. 2000; 26:23-30.
The way ahead 5. Bardes CL, Gillers D, Herman AE. Learning to look: developing clinical
observation skills at an art museum. Med Educ. 2001 Dec; 35(12):1157-61.
Currently the Indian MBBS curriculum is overloaded with 6. Bleakley A, Farrow R, Gould D, Marshall R. Making sense of clinical
knowledge and dominated by objective entrance examinations. reasoning: judgement and the evidence of the senses. Med Educ. 2003
The Medical Council of India in 2010-2011 introduced Vision Jun, 37(6):544-52.
7. Shapiro J, Morrison E, Boker J. Teaching empathy to first year medical
2015 – a curricular revision plan. Graduate Medical Regulations
students: evaluation of an elective literature and medicine course. Educ
proposed in 2012 include the introduction of a foundation Health (Abingdon) 2004 Mar; 17(1):73-84.
course in the undergraduate curriculum. They also propose 8. Das Gupta S. Reading bodies, writing bodies: self-reflection and cultural
a humanities curriculum to nurture in students a broader criticism in a narrative medicine curriculum. Lit Med. 2003 Fall; 22(2):241-
understanding of the socioeconomic framework and cultural 56.
9. Friedman LD. The precarious position of the medical humanities in the
context within which healthcare is delivered, through the study medical school curriculum. Acad Med. 2002 Apr;77(4):320-2.
of humanities and the social sciences. This is a welcome move 10. Ravi Shankar P, Piryan RM, Karki BMS. A medical humanities module
by the Medical Council of India. for the faculty members of the KIST MedicalCollege, Imadol, Lalitpur
[Internet]. Journal of Clinical and Diagnostic Research. 2011 Nov [cited
Every medical college should have an MH cell with a few 2012 Sept 28]; 5(7): 1489-92. Available from: http://www.jcdr.net/article_
designated members from the faculty, students, as well as fulltext.asp?issn=0973-709x&year=2011&month=November&volume=
external experts. The concept of MH should be introduced to all 5&issue=7&page=1489-1492&id=1669
11. Wershof Schwartz A, Abramson JS, Wojnowich I, Accordino R, Ronan
faculty and students through various programmes throughout EJ,Rifkin MR. Evaluating the impact of the humanities in medical
the year. Sessions may be conducted preferably every month, education. Mt Sinai JMed. 2009 Aug; 76(4): 372-80.
or once in two months. Involving teachers who are already 12. Ousager J, Johannessen H. Humanities in undergraduate medical
well versed in the humanities and who use every opportunity education: a literature review. Acad Med. 2010 Jun; 85(6):988–98.
to introduce art, history and literature to the students will 13. Gupta R, Singh S, Kotru M. Reaching people through medical humanities:
An initiative. J Educ Eval Health Prof. 2011; 8: 5.
be more successful than having structured curricula. There 14. Medical Humanities Foundation of India. (cited 2012, Sept 21). Available
should be open discussion after each session, with active from: http://www.medicalhumanitiesindia.org/home
participation from students and debriefing by experts. There is 15. Reddy MS. Humanities in medical education. Indian J Psychol Med.
a faculty shortage in many medical schools in India and hence, 2009;31(2): 57.
16. Pandya S. The humanities and the medical student [Internet]. Medical
initially external experts may be enlisted for initiating these
Humanities Foundation of India website. 2011 Aug 1[cited 2012 Sept 21].
programmes till internal expertise is available. Available from: https:// www.medicalhumanitiesindia.org /web/folder/
[ 265 ]
Klemenc-Ketis and Kersnik BMC Medical Education 2011, 11:60
http://www.biomedcentral.com/1472-6920/11/60
RESEARCH ARTICLE Open Access
Using movies to teach professionalism to

medical students
Zalika Klemenc-Ketis1,2* and Janko Kersnik1,2
Abstract
Background: Professionalism topics are usually not covered as a separate lesson within formal curriculum, but in
subtler and less officially recognized educational activities, which makes them difficult to teach and assess.
Interactive methods (e.g. movies) could be efficient teaching methods but are rarely studied. The aims of this study
were: 1) to test the relevance and usefulness of movies in teaching professionalism to fourth year medical students
and, 2) to assess the impact of this teaching method on students’ attitudes towards some professionalism topics.
Method: This was an education study with qualitative data analysis in a group of eleven fourth year medical
students from the Medical School of University Maribor who attended an elective four month course on
professionalism. There were 8 (66.7%) female students in the group. The mean age of the students was 21.9 ± 0.9
years. The authors used students’ written reports and oral presentations as the basis for qualitative analysis using
thematic codes.
Results: Students recognised the following dimensions in the movie: communication, empathy, doctors’ personal
interests and palliative care. It also made them think about their attitudes towards life, death and dying.
Conclusions: The controlled environment of movies successfully enables students to explore their values, beliefs,
and attitudes towards features of professionalism without feeling that their personal integrity had been threatened.
Interactive teaching methods could become an indispensible aid in teaching professionalism to new generations.
Background are very efficient [5,6]. Movies, for example, present

Professionalism can be defined as a collection of atti- developed scenarios and are a form of controlled envir-
tudes, values, behaviours and relationships that act as onment, which enables reproducible, focused and inde-
the foundation of the health profession’s contract with pendent student learning. Through art, students are able
society [1]. It is an essential ability to be instilled in to understand patients in their whole context [7]. The
medical students, alongside biomedical knowledge and use of movie clips or whole movies to help educate lear-
clinical skills [2]. The process of professionalism attain- ners about bio-psycho-social-spiritual aspects of health
ment is very long and affected by many factors among care - cinemeducation [8], has been widely used in med-
which the education process is regarded to be the cru- ical education [7,9-13]. It has been shown that students
cial one [3]. received this teaching method well [7,8,10,11] and that
Professionalism topics are often a part of a so called it was particularly good in the teaching of patients’ care,
“hidden curriculum”, which means that its determinants communication skills, breaking bad news, ethical issues
do not operate within the formal curriculum as a sepa- and family dynamics [6,8,10-12].
rate lesson, but in a more subtle and less officially Interactive methods could be efficient teaching meth-
recognized educational activity, which makes them diffi- ods but are rarely studied. So, the authors decided to
cult to teach but nevertheless should be taught [4]. perform a study about the relevance of including movies
Interactive teaching methods using art as a teaching tool in the curriculum. They chose the movie Wit. It deals
with the very personal story of a professor of English lit-
* Correspondence: [email protected] erature dying of metastatic ovarian cancer and describes
1
Department of Family Medicine, Medical School, University of Maribor, her experiences with medical care from first encounter
Slomskov trg 15, 2000 Maribor, Slovenia
Full list of author information is available at the end of the article
with the diagnosis to her death. It deals with many
© 2011 Klemenc-Ketis and Kersnik; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Klemenc-Ketis and Kersnik BMC Medical Education 2011, 11:60 Page 2 of 5
professionalism virtues, such as altruism, humanism, students had to write an essay and give an oral presen-
confidentiality and patient autonomy [14,15]. The aims tation on a chosen topic.
of this study were; 1) to test the relevance and useful-
ness of movies in teaching professionalism to fourth Instrument and analysis
year medical students and, 2) to assess the impact of In the essays, students had to describe and discuss their
this teaching method on students’ attitudes towards observations about the movie and the impact of the
some professionalism topics: positive and negative movie on their attitudes towards the three topics they
patients’ communication elements, empathy and the chose to be important in the movie at the beginning of
effect of the movie on students’ personal attitudes the course. The essays were presented as free text, but
towards death and dying patients. the teacher instructed students to incorporate in the
text the answers to the following questions: 1) which
Methods positive behavioural, communication and consultation
Study design elements of health professionals they found in this film
This was an education study with qualitative data according to the chosen topic, 2) which negative beha-
analysis. vioural, communication and consultation elements of
health professionals they found in this film according to
Study sample and setting the chosen topic, 3) which such topics they recognised
In the academic year 2010-2011, fourth year medical in the movie besides the general ones, 4) what would
students of the Medical School of University Maribor, they do in similar situations as seen in the movie, 5)
Slovenia, could choose among several elective courses, how did the movie affect their feelings, beliefs, values,
including one from the field of family medicine. The and 6) how do they think the movie will influence their
topic was professionalism in medicine. All 11 students future professional and personal life.
that chose this topic also participated in the project. Essays and oral presentations were evaluated by one
There were 8 (66.7%) female students in the group. The teacher (ZKK) using grounded theory based coding
mean age ± SD of the students was 21.9 ± 0.9 years. method (open coding) [16]. She read the essays and
defined discrete essay segments. When analysing oral
Course description presentations, she recorded the narrative statements.
This elective course lasted for 4 months (Table 1). The Each segment of an essay and each narrative statement
following teaching methods were used: lectures, group were then coded with a short phrase, which best
work with discussion and individual work. For the described the theme. Sections of text and narrative
group work, students were divided into three groups. statements could be assigned multiple codes. After the
Teachers used the following methods of assessment: coding, the teacher summarized the prevalence of codes,
marking an essay and an oral presentation of the topic. analysed the similarities and differences and came up
Topics for lectures were chosen by a teacher (ZKK) with several final themes [17].
and topics for three groups (doctor/patient communica-
tion, ethical issues and the role of doctor and nurse in Outcome measures
palliative care) were chosen during an introductory ses- Outcome measures were individual attendance in gen-
sion by the students themselves. Two sessions with in eral, and film specific professional themes discussions
depth discussions about the professional issues covered during the course, and identification, elaboration and
in the film followed and at the end of the course, reflection of the themes in written assignments and
Table 1 Time table and content of the course

Time Content Method Home assignment
Day 1 Introduction to professionalism and information about the course Lecture Watching a movie
Day 8 Doctor/patient communication, ethical issues and the role of doctor Group work Plenary Watching a movie with a special
and nurse in palliative care discussion emphasis on the topic chosen
Day Professionalism and humanism in medicine Lecture Group work Writing an essay on a chosen topic
30 Plenary discussion
Day Doctor/patient communication, ethical issues and the role of doctor Plenary discussion Writing an essay on a chosen topic
60 and nurse in palliative care
Day Palliative care Lecture Group work Preparing oral presentation on a chosen
90 Plenary discussion topic
Day Doctor/patient communication, ethical issues and the role of doctor Plenary presentation
120 and nurse in palliative care Discussion
presentations. The authors regarded mentioning themes, understand; they need emotional support, time, good
such as facing death in a patient, breaking bad news to explanation and understanding.”
the patient, communication skills, consultation skills and
human behaviour in health care professionals, as essen- Empathy
tial themes for this educational programme. They were Students recognised that a doctor-patient relationship
identified in written assignments and presentations. should be based on empathy, which is also the key issue
for good management of a dying patient. “The whole
Results point is in listening and empathy.” They described a
Students recognised the following dimensions in the doctor-patient relationship, presented in this movie, as
movie: communication, empathy, doctors’ personal cold, emotionless and too rational. “The doctor regarded
interests and palliative care. They also reported that this the patient as an object. In her, he saw just another case
movie made them think about their own life and death, of illness. He acted totally unprofessional.” On the other
and helped them to understand all phases of a dying hand, the students easily recognised the empathy, pro-
patient. vided in this movie by a nurse. “Nurse regarded this
patient as a subject. She saw her as a person who is
Communication breathing, thinking, hearing, seeing, talking, wanting, suf-
Students recognised that communication was an essen- fering and seeking support from other people.”
tial part of medicine. “A doctor-patient communication
seems as the most important element of healing and of Doctors’ personal interests
health itself. Namely, with good communication, we can Students reported that when dealing with patients, doc-
heal or relieve many patients’ problems or worries.” tors should forget about their personal wishes and goals.
Students stressed the importance of non-verbal com- They saw doctors in the movie as overly scientific and
munication as an essential part of good communica- research-oriented and ignorant about real patients’
tion. They noticed wrong ways of doctor-patient non- needs. “Doctor forced her to agree to the proposed treat-
verbal communication, presented in this movie: lack of ment and then he even insisted on the highest dosages of
eye contact, lack of physical contact, lack of noticing the drug - even though it was clear that the drug is
patient’s non-verbal signs and wrong reaction to doing more harm than benefit to the patient.”
patient’s non-verbal signs. “Doctor gave the impression Students recognised that doctors should not regard
that he had no interest to get closer to patient and the death of their patients as their personal failures.
thought that an occasional smile will calm every “Doctors in the movie regarded the patient’s illness as
patient’s worries.” On the other hand, students noticed their own failure so they were embarrassed when being
right ways of nurse-patient non-verbal communication, around her.”
presented in this movie: good eye contact, physical
contact, noticing and responding to patient’s non-ver- Palliative care
bal signs. “Among non-verbal elements, nurse-patient Students recognised that doctors should also provide
relationship was based on small things, i.e. nurse gave palliative care and that such care was also a kind of
an ice-stick to the patient. With these small things, treatment, where “treating symptoms is as important as
nurse made it clear that patient can always rely on pain management and providing psychological support.”
her.” Students accepted that the doctors’ role is also to enable
Another part of good communication, as observed by patients to prepare for their own death. “Management of
students, was good listening abilities of the doctors, i.e. a dying patient is as important as management of a
active listening and following patients’ clues. “The doctor patient with any other disease.”
listened but did not hear her. He seemed to have asked Students stressed that when dealing with a dying
all those questions just because he had to do so, not patient, it is very important that doctors act honestly
because he really wanted to find out what she felt.” “The and respect patients’ autonomy. “Doctor and patient
doctor did not allow the patient to express her fears and should agree about the course of the treatment and
expectations.” hence achieve a balance between honesty and auton-
Accessibility and openness were also recognised as omy.” Also, they thought that doctors should plan pallia-
important parts of doctors’ behaviour during communi- tive care in agreement with the patient - especially the
cation. Doctors should not have used too much jargon question of resuscitation. “During constant worsening of
when communicating with the patient in this movie. patient’s clinical state, nobody (except nurse) had talked
This made them inaccessible. about death and a possibility of non-resuscitation.”
“Such patients do not need statistical data and a bas- Students regarded the doctor’s management of their
ket, filled with medical terms which they do not patient in this movie as one-sided and purely bio-
medically founded. On the other hand, students honour, integrity and respect for others. This has been
regarded the nurse’s management of the patient in this showed also in other studies [5,19]. Providing featured
movie as comprehensive and holistic. “For nurse, living roles in a movie like Wit provokes strong natural emo-
meant to live as long as life has a meaning. For doctors, tions in students, which are one of the most powerful
life was determined only by patient’s vital functions.” learning experiences. They should in this case leave our
students with positive messages about how to behave
Students’ attitudes towards their own life, death and professionally as this teaching process gave them an
dying opportunity to learn by the mistakes made by others
Students reported that this movie made them think [7,9].
about human death and dying in general. They came to When it comes to doctors’ personal interests, altruism
the conclusion that all patients react the same way is an important part of professionalism [20]. But it is
when faced with their own death. They also expressed very hard to teach as it is usually connected to changing
that this film helped them to understand all phases of a the students’ values, not just their behaviour, which can
dying patient. “Future doctors should learn how to iden- provoke their resistance because the line between values
tify with the patients, how to show them a proper degree and personal attributes is very tiny [3]. By watching a
of empathy and how to practice a holistic approach.” featured movie on doctors’ behaviour in emotionally
Besides strictly curriculum based questions, students tense situations, students, who are as spectators not at
also reported that this movie made them think about the core of patient management and safe from medico-
their own life and about death as one of the important technical aspects of care, can gain better insights into
events in human life. “We made a critical review of our wrong values and behaviours through the eyes of the
life and came to a conclusion that death equates us and patients, which could make them elaborate or even
that the only thing important at the end of our life is change their professional values. Similar approach to
our satisfaction with our own life. At the time of death, changing values has been demonstrated in other studies
we should have no regrets about our life.” “This film [9,11,12]; some of them also used direct and narrow
represents an inspiration for us as human beings - it questions to provoke these changes [21].
enables us to be a better human being.” Palliative care is an emerging medical field where
positivism of modern medical technologies loses its
Discussion power edge and is therefore filled with ethical dilemmas,
Using cinemeducation in teaching professionalism communication problems and challenges to professional
proved relevant and useful in our study. Students have behaviour [22]. In the movie Wit, students recognised
recognised the following medico-professional and ethical many issues from palliative medicine and started to gain
dimensions of the movie: importance of doctor patient understanding of their importance. Besides exposure to
communication, empathy as a mile stone of doctor difficult ethical dilemmas in a safe environment, this
patient relationship, doctors’ selfish personal interests teaching process gave them the opportunity to build
and importance of palliative care. It also made them their own capacity for managing difficult cases, breaking
reflect on their attitudes towards life, death and dying. bad news and facing dying patients with the help and
Communication is an essential prerequisite when supervision of an experienced teacher to guide them
assessing professional behaviour. Although it is not when necessary. A very valuable result of this course is
directly listed among professional competencies [18], it a fact that it has led to students’ thinking about their
is a rather genuine ability of medical professionals. One attitudes towards their own life and death. This enables
of its features - respect for others - cannot be achieved them to grow into reflective doctors [23]. As recognised
without proper communication training and cinemaedu- also in other studies, cinema and theatre can provide
cation can be one of the important triggers to learn social, anthropological, and cultural knowledge about
communication skills. Using verbal and non-verbal com- people and in this way help to understand human life
munication skills, doctors can effectively express that [10,24,25]. This, again, can help students to change their
they care for their patients and that they listen atten- wrong values.
tively to their concerns. The importance of proper com- The reported dimensions correspond to the main
munication being a part of professional behaviour has components of medical professionalism, which are
been recognised also in other teaching programs that excellence, humanism, accountability and altruism [26].
dealt with cinemeducation, directly [6,8] or indirectly These categories are very broad and may include many
[5,13]. different aspects - as seen in this study. The students
Students also recognised another important dimension grasped the core message from the movie and it
of professionalism - empathy, which is a necessary con- enhanced their thinking about their future behaviours
dition if a doctor wants to develop attributes like and values when practising medicine. With such
interactive teaching methods, students could become References

1. Royal College of Physicians: Doctors in society: medical professionalism in a
aware that professionalism is more than merely adhering changing world. Report of a Working Party of the Royal College of Physicians
to professional guidelines and possessing an excellent of London London: Royal College of Physicians of London; 2005.
medical knowledge. It is about establishing proper 2. Baingana RK, Nakasujja N, Galukande M, Omona K, Mafigiri DK,
Sewenkambo NK: Learning health professionalism at Makerere University:
empathetic communication with patients and recognis- an exploratory study amongst undergraduate students. BMC Medical
ing the role of palliative care which ensures humanism Education 2010, 10:76.
and altruism, about putting aside doctors’ personal 3. Kirk LM: Professionalism in medicine: definitions and considerations for
teaching. Proc (Bayl Univ Med Cent) 2007, 20:13-16.
interests and defining appropriate moral and ethical 4. Sade R, Stroud M, Levine J, Fleming G: Criteria for Selection of Future
values and beliefs of doctors which ensures accountabil- Physicians. Ann Surg 1985, 201:225-230.
ity and lead to excellence, an essential part of profes- 5. Pavlov A, Dahlquist GE: Teaching communication and professionalism
using a popular medical drama. Fam Med 2010, 42:25-27.
sionalism [26]. 6. Winter RO, Birnberg BA: Teaching professionalism artfully. Fam Med 2006,
This study has several limitations. The first one is a 38:169-171.
small sample, which limits us to generalise conclusions 7. Blasco PG, Moreto G, Roncoletta AFT, Levites MR, Janaudis MA: Using
movie clips to foster learners’ reflection: improving education in the
to all students. Nevertheless, this was a small study affective domain. Fam Med 2006, 38:94-96.
using qualitative methodology which allowed us to 8. Alexander M, Hall M, Pettice Y: Cinemeducation: an innovative approach
explore students’ feelings, attitudes and values and as to teaching psychosocial medical care. Fam Med 1994, 26:430-433.
9. Blasco PG, Monaco CF, de Benedetto MAC, Moreto G, Levites MR: Teaching
such we can regard it as a representative one for further through movies in a multicultural scenario: overcoming cultural barriers
planning of the curriculum. Another limitation is the through emotions and reflection. Fam Med 2010, 42:22-24.
fact that results of qualitative analysis were not validated 10. Salinsky J: Half a day at the movies: film studies in the VTS course. Br J
Gen Pract 2005, 55:806-809.
with the students. This is a possible source of misunder- 11. Sanchez JC, Gutierrez JC, Morales MD: Cinema and theatre as training
standing between evaluator and students. With this tools for health students. Fam Med 2010, 42:398-399.
study, the authors did not explore how well the stu- 12. Weber CM, Silk H: Movies and medicine: an elective using film to reflect
on the patient, family, and illness. Fam Med 2007, 39:317-319.
dents’ knowledge, gained by this elective course, will 13. Belling C: The “bad news scene” as clinical drama part 2: viewing scenes.
translate into their later professional life. This should Fam Med 2006, 38:474-475.
also be assessed by further studies. 14. Wit film project. [http://www.growthhouse.org/witfilmproject/index.html].
15. Wit, directed by Mike Nichols, USA. 2001.
16. Glaser BG, Strauss AL: The discovery of grounded theory: Strategies for
Conclusions qualitative research Chicago: Aldine Pub. Co; 1967.
The controlled environment of movies successfully 17. Flick U: An introduction to qualitative research. Third edition. London: Sage
Publications Ltd; 2006.
enables students to explore their values, beliefs, and atti- 18. American Board of Internal Medicine: Project professionalism. [http://
tudes towards features of professionalism without feeling www.abimfoundation.org/Resource-Center/Bibliography/~/media/Files/
that their personal integrity had been threatened. Inter- Resource%20Center/Project%20professionalism.ashx ].
19. Rabow MW, Wrubel J, Remen RN: Authentic community as an educational
active teaching methods could become an indispensible strategy for advancing professionalism: a national evaluation of the
aid in teaching professionalism to new generations. Healer’s art course. J Gen Intern Med 2007, 22:1422-1428.
Further studies about the impact of movies should be 20. Schwartz AC, Kotwicki RJ, McDonald WM: Developing a modern standard
to define and assess professionalism in trainees. Acad Psychiatry 2009,
done on much larger samples of students and with the 33:442-450.
use of quantitative methodology. 21. Alexander M, Pavlov A, Lenahan P: Lights, camera, action: using films to
teach the ACGME competencies. Fam Med 2007, 39:20-23.
22. Morrison RS, Meier DE: Clinical practice. Palliative care. N Engl J Med 2004,
Acknowledgements 350:2582-2590.
The authors thank all students who participated in this study. 23. Blasco PG, Benedetto MAC, Garcia DSO, Moreto G, Roncoletta AFT, Troll T:
Cinema for educating global doctors: from emotions to reflection,
Author details approaching the complexity of the Human Being. Primary Care 2010,
1 10:45-47.
Department of Family Medicine, Medical School, University of Maribor,
Slomskov trg 15, 2000 Maribor, Slovenia. 2Department of Family Medicine, 24. Marcus ER: Empathy, humanism, and the professionalism of medical
Medical School, University of Ljubljana, Poljanski nasip 58, 1000 Ljubljana, education. Acad Med 1999, 74:1211-1215.
Slovenia. 25. Quadrelli S, Colt HG, Semeniuk G: Appreciation of the aesthetic: a new
dimension for a medicine and movies program. Fam Med 2009,
Authors’ contributions 41:316-318.
ZKK planned the study, performed qualitative analysis and wrote the first 26. Stern DT: Measuring medical professionalism New York: Oxford University
and the final draft of the manuscript. JK helped in the designing of the Press; 2006.
study and coordination and helped to draft the manuscript. All authors read
and approved the final version of the manuscript. Pre-publication history
The pre-publication history for this paper can be accessed here:
Competing interests http://www.biomedcentral.com/1472-6920/11/60/prepub
The authors declare that they have no competing interests.
doi:10.1186/1472-6920-11-60
Received: 13 April 2011 Accepted: 23 August 2011 Cite this article as: Klemenc-Ketis and Kersnik: Using movies to teach
professionalism to medical students. BMC Medical Education 2011 11:60.
Published: 23 August 2011
94 February 2006 Family Medicine
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Editor’s Note: In this column, teachers who are currently using literary and artistic materials as part of
their curricula will briefly summarize specific works, delineate their purposes and goals in using these
media, describe their audience and teaching strategies, discuss their methods of evaluation, and speculate
about the impact of these teaching tools on learners (and teachers).
Submissions should be three to five double-spaced pages with a minimum of references. Send your
submissions to me at University of California, Irvine, Department of Family Medicine, 101 City Drive
South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984.
[email protected].
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Humanities, Doctoring, people requires creating methods incorporated into the educational
and Emotions that address the human aspects of process, and allowed to flow freely
We live in an era where outcomes, medicine. in the educational setting, emo-
guidelines, and clinical trials are at Because people’s emotions play tions make learning both more
the forefront of medical training. a specific role in learning at- memorable and more pleasurable
However, to care implies having titudes and behavior, educators for students.
an understanding of the human be- cannot afford to ignore students’
ing and the human condition, and affective domain. Although tech- Why Movies?
for this endeavor, humanities and nical knowledge and skills can be Cinema is the audiovisual ver-
arts help in building a humanistic acquired through training with sion of storytelling. Life stories
perspective of doctoring. Through little reflective process, it is impos- and narratives enhance emotions
humanities and the arts, doctors are sible to refine attitudes, acquire and therefore set up the foundation
able to understand patients in their virtues, and incorporate values for conveying concepts. Movies
whole context. The humanities and without reflection. The point here provide a narrative model framed
arts provide a source of insight and is how to provoke students’ reflec- in emotions and images that is also
understanding for proper doctor- tive process. Learning through grounded in the students’ familiar,
ing and, as such, they should be as aesthetics—in which cinema is everyday universe. We know that in
much a part of medical education included—stimulates a reflective the clinical setting, the life histories
as training in differential diagnosis attitude in the learner. The first step of patients are a powerful resource
or medical decision making. Teach- in humanizing medical education in teaching. Similarly, when the
ing how to effectively take care of is to keep in mind that students goal is promoting reflection that
are reflective beings, and they need includes both cognitive and emo-
an environment that supports and tional components, life histories
(Fam Med 2006;38(2):94-6.)
encourages this activity. Because derived from the movies are well
emotions and images are privileged matched with the students’ desires
in popular culture, they should be and expectations.1
From the Brazilian Society of Family Medicine
(SOBRAMFA), University of São Paulo, São the front door in students’ learn- Cinema is useful in teaching
Paulo, Brazil. ing process. When systematically because it is familiar, evocative,
Literature and the Arts in Medical Education Vol. 38, No. 2 95
and nonthreatening for students. teaching with clips in which several important and constructive. There
Movies provide a quick and direct rapid scenes, taken from different may be a temptation on the part
teaching scenario in which specific movies, works better than viewing of both students and instructor to
scenes point out important issues, the whole movie. The effect is a feel satisfied with the emotions and
emotions are presented in acces- rich generation of perspectives and often tears appearing at the end of
sible ways where they are easy to points of view, which in turn trigger the clip. In fact, this is where the
identify, and students are able to multiple, often contradictory emo- real work starts. Students need to
understand and recognize them tions and thoughts in the viewers. share, and further consider, their
immediately. In addition, students In this context, learners have an thoughts and feelings in light of
have the opportunity to “translate” intensely felt need for reflection the comments and responses of
movie life histories into their own about what they have just seen. their peers. This final discussion
lives, and into a medical context, American movies are particularly is absolutely necessary to put into
even when the movie addresses a useful, since they tend to tell stories coherent perspective the emotions,
nonmedical subject. Movie experi- in a straightforward and uncompli- insights, dreams, and fears that the
ences act like emotional memories cated manner. Although European film clips evoked.
for students’ developing attitudes or Asian movies often stimulate In our experience, the topics that
and remain with them as reflective deep meditation on human values, emerge in these discussions are
reference points while proceeding they demand more time and atten- critical to understanding the hu-
through their daily activities, in- tion on the part of learners. man condition. Fostering reflection
cluding those related to their role after viewing often stimulates con-
as future doctors. Why Comments During versations about the interaction of
the Viewing? health and illness with the breadth
Why Clips? And Taken The value of instructor commen- of human experience and can elicit
From What Movies? tary during the viewing of clips is profound conflicts and concerns
Examples of useful film clips a conclusion based on the authors’ from students about their future
can be found in the Appendix, experience.2 Although the sudden professional roles and themselves
and additional examples can changing scenes in the clips effec- as human beings. Students identify
be found at the on-line Appen- tively evoke students’ individual easily with film characters and
dix provided by the authors at concerns and foster reflection on movie “realities,” and through a
ht t p://w w w.sobramfa.com.br/ these concerns, making comments reflective attitude gain new insights
docs/publicacoes/appendix.pdf. while the clip is playing acts as a into many important aspects of life
Cinematic teaching methodology valuable amplifier to the whole pro- and human relationships. The edu-
should be matched to the students’ cess. Because students are involved cational benefit also is expanded by
daily experiences. Young people to- in their personal reflective process, the phenomenon of students’ “car-
day live in a dynamic and sensitive they may at times disagree with rying forward” into their daily lives
environment of rapid information the teacher’s comments and form the insights and emotions initially
acquisition and high emotional im- their own conclusions. This is not generated in response to the movie
pact. In this context, it makes sense a matter for concern and may even clips. In other words, students
to use movie clips because of their be desirable. In fact, participants report that the movie clip training
brevity, rapidity, and emotional in- note that divergent comments are acts like “an alarm” to make them
tensity. Providing clips from differ- particularly useful to facilitate the more aware when similar issues
ent movies to illustrate or intensify reflecting process. A quote from and situations occur in their daily
a particular point fits well with the one medical student elucidates this lives.
dynamic and emotional nature of point:
students’ experience. Nevertheless, What About Assessment?
the purpose is not to show students Don’t keep quiet, please. You To measure outcomes such as
how to incorporate a particular atti- must make your comments while increased compassion, empathy,
tude but rather to promote students’ the movie is going on . . . Do and commitment poses significant
reflection. you ask if I agree with you? No, difficulties not just for medical
Because our goal is to promote I don’t agree at all . . . But your education but for real life. At this
reflection on attitudes and human comments push me to reflect . . . point, what we can say is that our
values from a broad perspective, so please, go on. experience with the movie clip
in our teaching we use clips from teaching methodology suggests that
nonmedical films. The intention is Bringing Together Emotions and it is well suited to the audiovisual
to expose students to life events, Reflections: Final Discussion culture in which our students are
not to specific medical situations. The last part of the movie clip immersed, resonates well with
For this purpose, in our experience, teaching methodology is the most students’ need to learn on affec-
96 February 2006 Family Medicine
tive as well as cognitive dimen- If I were unable to deal with a REFERENCES

sions, and results in high levels patient, to convince him, I would 1. Blasco PG. Medicina de Família & Cin-
of motivation and involvement. be helpless. ema: Recursos Humanísticos na Educação
In fact, movie clip methodology Médica. São Paulo, Brazil: Ed. Casa do
Psicólogo, 2002.
is a powerful resource to promote As our ability to assess the 2. Blasco PG, Alexander M. Ethics and human
reflective attitudes and to provide “intangibles” in medical practice values. In: Alexander M, Lenahan P, Pavlov
learning linked to experience.3,4 progresses, we will be better able A. Cinemeducation: a comprehensive guide
to using film in medical education. Oxford:
Another student quote illustrates to document the value of this and Radcliffe Publishing, 2005.
this conclusion: other humanities-based method- 3. Blasco PG, Roncoletta AF, Moreto G, Gal-
ologies, both in terms of effects on lian DMC, Freeman J. Teaching humanities
through movies: a cinema course for medical
I took up this work [medicine] students’ personal lives and on their students. Presented as a seminar at the 2003
because I liked it. Projects like interactions with patients. Society of Teachers of Family Medicine
this [the movie clip teaching] are Annual Spring Conference in Atlanta. Con-
Corresponding Author: Address correspondence ference program page 58.
necessary to prevent one from 4. Blasco PG, Levites MR, Moreto G, Ron-
to Dr Blasco, SOBRAMFA-Brazilian Society of
losing touch with the real world. Family Medicine, University of Sao Paulo, Rua coletta AFT, Tysinger J, Benedetto MAC.
With these themes, one questions das Camelias, 637, Sao Paulo, 04048-061 Brazil. Using movie and opera clips to teach family
[email protected]. medicine core values and address students’
not only medicine but also the emotions. Presented as a seminar at the 2005
human being. Physicians care Society of Teachers of Family Medicine
for something special, [because Annual Spring Conference in New Orleans.
Conference program page 48.
they are] obliged to treat people.
Appendix
Using Movie Clips to Foster Learners’ Reflections: Improving Education in the Affective Domain
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MEDICAL EDUCATION
Competency-based Medical Education, Entrustment and Assessment

*JYOTI NATH MODI, #PIYUSH GUPTA AND TEJINDER SINGH
From the Departments of *Obstetrics and Gynecology, People’s College of Medical Sciences and Research Center, Bhopal;
#Pediatrics, University College of Medical Sciences, New Delhi; and CMCL-FAIMER Regional Institute, CMC, Ludhiana; India.
Correspondence to: Dr Tejinder Singh, Program Director, CMCL-FAIMER Regional Institute, Christian Medical College,
Ludhiana, Punjab 141 008, India. [email protected]
The realization that medical graduates are failing to serve the health needs of the society has compelled the medical educationists and
regulatory authorities worldwide to review the medical training. A medical curriculum oriented towards developing the key competencies
that enable a fresh graduate to be delivering socially responsive health care is seen as a promising step towards alleviating this problem.
This calls for a departure from the traditional approach of organizing the curricular components around educational objectives, to a
competency-based approach for planning the curriculum. The present article discusses the concept of competency-based medical
education in Indian context, the steps in planning and implementing such a curriculum, and the key aspects of assessment for its effective
implementation.
Keywords: Competency, Competency-based medical education, Assessment, Outcome-based education, Competency framework.
M
edical schools came into being with the of a medical school viz, the array of abilities of a fresh
purpose of generating a scientifically graduate, so as to perform the expected roles in providing
trained professional workforce for serving health care to the community` has been lacking.
the health needs of the society. Over the Accordingly, assessment methods also were traditionally
years, a perceptibly increasing gap between the health designed to measure attainment of knowledge or specific
professionals’ education, health care delivered, and skills rather than the ability of the graduate in delivering
societal health needs has raised global concerns [1,2]. judicious and contextual health care in authentic settings.
Medical schools are increasingly facing the question,
‘Are they producing graduates who are competent to Awakened to this misalignment of training and needs,
cater to health needs of the society?’ – Perhaps, not in the efforts at making the ‘competencies’ as the chief
entirety. For any corrective action; therefore, it is only driving force of medical training and curricular planning
befitting that we re-trace and work our way backwards has gained momentum since the turn of the century
from first defining the expected roles of a physician that [1,2,4]. In this article we discuss the concept of
best serve the healthcare requirements of the community competency-based medical education in comparison to
(local and global) and also to clearly state the the traditional curricula in the Indian perspective, and
characteristics and abilities of doctors graduating from also its implementation, particularly the assessment for
medical schools that enable them to perform these roles such a medical training.
well [3]. The curricula then need to be designed towards DEFINITIONS
achieving these outcome requirements steered by
appropriate assessment methods. Herein lies the origin The dictionary meaning of the terms ‘competency’ or
and essence of Competency-based Medical Education ‘competence’ is “ability to do something” or “ability for a
(CBME). task”. While the two terms are used interchangeably,
competencies may also be viewed as ingredients of
The goal of Undergraduate (UG) medical training is competence i.e., many specific competencies in
to produce ‘doctors of first contact’ or ‘primary care combination constitute a broader area of competence [5].
physicians’. Having stated this goal, most traditional Competence in a particular area encompasses many
curricula and training programs, including those in Indian aspects and hence is best expressed as a description
institutions, have been designed around the educational/ (statement) of abilities in context of setting, experience
learning objectives [2]. These objectives largely allude to and time (or stage of training) [5-7].
knowledge base with some reference to procedural skills,
and behavior to be developed during the course of A comprehensive and widely cited definition of
training. The holistic description of the outcome product Professional competence as proposed by Epstein and
INDIAN PEDIATRICS 413 VOLUME 52__MAY 15, 2015

MODI, et al. COMPETENCY-BASED MEDICAL EDUCATION
Hundert in 2002, states: “the habitual and judicious use of framework in form of the document ‘Tomorrow’s
communication, knowledge, technical skills, clinical Doctors’ in 1993, that underwent further refinements over
reasoning, emotions, values, and reflection in daily time [12]. Three broad outcomes were specified for
practice for the benefit of the individual and community medical graduates: (i) Doctor as a scholar and a scientist,
being served” [4]. (ii) Doctor as a practitioner, and (iii) Doctor as a
researcher. Under each of these heads, sub competencies
With evolving understanding and increasing were further specified. The standards of teaching learning
consensus on the issue, a definition of Competency-based and assessment were further grouped under nine
Education as proposed by Frank, et. al. in 2010, makes domains. For each domain, the standards, the criteria and
the core purpose and curricular elements of CBME more the evidence (for evaluation) were specified in concrete
lucid: “Competency-based education (CBE) is an terms [12].
approach to preparing physicians for practice that is
fundamentally oriented to graduate outcome abilities and The Royal College of Physicians and Surgeons of
organized around competencies derived from an analysis Canada (RCPSC) expressed the outcome of
of societal and patient needs. It de-emphasizes time- undergraduate medical training in terms of seven ‘roles’
based training and promises greater accountability, of a physician and developed competency framework
flexibility, and learner-centeredness” [8]. Some experts based on these – the Canadian Medical Education
consider CBME as another form of outcome-based Directions for Specialists (CanMEDS) [13]. These roles
education (OBE), where learning outcomes assume more were: medical expert, communicator, collaborator,
importance than learning pathways or processes. manager, health advocate, scholar and professional.
GLOBAL MOVEMENT TOWARDS COMPETENCY-BASED The National Undergraduate Framework in

MEDICAL EDUCATION Netherlands is yet another example of a well
implemented outcome competency-based medical
Competencies are context-dependent and hence are education framework [3]. Medical educationists from the
contextually expressed and communicated. This has Netherlands further propose that competencies are
resulted in various competency frameworks in use in perhaps better observed and measured as Entrustable
different countries/regions. Also, within the same Professional activities (EPA), discussed later in the
country, these frameworks have undergone modifications article [14]. An effort at defining outcomes has also been
and refinements over time. noted from Vietnam, Mexico and China [15].
In United States, the Outcome Project was initiated COMPARISON WITH TRADITIONAL CURRICULUM
by the Accreditation Council for Graduate Medical A comparative analysis of traditional discipline-based
Education (ACGME) in 2001 for emphasizing the curriculum and competency-based curriculum is
‘educational outcomes’ in terms of competencies to be provided in Web Table I [2,3,5,14,16-18]. However, this
achieved during the course of training [9,10]. These analysis should not lead us to believe that one approach
competencies were identified under six domains, also should completely replace the other. Incorporating
referred to as general competencies, for all physicians elements of competency-based training utilizing the
irrespective of specialty. These are: Medical Knowledge, systems approach, and retaining the strengths of the
Patient care, Interpersonal and Communication skills, traditional curricula would be desirable. This would
Professionalism, Practice-based learning and improve- certainly be a challenging task.
ment, and System-based practice. They provided a
framework for education and evaluation by specifying the The three key steps in planning a competency-based
end product rather than the desired training process or curriculum, as suggested by experts and utilized by
pathway. As a refinement measure towards assessment institutions running such programs [5,19-22] are:
and defining the training pathway the ACGME launched 1. Identification of competencies
the ‘Milestones Project’ in 2007 [7,11]. Thus sub-
competencies, that serve as ‘milestones’ along the way to 2. Content identification and program organization
becoming fully competent, and hence must be achieved 3. Assessment planning and program evaluation
during the course of training were specified for each
outcome competency [9]. For implementation, they can be further divided into
component steps and strategies as shown in Table I.
In United Kingdom, the General Medical Council Additionally, faculty development and creating
defined the outcomes and standards of graduate medical conducive environment is a must for effective delivery of
education, and brought out the details of competency the curriculum.

For program organization and assessment planning, it illustrated in Table II. These meaningful achievement
is important to remember that the competencies are points that mark the attainment of a predefined
developmental, i.e., expertise in a said area progressively performance level during the learning phase have been
changes over time and with experience. This has two given different labels, e.g., the Accreditation Council for
implications: first, attainment of a competency can be Graduate Medical Education (ACGME), USA, refers to
viewed as passing through intermediate levels of these as ‘Milestones’ to be achieved on way towards
expertise in various aspects of that competency, to be becoming fully competent [7,25].
achieved (corresponding to the stage of learning) during
the course of becoming fully competent – akin to the The second consequence is, that a level of expertise
rungs of a ladder. Dreyfus and Dreyfus proposed a model for being called ‘fully competent’ needs to be specified.
of phase-wise learning with developmental stages of skill This cut-off is not set at the minimum level of expertise
acquisition, the stages being Novice, Advanced beginner, but at a level when the person can act independently and
Competence, Proficiency and Expertise [23,24]. This take responsibility for his action or performance in that
model can also be applied to medical education as area. Therefore, it is rightly said that the ultimate goal in
TABLE I STEPS OF COMPETENCY-BASED CURRICULUM PLANNING AND STRATEGIES FOR IMPLEMENTATION
Steps for planning Competency-based Curriculum Steps and strategies for implementation
I Identification of competencies • Competency identification by consensus opinion of experts, health

needs, analysis of physician activities, self-report by physicians to
identify critical elements of behavior, critical incidents, public health
statistics, medical records, practice setting and resources.
• Exactly define required competencies and their components: Bring
out statement of learning outcomes and communicate to faculty and
students
II Content identification & Program organization • Identify corresponding course content
• Course organization: sequencing, learning opportunities, select
educational activities, experiences and instructional methods
• Time organization: delineate minimum and maximum time period of
training; Create space for feedback sessions and opportunity to
reflect.
• Define the desired level of mastery/expertise in each area
• Define milestones or achievement points along development path for
competency i.e. charting of student progression pathway.
III Assessment planning and Program evaluation • Identify observable and measurable form of competencies in real
settings; e.g. EPA
• Define performance criteria: Establish minimum acceptable norms of
summative performance and intervening levels of expertise.
• Select assessment tools to measure progress along the charted
pathways i.e. formative assessment for achievement of milestones
• Develop a longitudinal assessment program (rather than standalone
formative and summative assessments), with emphasis on WPBA
methods: Make a blueprint with areas to be assessed, timing and
assessors
• Design an outcomes evaluation program with scope for curricular
review and improvement
• Faculty development and student orientation
• Ensuring conducive educational environment
• Student selection: incorporate some mechanism for assessing
aptitude and motivation towards pursuing medical studies and
delivering health care

TABLE II APPLICATION OF DREYFUS MODEL TO CURRICULAR FRAMEWORKS OF COMPETENCY-BASED MEDICAL EDUCATION
Dreyfus model Assessment of ‘Competency’ in CBME Assessment of an ‘Entrustable professional

Activity’ (EPA)
Developmental Stepwise achievement of ‘Milestones’ towards Stepwise acquisition and integration of
steps of skill acquisition of a Competency several competencies towards achieving
acquisition as entrustable level of job responsibility
studied in (EPA)
various learning
situations
Example1: Communication with Example 2: Performance Example: ‘Care of the Neonate’ as an

patients of Caesarian section EPA for PG training in Pediatrics
(This EPA requires an integration of
(UG to PG years) (PG training in OBG) competency in patient care, procedural
skills, communication & counseling skills,
teamwork, managerial & leadership skills)
Novice Able to talk with the patient so as to Observes: Level 1:Can be entrusted with examination
take basic medical history according As second assistant during of newborn to look for congenital
to established framework. surgery anomalies
(At entry: II-III Semester MBBS
student)
Advanced Able to establish rapport with the Assists: Level 2:
beginner patient and take a medical history As first assistant to a senior Can be entrusted to attend deliveries,
for a diagnostic workup. Able to during surgery receive and resuscitate term newborns in
counsel the patient for health uncomplicated cases.
practices such as diet, hygiene.
(Mid level: IV – VII Sem MBBS)
Competence In addition to above: able to take a Directly supervised: Level 3:
history of delicate personal issues Operates under supervision Can be entrusted with immunization and
and make a provisional diagnosis of a senior who scrubs and management of common problems in
based on history. assists during the surgery. newborns in outpatient setting.
Able to counsel for taking informed
consent for surgeries and procedures
(UG Exit level: VIII-IX Sem &
Internship)
Proficiency In addition to above: Indirectly supervised: Level 4:
Able to counsel patient and care givers The expert is available and Can be entrusted with receiving and
for a newly made diagnosis, diagnosis supervises without actually resuscitation of the newborn in
of serious illness and for seriously ill scrubbing for surgery. complicated cases such as preterm,
patients. growth restriction, large baby.
(I-II Year PG students)
Expertise In addition to above: Independent: Level 5:
Able to counsel Patient’s care givers Without senior supervision Can be entrusted with management of
in the event of death of patient. common problems in the newborns in
(III Year PG student) intensive care setting
CBME is not merely attainment of competency but an CBME are discussed below:
expertise (specified) in the area [16]. These two aspects
What to assess?
are an important consideration in designing the formative
and summative assessment in competency-based In CBME, the outcome is expressed in terms of
education. competencies. Medical education literature distinguishes
between the terms ‘competence’ (meaning ‘able to do’)
ASSESSMENT IN CBME
and ‘performance’ (meaning ‘actually does’). According
Some pertinent issues with regards to assessment in to Miller’s pyramid model of clinical competence, the

assessment of performance is at the highest level i.e. the upon their degree of expertise, stage of training and
‘Does’ ; and competence assessment is a level below i.e context of performance. The concept of EPA will be
‘Shows how’. Naturally, performance assessment further discussed in detail in our next article in this series.
provides a more authentic picture of trainees’ In our day-to-day practice, we all entrust night on- call
functionality in real clinical settings [17]. While residents with different levels of tasks – we depend on
competence can be assessed in examination setting using someone to be able to decide on what samples to collect but
simulations and with tools such as Objective Structured may not depend on him/her to make the choice of an
Clinical Examination (OSCE), it can perhaps be better antibiotic. EPAs help us to decide the level of trust we can
inferred from observable workplace performance using place on a trainee to independently handle a given task.
Workplace-based Assessment (WPBA) tools [18] .
It is also easier to observe and judge the proficiency
What to Measure While Assessing? with which a certain job activity is performed rather than
Assessment requires identification of measurable and trying to observe and measure each competency
observable entities. This could be in the form of whole contributing to it. The term ‘entrustable’ in EPA
tasks that contribute to one or more competencies or inherently conveys the minimum acceptable standard i.e.,
assessment of a competency per se. While it appears the trainee is able to carry out the said clinical activity
reasonably justifiable to work on this framework, there independently, can take responsibility for the same and
have been concerns that attaining individual hence can be entrusted with it. Ten Cate proposed that
competencies may not actually lead to actual or once the EPA is of an acceptable standard, a written
acceptable performance. A trainee who is competent in statement to this effect may be issued to the trainee: a
history taking, physical examination and treatment Statement of awarded responsibility (STAR) [14].
planning, may still be unable to actually treat a patient. In Assessment of EPA may have a relatively more
this context, the concept of ‘Entrustable Professional meaningful and utilitarian interpretation, especially in
Activity’ (EPA) [6] makes a lot of sense. formative assessments.
The EPA encompasses a set of professional work Also, it is of extreme importance to define standards
activities that together constitute the particular profession of measurement of sub-competencies (e.g., Milestones or
or specialization. Only after mastering a certain set of benchmarks; Levels of EPA) to be achieved at various
competencies can a trainee be entrusted with carrying out stages of training. This charts out the desired pathway to
a particular professional activity with responsibility becoming fully competent. Examples of developmental
[14,26]. Observing and measuring competencies in form phases of attainment of competency and entrustment of
of EPA gives a more authentic information about the professional activity, based on Dreyfus model are shown
ability of the trainee to function as a professional in real in Table II. Though the framework of EPA appears more
life situation, and hence a better validity to assessment. suitable for Postgraduate training, it may also by utilized
for Undergraduate medical training thus providing a
Let us try to illustrate this concept by using a simple developmental continuum to specialist training [27] The
example. While teaching driving to a novice, we set next paper in this series of medical education articles is
certain objectives for ourselves. For example, he ‘should dedicated to a full discussion on EPA.
be able to start the engine’, ‘change the gears’, and
‘coordinate the release of clutch and accelerator’ and so How to Measure: the Methods, Tools and Reporting
on. Attainment of these does not mean that he will be able Since CBME focuses on the outcome, it is important to
to drive a car. However, if we change our outcome to observe and assess (and learn) at workplace. Daily
‘competent to drive a car’ then this problem can be practice area provides a richer source of information
avoided and we will continue our training till the trainee rather than isolated hand-picked tasks in examination
is able to drive a car. When the trainee demonstrates his setting. The WPBA methods assess at the ‘does’ level of
ability to drive a car, we can call him competent. Miller’s pyramid and hence are most suitable [18]. These
However, there may be more issues to it. He may be able include mini-Clinical Evaluation Exercise (mini-CEX),
to drive a small car but not a large one or he may be able Directly Observed Procedural Skills (DOPS), mini-Peer
to drive a car in a small town but not in the traffic of a Assessment Tool (mini-PAT), Multisource feedback
metropolis or not in a hilly terrain. We may entrust a (MSF) as some of the common ones. Each of the tools can
trainee driver to drive us in a small town with not much of provide information about more than one competency;
traffic but need to provide more training before we can and any competency can be assessed in a better way by
entrust him to drive us in a metro. On the same analogy, using more than one tool (triangulation). We have already
we have different levels of trust on the trainees depending discussed WPBA in detail in an earlier paper [27].

Another aspect is the recording and reporting of standards of acceptable level of expertise must be well-
observations. There has been an undue emphasis on defined in competency-based training programs, and
objectification of assessment scores [16]. Subjective these must be defined not just for the outcome-
interpretations of assessment have been underutilized and competencies but also for the intervening milestones to
in fact been maligned to some extent. To some extent, it be achieved by the trainee. While establishing cut off
has been so because subjectivity has been misinterpreted standards, it is important to adopt a criterion-based
as bias. This concern can be minimized by utilising approach [16,17]. That is, the set standard is an absolute
multiple assessors over multiple occasions and settings. level of performance (or competence) and is not
Judgment by an expert can be well expressed subjectively dependent on the performance of other students.
in words. It may in fact be more meaningful and useful to Adopting a normative-approach has the inherent risk that
the trainee than a set of scores or categories conveyed at the standards may be set below acceptable level of
the end of assessment. This is particularly true for CBME expertise.
since competencies are developmental and their
progression depends heavily on the appropriate steering CBME: THE INDIAN SCENARIO
by assessment. The formative function of assessment is In India, there has been a relatively recent need-driven
served well by subjective reporting of assessment. movement towards competency based medical
Recently, there is increasing emphasis on utilising education, and it is yet in a fledgling stage of discussions
qualitative approach in assessment [16]. Use of student and planning. The Graduate Medical Education
narratives and portfolios can be a rich source of Regulations 1997 (GMER) of the Medical Council of
information about student learning. Tekian, et al. [28] India (MCI) mention the term ‘competent’ under
propose redefining of ‘competence’ itself in terms of institutional goals but do not define it further [29].
construct narratives rather than as a checklist of Following a series of meetings and deliberations, reforms
component tasks. were suggested in the form of ‘Vision 2015’ document in
2011 [30]. For the first time, the outcomes of graduate
Feedback: Whatever the assessment method, tool or medical education were expressed as the competencies
reporting format, it is of utmost importance to provide an that an ‘Indian Medical Graduate’ would develop so as to
early and effective feedback to the trainee, preferably function as a ‘Basic Doctor’ or physician of first contact
based on direct observation. Development of to the people of India and the world. The five roles of a
competencies hinges on the feedback received by the Basic doctor were stated as: Clinician, Leader and team
student trainee so that student progresses through the member, Communicator, Lifelong learner, and
charted milestones. There is evidence in literature that Professional (who is ethical, responsive and accountable
establishes feedback as the most important determinant to patients, community and profession). The
of learner progression [16]. competencies to be developed to perform the above roles
When to Assess? were also specified. The term competency was meant to
imply ‘desired and observable ability in the real life
Frequent (or continuous) formative assessments that situation’. Unfortunately, in these deliberations,
allow for and promote developmental progression are assessment was neither discussed in appropriate details
desirable in CBME. This helps to keep the trainee on the nor was an assessment program aligned to outcome-
correct trajectory towards end outcomes [18]. Hence measurement included. The document did mention in
there is a greater emphasis on formative assessment in passing that assessment be ‘criterion referenced’ without
CBME. giving any further details.
Who Should Assess?
Based on above deliberations and documents, the
Faculty, peers, colleagues may assess depending on the new Graduate Medical Education Regulations 2012
competency being assessed. It is more important that the (GMER 2012) were proposed [31]. A salient feature of
assessors are trained in using the method and tools that this revision of medical curriculum was emphasis on
they use. Inter-rater variation in assessment can be competency-based curriculum. While subject-wise
reduced by assessor training as well as defining the specific outcome competencies were mentioned in this
standards for expected outcomes. document, the alignment of assessment towards
measuring competencies again remained largely
Standards of Assessment in CBME
unaddressed. The Postgraduate Medical Education
It is well expressed by educationists that expertise and not Regulations 2000 (PGMER) of the MCI merely mention
competence is the ultimate goal in CBME [16]. The that the PG curriculum be competency-based, and that

each department must produce statement of November 15, 2014.

competencies [32]. 7. Orgill BD, Simpson D. Towards a glossary of competency-
based medical education terms. J Grad Med Educ.
Hence, we as a country still have a long road ahead 2014;6:203-6.
towards implementing competency-based medical 8. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S,
training. There is a need to review and revise our Horsley T. Toward a definition of competency-based
curriculum respecting the key role of assessment in education in medicine: a systematic review of published
achieving the deliverables. With the benefit of the definitions. Med Teach. 2010;32:631-7.
9. Accreditation Council for Graduate Medical Education.
existent curricular frameworks in use in different nations,
ACGME Outcome Project enhancing residency education
we need to develop a competency framework suited to through outcomes assessment: General Competencies.
our needs and feasible in our settings and resources. 1999. Available from: http://www.acgme.org/outcome/
Faculty Development comp/compFull.asp. Accessed November 9, 2014.
10. Joyce B. Introduction to Competency-based education.
Since the competency-based training program and Facilitators guide ACGME. 2006. Available from: http://
assessment methods differ in many ways from the www.paeaonline.org/index.php?ht=a/GetDocument
traditional curricula, it is important not only to orient the Action/i/161740. Accessed December 27, 2014.
11. Weinberger SE, Pereira AG, Lobst WF, Mechaber AJ,
faculty to it but also to train the faculty in using the
Bronze MS, Alliance for Academic Internal Medicine
appropriate assessment methods. Of particular Education Redesign Task Force II. Competency-based
importance is the faculty training for improving the direct education and training in Internal Medicine. Ann Intern
observation skills and feedback skills. Med. 2010;153:751-6.
12. General Medical Council. Tomorrow’s Doctors: Education
WHERE WE STAND AND WHAT NEEDS TO BE DONE
Outcomes and standards for undergraduate medical
As we move towards developing a competency-based education. Available from: http://www.gmcuk.org/
approach to medical education in our country, it is crucial Tomorrow_s_Doctors_0414.pdf_48905759.pdf. Accessed
December 27, 2014.
to sensitize and prepare the faculty for the change. An
13. Frank JR, Danoff D. The CanMEDS Initiative:
initial combined and organized effort for identification of implementing an outcomes-based framework of physician
general competencies and specialty competencies may be competencies. Med Teach. 2007;29:642-7.
a good starting point. Assessment has a key role in 14. ten Cate O, Scheele F. Competency-based Postgraduate
shaping the outcomes and success of a curriculum and training: Can we bridge the gap between theory and clinical
hence must be carefully planned. practice. Acad Med. 2007;82:542-7.
15. Harden RM. Outcome-based education – The future is
Contributors: TS: conceptualized the paper; JNM wrote the first today. Med Teach. 2007;29:625-9.
draft; PG provided critical comments. All authors approved the 16. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR,
final draft. for the International CBME Collaborators. The role of
Funding: None; Competing interests: None stated. assessment in competency-based medical education. Med
REFERENCES Teach. 2010;32:676-82.
17. van Mook WNKA, Bion J, van der Vleuten CPM,
1. Long DM. Competency-based residency training: The next Schuwirth LWT. Integrating education, training and
advance in Graduate Medical Education. Acad Med. assessment: competency-based intensive care medicine
2000;75:1178-83. training. Neth J Crit Care. 2011;15:192-8.
2. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et 18. Boursikot K, Etheridge L, Zeryab S, Sturrock A, Ker J,
al. Health professionals for a new century: transforming Smee S, Sambandam E. Performance in assessment:
education to strengthen health systems in an interdependent Consensus statement and recommendations from the
world. Rev Peru Med Exp Salud Publica. 2011;28:337-41. Ottawa conference. Med Teach. 2011;33:370-83.
3. Harris P, Snell L, Talbot M, Harden RM for the 19. Chacko TV. Moving towards competency-based education:
International CBME Collaborators. Competency-based Challenges and the way forward. Arch Med Heath Sci.
medical education: implications for undergraduate 2014;2:247-53.
programs. Med Teach. 2010;32:646-50. 20. McGaghie WC, Miller GE, Sajid AW, Telder TV.
4. Epstein RM, Hundert EM. Defining and assessing Competency–based Curriculum Development in Medical
professional competence. JAMA. 2002;287:226-35. Education. An Introduction. Geneva: World Health
5. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Organization; 1978.
Swing SR, et al. Competency-based medical education: 21. Harden RM. Outcome-based education – the ostrich, the
theory to practice. Med Teach. 2010;32:638-45. peacock and the beaver. Med Teach. 2007;29:666-71.
6. Englander R. Glossary of Competency-based Education 22. Smith SR, Dollase R. AMEE guide No. 14: Outcome-
terms. Available from: http://dev.im.org/AcademicAffairs/ based education Part 2 – Planning, implementing and
milestones/Documents/CBME%20Glossary.pdf. Accessed evaluating a competency–based curriculum. Med Teach.

1999;21:15-22. Med Teach. 2014;19:1-4.

23. Dreyfus HL, Dreyfus SE. Mind over Machine: The Power 29. Medical Council of India Regulations on Graduate Medical
of Human Intuition and Expertise in the Age of the Education 1997. Available from: http://www.mciindia.org/
Computer. Oxford: Basil Blackwell; 1986. RulesandRegulations/GraduateMedicalEducation
24. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. Regulations1997.aspx. Accessed November 10, 2014.
General competencies and accreditation in Graduate 30. Medical Council of India. Vision 2015. Medical Council of
medical education. Health Affairs. 2002;21:103-11. India. New Delhi. 2011. Available from: http://
25. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME www.mciindia.org/tools/announcement/MCI_booklet.pdf.
accreditation system – rationale and benefits. New Eng J Accessed November 10, 2014.
Med. 2012;366:1051-6. 31. Medical Council of India Regulations on Graduate Medical
26. van Loon KA, Driessen EW, Teunissen PW, Scheele F. Education 2012. Available from: http://www.mciindia.org/
Experiences with EPAs, potential benefits and pitfalls. Med tools/announcement/Revised_GME_2012.pdf . Accessed
Teach. 2014;36:698-702. October 2, 2014.
27. Singh T, Modi JN. Workplace based assessment: A step to 32. Medical Council of India, Post Graduate Medical Education
promote competency based training. Indian Pediatr. Regulations 2000, Medical Council of India, New Delhi.
2013;50:553-9. Available from: http://www.mciindia.org/Rules-and-
28. Tekian A, Hodges BD, Roberts TE, Schuwirth L, Norcini J. Regulation/Postgraduate-Medical-Education-
Assessing competencies using milestones along the way. Regulations-2000.pdf. Accessed November 29, 2014.

Competency Based Medical Education
[CBME]
Learning Objectives:
1. Define competency based medical education and the need to adopt it.
2. Enlist the advantages and disadvantages of competency based medical education
3. Design a curriculum based on competencies.
4. Outline the challenges one is likely to face while implementing a CBME curriculum.
5. Discuss the future prospects for CBME in India and worldwide.
Team VIBGYOR:
(Moderation team for March 2015)
Faculty: Dr Tejinder Singh, Dr. Jyoti Nath Modi, Dr. Sandeep Dogra
Fellows 2014: Gokul, Nilima
Fellows 2015: Sukhinder, Swapnil
Summary prepared by: Gokul, Nilima
1|Page
INDEX
No. Thread Description Page
No.
1 Thread 1, Part A 2 min elevator talk on Introducing CBME 03
2. Thread 1, Part B Introduction to CBME 09
3. Thread 2, Part A Introducing 2 different perspectives 17
4. Thread 2, Part B The Debate: For or against CBME 28
5. Thread 2, Part C Coming to a consensus 31
6. Thread 3 How to implement CBME in the institute 35
7. Thread 4 Part A: Task Group work on identifying a competency, its components 48
and milestones
8. Thread 4 Part A: țɀȺȿȸȣɆȾȳȲɃȧɆȿȴɅɆɃȶȲɄȲȴɀȾɁȶɅȶȿȴɊ 49
Team Canary Yellow
9. Thread 4 Part A: ȠȿɅȶɃɁȶɃɄɀȿȲȽ Ȳȿȵ ȴɀȾȾɆȿȺȴȲɅȺɀȿ ɄȼȺȽȽɄ ȫȲȼȺȿȸ ȠȿȷɀɃȾȶȵ 51
Team Brick Red Consent before a diagnostic procedure
10. Thread 4 Part A: ȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾȲȿȵȶɅȹȺȴɄȠȿȲȿɀɆɅɁȲɅȺȶȿɅsetting 54
Team Turquoise Blue
11. Thread 4 Part B: Task Group work on designing the teaching-learning activities for 59
the decided competency
12. Thread 4 Part B: T-L methods for performing Lumbar Puncture 60
Team Canary Yellow
13. Thread 4 Part B: T-L methods for taking informed consent before a diagnostic 64
Team Brick Red procedure
14. Thread 4 Part B: T-L methods for professionalism and ethics in an outpatient 67
Team Turquoise Blue setting
15. Thread 4 Part C: Task Group-work on designing the assessment of the decided 69
competency
16. Thread 4 Part C: Assessment of the performance of a lumbar puncture 70
Team Canary Yellow
17. Thread 4 Part C: Assessment of how to take an informed consent before a 74
Team Brick Red diagnostic procedure
18. Thread 4 Part C: Assessment of professionalism and ethics in an out-patient 78
Team Turquoise Blue setting
19. Thread 5 Challenges in the implementation of CBME and its future 80
20 Resources A collection of the resources shared during the month 92
2|Page
Thread 1(Part A):
The 2-minute elevators talk on introducing CBME
Dr. Established is the dean of a reputed medical college. The students from his college
have been winning laurels in the university, making him very proud indeed. Dr Health,
from the community medicine department, brings to his notice the following observation
ȾȲȵȶȳɊȹȺȾȫȹȶɄɅɆȵȶȿɅɄȼȿɀɈ ɅȹȶɃȲɃȶɄɅɀȷɃȲɃȶȵȺɄȶȲɄȶɄȳɆɅȲɃȶɆȿȲȳȽȶɅɀ
effectively manage the routine patients at the rural health centre.
Dr Innovative, an Associate Professor and FAIMER Fellow in the same college, wants to
tell Dr Established about competency based medical education (CBME); that this is the
ȺȿɅȹȺȿȸȲȿȵɄɀɀȿȺɅɈȺȽȽȳȶȲȵɀɁɅȶȵɈɀɃȽȵɈȺȵȶȦȿȶȷȺȿȶȵȲɊȹȶȸȶɅɄɅȹȺɄɀɁɁɀɃɅɆȿȺɅɊ
when he finds himself with the Dean in an elevator.
Please help Dr Innovative draft a 2 minute elevator talk; wherein he tells Dr Established
What is CBME?
The rationale/ need for adopting CBME.
Contributors:
1ST March: Sukhinder, Hem, Gokul, Soum, Tapasya, Purnima, Bharati, Shuchi, Juhi, Mullai, Swapnil
2nd March: Hironmoy, Abhijit, Krithica, Sanjoy, Kavita, Vijay, Soum, Vanita, Sumnath,Gita, Gagan,
Sukhinder
3|Page
The following discussion took place on the thread:
What is CBME?
1) It¡ȺɄȲȿȲɁɁɃɀȲȴȹɅɀɁɃȶɁȲɃȺȿȸɁȹɊɄȺȴȺȲȿɄȷɀɃ practice that is fundamentally oriented to graduate
outcome abilities and organized around competencies derived from an analysis of societal and
patient needs. It deemphasizes time-based training and promises greater accountability, flexibility,
and learnȶɃ ȴȶȿɅȶɃȶȵȿȶɄɄ ȪɀɆɃȴȶ 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
Flexibility and
Learner accountability
centered
Patient
centered
Community
and soiety
centered
Outcome
based
of published definitions. Med Teacher. 2010;32: 631-7.
2) Competency based medical education system is an outcome-based model of education. In this

system, specific, measurable competencies are identified that is guided by the needs of the
community and the learners will work towards them until they are achieved. This is a system
wherein the core competencies are identified prior to the course commencement and the entire
curriculum is built around these competencies. Each student will be assessed using a measurable
standard which is not influenced by the performance of other student. Thus the system ensures each
student graduates with a set standard that the society needs. Competency based education is an
approach to preparing physicians for practice that is fundamentally oriented to graduate outcome
abilities and organized around competencies derived from an analysis of societal and patient needs.
Helping the learners acquire competencies needed to carry out professional tasks wherein the tasks
and duties are aligned to the societal needs.
3) CBME is about coming out of all the enclosures of all the earlier defined curriculum types. The
approach is more holistic to produce proficient health care professionals and beyond.
4|Page
4) A continuous, comprehensive and constructive feedback to the students during formative
assessments makes a mandatory part of this paradigm. This enables the development and the
acquisition of the necessary competencies required for medical practice (our defined outcome).
5) The skills (competencies) of a student are judged and for those students with deficiencies in certain
knowledge areas/ skills, more time may be given or different strategy will be applied to ensure the
defined outcome.
6) Priority health needs of the population are identified, based on those health needs competencies are
than considered in the design of the curriculum.
7) Competency Based Medical Education is an outcome-based approach to design the (a)

Implementation (b) Assessment and (c) Evaluation, of a medical education program using a defined
framework of competencies. Here the ultimate output is fixed as acquisition of certain defined
competencies covering the aspects of knowledge, attitude, skill as well as social values.
ȘȽȽɅȹȶȲɄɁȶȴɅɄɀȷȼȿɀɈȽȶȵȸȶȲɅɅȺɅɆȵȶɄȼȺȽȽȲȿȵɇȲȽɆȶɄȴȲȿȳȶȺȿȴɀɃɁɀɃȲɅȶȵȲɄɅȲɃȸȶɅɀɃɀɆɅȴɀȾȶ
The teaching ways, methods and even the time, can differ from student to student; but on
evaluation, it gets assured that the entire student-ȴɀȹɀɃɅȲȴȹȺȶɇȶɄɅȹȶȾȺȽȶɄɅɀȿȶɄȘȴɅɆȲȽȽɊȷɀȴɆɄȶɄ
on what a medical student should actually be able to do after he passeɄɀɆɅ
8) CBME is such an effective strategy where all the domains are given equal importance right from its
ɁȽȲȿȿȺȿȸȲȿȵɅȹɃɀɆȸȹȺȾɁȽȶȾȶȿɅȲɅȺɀȿȲɄɄȶɄɄȾȶȿɅȲȿȵȶɇȲȽɆȲɅȺɀȿ ȠɅɄȲȽȶȲɃȿȶɃ-centered teaching
method where each student is taken care of individually throughout the teaching session and
attainment of clinical competencies are given due importance and he is assessed through
ȴɀȿɅȺȿɆɀɆɄȷɀɃȾȲɅȺɇȶȲɄɄȶɄɄȾȶȿɅȪɅɆȵȶȿɅɄȧȲɄɄȴȶɃɅȺȷȺȴȲɅȺɀȿȺɄdependent on attainment of all
these essential competencies.
9) CBME aims at possessing and applying required abilities by integrating knowledge, skills, values
and attitudes. It focuses on acquiring and demonstrating the competencies required to practice in
today's health care systems. It focuses on patient needs. It is based on determining what
competencies and assessment tools are required to meet those needs. Outcomes are based on
assessment and insist on formative assessment. It is based on knowledge application rather than
knowledge acquisition. It is about making the medical graduate competent in knowledge, skills and
attitude. It is about achieving planned outcomes in learning that would also include social values.
It will help our students to become good basic physicians who can confidently handle common
health problems efficiently in a holistic and humane manner.
5|Page
10) ȚɀȾɁȶɅȶȿȴȶșȲɄȶȵȚɆɃɃȺȴɆȽɆȾȚșȚɈȹȺȴȹȺɄɅȲɄȼ-ɀɃȺȶȿɅȶȵɀɃȲȴɅȺɇȺɅɊȳȲɄȶȵ. Not to confuse
same acronym used for community based medical education, basically look into competencies
derived from an analysis of needs at society and patient as per our future graduates concerned.
ȪɁȲȵɊɄɅȲɅȶɄ¡ȮȟȘȫȲȿȵȮȟȜȫȟȜȩɄɅɆȵȶȿɅɄȽȶȲɃȿɄɆȴȴȶɄɄȷɆȽȽɊȺɄȾɀɃȶȺȾɁɀɃɅȲȿɅ
than WHEN and HOW they learn something. Probably CBE tries to address the later two too. And
remember CBE created from analyzing societal & patient needs unlike OBE defines outcomes
based on expert opinion, from critical incident, task analysis, interviews of graduates etc...
The outcomes are closely linked to job skills or mastery and the method is very prototype and self
paced. It is a curricular concept designed to provide skills clinician need rather than solely a large,
prefabricated collection of knowledge. Competency based Medical Education, on the other hand,
will have variable length but defined outcomes.
11) Roles and competencies of a basic doctor represented in a tabular format:
Basic Doctor Competencies

Clinician Medical knowledge, Patient care and procedural skills
(Promotive, Palliative, Preventive, Curative, Holistic health care with
compassion)
Leader & Member of a Systems-based practice

health care team (interpersonal respect for colleagues in diverse roles )
Communicator Interpersonal and communication skills
(sensitive & ɃȶɄɁȶȴɅɁȲɅȺȶȿɅɄɁɃȶȷȶɃȶȿȴȶɇȲȽɆȶɄȶɉɁȶɃȺȶȿȴȶɄȳȶȽȺȶȷɄ
privacy, confidentiality )
Lifelong Learner Practice-based learning and improvement
(self-reflect, introspect, develop Research Question)
Professional Professionalism
(ethical, responsive, accountable)
The rationale for CBME:

1) In our traditional system, learner is left with responsibility of acquiring various skills causing gap
in desired performance. So CBME might solve this issue by defining and identifying various skills
in terms of objectives which would be assessed assuring proper learning and application.
6|Page
2) I think the problem is not with our students, but with our curriculum. Our present curriculum is not
focused on the needs of our rural population. Non- alignment of training and learning with
outcomes makes it necessary to implement CBME.
3) Assessment is not aligned with to specific tasks and real work conditions, not focused on the
acquisition of competency required. It is time-bound and fixed, dɀȶɄȿɅȳuild confidence as they are
ready for the job once they are released into the community.
4) Our existing system of education is the one with fixed length and variable outcomes. A single
subjective assessment which primarily assesses the knowledge of the student is in practice. This
system has a defined time line but not outcomes.
5) Globally there has been a realization that many health professional cannot effectively manage the
health problems of their patients & communities because they are not adequately trained in some
essential competencies required for their job. We need to identify knowledge gap than identify
relevant knowledge & skill needed by medical graduate to address the observed competency gap.
There is a lack of practical skills for our students.
6) Current curricula are such that they do not explicitly define the outcome abilities expected of
graduates, let alone ensure they are learned, assessed and acquired. Current curricula focus on
knowledge at the expense of skills and attitudes.
7) It is rational in the given scenario of ɆȿɄȲɅȺɄȷȲȴɅɀɃɊɁȶɃȷɀɃȾȲȿȴȶɀȷɄȴȹɀȽȲɃȾȶȵȺȴȲȽɄɅɆȵȶȿɅɄ as

reported from the RHTC; as in the traditional medical teaching approach, within a certain time
frame we target that the students will gain certain knowledge, which is assessed and evaluated in
university exams. But there is almost nil or a very limited scope to assess their development of
attitude, skill and social-values, which always get importance in their service-field. And so why a
scholar student may produces unsatisfactory performance.
8) I have noticed that, one might very much appreciate the fact that students learn in different ways
and at different speeds. Time bound MBBS course where teaching is very much subject centered,
time conscious and focuses mainly on cognitive domain, where attainment of skill and attitude are
not given due importance.
9) Our curriculum fosters knowledge component of learning while other two very important
components skill and attitude are missing. CBME focuses on Knowledge acquisition but our
traditional curriculum is all about Knowledge acquiring. CBME is achieved with a mix of
knowledge, skill, ability and gradually, the ladder from clinical ability to clinical performance is
climbed.
7|Page
10) Our entire focus of teaching and assessing them revolves around theoretical knowledge. Currently,
ɅȹȶɃȶ ȺɄ Ȳ ɈȺȵȶ ɇȲɃȺȲȳȺȽȺɅɊ Ⱥȿ ȸɃȲȵɆȲɅȺȿȸ ɄɅɆȵȶȿɅɄ ȴȽȺȿȺȴȲȽ ɄȼȺȽȽɄ ȳȶ ȺɅ ȺȿɅȶɃȿɄȹȺɁ ȟȺɄɅɀɃɊ ɅȲȼȺȿȸ
Examination, patient Counseling and informed decision making. These are all very subjective
areas with immense variability.
11) Certain questions will be asked when we shall broach this subject before the policy makers. These
questions will have to be answered before we emphasize and convince people that competency is
needed in medical curriculum, like--Are graduates currently not achieving the competency required
for safe and effective unsupervised practice? The answer is definitely a big No!
Time bound
tradiotional
model
Knowledge Rationale Lack of

driven for CBME professsionalism
Lack of
communication
and
interpersonal
relationship
8|Page
Thread 1 (Part B):
Introduction to CBME
Dear All,
The elevator conversation has stimulated Dr Established to think and so today morning he had called
țɃȠȿȿɀɇȲɅȺɇȶɅɀȹȺɄɀȷȷȺȴȶɅɀȷɆɃɅȹȶɃȵȺɄȴɆɄɄȺɅȟȶɄȲȺȵȠȹȲɇȶȳȶȶȿɅȹȺȿȼȺȿȸȲȳɀɆɅɈȹȲɅɊɀɆɄɁɀȼȶɅɀ
me about and it has appealed to me. However, I have a very basic question:
What is competency in the parlance of medical education?
How this competency is based training going to be different from the present training that we are
imparting?
ȢȺȿȵȽɊȲȿɄɈȶɃɅȹȶțȶȲȿɄɂɆȶɃȺȶɄȺȿɅȹȶȿȶɉɅɅɈɀȵȲɊɄɆɁɅɀɅȹȶ morning of 5th March.
Regards,
Team Vibgyor Sukhinder 2015
Contributors
3rd March: Mohit, Shuchi, Sukhinder, Purnima, Gita, Vanita, Swapnil, Kavita, Purnima, Juhi
4th March: Juhi, Swapnil, Purnima, Hem, Shuchi, Amir
9|Page
The following discussion took place further on this thread:
What is competency in the parlance of medical education?

1) I would put that as competencies being a part of the curriculum and the outcome being to be able
ɅɀɄȶɃɇȶɅȹȶȿȶȶȵɄɀȷɅȹȶɄɀȴȺȶɅɊ ȫȹȶȵȺȷȷȶɃȶȿȴȶbetween OBME and CBME is the same as the
ȵȺȷȷȶɃȶȿȴȶȳȶɅɈȶȶȿȨɆȲȽȺɅɊȚɀȿɅɃɀȽȲȿȵȨɆȲȽȺɅɊȘɄɄɆɃȲȿȴȶ
2) ȚɀȾɁȶɅȶȿȴɊɃȶȷȶɃɄɅɀɀȿȶɄ ability to perform a specific task whereas a number of competencies

constitute a larger area of ȴɀȾɁȶɅȶȿȴȶ Competency is a skill and competence is the attribute of a
person.
3) Competence is a point on the spectrum of improving performance. Performance is affected by a

ȾɆȽɅȺɅɆȵȶɀȷȷȲȴɅɀɃɄȲȿȵȴȲȿȳȶȴȽȲɄɄȺȷȺȶȵȲɄȘȴɅɆȲȽȧȶɃȷɀɃȾȲȿȴȶ ȲȿȵȦȳɄȶɃɇȶȵȧȶɃȷɀɃȾȲȿȴȶfor
assessment purposes. ȡɆɄɅȽȺȼȶɄɆɃȸȶɃɊɀɃȷɀɃɅȹȲɅȾȲɅɅȶɃȲȿɊɁɃɀȴȶȵɆɃȶȴȲɃɃȺȶȵɀɆɅȺȿȤȶȵȺȴȺȿȶȺɄ
science as well as art, first it has to be learnt thoroughly with assessments involved to judge that
you are a competent enough..But to perform it in actuality is competency...self-paced & self
ȵɃȺɇȶȿ
4) The move to competency-based education has much in common with outcome-based education,
and competency frameworks may be similar to outcome frameworks ( Albanese et al 2008 )
Albanese MA, Mejicano G, Mullan P, et al. Defining characteristics of educational competencies,
Medical Education 42 : 248-255,2008.
5) Specific elements of knowledge, skills and attitudes are the components of a given specific ability,
and several of these specific competencies can be combined into a broader, overarching
competency.
6) Competencies :
Competencies are considered abilities or capabilities, and are considered the organizing units
of CBME.
Competency: An observable ability of a health professional, integrating multiple components
such as knowledge, skills, values and attitudes.
Competent: Possessing the required abilities in all domains in a certain context at a defined
stage of medical education or practice.
Competence: Entails more than the possession of knowledge, skills and attitudes. It requires
you to apply these abilities in the clinical environment to achieve optimal results.
10 | P a g e
Competency based medical education: An outcomes-based approach to the design,
implementation, assessment, and evaluation of medical education programs, using an
organizing framework of competencies.
Competencies are the organizing units or building blocks of CBME.
Several competencies make a competency.
One who possesses these competencies is competent, application of these competencies in the
clinical environment, is competence.
7) Currently, a physician is deemed competent at the point where he or she is considered ready to
practice independently. This is a static view. A new definition of 'competent' has been proposed
that specify which domains of ability, -which context, -what stage of medical education or practice
it refers to
Examples : a second-year medical student could be competent to enter a supervised undergraduate
clinical rotation on the ward of a teaching hospital, a resident trainee could be competent to run an
intensive care unit autonomously overnight. A graduate of a resident program could be competent
to perform some, but not all, procedures independently in a rural institution.
8) "We believe that in the future, expertise rather than experience will underlie competency-based
practice and . . . certification" (Aggarwal & Darzi 2006).
9) Competence: The array of abilities across multiple domains or aspects of physician performance in
a certain context. .Competence is multi-dimensional and dynamic. It changes with time, experience
and setting.
Competency: An observable ability of a health professional, integrating multiple components such
as knowledge, skills, values, and attitudes. Since competencies are observable, they can be
measured and assessed to ensure their acquisition. Competencies can be assembled like building
blocks to facilitate progressive development.
10) Competency-based medical education: An outcomes-based approach to the design,

implementation, assessment, and evaluation of medical education programs, using an organizing
framework of competencies. The building blocks of our medical education programs are specific,
measurable learning objectives. These objectives are categorized under the more broadly defined
competencies. The competencies, in turn, roll up under the umbrella of the seven domains of
competence. Collectively, these three tiers represent the building blocks of the competency-driven
learning strategy.
11) Seven Domains of Competence:

Medical Knowledge
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Clinical skills and patient care
Professionalism
Scientific and clinical Inquiry
Interpersonal and communication skills
Systems of Health care
Continuous improvement of care through reflective practice
How is competency based training going to be different from the present

training that we are iȾɁȲɃɅȺȿȸ"
1) The competency-based education (CBE) approach allows students to advance based on their ability
to master a skill or competency at their own pace regardless of environment. This method is
tailored to meet different learning abilities and can lead to more efficient student outcomes.
2) Competency-based education turns the traditional model on its head. Instead of awarding credits
based on how much time students spend learning, this model awards credits based on whether
students can prove they have mastered competenciesthe skills, abilities, and knowledge required
in an area of study. To put it simply: In competency-ȳȲɄȶȵ ȶȵɆȴȲɅȺɀȿ ȺɅɄ ȿɀɅ ȲȳɀɆɅ ɅȺȾȶȺɅɄ
about what you know and are able to do.
3) The competency-based education- approach allows students to advance based on their ability to
master a skill or competency at their own pace regardless of environment. This method is tailored
to meet different learning abilities and can lead to more efficient student outcomes.
4) Competencies are the measurable or observable knowledge, skills, attitude and behavior critical to
successful job performance. Yes Sir, job performance would mean ability to proficiently execute
the KSA acquired during the training in real work settings. Basically, it would mean application of
knowledge.
5) The way we were taught or are teaching is teacher-centric. The teacher decides what all has to be
learnt and students are assessed to check if they have actually learnt what was taught. It is more
subjective. A lot of importance is given to the summative assessment irrespective of the fact that
the attainment of the required skills is not up to the mark or not.
6) CBME assesses in the formative stage and is not time bound like the traditional ways. It lays stress
on the achievement of the pre-determined competencies which are aligned to the health needs of
the community.
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7) In an era of accountability, medical educators have a duty to ensure that every graduate is equipped
for practice. Competence in medical education, in the most simplistic terms implies the possession
of knowledge, skills and attitudes to handle clinically challenging environment to produce socially
accountable doctors.
8) The other question that may arise is - Is CBME a perfect tool? And to my knowledge, the answer
is that CBME is not a perfect tool, it restricts us CBME is said to be overly concerned with training
to meet a threshold minimum level of competency and not with promoting excellence.
9) Competency is a penultimate goal to excellence and hence not compromise to the latter. Hence
acquisition of predefined basics must precede excellence. Competencies are the first step to
excellence; we cannot go the reverse way.
10) CBME will be different from our present system of education that gives us too much flexibility at
the cost of quality. We need to put some checks in forms of standardization and CBME is a step
towards standardization.
11) The difference between OBME and CBME is same as the difference between Quality Control and
Quality Assurance.
12) OBE differs from CBE in being - integrated across curriculum and learning areas, curriculum is
flexible and changeable and encourages capacity building as all progress through it based on their
individual abilities. Interestingly an article calls CBE and ȦșȜ ȴɀɆɄȺȿɄ ȡȶȲȿ ȢȺȿȸ ȢȲɃȶȿ
Evans 1991).
13) Comparison of CBME with Traditional Curriculum :

Focus of curriculum: In current system graduate need to pass the qualifying exam that does not
mean they need to acquire required competency. In CBME, competencies are clearly defined and
that needs to be achieved at the end of training.
Structure and content of curriculum: Current system has fixed duration while CBE is paced
Goal: In current system goal is mainly knowledge acquisition where as in CBME it is knowledge
application.
Learning style: Learning is guided by teachers where as in CBME Teachers and learners are both
equally involved.
Logistics of training Implementation: Training is implemented as fixed rotations in current system
but in CBME it is not time bound.
Assessment: Current system the evaluation is non-referenced and has summative exam. In CBME
the assessment is based on Formative assessment, criterion referenced and evaluation of portfolio.
13 | P a g e
Suitability: CBME is better suited for procedurally oriented programs but less appropriate if it is
knowledge based one.
Table No. 1 Comparison of CBME and Traditional Curriculum
Variable Traditional education Competency Based

Driving force of curricula Content Outcome
Goal of education encounter Knowledge acquisition Knowledge application.
Type of assessment tool Single subjective measure Multiple objective measure
Assessment tool Proxy Authentic(mimics real task of
profession)
Setting Removed(gestalt) Direct observation
Focus of assessment Non referenced Criterion referenced
Assessment Emphasis on summative Formative
Program completion Fixed time Variable time
14) Planning for a CBME Curriculum: At this juncture, we need to identify and define first what are
the competencies our students need to achieve during this MBBS course, so that they can
ȶȷȷȶȴɅȺɇȶȽɊɃȶɄɁɀȿȵɅɀɄɀȴȺȶɅɊɄȵȶȾȲȿȵɄɈȹȶȿɅȹȶɊȲɃȶɁȽȲȴȶȵɅȹȶɃȶȲɄȾȶȵȺȴȲȽɁɃɀȷȶɄɄȺɀȿȲȽɄ Need
small workshops for students as well as faculty to get an overall view of CBME. Its importance can
be explained along with all positive and negative effects at the level of under-graduation.
15) Plan for training sessions of students and ultimately can think of curriculum designing according to
it. Add post graduates to this program. It will be best to inculcate qualities of good practitioner into
them for future. Article by Wouter Kerdijk: The effect of implementing undergraduate
competency-ȳȲɄȶȵȾȶȵȺȴȲȽȶȵɆȴȲɅȺɀȿɀȿɄɅɆȵȶȿɅɄȼȿɀɈȽȶȵȸȶȲȴɂɆȺɄȺɅȺɀȿȴȽȺȿȺȴȲȽɁȶɃȷɀɃȾȲȿȴȶȲȿȵ
perceived preparedness for practice: a comparative study. Author has compared knowledge
acquisition, clinical performance and perceived preparedness for practice of students from a
competency-based active learning (CBAL) curriculum and a prior active learning (AL) curriculum.
The data obtained do not support the assumption that competency-based education results in
graduates who are better prepared for medical practice. More research is needed before we can
draw generalisable conclusions on the potential of undergraduate competency-based medical
education.
16) At this juncture, we need to identify and define first what are the competencies our students need
Ʌɀ ȲȴȹȺȶɇȶ ȵɆɃȺȿȸ ɅȹȺɄ ȤșșȪ ȴɀɆɃɄȶ Ʉɀ ɅȹȲɅ ɅȹȶɊ ȴȲȿ ȶȷȷȶȴɅȺɇȶȽɊ ɃȶɄɁɀȿȵ Ʌɀ ɄɀȴȺȶɅɊɄ ȵȶȾȲȿȵɄ
when they are placed there as medical professionals. CBME needs proper designs, implementation
and assessment, evaluation framework. It is time we standardize learning outcomes nationwide
14 | P a g e
while letting flexibility prevail in our methods of learning. Keeping in mind the inherent variability
of a science as vast as medical education where the stakes are high and the repercussions as grave
as life and death, we cannot standardize every step, yet we can standardize the outcome. Preserve
the originality of an individual which is also an ethical issue of freedom of expression and hence of
learning, but shall minimize the loss of target as one wanders in vast expanse of knowledge. This
shall directly as well as indirectly influence the difficult to address area of Quality assurance in
ɁȶɃɄɁȶȴɅȺɇȶɀȷȾȶȵȺȴȲȽȸɃȲȵɆȲɅȶɄȾȺȿȺȾȲȽɄȼȺȽȽɄ
17) Whereas a traditional program may begin with the question, "What do learners need to know?" or
"How shall we teach our learners?" CBME begins with outcomes. CBME is organized around the
question, "What abilities are needed of graduates?" The answer to this question can come from
educational needs assessment. Needs assessment can be carried out by practice profiling, task
analysis, defining population health needs, taking into consideration views of all stakeholders viz.
practitioners, students, society, patients.
18) I believe that since CBME is an outcome based system of education, hence keeping the outcome in
mind we shall have to redesign our teaching, lesson plans and simultaneously our methods of
assessment. The wisest of the teachers have already been doing but to make it universal, a blue
print will be needed. Identifying the areas that need modification will have to be done first as each
specialty will have its very specific set of requirements and hence of competencies too. The
identified abilities are organized as competencies for a curriculum, and are further delineated in
terms of their building blocks. Working backwards, educators can then identify milestones that
trainees will need to reach as they acquire the required competencies. Instructional methods and
assessment tools can then be selected to facilitate the development of learners for these abilities.
19) Steps in planning CBME curricula

Identify the abilities needed of graduates.
Explicitly define the required competencies and their components.
Define milestones along a developmental path for the competencies.
Select educational activities, experiences and instructional methods.
Select assessment tools to measure progress along the milestones.
Design an outcome evaluation of the program.
20) Example: Competency -ACGME- patient care- one of the competencies - Manage a case of
hypertension
Milestones:
1st year - be able to define blood pressure, and describe the mechanisms involved in the
regulation of blood pressure
15 | P a g e
2nd year - describe patho-physiological mechanisms and enlist drugs for the treatment of high
blood pressure + describe these drugs
3rd year -decide appropriate line of treatment
4th year- appropriately manage a case of hypertension
Instructional methods and assessment tools for each stage can then be designed. Thus, planning for
a CBME curricula differs from planning for a traditional curriculum.
21) Simple Example: Suppose you want to educate a resident to suture correctly. You might decide to
have a suturing worȼɄȹɀɁɈȺɅȹɁȺȸɄȷȶȶɅɈȹȶɃȶɃȶɄȺȵȶȿɅɄȴȲȿȽȶȲɃȿɅȹȶɅȶȴȹȿȺɂɆȶɀȷȲɁɁɃɀɁɃȺȲɅȶ
suturing. The objectives would be the specific tasks the resident has to complete accurately:
Identify differing suturing techniques
Identify when to use different techniques
Demonstrate various suturing techniques.
The learning outcome is complete when faculty observes that residents have met the three
objectives as they complete the workshop. In this example, resident performance (learning
ɀɆɅȴɀȾȶȲȿȵɅȹȶȽȶȲɃȿȺȿȸȶɉɁȶɃȺȶȿȴȶɄɆɅɆɃȺȿȸɈɀɃȼɄȹɀɁɄȸɀȲȽɄȲȿȵɀȳȻȶȴɅȺɇȶɄȲɃȶȽȺȿȼȶȵ
16 | P a g e
Thread 2 (Part A):
Introducing two different perspectives
Well motivated the Dean Dr. Established attends an International Medical Education Conference on
CBME. Having met several educationists from India and abroad, he is convinced that this is the need of
the hour and it can address some of the problems in the present system. He returns with a resolve to
introduce CBME in his own institute. He calls a meeting of all the faculty members to discuss this.
The opinion of the faculty members is divided regarding the introduction of CBME.
Team Change believes progress is impossible without change and CBME holds the promise of a
progressive tomorrow.
Fellows 2014 Clarence, Gita, Gokul, Manjinder, Mohit, Mullai, Peter, Rahman, Sabita.
Fellows 2015- Abhijit, Amir, Hem, Hironmoy, Juhi, Kavita, Shuchi, Sukhinder.
Team Preserve believes change is not always for the best, at times it brings with it lots of potential
dangers too.
Fellows 2014 Heetal, Krithica, Neeti, Nilima, Ruchi, Simer, Tapasya, Vijay.
Fellows 2015- Bajaj, Bharati, Poornima, Sanjoy, Sumanth, Swapnil, Upreet, Vanita.
Dr. Established has given all faculty members the next four days i.e. upto 8th March to share their
viewpoint with their team members and prepare to debate the promise of CBME v/s the potential perils
of CBME. Both the groups are requested to have their intra-group discussion on the separate thread till
8th March, which will be followed by an open debate on the main thread from 9th March.
Regards,Team Vibgyor - Sukhinder 2015 (Moderator)
Contributors:
Team Change
5th March: Sukhinder, Kavita, Juhi, Hironmoy, Gita, Abhijit, Hem
6th March: Amir, Gokul, Richa, Soum, Kavita, Hironmoy, Abhijit, Sabita, Shuchi, Juhi 7th March:
Hironmoy, Amir, Juhi, Shuchi, Kavita, Soum, Abhijit
8TH Juhi, Amir, Mohit, Kavita
Team Preserve
5th March: Sukhinder, Purnima, Bharati, Upreet, Sanjay, Krithica, Vanita, Sumnath, Gagan, Swapnil,
Nilima
6th March: Swapnil, Richa, Upreet, Sumnath, Vanita
7th March: Sanjoy, Vanita, Gagan, Sumnath, Vanita
8th March: Purnima, Upreet, Sanjoy
17 | P a g e
The following discussions took place on the individual threads of both the teams:
Discussions in Team Change Discussions in Team Preserve

Demerits of Present medical curriculum: Merits of Present medical curriculum:
Students undergo a time-based learning Includes teaching 'something of everything'

Teachers undergo a time-framed teaching It provides a comprehensive knowledge base
Ambition to cover the syllabus in stipulated Time bound - so one can plan the future
time Students will not remain under the impression
Assessor asses a students ȼȿɀɈɄȹɀɈ that ' one day I will learn' which could be
ȪɅɆȵȶȿɅɄɀȿȽɊmugs up and vomits in exam possible if it is time free.
Teachers also seldom describe them the Provides a wide knowledge base
learning objectives in sessions Learners can build their practice
No scope for a learner to get enlightened Using their own analytical skills and link
about the goal of learning, different objectives theory to practice
of learning and arenas of service to society An article that provides an understanding of
CBME and its rationale in general, along with
Ȫtudent becomes a good regurgitator and zero some perils or drawbacks including the 'threat
performer of reductionism' and 'logistic chaos. Other
perils mentioned include 'promoting the
șȶȴɀȾȶɄȲɅȹȶɀɃȶɅȺȴȺȲȿȳɆɅȿɀɅȲȴȽȺȿȺȴȺȲȿ¡¡ȹȶ lowest common denominator, loss of
achieves a high marks in exam, targets a high rank authenticity, the tyranny of utility, need for
ȺȿȧȞȶȿɅɃȲȿȴȶȶɉȲȾ¡¡ȳɆɅȷȲȺȽɄɅɀɄȶɃɇȶɅȹȶ new educational technologies, inertia and lack
need of community as a basic family physician. of resources'.
The tradition system of education has
ȥȶɈȸȶȿȶɃȲɅȺɀȿɀȷȵɀȴɅɀɃɄȺɄȶɇɀȽɇȺȿȸȺȿɅɀȾɀɃȶ produced some of the great doctors
of crammers and less of ȵɀȶɃɄ Provides a comprehensive knowledge base
Time bound - so one can plan the future
"ȫɀȵȲɊɄȸɃȲȵɆȲɅȶȺɄȿɀɅKnowledgeable,
communicator, collaborator, manager, health Current Curriculum:
advocate, scholar and professional" Problem lies in the implementation of this
curriculum Reduced student to teacher ratio
Current Curriculum: Inadequate teaching skills
Curricula fail to ensure that all medical Scanty facilities
graduates demonstrate competence in all the Lack of motivation among faculty members
domains of their intended practice. Political and regulatory disinterest
No explicit definition of outcome
18 | P a g e
abilities needed of graduates
Focus on one skill i.e. Recall Demerits of CBME:
Allowing ability in one essential domain
(e.g., procedural skills) to compensate Require a great upheaval of the curriculum
for lack of ability in another (e.g., and that is not easy.
communication) does a disservice to
both the profession and the public Old timers will argue: Aren't we good physicians
served. the way we learned? We have taught for decades
Clearly mentioned skills are often lacking in a and prɀȵɆȴȶȵɄɀȾȶɀȷɅȹȶȳȶɄɅȵɀȴɅɀɃɄ
conventional curriculum.
Decline in the quality of medical students Why should we experiment when there is already
passing out from medical colleges in India such a shortage of teaching faulty?
Decline is in the 'clinical skills' and the way
they 'behave' with the patients. Specialties like Psychiatry where behavioral
Graduate is not able to perform the clinical competencies are dealt with, a forthright
tasks expected of them outcome and assessment cannot be made
Overcrowded medical students competing Faculty have to become competent to make
with each other for having a glance at the students competent
signs Financial burden in implementation
Lack of knowledge of learning objectives and As CBME is need based catering to ethnic
domains among faculty population what about doctors going abroad.
ȪɅɆȵȶȿɅɄɄɆȴȴȶɄɄȺɄmore a function of 'luck' Again there the needs would be different. So
rather than the medical education system. the whole idea of teaching him/her in this
trend becomes fruitless
ȮȶȴȲȿ
ɅȸɀɀȿɅȶȲȴȹȺȿȸɀɆɃȷɆɅɆɃȶ Requires lots of planning and logistics support
physicians using yesterdayɄȴɆɃɃȺȴɆȽȲ Financial burden heavily on the institute
Increase in expenses for the patients
ȮȲɅȶɃȺȿɅȹȶɈȶȽȽɄȹɀɆȽȵȳȶɈȺɅȹȺȿɅȹȶɃȶȲȴȹ of Execution could result in chaos within the
the horse and the very water in the well should be institute Finish the standard systems that is
ɁɀɅȲȳȽȶ existing
Difficult in job recruitment
Increasing number of litigations negligence in
traditional system So CMBE should be a bygone¡To stay forever
Lack of patient tackling skills is the standard conventional teaching
Poor procedural /technical skills, like
forgetting to take consent, wrong prescriptions Students may find it difficult to take charge of
etc their learning, coming from a background that
encourages tuition and teacher-driven learning
19 | P a g e
Merits of CBME: Progress in the course depends on acquisition
A focus on outcomes, of particular competencies - a student may not
An emphasis on abilities be equally adept in all domains/competencies,
De-emphasis of time-based training and so may never achieve some milestones,
The promotion of learner-centeredness resulting in anxiety and frustration
Inherently tied to the needs of those Bias (negative or positive) may play a role
served by graduates since students' progress depends on
Explicit definitions of all essential assessment (by teachers) of competencies
domains of competence to be acquired acquired in day-to-day practice.
Higher order skills required for medical Students may exploit teachers and assessment
professionals can be promoted through CBME results may have nothing to do with their
CBME helps to identify the infrastructure competency and lots to do with favors granted
required to impart proper training
Specific guidance on attainment of particular Given that many educational systems around the
skill/ability both to teachers and students. world are time-bound, how can a transition to a
Specific guidelines for a curriculum more competency-based system be
development or change accomplished?
Transparent as far as assessment is concerned
Assessment is more valid and reliable as How can health systems manage the scheduling
formative assessment, criterion referenced and of the thousands of medical trainees progressing
evaluation of portfolio are used at their own pace? $Reductionism]
Helps ascend the miller's Pyramid level
Endless nested lists of abilities that frustrate
Potential to transform regurgitators to
learners and teachers alike
performers
Does not guarantee excellence and brings a
Criterion referenced norms of CBME make
pseudo sense of contentment in clinicians
the assessments more transparent
about the excellence of their skills
Clearly paves way from instructions to
outcomes
Ƞmplementation without readiness (which is
Takes beneficiaries and societal needs into
questionable in most of the Indian scenarios) can
account at the very outset
actually backfire!!
Takes the learner's pace into account, slow
learners get time to master at a better pace
A simple analogy, If I can demonstrate
with less anxiety
satisfactory skills to wash vegetables, cut
Promotes development of Curriculum with a vegetables, light the gas stove, keep vessels on
clearly defined space for skills. stove, add oil and spices, play with vessels on
Cover all domains in an equitable fashion stove etc. then, there still remains no guarantee
without compromising one at the expense of that I would prepare a delicious dish which will
other
20 | P a g e
Link between theory and skills and hence satisfy the people to whom my preparation is
amounts to Clinical expertise being ɄȶɃɇȶȵɅɀ
Amalgamation of art and science, and hence
an attractive, wholesome model Lastly, things at neighbors house always look
Helps to keep pace and triggers rapid revision beautiful from our house but only he knows how
of curriculum with rapid advances in Field of difficult ȺɅȺɄɅɀɀɈȿȲȿȵȾȲȺȿɅȲȺȿɅȹȶȾ
Medicine.
The only option is to change the existing Larger scale would require new teaching
medical education system and see whether it techniques, new modules, new assessment, to
improves the things or not. be practical and effective
Better infrastructure and enhanced logistical Inertia and lack of resources
support in the medical schools Significant investments in teaching,
Improving the overall quality of the medical infrastructure and assessment perhaps even
schools. an augmented workforce
The contextual nature of medical education
Help in avoiding internal as well as external ȠȹɀɁȶɅȹȶȴɀȾɁȲɃɅȾȶȿɅȲȽȺɋȲɅȺɀȿȳɊȴɀȾɁȶɅȶȿȴɊ
conflicts approach does not take the heart out of the
More accountability and transparency ɄɊɄɅȶȾ
Better utilization of the resources i.e.
Manpower, funds and time ȪɀȾȶɅȹȺȿȸȿȶɈmay not be necessarily
ɄɀȾȶɅȹȺȿȸȸɃȶȲɅ
Students will use systematic and scientific
approach in patient management
Require great upheaval of the curriculum and
Assures freedom of self pacing, that is not easy
Defines why, what, how and when a student Patients are his subjects, why go in for
would learn, simulators, mannequins.
Assuring acquisition of mandatory skills Much of objectivity and tight
Non-opportunistic taking care of influential as compartmentalization will shed off its charm
well as slow learners Students may learn less as increased stress of
Equal chance of learning to all continuous
More objectivity in evaluation Create lot of space for nepotism, favoritism
Better communication skills by future
clinicians Better doctor patient relationship ȮȹȺȴȹȵȶɇȶȽɀɁȶȵȴɀɆȿɅɃɊɅɀȵȲɊȹȲɄ
Increased interest and involvement of learners ȚȤșȜȽȲɆȿȴȹȶȵȺȿɅȹȶȺɃȴɆɃɃȺȴɆȽɆȾ"
Increased satisfaction in patients about the Interference with present PG selection process
care given
Clinicians who have human values and ȮȹɊȺɄȺɅɅȹȲɅȜȚȝȤȞȲȿȵɅȹȶȩɀɊȲȽCollege in
concern UK or Australia are yet to embark ɀȿȚșȤȜ
Focuses on patient needs
21 | P a g e
Based on determining what competencies & ȘȹɊȳɃȺȵɁɀȽȺȴɊɈȹȺȴȹȺȿȴȽɆȵȶɄȾȶɃȺɅɄɀȷ
assessment tools are traditional and CBME curriculum, based on the
Provide more personalize experience for institutional needs should be the answer for the
residents &fellows than current approach ȴɆɃɃȶȿɅɁɃɀȳȽȶȾ
Provide a more flexible time frame for
learning new skills & acquiring knowledge.
More frequent formative assessment
&feedback by expert faculty
Grading against each specific competency
achieved.
Move from Theory to Practice.
Subject Centered to Learner centered
approach.
Address topic anthropology, sociology &
communication
Focuses on learner performance and specific
objectives
Shift our focus away from process-oriented
measures of education (i.e., how many
procedures a resident completed) to outcome-
oriented measures (how well the resident
completed the procedure)
Designed to provide the skills physicians
need, rather than prefabricated collection of
knowledge
ȡɆɄɅȽȺȼȶȶɇȶɃɊɄɀȽȵȺȶɃɆȿȵȶɃȸɀȶɄɃȺȸɀɃɀɆɄ
training before passing out of the national
defense academy so also should our medical
ȸɃȲȵɆȲɅȶɄ
ȠȳȶȽȺȶɇȶɅȹȲɅȚșȤȜȺɄȲȽȺȿȼȳȶɅɈȶȶȿ
Medical Education and ȨɆȲȽȺɅɊȲɄɄɆɃȲȿȴȶ
22 | P a g e
Comments and discussion:
Soum commented on the ongoing discussion by talking about authentic learning:
Authentic learning engages all the senses of the student to create a meaningful and useful outcome
Self directed and self motivated.
Teacher assumes a role of guide, facilitator or philosopher not dictator
ȪɅɆȵȶȿɅɄȺɅɅȺȿȸȲɅȵȶɄȼɅȲȼȺȿȸȿɀɅȶɄɃȶȸɆɃȸȺɅȲɅȺȿȸȴɆɃɃȺȴɆȽɆȾȺȿȶɉȲȾȺȿȲɅȺɀȿɆɄȶɄɀȿȽɊɀȷ
ȳɃȲȺȿȴȲɁȲȴȺɅɊɆɄɆȲȽȽɊɅȶȲȴȹȶɃȴɀȿɅɃɀȽȽȶȵ
Has a definite niche in CBME
Means engaging students into active learning
Closely relates to concept of CBME
Based on creating
Comparing the authentic learning model to other models of education: Steve Revington
23 | P a g e
Final Submission of Team Preserve on main thread 2:
We need to preserve the traditional curriculum and not switch to CBME because of the following
points:
1. Universal acceptance and eligibility:

As CBME is need based catering to ethnic population what about doctors going abroad. Again
there the needs would be different. So the whole idea of teaching him/her in this trend becomes
fruitless. Recruitment in jobs will again be a random selection as to gauge competency across
tables during interview.
May not be suitable for the present Postgraduate selection process.
Aren't we good physicians the way we learned? We have taught for decades and produced some of
the best doctors.
2. Student perspective:
Some students may find it difficult to take charge of their learning, coming from a background that
encourages tuition and teacher-driven learning.
Progress in the course depends on acquisition of particular competencies - a student may not be
equally adept in all domains/competencies, and so may never achieve some milestones, resulting in
anxiety and frustration.
Bias (negative or positive) may play a role since students' progress depends on assessment (by
teachers) of competencies acquired in day-to-day practice. Conversely also, students may exploit
teachers and assessment results may have nothing to do with their competency and lots to do
with favors granted.
Time bound - so one can plan the future. Students will not remain under the impression that ' one
day I will learn' which could be possible if it is time free.
3. Logistical chaos:
Given that many educational systems around the world are time-based ( e.g. requiring a prescribed
number of weeks for each rotation), how can a transition to a more competency-based system be
accomplished ?How can health systems manage the scheduling of the thousands of medical
trainees progressing at their own pace ( in a pure CBME curriculum, for example )?
As it requires lots of planning and logistics support. Both man and material wise, will incur
financial burden heavily on the institute and finally health care sector would be very expensive for
the end user i.e. patients. Ours is a poor country with large population and it's poor citizens cannot
bear such expenses.
24 | P a g e
The proponents of CBME, in spite of claiming to know the depth of it often tend to forget the
magnitude of readiness (with respect to resources, manpower and other logistics), which is required
for its implementation. And implementation without this readiness (which is questionable in most
of the Indian scenarios) can actually backfire!!
The need for new educational technologies: Adopting CBME, on a larger scale would require new
teaching techniques, new modules and new assessment tools to be practical and effective.
Inertia and lack of resources: For many jurisdictions, adopting a CBME approach would require
significant investments in teaching infrastructure and assessment perhaps even an augmented
workforce.
Why should we experiment when there is already such a shortage of teaching faulty?
Financial burden is another drawback of implementing CBME.
For CBME, the faculty members also require to develop a capacity to assess these competencies
for which they have to be trained i.e. the faculty have to become competent to make students
competent.
It will require a great upheaval of the curriculum and that is not easy.
4. The threat of Reductionism:

In an effort to address the challenges of defining and assessing competencies, some have resorted
to breaking them down into the smallest observable units of behaviour, creating endless nested lists
of abilities that frustrate learners and teachers alike.
CBME somewhere tends to convey a sense that minimal attainment of certain skills is sufficient. In
other words, it does not guarantee excellence and brings a pseudo sense of contentment in
clinicians about the excellence of their skills.
A simple analogy, If I can demonstrate satisfactory skills to wash vegetables, cut vegetables, light
the gas stove, keep vessels on stove, add oil and spices, play with vessels on stove etc. then, there
still remains no guarantee that I would prepare a delicious dish which will satisfy the people to
whom my preparation is being served to.
Traditional curriculum includes teaching 'something of everything' and provides a comprehensive
knowledge base. Something new may not be necessarily something great. Our traditional
curriculum provides a wide knowledge base, on which our learners can build their practice, using
their own analytical skills and link theory to practice.
5. Miscellaneous:
CBME will be suitable for those specialties where the outcome is defined making assessment clear-
cut, but in specialties like Psychiatry where behavioral competencies are dealt with, a forthright
outcome and assessment cannot be made.
25 | P a g e
The teaching of CBME if not planned with minutest of details with respect to its execution could
result in chaos within the institute, leave alone medical colleges in same city. It would finish the
standard systems that are existing.
Final Submission of Team Change on main thread 2:

The points in favour of change to CBME are as follows:
1. Outcome oriented nature:

The learner, the teacher, the administration, the recruiters, the patient, the society and all the other
stake holders are sure about the outcome right from the beginning.
Thus aligning the resources towards a common, known, measurable, community-responsive,
learner centered goal (competency) will be feasible and effective.
It's like beginning with the end in mind.
Current system is not outcome oriented in terms of competencies; the only outcome is that most of
the medical graduates are paper tigers (with degrees on a sheet of paper) and left in this world to
become real tigers if they can.
2. Authentic learning is promoted:

Who thinks about learning in the current system, forget about authentic learning? The current
system is so much busy in 'just teaching'.
CBME being learner centered, the teachers will have to facilitate and achieve learning and their job
will not just stop at teaching.
It also accepts that every learner is unique and learns at her/his own pace.
When all the senses will have to be used to make the student learn, it will result in authentic (true)
learning. Isn't that what we all want?
3. Teaching the 'art' of medicine also:

CBME through the option of having multiple competencies can easily other competencies if it is based
on the patients'/society's needs. Thus the opportunity of producing a holistic doctor is higher than that
in the traditional teaching pattern.
26 | P a g e
4. Accountability:
CBME defines and designs the framework to achieve the outcomes and makes specific references
to the time, setting, facilitators, teaching tools and outcomes. Thus there is greater accountability in
CBME.
In traditional system, who cares ? And the reply of a medical faculty/ medical college will be: I
taught (in whatever way I felt appropriate) but the student did not learn, so ultimately if there is
someone to blame, it is the student.
5. Assessments:
The assessment method is suited to the competency and hence valid and reliable.
It is transparent, thus building trust between the learner, the teacher, the medical institution and the
society.
The current system is left open to numerous bias due to the high proportion of subjectivity involved
6. Contextual:
The contextual teaching inculcates a sense of relatedness to the topic being taught and makes it
useful from the real world perspective thus heightening interest and leading to better learning.
In the current system, the student is left to search the context on his/her own after s/he has been
taught the topic. There is no responsibility of the medical educations system to explain the context.
7. Medical council of India:

The topmost authority in the field of medical education recognizes that competency based teaching
should be encouraged.
Thus it is being perceived at the top most levels also that the traditional system is insufficient to
meet the needs of medical education of today and tomorrow.
8. Enhance the medical education infrastructure:

CBME will layout an increased and/or reallocation of the resources in the medical education field.
This will be justified and not based on some random assumption. It will be also assuring for the
policy makers to invest money in a system that has a defined output and also a well drawn strategy.
Thus overall, it seems that CBME is an idea whose time has come.
27 | P a g e
Thread 2 (Part B):
The Debate: For or against CBME
Dear All,
Now that both the teams have put forward their points, following ground rules to apply-
1. All to participate actively.

2. Any team can pick up one point at one time and then both team members can rebut and counter
rebut.
3. Feel free to respectfully counter the points of the other team.
4. No personal attacks.
5. Remember the idea of debate is not to win, but to develop a deeper understanding of the subject.
HAPPY DEBATING.
Open to any further queries.
Regards
Team Vibgyor - Sukhinder2015
Contributors:
9th March: Sumanth, Sanjoy,Amir, Soum, Purnima, Sukhinder, Kavita, Hem, Sumanth, Nilima,Vanita,
Juhi, Gagan, Abhijit
10th March: Shuchi, Hironmoy, Kavita, PurnimaGokul, Bharti, Sanjoy, Abhijit, Juhi, Gagan, Upreet,
Sumanth, Vijay
28 | P a g e
The main points put forward on the main thread debating on whether to have CBME, were as follows:
Debate 9-10TH March: CBME Vs Traditional medical education
To have CBME Not to have CBME

Great concept which is gaining consensus in US, Skills are difficult to assess and
Australia standardize the assessment method
MCI has already proposed it in its vision 2015 Subjectivity of the assessor
No effect on universal acceptance and eligibility CBME would reduce doctors to machines
of our graduate Traditional curricula provide doctors with
Competency based on societal needs a wide knowledge-base
No problem with recruitment Challenge the doctor to use his/her
Skills are assessed as competency analytical and problem-solving skill
Competences don't come by chance alone CBME ȵɀȶɄȿɅ ɁɃɀɇȺȵȶ any assurance
Combined with other methods like small group about the excellence of the clinician
discussions, journal club, role plays, portfolio, CBME may not assure problem solving
reflection diary etc and should be assessed using skills
360 degree assessment, portfolio, mini-CEX Lack of promotion of this interaction in
Sound knowledge base in small well planned the student clinicians
quanta And this unique best, decided by the
Encompasses the components of adaptive doctor, for that unique patient, can never
expertise as focus innovation and creativity be learnt by a pre-defined competence
More rooms for such concept Deduced from a wide knowledge base
Today patients are not satisfied by the majority with clinical experience under expert
proportion of clinicians guidance, sharp analytical skills and
Traditional teaching stands mostly handicapped empathy
on the issue of imparting adaptive expertise Competence in communication skills,
So empathy etc do not compensate for a bad
Enhancing Capabilities of doctor in making to or wrong or inappropriate treatment
hone their skills in dealing with common health Capability for each patient can be
Not take away power of reasoning &analytical acquired perfectly in a traditional
thinking curriculum.
Better we concentrate on service to society rather CMBE will reduce doctors to robots
than the possibility of high recruitment in Empathy will definitely diminish
corporate sectors Traditional curriculum will give more
No scope of self-ɃȶȽȲɉȲɅȺɀȿɀȷɅȹȶȷȶȶȽȺȿȸɀȷɀȿȶ opportunities to deliver adaptive expertise
ȵȲɊȠȽȶȲɃȿ Outlook or reasoning is not tunneled as
Requires a planning like in CBME
29 | P a g e
Education management and that means it Cognitive frame needs to be strengthened
is manage the men in time as a priority
Requires a managerial expertise for proper Introducing the concept of competencies
utilization of the resource comes only at a later stage
Proper sensitization, planning is
Nation-wide team-work
Immense scope to emphasis on building up
the communication skill
Imparting capabilities to master must know &
should know areas
Make our graduates focus on common diseases
Broader context of a ɁȹɊɄȺȴȺȲȿɄɅȲɄȼɄȲɄȲ
healer
Greater diversity among medical students
Factoring in skills and backgrounds that
could enable them to meet the needs of their
communities
Address topics in anthropology, sociology,
or communications.
May call for new technologies and expenses
Nierenberg argues that such expenses, like
the purchase of simulation tools, are
justified by their role in improving patient
care and preventing harm.
Traditional medical education is opportunistic
Inequality and favoritism by non academic
characteristics of students
Subjective and biased
Teacher controlled like students try to follow what
pleases the teacher to get passing
Competencies are not defined and considered to
be acquired by student at the end of course
Clinical subjects are evaluated like
theoretical knowledge
30 | P a g e
Thread 2 (Part C):
Coming to a consensus
Dear All,
Dr. Established has witnessed a very heated debate between both the teams. He is happy that the
faculty has brought up some very interesting points during the discussions and the debate.
The Dean requests both teams change & preserve to resolve their differences and come to a final
conclusion regarding the future course for the institution.
Team members have one day i.e. today 11th march to try and reach a consensus.
Regards,
Team Vibgyor - Sukhinder 2015.
Contributors:
11th March: Hironmoy, Juhi, Kavita, Soum, Tapasya, Gokul, Richa, Swapnil, Upreet, Sanjoy
12th March: Abhijit
31 | P a g e
Comments and Discussions:
1) Soum mentioned about ɅȹȶȴɀȿȴȶɁɅɀȷȘȵȲɁɅȺɇȶȶɉɁȶɃɅȺɄȶ
He said: I would like to make you aware of a new dimension to Physician's expertise ȘȵȲɁɅȺɇȶ
ȶɉɁȶɃɅȺɄȶ which may be needed at some unique situation. This differs from 'Routine Expertise',
which is cultured through the current educational strategies & by gaining experience in real
practice. This new dimension of expertise focuses more on creativity and innovation & out of the
box thinking in solving complex clinical problems during practice.
The question is.....which of these two educational strategies (Traditional & CBME) would help to
hone this new expertise?
CBME encompasses the components of adaptive expertise
Adaptability allows experts to think alternatively when rules and principles that generally
govern their performance do not apply to certain problems or situations
Routine expertise focuses on accuracy and efficiency where as adaptive expertise focuses on
innovation and creativity.
Includes data driven forward reasoning, cognitive flexibility
Thinks outside the box to solve challenging problem
2) A few suggestions were given by Hironmoy as follows:
Step 1: Each department can be given the responsibilities to form the SIOs and define the must-
know areas (having guidance from the institutional objectives from GME, MCI)
Step 2: Once these get framed, the departments can be asked to make a blue-print of the
teaching-sessions as, which area will be covered in lecture session, which area will be carried
on in small group tutorial/demonstration classes and which areas can be covered with some
assignments and mini-projects ȳɊ Ʌȹȶ ɄɅɆȵȶȿɅɄ ȫȹɀɄȶ ȾȺȿȺ-ɁɃɀȻȶȴɅɄ ȴȲȿ ȳȶ ɅȹȶȾȶȵ ɀȿ Ʌȹȶ
competencies covering the knowledge, attitude, behavior and skill. This mini-projects or small-
assignments are preferably to be carried on outside the college campus, especially in UTC of
RHTC allied to the institute. (This exposure starting from the basic pre-clinics days will
definitely orient the students towards the need of the community).
Step 3: Within a laxmanrekha of time, those mini-projects are to be completed. There will be an
assessment on those projects and that credit marks will directly to add in university marks.
There would be separate marks on the quality of the project work and viva on it.
Thus the projects of the UG pupil, not only will make them to learn on that topic in self-
directed way; but also each of the students will get exposed in different dimensions of
competencies during the project times.
The final consensus document was prepared and presented by Upreet as follows:
32 | P a g e
From the teacher's point of view, it would be great if we could identify when a medical trainee is
ready to safely and effectively practice unsupervised in that respect, CBME is a great idea. From
the student's point of view, too, it would be of great help if he could know what competencies he is
expected to develop during - and at the end of - training.
What we cannot ignore is the huge investment in terms of faculty training, infrastructure
development, module preparation, curriculum planning etc if we are to implement CBME.
Also, we would not want students unused to self-study to suddenly take charge of their learning. In
the early stages at least we would want to keep a close track of student learning so as to prevent
student frustration and despair over imagined lack of teacher input. When students are not bound
by time to acquire competencies, we would want to ensure that no student tarries to the point of no
return.
Developing a hybrid curriculum (part traditional and part competence-based) would avoid all the
disadvantages of an abrupt change and would give us time to develop the logistics required to go
fully CBME (if we ever need to).
Since the emphasis these days, in all fields of learning, including medical, is to develop competent
graduates, we recommend that each department develop competency-based outcomes as a first
step. These should be based on the needs of the graduates, of the patients, and of the community to
ensure that the outcomes are contextual.
To carry along all types of students we could use traditional teaching-learning (TL) and assessment
methods for the acquisition of knowledge component of the curriculum.
We may consider introducing newer assessment systems to check knowledge aspect. For example,
problem based questions can be introduced to check not only knowledge but also the application of
knowledge.
To build up confidence in self directed learning, we can implement problem-based learning for a
part of the curriculum as an interim measure. Initially only 25% of the curriculum can be covered
by PBL. This might alleviate any anxiety both teachers and student have due to implementation of
CBME.
To encourage learner-centeredness and emphasize 'abilities', we could use competency-based T-L
and assessment methods to bring about learning in the affective and psychomotor domains.
To do away with fears that a time-free course will result in some students delaying their
progression in the course, we could keep both a minimum and a maximum time limit for the
acquisition of each competency.
To monitor student learning, we could have a continuous in-training assessment of each student by
three independent assessors, assessment methods depending upon the T-L method employed. The
in-training assessment (internal assessment/formative assessment) would document progression
and milestone achievement.
33 | P a g e
The role of summative assessment would be to ensure acquisition of knowledge and the
achievement of competencies. It could be done away with completely; if not, internal assessment
should form a much larger chunk of the summative assessment (perhaps half or more) than it
currently does.
For slow learners we may add a training module to identify them after 2 failed attempts and
facilitate their learning. However they should not be allowed to practice unless they have mastered
the required competencies (the number of attempts then need not be specified).
Simultaneous training of teachers and development of modules for CBME can be done to prepare
the Institution for starting CBME
34 | P a g e
Thread 3
How to implement CBME in the institute.
The Team members have reached a consensus that they need to
ȪȺȾɆȽɅȲȿȶɀɆɄȽɊɅɃȲȺȿɅȹȶȷȲȴɆȽɅɊȲȿȵȵȶɇȶȽɀɁȾɀȵɆȽȶɄȷɀɃȚșȤȜȺȿɅȹȶȺɃȺȿɄɅȺɅɆɅȶ
"Gradual and planned amalgamation of traditional & Competency based medical education".
Dr. Established, the dean appoints Dr Innovative, as the coordinator of MEU. The first responsibility
on his shoulders is to make a blueprint of a plan to implement CBME. He has to present the plan to the
Dean on 15th March.
In the next three days (12-14 March) please help Dr Innovative outline the steps in planning a CBME
curriculum. (The discussion continued further for 3 more days)
Regards,
Team Vibgyor - Moderator (Sukhinder 2015).
Contributors:
12th March: Sukhinder, Swapnil, Vanita, Purnima, Gokul, TS sir, Soum sir, Abhijit, Sumnath
13th March: Vanita, Juhi, Kavita, Shuchi, Krithica, Sanjoy, Upreet, Amir, Purnima
14th March: Bharati, Shuchi, Hem, Abhijit, Neeti, Gagan, Mohit, Sumnath, Upreet, Soum, Sanjoy,
Hironmoy
15th March: Shuchi, Vanita
16th March: Abhijit, Kavita, Sanjoy, Juhi, Gagan, Purnima,
17th March: Hironmoy, Manjinder, Krithica, Amir
35 | P a g e
The following discussion took place on this thread.
ȟɀɈɅɀɁȽȲȿɅȹȶȺȾɁȽȶȾȶȿɅȲɅȺɀȿɀȷȚșȤȜȺȿɅȹȶȺȿɄɅȺɅɆɅȶ -
The following ideas were shared by various participants.
1) Team Innovative can constitute a the board of members having sound background knowledge in
Medical Education and keen interest in teaching. After the debate, the board can think of
incorporating 20% of marks for CBE (in form of OSPE/OSCE /Mini C Ex etc.) University
permission has to be taken beforehand. Even for initiating for 1/5th Marks (20%), faculty and
auxiliary staff has to be trained. Students have to be primed repeatedly before and the pattern
introduced to them ...in Midterms and Terms. There should be no space for any surprise elements
in Medical Education.
However, this idea was corrected by faculty intervention. It ɈȲɄȾȲȵȶȴȽȶȲɃɅȹȲɅȚșȤȜȺɄȿɀɅ

another methodology or another system, where you can assign a portion of marks to it. In fact,
combining marks is against the basic concept of CBME. What we need in competency based
system is that every student should be competent in every competency selected for that course.
When you combine marks, you compensate for a poor skill by a good communication. This would
ȵȶȷȶȲɅɅȹȶɈȹɀȽȶɁɆɃɁɀɄȶ
2) Dr. Innovative should first ask each department to identify at least four to five core competency
areas (CCA). Once these areas are approved in the faculty meeting, then the method of teaching
and assessing these CCA should be finalized. MEU should train faculty members to revise the
curriculum accordingly. Without disturbing the traditional curriculum much, these CCA should be
adjusted in the time-table (Most challenging aspect!). Portfolio/ student log books should have
these CCA assessment sheets and a minimal score in these assessments will be one of the eligibility
factors to appear the professional exam. This blue printing method can start year wise and will
answer most of our concerns about the CBME.
Again, faculty guidance came in and it was suggested that we should ponder on how to address the
essence of CBME; that is flexibility in learning and acquiring competency; and to keep suggesting
feasible and effective plan.
3) Initially, determine the competency which is expected of the graduate. Describe it. Determine
the competencies which make up the competency. Determine the milestones to be achieved at the
end of the 1st, 2nd, 3rd and 4th years. Accordingly, plan the teaching-learning methods for each of
the competencies. Then, plan the assessment methods to determine if the milestones have been
achieved. Finally, plan how you will evaluate the curriculum.
36 | P a g e
4) Make a team / committee for this purpose. The team should be comprised of three members from
each department. ȠȵȶȿɅȺȷɊɅȹȶȾɆɄɅȼȿɀɈ areas of the subject concerned. Develop the appropriate
T-L tools to assist the students to develop such competencies with ease. Design the assessment
methods/ tools for assessing each skill or competency. Plan for more of formative assessment and
less of summative assessment.
5) Prepare a time line. To organize an all-faculty meets to sensitize about CBME. Hold a workshop on
CBME and especially seek participation from the senior faculty members. While the air of CBME
would be on, immediately after the workshop request the faculty who are interested and willing to
devote time to volunteer and be a part of the CBME curriculum implementation committee. Enlist
the Competencies. Focus would be to align the competencies to the health need of the community.
Specifying the learning objectives, instructional methods, level of competence, methods for
assessment, and the level of assessment had to be prepared keeping in mind the different
semesters. Sensitize more and more faculty towards CBME. Simultaneously, the new roles of the
teacher and the students must be assigned and clear -cut instructions on what is expected of them.
Possibility of confusion in the early phase of implementation must not be overlooked.
6) Stage 1: Developing desirable competencies

Stage 2: Implementation strategies: Use COBES, which has provided students with learning
experiences to acquire competencies in the domains of population health, leadership and
management skills, as well as health systems management.
Stage 3.-Curriculum review and implementation
Stage 4: Outcomes (Successes, Opportunities and Challenges)
7) Conduct an introductory workshop so that the faculty of various departments understand the
concept of CBME. Identify the various competencies and frame them in relation to the gaps
assessed. What the proposed CBME based learning is intended to address. Design a curriculum to
suit individual department needs. Design assessment methods and tools.
8) Delphi technique - for consensus of individual experts

Nominal group technique: for group consensus
Task analysis through observations of professionals -on-the-job
Practitioners' survey
9) The following needs to be done:

Community to identify the problems they are facing while working in real life situation
37 | P a g e
Meeting with non medical administrative officers and policy makers to figure out
whether demonstrating the competencies like leadership, collaborator, professionalism,
manager etc.
Consumer forum about their expectation about the competent medical graduates
Researchers provide us feedback on what we are doing
Learning from the institute who has already had some experience
Formulation of desired competencies
10) We need to:

Sensitize all the faculties to CBME
Understand the meaning of competencies
Focused group discussions for the respective stakeholders to generate the important domains
Identify the salient competencies which are expected to be achieved
Define the milestones of each of these as per the academic developmental age of the student
11) Getting up the deficient areas of competencies of a passed out medical graduate from: faculties- by
discussion, interview etc, university results- if possible, the areas of improvement, passed out
students-as they felt or getting felt; by FDG or interview, society-general practitioners, what they
are getting felt in day to day practice, social leader (Village-pradhan), media reports
Sensitization workshops to be done for faculties (step wise, at first it needs to sensitize the HODs
and students on CBME
Decentralization of framing competencies in individual departments. As an example,

List of topics to be covered in next three months Lectures
A Lecture session
B Mini-projects (CBME)
C Practical classes
D etc. Lecture sessions
Department can be given free-hand in making the CBME topics and its way of execution and
assessment methodology.
Horizontal and vertical integration of different disciplines.
Scheduling for the students.
12) A strong dedicated and transparent team would be required to implement CBME in India. A group
of dedicated volunteers will have to be selected for making some modules and for guiding others to
prepare them. Emphasis should be on strengthening formative assessments. These assessments
38 | P a g e
should be multiple and of increasing difficulty. Each module of the identified competencies should
be subdivided into two stages:
Stages-1 Should focus on 'knows' and 'knows how'
Stage- 2 can deal with mastering of skills and attitudes.
5. MEU Units of each college should take the lead to begin designing these modules.
13) A tabulated plan to implement CBME was also discussed on this thread:-
Areas of Steps resources Expected outcomes

Concern
Identify To identify currently deficient 1.Faculty interviews 1.Early identificati
deficient competencies regarding current on of deficiencies
areas deficiencies identified with
working practices of Interns 2.Alignment of
and 1st year PG Residents- Basic with clinical
Institutional level subjects to form a
good foundation at
the outset
2. Capacity 1.Informing faculty and baseline data on deficiencies, To promote faculty
building preparing faculty to accept the feedback reports acceptance that
concept of BME through series shall be a major
of meetings/CMEs challenge
2. Showing baseline data of
success and utility of CBME at
other Institutes
3. By discussing areas where
faculty has expressed and
highlighted deficiencies in the
institute (using the data from
point 1)
4.Training faculty for CBME
3.Meetings/n Meetings/networking/partnership Administrative backup Exchange of ideas

etworking/ s Institutional/across institutes Strengthening Institutional for developing a
partnerships that have competency based FDPs through MEUs sound curriculum
systems/collaborative and plan of action.
workshops/memorandum of
assistance and long term co-
39 | P a g e
operation
4.Outline To categorize core competencies Faculty and MCI Document To modify/reassess
needs in each specialty/subject Meetings with various competencies
departments
4.Framing Short term- based on existing Formulation of competencies For a phased
competencies facilities by each department - Basic approach
(Phased Midterm based on logistic Sciences to do it in
planning) support that can be acquired in 2 conjunction with Clinical
ɊȶȲɃɄɅȺȾȶ subjects
Long term- based on logistic
support that can be acquired after
2 year time
5.Resource Logistics to be re-assessed and Simulation Labs For logistic support

development existing facilities to be judged Reference books/material to
(Infrastructur with reference to their ability to be organized
e/ fulfil the desired objectives of
And basic the framed competencies
requirements
)
6. 1.To modify curriculum
Institutional 2. For logistic support
Administrati 3. For implementation
ve support
Competencies and Entrustable ȧɃɀȷȶɄɄȺɀȿȲȽȘȴɅȺɇȺɅȺȶɄ ȜȧȘɄ

The following ideas and concepts about competencies and EPAs were shared on this thread, as a part of
formulating the steps to introduce a CBME curriculum:-
1) Identify various core competencies which should be acquired by all the students. E.g. Patient care,
Medical Knowledge, Practice based learning and improvement, interpersonal and communication
skills, professionalism; System based practice, medical expert, manager, collaborator, Advocate,
Communicator and professional etc.
To bridge the gap between theory and practical of CBME, concept of Entrust able Professional
Activity [EPA] is needed. ȘȿȜȧȘȺɄȲȴɃȺɅȺȴȲȽɁȲɃɅɀȷɁɃɀȷȶɄɄȺɀȿȲȽɈɀɃȼɅȹȲɅȴȲȿȳȶȺȵȶȿɅȺȷȺȶȵȲɄȲ
40 | P a g e
unit to be entrusted to a trainȶȶɀȿȴȶɄɆȷȷȺȴȺȶȿɅȴɀȾɁȶɅȶȿȴȶȹȲɄȳȶȶȿɃȶȲȴȹȶȵȫȶȿȚȲɅȶȫȶȿ
Cate & Scheele 2007). Competence is thus translated and made manageable in terms of the tasks or
activities that can be safely entrusted to someone who has shown the required ability.
Plan learning and assessment of EPA, Schedule EPA over the course of training, do fine tuning of
the schedule e.g. Levels of competency, related to levels of supervision (Ten Cate & Scheele
2007):
Level 1: has acquired knowledge and skills, but insufficient to perform

Level 2: may perform an activity under full, proactive supervision: the supervisor decides about the
intensity of supervision
Level 3: may perform an activity under qualified, reactive supervision: the student asks for
supervision
Level 4: may perform an activity with back stage, mainly formal supervision
Level 5: may provide supervision to others
Level 4 is the threshold level of competence. Once this level is reached, the activity may be safely
entrusted to the student. Growth of competency after reaching this threshold is likely as a result of
further deliberate practice.
2) Competencies proposed by various institutes and organizations in different countries:

a) Six competencies proposed by ACGME (Accreditation Council on Graduate Medical
Education, USA)
ǵ Patient care
ǵ Medical knowledge
ǵ Practice based learning and Improvement
ǵ Inter-personal and communication skills
ǵ Professionalism
ǵ System based practice
b) ȪȴɀɅɅȺɄȹȵɀȴɅɀɃȾɀȵȶȽ
clinical skills
practical procedures
patient investigations
patient management
health promotion and disease prevention
communication
medical informatics
c) How the doctor approaches his or her practice:
41 | P a g e
basic, social and clinical sciences
attitudes, ethical understanding and legal responsibilities
decision-making skills and clinical reasoning
d) The doctor as a professional:
the role of the doctor within the health service
personal development
e) Brown School Model (USA)

Effective communication
Basic clinical skills
Using basic science in the practice of science
Diagnosis, management, and prevention
Lifelong learning
Professional development and personal growth
The social and community contexts of healthcare
Moral reasoning and clinical ethics
Problem solving
f) University of Minnesota Medical School Model

Medical knowledge
Clinical skills and patient care
Scientific and clinical enquiry
Professionalism
Inter-personal and communication skills
System healthcare
Continuous improvement through reflective practice
g) MCI guidelines for five competencies of ȠȿȵȺȲȿȤȶȵȺȴȲȽȞɃȲȵɆȲɅȶ

Clinician who understands and provides preventive, promotive, curative, palliative and
holistic care with compassion
Leader and member of the health care team along with capabilities to collect analyze and
synthesize health data.
Communicator with patients, families, colleagues and community
Lifelong learner committed to continuous improvement of skills and knowledge through
research
Professional, who is committed to excellence, is ethical, responsive and accountable to
patients, community, and profession
42 | P a g e
3) Identify the Core Competencies
Define the Levels and Criteria for Each Competency- to define the various levels of each
competency and the criteria to for determining students achievement at each level
Map the Competencies to the Curriculum
Design Assessment Procedures for Each Competency
Implement the Assessment Procedures
4) The competencies have ɅɀɅȲȼȶȺȿɅɀȴɀȿɄȺȵȶɃȲɅȺɀȿȴɀɆȿɅɃɊɄȹȶȲȽɅȹȿȶȶȵɄȲȿȵȹȶȲȽɅȹȲȿȵȶȵɆȴȲɅȺɀȿ

systems. The faculty should understand the relatively new paradigm of CBME and should be
trained for the development of appropriate teaching - learning methods and materials
5) 'Curriculum map' is a tool which allows educators to identify core concepts

Students are required to learn, determine the sequence of the concepts within the curriculum and
identify any overlap or omission of concepts. Resources were shared to elaborate the steps of
using curriculum mapping to link the competencies with assessment tools; and to assess the level
of learning and the skill stage.
6) We need to identify certain core competencies. They should them be implemented semester
wise and through an integrated approach. Communication and Interpersonal skills and
Professionalism may be the initial domains. Experience thus gained can be gradually translated to
other identified health needs.
7) Another idea shared was :

Core competency areas as minimum clinical competency areas (must know), expected clinical
competency areas (good to know).
Competence will be identified from every specialty.
Minimal clinical competency areas will be tested prior to the professional exam.
Passing this test is a pre-requisite for appearing the year 5 professional exam.
Student gets time till the end of year 5 exam to learn these competencies at his own pace
Expected clinical competency areas can be similarly tested but it is optional and each
institution can decide on the criteria
8) Graded responsibility is an integral part of medical education. As the Trainee becomes more
proficient they are entrusted with more complex or critical tasks and require less direct
supervision.
The tasks that are chosen to be measured ȲɃȶȴȲȽȽȶȵȜȿɅɃɆɄɅȲȳȽȶȧɃɀȷȶɄɄȺɀȿȲȽȘȴɅȺɇȺɅȺȶɄȜȧȘɄ
ȜȧȘɄȲɃȶɅȲɄȼɄɅȹȲɅȲȿȺȿȵȺɇȺȵɆȲȽȴȲȿɁȶɃȷɀɃȾɅȹȲɅȲɃȶȴɀɃȶɁȲɃɅɄɀȷɅȹȶȺɃɁɃɀȷȶɄɄȺɀȿȲȽɈɀɃȼȲȿȵ
they need to be observable and measurable
43 | P a g e
ȜȧȘɄȲɃȶȵȺɇȺȵȶȵȺȿɅɀȷȺɇȶȽȶɇȶȽɄ
At Level 1: The trainee has insufficient knowledge and skills to perform the task.
At Level 2: The trainee may perform the activity under full proactive supervision, the supervisor
deciding the level of supervision.
At level 3: The trainee can be trusted to know when to ask for help (reactive supervision).
At level 4: The Trainee may perform an activity with back stage, mainly formal supervision.
At level 5: The trainee has enough skills, knowledge and appropriate attitude that they would be
suitable to supervise others.
Steps in designing EPAs

1. Analyse which activities are central or critical to the practice of the speciality, require adequate
skill, knowledge and attitude and are entrusted to a Trainee once he or she is sufficiently
ȴɀȾɁȶɅȶȿɅȫȹȶɊȿȶȶȵɅɀȳȶȲɆɅȹȶȿɅȺȴɅȲɄks.
2. Describe the level. Simpler, more frequently done or essential tasks should be mastered sooner.
Have some idea of the scope (small or broad)
3. Provide description of task/ responsibility
4. Summarise the task that clarifies responsibility, referring to standards and protocols where
appropriate.
5. Specify required knowledge and skills.
6. Describe assessment methods: What will assist the supervisor in entrusting this trainee in
performing the task under limited supervision? It might be a miniǦCEX, multi-source feedback to
ȴȲɁɅɆɃȶɁȶɃȷɀɃȾȲȿȴȶɀɇȶɃȲȽɀȿȸȶɃɁȶɃȺɀȵɀȷɅȺȾȶȶɅȴȮȹȺȽȶȺɅȾɆɄɅȲɄɄȶɄɄɁȶɃȷɀɃȾȲȿȴȶȵɀȶɄɀɃ
ɄȹɀɈɄȹɀɈɁȲɃɅɀȷȤȺȽȽȶɃɄȧɊɃȲȾȺȵɄȶɁȲɃȲɅȶȲɄɄȶɄɄȾȶȿɅɄɀȷȼȿɀɈȽȶȵȸȶȢȿɀɈɄȼȿɀɈɄ
ȹɀɈȾȲɊȳȶȿȶȶȵȶȵ It may involve more than one supervisor.
7. Train Supervisors.
8. The Trainee keeps a developmental portfolio.
9) The concept of competencies and EPAs was further clarified as: Milestones help to gradually
reach Competencies, Competencies combine to achieve a domain of competence, Domains of
competence combine to give an Entrustable Professional Activity. EPAs are units
of work whereas Competencies are the abilities of an individual.
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Teaching-learning methods as a part of CBME curriculum
The following points were discussed regarding the ideal teaching methods to implement a CBME
based curriculum:
1) New methods of teaching are needed to translate the desired learning objectives and competency
domains into education. These methods include:
Problem-based learning in the pre clinical years
Case-based learning in the clinical years
Practical sessions
Self-directed learning
Use of information communication technology
Clinical pathological conferences
Clinical audits
community-based education,
Research, and service
Early clinical exposure
Community projects.
These methods should be integrated with traditional methods, including ward teaching,
lectures, journal clubs and grand rounds.
2) It was further added that in the process of developing T-L methods for CBME, Dr Innovative
should keep in mind the following points :
T-L sessions should not be confined to any specific method. In fact, there is necessity for multiple
methodologies ȲɄȺɅɄȲȸɃȲȵɆȲȽȾɀɇȶȾȶȿɅȷɃɀȾȲ teacher-centered approach to a student centered
approach. In addition to conventional interactive lectures and small group discussions there is need
for some newer techniques of T-L methods like Teaching in the clinical skills center, Ward based
teaching, Ambulatory care teaching (eg.OPD teaching), Teaching-learning in the
community and Peer-assisted learning (PAL). These were further elaborated with examples.
3) Other teaching-learning methods discussed were mini-projects, problem based learning (PBL),
team based learning (TBL), even the team assisted learning (TAL), Group discussions, active
clinical learning (ACL), and seminars.
If the cognitive domain if to be addressed, then chart-preparation, seminars, presentations can be
carried on. If affective domain is to be addressed, values clarification exercises (in self study or
group study), writing up of analysis of different codes of ethics etc. can be undertaken. When
the psychomotor domain is to be addressed, repeated practice of skills in simulated laboratory
45 | P a g e
using plastic models, mannequin etc. can be done. In every case the teacher will be passive and
behave as the facilitator.
4) For teaching-learning tools, we first need to decide the content of the CBC. Use all the three
domains of learning, build up the level from lowest to highest in each domain, organize the
knowledge, skills and abilities into a competency and finally relate competencies to pre-requisites
and general education requirements. The student, not the discipline, is central to the learning
process in a competency-based program. Achievement, not time, is the driver.
The following teaching-learning methods can be used:
Didactic lectures, clinical teaching, case-based teaching, role-modeling, journal club, mentoring,
simulations, self-directed learning modules, individual or group projects, research projects, chart
audit.
ȘɄɄȶɄɄȾȶȿɅȲɄȲɁȲɃɅɀȷȚșȤȜȴɆɃɃȺȴɆȽɆȾ
The following thoughts and concepts about Assessment as a part of a CBME- curriculum were
discussed on this thread:
1) Assessment is the tail that wags the curriculum ȵɀȸɈȹȲɅ is not assessed is not learned; learning
is driven by assessment'-(source-Principles of assessment by TS sir). The following assessment
methods could be used:
Mini CEX
OMP
Use of portfolios
Workplace based assessment
OSCE
Continuous internal assessment
2) Robust Core Competency Assessment tools would be

OSPE for testing basic clinical skill
OSCE for testing the Basic communication skill
Electronic Portfolios
Continuous Clerkship monitoring
Faculty development in assessment
46 | P a g e
3) Regarding assessment, it was discussed that the various methods of work-place based assessment
such as portfolios and Mini CEX could be used. Also, a score-card for assessing competencies
could be used, during internship.
4) In a CBME system, assessment and feedback must be frequent and real time. Every competency is
to be assessed ɂɆȲȽȺɅȲɅȺɇȶȽɊțȶȷȶȿɄȺɇȶȶɇȲȽɆȲɅȺɀȿ ȴȲȿȳȶɆɄȶȵɅɀȲɄɄȶɄɄȵȺȷȷȺȴɆȽɅȴɀȾɁȶɅȶncies
like professionalism. Portfolios can be used to assess qualitative ones.
5) Assessment should be criterion based through milestones or benchmarks. Milestones are
description of typical developmental growth within each domain. They determine as to what the
current level of performance is and what behavioral changes are required for the student to
graduate to the next level of performance.
6) Assessment in CBME should have the following characteristics:

Assessment processes are continuous and frequent. Robust, on-going feedback is essential
Assessment is criterion-based, using a developmental perspective. Commonly
called milestones or benchmarks.
CBME, with its emphasis on preparation for what the trainee will ultimately do, requires
robust work-based assessment, real-time evaluation and feedback.
Training programs must use assessment tools that meet minimum requirements for quality.
Assessment must incorporate more ɂɆȲȽȺɅȲɅȺɇȶ ȾȶȲɄɆɃȶɄ and methods.
Assessment needs to draw upon the wisdom of the group and to involve active engagement of
the trainee.
7) ȘɄɄȶɄɄȾȶȿɅȴȲȿȳȶɀȷɅɊɁȶɄ¡
Evaluator assesses the candidate: OSCE (Check lists), mini-CEX, work-place based
assessment etc.
Self-assessment: if the checklist/milestones get available to the learner, the learned him/herself
assess his/her condition and can accelerate the self-learning
Multi-source (360 degree) assessment: when multiple evaluator evaluates and provides the
feedback
8) It was added that the preferred method for the assessment of the competency is the use of criterion -
referenced measures that compares performance against set standards or threshold. Additionally, it
would be important to document competency progression.
9) A question raised about OSCE not so frequently described in the literature on assessment in
CBME. The clarification provided was that the intention is not to indicate that objective methods
are bad, but that subjective methods are also good and quite helpful.
47 | P a g e
Thread 4 (Part A):
Group work on identifying a competȶȿȴɊȺɅɄcomponents and
milestones
Dear All,
Dr. Innovative is very pleased with the interesting discussions and the active participation of the
faculty. He hopes the discussions have brought lucidity to a number of concepts regarding CBME.
Dr. Innovative was waiting for an opportunity to build some team spirit amongst the members of MEU.
One thing he has definitely learnt from his FAIMER experience is that no discussion is ever complete
without a hands-ɀȿɁɃȲȴɅȺȴȲȽȲɁɁȽȺȴȲɅȺɀȿȪɀȹȶȵȶȴȺȵȶɄȺɅɄɅȺȾȶȷɀɃɄɀȾȶȸɃɀɆɁȲȴɅȺɇȺɅɊȟȶȹȲɄ
divided his faculty members into the following groups -
Canary Yellow Group :

Fellows 2014 - Hetal, Neeti, Ruchi, Tapasya, Clarence, Gokul.
Fellows 2015 - Abhijit, Hem, Juhi, Bajaj, Poornima.
Brick Red Group :

Fellows 2014 - Sabita, Mullai, Simer, Vijay, Gita, Manjinder.
Fellows 2015 - Amir, Kavita, Sukhinder, Sumanth, Upreet.
Turquoise Blue Group:

Fellows 2014 - Mohit, Peter, Rahman, Krithica, Nilima.
Fellows 2015 - Hironmoy, Shuchi, Bharati, Sanjoy, Swapnil, Vanita.
All the groups have 2 days (17-18 March) to

x Identify a competency.
x Describe its components.
x Identify the milestones for achieving the competency.
Separate threads have been made for the groups for their intra-group discussions.
All groups will then present it on the common thread for discussion on 19th March by 9:00AM.
Warm Regards,
Team Vibgyor - Sukhinder 2015.
48 | P a g e
Canary Yellow Group:
Brainstorming within the group:

First, the group thought of efficiency in clinical examination to arrive at a diagnosis as a competency,
then thought of picking up a topic like professionalism, scholar, manager, collaborator etc. Finally the
group finalized a cɀȾɁȶɅȶȿȴɊɃȶȽȲɅȶȵɅɀɁɃɀȴȶȵɆɃȲȽɄȼȺȽȽɄȧȶɃȷɀɃȾȺȿȸȣɆȾȳȲɃȧɆȿȴɅɆɃȶȫȹȶȸɃɀɆɁ
brainstormed on various skills required, i.e. communication and counseling skills, maintaining aseptic
environment throughout the procedure and handling and transportation of collected sample (to be
added in cognitive portion too). The team decided to elicit all the competencies using the structure of
ɅȹȶȤȺȽȽȶɃɄɁɊɃȲȾȺȵȫȹȶɃȶɈȲɄȲȵɀɆȳɅɃȶȸȲɃȵȺȿȸȺȿȴȽɆɄȺɀȿɀȷɅȺȾȶ-frame, but since CBME is not
time-bound, the team decided to skip that. They also considered adding OSCE and including informed
consent in the affective domain. The final result of their team work, posted on main thread 4was as
follows:-
Final submission:
The title of our EPA is ȧȶɃȷɀɃȾȽɆȾȳȲɃɁɆȿȴɅɆɃȶ
The components of the competencies needed to acquire to achieve that EPA are put on matrix.
Regards
Hem 2015
Domains Components of competency 1st 2nd 3rd

Prof Prof Prof Internship
1. Acquire Knowledge about spinal X
cord and vertebral column
2. Knowledge about site of lumbar X
puncture
3. Acquire Knowledge about X
physiology of CSF formation
Cognitive domain 4. Knowledge about organism x
(Knows) causing CNS infection
5. Knowledge about handling and x
transportation of collected CSF
6. Acquire knowledge about x
interpretation of findings of CSF
examination
49 | P a g e
Cognitive domain (Knows 1. Acquire knowledge about X
how) indication and contraindication of
Lumbar puncture X
2. Learn the procedure of doing LP
3. Learn about the instruments X
needed to perform LP
4. Learns about obtaining informed X
consents
Psychomotor domain 1. Assist in performing LP X
(Shows how) counseling skills
2. Keeps aseptic environment X
throughout the procedure
Affective domain 3. Collaborates with staffs X
4. Professional behavior exhibited X
Psychomotor domain 1. Performs Lumbar puncture with X
supervision
Affective attitude domain 2. Performs LP (unsupervised) X
and psychomotor
domain(Does)
Comments and Discussion:

1) The main competency and last sub competency are identical i.e. Perform lumbar puncture. The
main competency should be reframed. Also, exhibiting professional behavior seems too broad.
More specificity is needed.
ȩȶɄɁɀȿɄȶȷɃɀȾɅȹȶɅȶȲȾȠȿɄɅȶȲȵɀȷȧȶɃȷɀɃȾȣȧɆȿɄɆɁȶɃɇȺɄȶȵȺɅȾȲɊȳȶɁɆɅȲɄȠȿɄȶɃɅɅȹȶȣȧ
needle to the spinal canal, assess the CSF pressure and collect CSF in 3 or 4 sterile vials
ɆȿɄɆɁȶɃɇȺɄȶȵ
2) It is a very well worked out matrix and includes everything from informed consent to
communication, and asepsis. A few comments though:
In the last row, I feel we should include cognitive domain also, since he must use knowledge to
perform well.
Competency is ability. In that case, perhaps we should frame the components of competency
(column two of your table) as 'will be able to.....'
Regarding the milestones: Physiology of CSF formation should perhaps come in first proff?
Milestones should be expressed as expectations - what and how much and how well do we
expect the student to do at that stage of life - rather than as a checklist.
50 | P a g e
Brick Red Group::

Initially the group thought that since they were all from different specialties they should decide upon a
general topic such as communication or cardiopulmonary resuscitation or ethics. Then they decided to
ȾȲȼȶȺɅȾɀɃȶȷɀȴɆɄȶȵȲɄȳɃȶȲȼȺȿȸȳȲȵȿȶɈɄɀɃȶɉɁlaining a chemotherapy protocol and its effects to
the patient. Then they thought that the latter would not be a core area. A suggestion then came up to
ɅȲȼȶȺȿȷɀɃȾȶȵȴɀȿɄȶȿɅȷɀɃȴȲɅȲɃȲȴɅɄɆɃȸȶɃɊ. Then the group discussed the Canmeds framework
describing the 7 roles that all physicians need to have, i.e. medical expert, communicator, collaborator,
manager, health advocate, scholar and professional. Then the group looked at a different approach
proposed in the ACGME framework, in which six competencies viz. medical knowledge, patient care,
professionalism, interpersonal communication, practice based learning and system based practice. They
are further divided into sub-competencies and graded into levels of expectations, consisting of
milestones. They incorporated the latter idea into their Google document. After that certain resources
on informed consent were shared. Then, a doubt came up whether something was missing, and whether
the group was looking at the competency framework through the OSCE lens. It was clarified by further
refining the document with inputs from all, and the final submission on the main thread was as
follows:-
Final Submission:
Team Brick Red did a lot of reading and brainstorming and mentoring and has come up with this:
Broad competency: Interpersonal and communication Skills
Sub-competency: obtaining informed consent prior to a diagnostic or investigative procedure
Setting: inpatient / routine admission
Target: 5th semester MBBS to 9th semester
Components:
S.no Includes Other competencies/Domain
1. Greets the patient and introduces Professionalism/Attitude
himself/herself
2. Explains the need for the procedure Medical expert/Knowledge
3. Includes spouse/relatives in the discussion Professionalism/Attitude
4. Explains other available options, including Medical expert/Knowledge

advantages and disadvantages
51 | P a g e
5. Explains the possible risks/complications of the Professionalism/Knowledge
procedure as well as its benefit
6. Informs the cost involved in the surgery Professionalism/Knowledge
7. The information given is clear and Communication skills/Attitude

unambiguous, using simple language that the
patient can understand
8. Gives opportunities to the patient /Spouse/ Professionalism/Attitude
relatives to express their doubts
9. Confirms - to find out if the patient has really Professionalism/Attitude
understood the information
10. Reassures patient, if he/she is anxious Professionalism/Attitude
11. Explains prognosis Medical expert/Knowledge
12. Knows when to ask for help Medical Expert/
Professionalism/Attitude
Milestones for achieving the competency:

Level one Level two Level three Level four Level five (expert)
(novice) (Advanced (Competent) (Proficient)
Beginner)
5th semester 7th semester 9th semester Internship PG first year
Knows why a Is able to seek Is able to seek Is able to seek Is able to seek
doctor must consent for simple consent for consent for consent for
inform patient procedures like IV simple complex complex or
before a line insertion or procedures as procedures multiple
procedure incision and at milestone including those procedures in
drainage of two that have ethical complicated
Knows the abscess after connotations (for scenarios (for
components of establishing Is able to example example poly
an informed rapport with suggest abortion/organ trauma or medico-
consent patient and options, listing donation) legal cases) and
explaining need in advantages and explain prognosis
Communicates simple language disadvantages Is able to suggest - including death
clearly in options, listing on table or death
simple language lists some is able to list advantages and during procedure
52 | P a g e
Listens common and explain disadvantages Is able to explain
attentively to complications complications options and assist
the patient and describe Is able to explain patients and
how they will prognosis; detail relatives at
Limits: be managed complications; arriving at a
Is not permitted and engage collaborative
to ask for patients and decision making
consent for relatives in
procedures decision making
Level of competence to be achieved at the end of 9th semester: level three

After the team posted the final submission, it was congratulated for excellent compilation and no
queries or doubts were raised.
53 | P a g e

ȫȹȶɅȶȲȾȷȶȽɅɅȹȲɅȺȿɅȶɃɁȶɃɄɀȿȲȽȲȿȵȴɀȾȾɆȿȺȴȲɅȺɀȿɄȼȺȽȽɄɈȲɄɅȹȶȴɀȾɁȶɅȶȿȴɊɅȹȶɊɈȲȿɅȶȵɅɀɈɀɃȼ
on. It was further decided to narrow it down to communicating bad news or taking an informed
consent, for exploratory laparotomy, for example. But, once they found out that another team was
ɈɀɃȼȺȿȸɀȿɅȹȶɄȲȾȶɅɀɁȺȴɅȹȶɊɅȹɀɆȸȹɅɀȷɈɀɃȼȺȿȸɀȿȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾȲȿȵȶɅȹȺȴɄȫȹȶȿɅȹȶɃȶɈȲɄ
confusion whether to consider professionalism as a whole, or in a particular scenario. In between, there
ɈȲɄȲɄɆȸȸȶɄɅȺɀȿɅɀɈɀɃȼɀȿȹɀɈɅɀȾȲȺȿɅȲȺȿȴɀȿȷȺȵȶȿɅȺȲȽȺɅɊThen the team referred to a resource
ɅȹȲɅȵȶɄȴɃȺȳȶȵɇȲɃȺɀɆɄȤțȴɀȾɁȶɅȶȿȴȺȶɄȲɄɁȶɃɅȹȶȬȿȺɇȶɃɄȺɅɊɀȷȚȲȽȺȷɀɃȿȺȲɄȴɀȾɁȶɅȶȿȴȶȳȲɄȶȵ
medical education programme. It described the various domains in which learners should achieve
competence such as patient care, communication skills, and professionalism, practice based learning
and so on; and how these competencies could be achieved, step by step. Then, various definitions of
professionalism were discussed. Then, some clarity came in, that they needed to identify a competency
related to professionalism, describe its components and determine the milestones. Then the attributes of
good and poor ethics at workplace, characteristics of a professional in terms of character, attitude,
excellence and competency were compiled. Again there was a confusion regarding how to break the
competency to form a sub competency. After sorting it out, and with inputs from all the team members,
ȫɆɃɂɆɀȺɄȶșȽɆȶȸɃɀɆɁȴȲȾȶɆɁɈȺɅȹɅȹȶȷɀȽȽɀɈȺȿȸȵɀȴɆȾȶȿɅɀȿȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾȺȿȵȶȲȽȺȿȸɈȺɅȹȲ
ɁȲɅȺȶȿɅȺȿȦȧț-
Final Submission:
Broad competency: Professionalism &ethics.
Sub-competency:
Setting: Outpatient
Target: 3rd semester MBBS to 9th semester
Q. Describe a competency (Theme: Professionalism and ethics)

A. medical graduate should demonstrate proper respect to a patient while examining in OPD.
Q. Determine its components

A medical graduate should
1. Properly greet the patient
2. Passionately hear his problems
3. Explain the examinations what he likes to do with the patient and assure him/her that the procedures
will not do any harm to him/her
54 | P a g e
4. Be respectful while to asking the patient to expose the areas to be examined.
5. Maintain the privacy of the patient
6. Do the examination on the patient with proper empathy
Q. Determine its milestones
Milestones: Domains tested To be achieved by the Assessment method

A medical graduate should: end of which semester
Properly greet the patient coming Affective 1st, 2nd (if possibility Workplace based
in OPD. of the early clinical assessment
exposure); and 3rd Patient simulation
Demonstrate the passion on Affective 3rd, 4th semester Workplace based
hearing the problems of the assessment
patient attending OPD
Explain the examinations what he Affective 5th semester Workplace based
likes to do with the patient and assessment
assure him/her that the procedures
will not do any harm to him/her
Show proper respect on asking the psychomotor 5th, 6th semester Workplace based
patient to expose the areas to be assessment, patient
examined. simulation, 360
degree assessment
Demonstrate the maintenance of psychomotor 5th, 6th semester Workplace based
privacy of the patient on assessment, patient
examining him/her. simulation, 360
Be able to avoid any harm to the psychomotor 7th, 8th degree assessment
patient on examining him/her
Demonstrate the cooperation to psychomotor 8th, 9th
the patient on dressing him after
the clinical examination.
Greet the patient and convey affective 9th semester
thanks to him/her on cooperating
for clinical examination.
55 | P a g e
Professionalism and ethics in dealing with patient in OPD:-
Sub domains Domain tested Milestones to be achieved

Work habits, appearance, etiquette
Punctual-comes on time in OPD. Affective 3 rd semester
Comes dressed well &appropriately. Affective 3 rd semester
Displays preparedness to see patients Affective 3 rd semester
&takes initiative.
Maintains good demeanor &behavior Affective 3 rd semester
during work hours.
Writes prescription accurately &legibly. Cognitive 8 th-9th semester
Uses appropriate language Affective 3rd, 4th, 5th semester.
Uses simple language patient can Affective 6th,7th semester
understand
Washes hands prior to and after seeing Affective 8th,9th semester
patient.
Hears patiently to patient. Affective 3rd semester
Warms hands prior to examining patient Affective 5th,6th semester

in cold .
Address patient with respect. Affective 3rd semester
Gives opportunity to patient, spouse Affective 8th,9th semester

&relative to express their doubts.
Examines patient to come to proper Cognitive 8th,9th semester

diagnosis.
Professional Relationship
Greets patient Affective 5th,6th semester
Demonstrates sensitivity Affective 8th,9th semester
&responsiveness to patient
Demonstrates respect, compassion, Affective 8th,9th semester
accountability, when interacting with
peers, interprofessional health care
provider, patient, family.
Maintains boundaries & priority Affective 8th,9th semester
Respects peers & senior. Affective 3rd semester
Ethical principle
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Taking informed consent prior to Affective 3rd semester
examining patient.
Respects patient privacy while Affective 5th,6th semester
examining.
Maintains confidentiality about patient Affective 8th,9th semester
disease.
Acknowledges gaps in knowledge cognitive 8th,9th semester
&skills &take help from seniors if case
not clear.
Being polite &soft spoken. Affective 8th,9th semester
Not prescribing unnecessary drugs for Affective 8th,9th semester
personal benefit.
Not writing unnecessary investigations. Affective 8th,9th semester
Not taking favors from pharmaceutical Affective Life long
company.
To continue further-
At the end graduate would have acquired the following competencies-
x Form good Doctor-patient relation demonstrating sensitivity responsiveness.

x Demonstrates respect, compassion, accountability, Dependability & integrity when interacting with
peers, interpersonal healthcare providers, patients &families.
x Will be responsive to the needs of patients and society.
x Practices ethically with integrity, including maintaining patient confidentiality taking appropriate
informed consent& responding to medical errors.

1) The milestone described as 'A medical graduate should show proper respect on asking the patient to
expose the areas to be examined' should go under affective domain, rather than psychomotor as
mentioned. Another comment came that this could also include cognition because the student
should know which areas need examination.
2) The matrix is nicely thought out - very detailed and includes all aspects of professionalism in
dealing with a patient. Some specific concerns are:
a) It might be better to broaden the scope to 'demonstrate professionalism in dealing with patient
in OPD' rather than just respect. I say this because your milestones encompass many important
professionalism issues - like coming on time, dressing well, privacy, confidentiality etc
57 | P a g e
b) There is a lot of overlap in domains (this is usually the case because we cannot reasonably
isolate domains) - this could be reflected in the milestones. For example, not writing
unnecessary drugs or investigations, washes hands, takes informed consent etc will involve
both cognitive and affective domains. It is important to know which domain is involved
because then interventions and assessments can be appropriately designed.
58 | P a g e
Thread 4 (Part B):
Group work on designing the teaching-learning activities for the
decided competency
Dear All,
The group dynamics has come into play and team spirit is shining through. A very comprehensive plan
provided by all the groups, that too in such a short time, so congratulations to all for a job well done.
And I am sure all will agree that this task has put a lot of areas of CBME into perspective.
So continuing with our learning objectives in mind Dr. Innovative has yet another innovative group
activity in store for us all.
The same groups shall continue.
- Design the teaching & learning methods for teaching the competencies.
(All groups to work on the same competency they have already identified).
All intra-group discussions to be carried out on the sub-thread.
All groups will then present it on the common thread for discussion on 22nd March by 9:00AM.
Warm Regards,
Team Vibgyor Moderator -Swapnil (2015)
59 | P a g e
The group started discussing about various methods for acquisition of knowledge, skills and attitudes.
For knowledge they suggested lectures with integrated approach, interactive learning, problem based
learning, small group discussions, FGDs, seminars and case scenario based discussion.
For skills, they discussed about video demonstrations, demonstrations by faculty members,
standardized patient based teaching, simulation using mannequins, computer based teaching with self-
instructional manual and DOPS.
For attitude, role modeling and supervision by seniors, lectures with role-plays, simulated case
scenarios and on-job training were suggested. Supervised communication of students/internees with
the patient/his family members on the matters of taking consent or explaining the procedure with its
necessity for making diagnosis would have to be planned.
A suggestion came up that while planning the T-L methods, milestones would also have to be kept in
mind. Hence tutorials could be added. Then a query came up whether OSCE could be used as
formative assessment to enhance learning. Faculty guidance came in and it was clarified that in order
use OSCE as a learning tool, time must be built for a group or a one-one feedback. Meanwhile an
opinion came that skills could be attained only by practice, so simulation was a must and hence a skills
lab/simulation lab would be ideal. Now the team was ready to propose these teaching-learning methods
in the context of performing lumbar puncture, and decide the time-frames. The tem thought that surface
marking for defining the right intervertebral disc space should ideally be taught in the Dissection Hall
at the point of first contact of student with a human body. The team then brainstormed on the ethical
issue of whether Lumbar Puncture could be performed independently earlier or only after internship.
Then it was added that maintaining asepsis must be included in the cognitive and psychomotor domain.
Finally, incorporating all these suggestion, the team decided that the students would first observe others
performing LP during ward posting, and then perform it with and without supervision successively.
Their final submission was as follows:-
Final Submission:
Competency: Performing Lumbar puncture
60 | P a g e
Matrix showing components of competency and relevant T-L methods:
1. Components of Domains 1st 2nd 3rd Internshi T-L tools
competency Pro Pro Pro p
f f f
2. Knows about Cognitive X Interactive lecture
spinal cord and
vertebral column
3. Knows about Cognitive X Focused group
site of lumbar discussion/Small
puncture group discussion
4. Knows about Cognitive X
physiology of Tutorials
CSF formation x
5. Knows about Cognitive Problem based
organism learning followed
causing CNS x by seminar at the
infection end.
6. Knows about Cognitive x
handling and
transportation of
collected CSF
7. knows about Cognitive
interpretation of
findings of CSF
examination
8. Knows about
indication and
contraindication
of Lumbar
puncture
1. Learns the Psychomotor/Cognitive X Demonstration by
procedure of simulation using
doing LP Mannequin
2. Learn about the Psychomotor/Cognitive X Video

instruments demonstration of
needed to LP
61 | P a g e
perform LP Practical
demonstration on
patients having LP
done
Case scenario
Demonstration of
LP set and other
required materials
in Ward teaching
1. Assist in Psychomotor X Demonstration of
performing LP LP by a faculty
member in a real
2. Learns the Affective X patient keeping
counseling skills trainee as assistant
3. Keeps aseptic Role play

environment Cognitive/Psychomotor X
throughout the Demonstration of
procedure LP by faculty
member
4. learns to Role modelling
collaborate with Affective X from faculty as an
staffs expert
5. Learns proper Role play from

interpersonal and Affective X faculty
interprofessional
behavior
1. Obtains Affective X 1. Direct

informed observation of
consent from the intern - while
patient communicatin
g with patient
62 | P a g e
2. Provides local Cognitive / Psychomotor X and families
analgesia followed by
corrective
3. Inserts LP Psychomotor X feedback
needle in the
spinal canal 2. Direct
observation of
4. Assesses CSF Psychomotor/Cognitive X intern while
pressure doing
procedure and
5. Collects CSF in Psychomotor/Cognitive X corrective
3 different sterile feedback
vials
6. Puts labels Psychomotor X

appropriately
and sends to the
lab.
X
7. Completes Cognitive/Psychomotor/Affecti
performing LP ve
with supervision
8. Counsels Cognitive/Affective X
patients and
family post
procedure.

1) We should do away with lectures for the cognitive component and replace it with small group
teachings. The team justified it by saying that interactive teaching as opposed to traditional
lecturing still had a role and therefore they had included it, in addition to small group teaching.
2) The T/L methods have been mentioned by linking with Bloom's domains and year in which the
particular component will be taught.
63 | P a g e
Brick Red Group:

The team started by adding various teaching-learning methods to the Google doc. They also thought it
would be good if the reasons behind choosing a particular method could be mentioned. A suggestion
came up to write T/L methods under separate headings of cognitive aspects of informed consent
(independent learning and interactive learning in seminars and small group discussions) and informed
consent in a clinical context (Role modeling, faculty mentors, formative feedback sessions, narratives,
chart-simulated recall, bedside teaching, grand rounds, role-plays and video demonstrations). With
these separate headings, a doubt came up that the team was not mentioning psychomotor and affective
ȵɀȾȲȺȿɄȘȽɅȶɃȿȲɅȺɇȶȽɊɅȹȶȹȶȲȵȺȿȸɄɀȷɅȶȲȴȹȺȿȸȺȿȿɀȿ-ȴȽȺȿȺȴȲȽȲȿȵȴȽȺȿȺȴȲȽɄȶɅɅȺȿȸɄȴɀɆȽȵȳȶɆɄȶȵ
Then a practical query came up, whether so many T/L methods were really needed to teach informed
consent; and whether it would be feasible to execute them. Also, the hidden curriculum would play its
own role. Then it was clarified that informed consent would not be taught in isolation; first the
foundation of communication and interpersonal skills would be laid down, built upon by respect,
empathy, accountability and so on.. Finally, the team submitted their teaching-learning plan as follows:
Final Submission:
Setting: inpatient / routine admission
Milestones
Level one Level two Level three Level four Level five (expert)
(novice) (Advanced (Competent) (Proficient)
Beginner)
Knows why a Is able to seek Is able to seek Is able to seek Is able to seek consent
doctor must consent for consent for consent for complex for complex or
inform patient simple simple procedures including multiple procedures in
before a procedures like procedures as at those that have complicated scenarios
procedure IV line insertion milestone two ethical connotations (for example poly-
64 | P a g e
or incision and (for example trauma or medico-
Knows the drainage of Is able to abortion/organ legal cases) and
components of abscess after suggest options, donation) explain prognosis -
an informed establishing listing including death on
consent rapport with advantages and Is able to suggest table or death during
Communicates patient and disadvantages options, listing procedure
clearly in simple explaining need advantages and Is able to explain
language in simple is able to list disadvantages options and assist
Listens language and explain patients and relatives
attentively to the complications Is able to explain at arriving at a
patient lists some and describe prognosis; detail collaborative decision
Limits: common how they will complications; and making
Is not permitted complications be managed engage patients and
to ask for relatives in decision
consent for making
procedures
Teaching Learning Methods
Cognitive aspects of informed consent
Independent Independent Independent Independent Independent Learning

Learning Learning Learning Learning x Portfolio
x Reading x Reading x Reading x Portfolio x Interactive
assignments assignments assignments x Interactive Learning
x Portfolio x Portfolio x Portfolio Learning x Small Group
Interactive Interactive Interactive x Small Group Discussions
Learning Learning Learning Discussions
x Seminar x Seminar x Seminar
x Small x Small x Small
Group Group Group
Discussions Discussions Discussions
Informed Consent in Clinical Context
x Role x Role x Role x Role x Role modeling

modeling modeling modeling modeling x Faculty
65 | P a g e
x Bedside x Formative x Faculty x Faculty mentor
teaching feedback mentor mentor x Formative
x Role plays sessions x Formative x Formative feedback
x Video x Narratives feedback feedback sessions
demonstratio x Bedside sessions sessions x Narratives
n teaching x Narratives x Narratives x Chart
x Role plays x Chart x Chart stimulated
x Video stimulated stimulated recall
demonstrat recall recall x Bedside
ion x Bedside x Bedside teaching
teaching teaching x Grand rounds
x Role plays x Grand x Role plays
x Video rounds x Video
demonstrati x Role plays demonstration
on x Video
demonstratio
n

1) The listing of T-L methods in the form of a matrix is wonderful. However, towards the end of the
session for that particular milestone, the student should also be taught to design a "Written
Informed Consent Form" for the procedure. The problem today is a blanket or semi blanket consent
form that can often be often challenged in litigation. A clear consent form is essential to confirm
that all the required information has been provided to the patient and he has given his free and
voluntary consent for the same. This will induce high order thinking in the synthesize - create level.
2) Team Red has mentioned the TL methods by linking it with milestones (and not dividing it into
Bloom's domains explicitly) and year in which component will be taught/learnt.
66 | P a g e

The team started by commenting that professionalism and morality were the priority topics in modern
medicine, however there was a perceived ȽȲȴȼɀȷɃȶɄȺȵȶȿɅɄȺȿɅȶɃȶɄɅȲȿȵȷȲȴɆȽɅɊȶɉɁȶɃɅȺɄȶȭȲɃȺɀɆɄɈȲɊɄ
to teach this core competency would be narrative writing in clinical postings, video clips/ movies, role-
plays, biographies of great doctors, reflections, anecdotes or experiences of peer-group and faculty,
case-based discussions, development of practical wisdom (phronesis) and moral orientation seeping in
by actual patient interaction. A few members in the team opined that professionalism could not be
taught in a classroom with chalk and talk. It needed moral building exercises, role-plays, movie-clips,
narratives and group-discussions. It was added that during ward postings, students would see their
seniors and teachers who would serve as role-models, and students would learn from them. But then it
was decided to plan out the teaching-learning activities such that they would align with the
competencies expected to be achieved. Literature excerpts were shared regarding the teaching of
morality in academic science. It was noted that professionalism would be imbibed majorly through
hidden curricula. Another thought shared was that a bit of professionalism and ethics should be taught
right from school days. A suggestion came up to ponder over the concepts of explicated role modeling,
mindful practice and service learning while planning the teaching-learning methodology. The team
then started thinking of how to teach the desired competency, for e.g. the general principles of code of
conduct by a lecture, informed consent by role-plays and so on. Finally, the following submission was
done on the main thread by the team:
Final Submission:
ȫȹȶȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾȲȿȵȜɅȹȺȴɄ ȺȿȾȶȵȺȴȲȽȶȵɆȴȲɅȺɀȿȺɄɄɀȾȶɅȹȺȿȸɈȹȺȴȹȴɀɆȽȵ not be addressed
fully, in whichever be the method of teaching-learning. As there is never any defined curriculum for it,
ɃȲɅȹȶɃȺɅɃȶȾȲȺȿɄȹȺȵȵȶȿȺȿȶɇȶɃɊȴɆɃɃȺȴɆȽɆȾȠɅȿȶȶȵɄɅɀȳȶȺȾȳȺȳȶȵɃȲɅȹȶɃɅɀȳȶȽȶȲɃȿȶȵ
So after a brain-storming discussion on it, our group likes to suggest that the teaching-learning method
ȺȿȴɀȾɁȶɅȶȿȴɊȳȲɄȶȵȽȶȲɃȿȺȿȸȷɀɃɅȹȶɅȹȶȾȶɀȷȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾ ȜɅȹȺȴɄ ȴȲȿȳȶ Role model (where a
student observes the teachers, how passionately he/she behaves with the patient/ ɁȲɅȺȶȿɅɄɃȶȽȲɅȺɇȶɄɈȺɅȹ
earnest EMPATHY etc), Role play (with patient simulation, the artificial situation can be created and
students to made involved with it, followed by ɅȹȺȿȼɁȲȺɃȲȿȵɄȹȲɃȶ, where they are to requested to
come up with their feelings), Reflections & Narratives ȶɄɁȶȴȺȲȽȽɊɀȷɁȲɅȺȶȿɅɄɃȶȷȽȶȴɅȺɀȿɈȹȶɃȶȲ
patient is asked to narrate his/her own feelings from the behavior with the doctor), Moral-building
exercises (group-tasks; where specific tasks can be assigned to a group of students for some observable
and measurable jobs on ethical issues), Case based discussions etc.
67 | P a g e
1) Teaching Learning strategy submitted by team blue covers the affective domain and role model
with role play is the best way to teach it. A suggestion is that Reflections & Narratives (especially
ɀȷɁȲɅȺȶȿɅɄɃȶȷȽȶȴɅȺɀȿɈȹȶɃȶȲɁȲɅȺȶȿɅȺɄȲɄȼȶȵɅɀȿȲɃɃȲɅȶȹȺɄȹȶɃɀɈȿȷȶȶȽȺȿȸɄȷɃɀȾɅȹȶȳȶȹȲɇȺɀɃ
with the doctor): can better be used as an assessment tool not T-L tool.
It was clarified by the team that self -reflections and periodic narratives would give insights into
how we might develop students' learning experiences, facilitating their development of a doctor
identity that is more in line with desired requirements. And that is how it could be included as a
part of T-L Method.
2) With respect to professionalism and ethics nowadays there are issues of medical negligence, or
professional misconduct and plagiarism etc. which the student needs to 'know'. Hence there should
be scope for the cognitive component.
3) Team Blue mentioned the T/L methods without linking it to any other characteristics.
68 | P a g e
Thread 4 (Part C)
Group work on designing the assessment of the decided competency
Dear All,
Dr. Innovative is very pleased and motivated by the CBME modules being designed by the groups.
Moving on now to the final step of the group activity ȲɄɄȶɄɄȾȶȿɅȘɄɅȹȶɊɄȲɊȘɄɄȶɄɄȾȶȿɅȵɃȺɇȶɄ
ȽȶȲɃȿȺȿȸȠɅȺɄȲɇȶɃɊȺȾɁɀɃɅȲȿɅɅɀɀȽȷɀɃɄɆɁɁɀɃɅȺȿȸȲȿȵȺȾɁɃɀɇȺȿȸɄɅɆȵȶȿɅȽȶȲɃȿȺȿȸ
The same groups shall continue.
- Design the assessment tools for assessing the competency.
All intra-group discussions to be carried out on the sub-thread.
All groups will then present it on the common thread for discussion on 25th March by 9:00AM.
Warm Regards,
69 | P a g e

The discussion started with deciding the roles for the group dynamics and then they proceeded to adding
assessment methods in the already existing framework of the CBME curriculum. They added assessment
methods such as Rubrics in a scenario, demonstration on a mannequin, skill stations in an OSCE. They also
added a column on which domain they intended to test by which assessment method. The other participants
went on adding assessment methods such as written exam, viva, instrument based viva and 360 degree
assessment. However there was some doubt about OSCE, how exactly should it be used, and confusion
about multisource feedback being used to assess a lumbar puncture. The team agreed that it can be used,
especially to check for the affective domain.
A suggestion came up that video recording in skills lab during the learning phase of Lumbar puncture
would help in student assessment. It shall serve as a feedback tool for the learner as well as the assessor.
Since expertise would be a very important milestone here, the lab would act as a context based micro
system for such an assessment, to check on the expertise. However multiple assessments would be needed
in this setup before the student would be ready for a WPBA. The team then decided to concentrate on four
aspects i.e. the competencies, domains to be tested for the competency, assessment method for that
competency and rationale for the use of a given assessment method for a given competency. A doubt then
came up about the feasibility and the practicability of the assessments.
Then a thought from a of a study by Holmboe et al, 2010 was shared: "CBME further requires assessment
processes that are more continuous and frequent, criterion-based, developmental, work-based where
possible, use assessment methods and tools that meet minimum requirements for quality, use both
quantitative and qualitative measures and methods, and involve the wisdom of group process in making
judgments about trainee progress." After a small discussion on who should do counseling for the LP and
how it should be a done, and a little change in the order of the points stated, this is what the team finally
posted on the main thread:
Final Submission:
Competency: Performing Lumbar Puncture
70 | P a g e
Components of Domains T-L tools Assessment Summary of most feasible
competency methods methods for assessing
KNOWLEDGE
1.Knows about Cognitive Interactive lecture Continuous Assessment methods
spinal cord and assessment using during learning stage
vertebral column /PBL
Small group /seminar/tutorial / ȪɅɆȵȶȿɅɄɁɀɃɅȷɀȽȺɀ and
2. Knows about Cognitive discussion short answer maintenance of log book
site of lumbar questions shall help assess various
puncture milestones and shall form
Tutorials an important component
3.Knows about Cognitive of continuous internal
physiology of Problem based assessment.
CSF formation learning followed a It can form a basis for
by seminar at the Documentation of the
4. Knows about
Cognitive end. ȲɄɄȶɄɄɀɃɄȷȶȶȵȳȲȴȼ
organism causing
CNS infection
1.Knowledge can be
5. Knows about assessed using
handling and Cognitive PBL and tutorials
transportation of followed by written tests
collected CSF on all the components of
Competency.
6. Knows about small group discussions
interpretation of Cognitive can strengthen the
findings of CSF knowledge base and can
examination become platforms for
timely feedback and
7. Knows about corrective measures
indications and
contraindications
of Lumbar
puncture
SKILLS &
ATTITUDE
71 | P a g e
1. Learns the Psychomotor/ Demonstration of OSCE with one to
procedure of Cognitive LP by simulation one feedback (
doing LP using Mannequin/ checklist can be Skills can be assessed
Video, used) using OSCE initially and
standardized patients later
Demonstration on Ward leaving test
patients having LP in the skill lab OSCE can be the most
done comprehensive method to
2.Learns about Psychomotor/ assess skills attitudes and
the instruments Cognitive Case scenario knowledge using multiple
needed to stations like:
perform LP Demonstration of a) communication,
LP set and other b) Handling of
required materials CSF/Labelling of
in Ward teaching Samples/aseptic
precautions/procedure c)
3.Assists in Psychomotor Demonstration of Direct observation Arranging for logistics for
performing LP LP by a faculty during assisting the procedure.
member in a real for procedure
4. Learns the patient keeping Linked stations can be
counseling skills Affective trainee as assistant used to find out about
related factual knowledge.
5. maintains Cognitive/ Role play
asepsis Psychomotor 2.Standardized patients
Demonstration of Assess the can be good for
6.learns to Affective LP by faculty counseling and assessing attitudes and
collaborate member communicating issues like
with staff Role modelling skills at an OSCE Communication
from faculty as an station. (counseling skills) and
7.Learns proper expert informed consent.
interpersonal and Affective
inter- Role play from
professional faculty
behavior
Assessment methods
8,.Obtains Affective 1.Direct DOPS and grade
when student becomes an
informed consent observation of it
independent performer
from the patient intern - while
and works with a real
communicating
patient can be by WPBA
72 | P a g e
9. Gives local Cognitive / with patient and 360degree evaluation
anaesthesia Psychomotor followed by
effectively corrective
feedback(DOPS) 1.Workplace based
10. Inserts LP Psychomotor assessments can be used
needle in the at the stage when student
spinal canal is ready for performing
Psychomotor/ the task independently on
11. Assesses CSF Cognitive 1.Direct real patients by
pressure observation of a. Direct observation
intern while doing during assisting for
12. Collects CSF
Psychomotor/ procedure and procedure for skills and
in 3 different corrective feedback
Cognitive expertise
sterile vials
13. Adequately Cognitive/ b. Attitudes can be

labels the CSF Psychomotor/ assessed using
sample and sends Affective 360 degree evaluation-
to the lab. accompanied by frequent
feedbacks to students-
14. Counsels Affective Multisource feedback
patients and from peers, staffs,
family supervisors and patients
post procedure. are useful methods of
evaluation

1) It was wonderful reading the exhaustive and nicely explained matrix for lumbar puncture. However I
would like to know, whether Portfolios and log book maintenance mean the same or are different. Can
portfolio building be started from the initial learning stage or it is appropriate to introduce at some other
stage. This was clarified as in the form of an equation 'logbook + reflection = Portfolio'; and that it could be
incorporated early in a training/ residency program. An article on portfolio based learning and assessment
was also shared.
73 | P a g e
Brick Red Group:

The team started off with various assessment methods for the cognitive domain such as pre- and post-
testing of knowledge, Self-reported confidence survey in specific areas, standardized written or oral
exams, attendance records and portfolio documentation of discussion, faculty led chart stimulated recall
exercise and resident self-reflection with chart audit, and resident portfolios. Work-place based assessment
was then added to the list. Then, a point was made that the assessment tools required would need to be very
well thought of and meticulously planned to ensure the competency rather than mere passing of an exam.
Some key features and characteristics of effective quality assessment in CBME were shared such as
-Should be continuous and regular, Conform to minimal quality standards at least, WPBA are very
important and Active engagement of trainee is a must. Few more assessment methods were added, to be
done in the clinical context, such as global evaluation forms, patient satisfaction surveys, direct
observation, critical incident techniques or sentinel event marȼȶɃɄɁɀɃɅȷɀȽȺɀȩȶɄȺȵȶȿɅȲɄɅȶȲȴȹȶɃ
programs and longitudinal tracking of residents for critical events.
The team then discussed about using role-plays with simulates patients and check-lists as an assessment
tool. Then they thought of how they would assess professionalism while performing the procedure, and the
usefulness and limitations of the global evaluation form in doing so. Then one of the team-members
suggested that they should divide the assessments into formative and summative and also go along with the
mile-stones. Here a brainstorming took place on whether formative or summative assessments were more
important in CBME, and finally it got clear with the discussions that since CBME was not time-bound, and
the main aim was to achieve the competency, assessments would by and large be formative. Resources
were shared and discussed to throw more light on this. While adding assessments as per mile-stones,
another question came up that what assessment could be done at the expert level? Then they thought of
including patient feedback forms and hospital satisfaction surveys.
ȘȷɅȶɃɄȹȲɃȺȿȸɅȹȶɄȶȽȺȿȶɄȷɃɀȾȲȿȲɃɅȺȴȽȶɀȿȫȹȶɃɀȽȶɀȷȲɄɄȶɄɄȾȶȿɅȺȿȚșȤȜȘ competency-based
education program emphasizes formative over summative assessment. This is not to say that summative
assessment is unimportant; indeed, the medical education community has a professional obligation to the
public to ensure that its trainees are ultimately competent for unsupervised practice. Work-based
assessment is an essential component of CBME, especially given the greater need for formative assessment
and fȶȶȵȳȲȴȼ ; the team submitted their final plan on the main thread as follows:
74 | P a g e
Final Submission:
Setting: inpatient/routine admission
Milestones
Level one (novice) Level two Level three Level four Level five (expert)
(Advanced (Competent) (Proficient)
Beginner)
Knows why a Is able to seek Is able to seek Is able to seek Is able to seek
doctor must inform consent for simple consent for simple consent for consent for complex
patient before a procedures like IV procedures as at complex or multiple
procedure line insertion or milestone two procedures procedures in
incision and including those complicated
drainage of abscess that have ethical scenarios (for
after establishing connotations example polytrauma
Knows the rapport with Is able to suggest (for example or medico-legal
components of an patient and options, listing abortion/organ cases) and explain
informed consent explaining need in advantages and donation) prognosis -
simple language disadvantages including death on
Communicates Is able to table or death
clearly in simple suggest options, during procedure
language listing
Lists some Is able to list and
advantages and Is able to explain
Listens attentively common explain
disadvantages options and assist
to the patient complications complications and
patients and
describe how they Is able to
Limits relatives at arriving
will be managed explain at a collaborative
Is not permitted to prognosis; detail decision making
ask for consent for complications;
procedures and engage
patients and
75 | P a g e
relatives in
decision making
Teaching Learning Methods
Cognitive aspects of informed consent
Independent Independent Independent Independent Independent

Learning Learning Learning Learning Learning
x Reading x Reading x Reading x Portfolio x Portfolio

assignments assignments assignments x Interactive x Interactive
x Portfolio x Portfolio x Portfolio Learning Learning
x Interactive x Interactive x Interactive x Small Group x Small Group
Learning Learning Learning Discussions Discussions
x Seminar x Seminar x Seminar
x Small Group x Small Group x Small Group
Discussions Discussions Discussions
Informed Consent in Clinical Context
x Role modeling x Role x Role modeling x Role x Role modeling

x Bedside modeling x Faculty modeling x Faculty mentor
teaching x feedback mentor x Faculty x Feedback
x Role plays sessions x Feedback mentor sessions
x Video x Narratives sessions x Feedback x Narratives
demonstration x Bedside x Narratives sessions x Chart stimulated
teaching x Chart x Narratives recall
x Role plays stimulated x Chart x Bedside
x Video recall stimulated teaching
demonstration x Bedside recall x Grand rounds
teaching x Bedside x Role plays
x Role plays teaching x Video
x Video x Grand rounds demonstration
demonstration x Role plays
x Video
demonstration
Assessment methods*
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Peer feedback; Verbal/written Direct observation assessment Resident as teacher
faculty feedback; feedbacks from ; OSCE ; Patient programs; Portfolio;
before and after faculty and Verbal/written satisfaction mini-CEX (WPBA),
evaluations, case standardized feedbacks; survey;
based discussion patients regarding VOSCE, Case Critical
informed consent based discussion; incident
Case based peer assessments, techniques, Self assessment,
discussion narratives Peer patient satisfaction
assessments survey.
Best case
videotapes
WPBA:
Global
evaluation;
mini-CEX
*Note that formative assessment is the cornerstone of assessment in a competency based education
system.

1) Wonderful compilations of TL & Assessment during CBME. As you know; one of the important
attributes of CBME is flexibility in learning to achieve the competency. Can any group reflect this within
their assessment strategy?
The Team Brick Red clarified this by saying that we should include Self-assessment at all levels of the
time-line and if the student feels incompetent in any of the domains (cognitive, psycho motor or affective),
he should have the freedom to choose the related assessment during any time-line. For example: If a post-
graduate student feels that he is not competent in communication, he can prepare himself for an assessment
in that area.
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Team Turquoise Blue:

The discussion started with the idea that for assessing professionalism, peer assessments and patient
assessments were important but, most important would be 360 degree assessment with real or simulated
scenarios. It was clarified that Workplace based assessment was always in a real life scenario. It would test
ɅȹȶȵɀȶɄɁȲɃɅɀȷɅȹȶȤȺȽȽȶɃɄɁɊɃȲȾȺȵȭȲɃȺɀɆɄɅɊɁȶɄɀȷȮȧșȘɈȶɃȶȵȺɄȴɆɄɄȶȵȦȿȶɅȶȲȾ-member felt
ɅȹȲɅɁȲɅȺȶȿɅɄȷȶȶȵȳȲȴȼɈɀɆȽȵȳȶɇȶɃɊȸɃɀɄɄȲȿȵɄɆȳȻȶȴɅȺɇȶɈȺɅȹȽɀɅɄɀȷȳȺȲɄȶɄȟɀɈȴɀɆȽȵɅhey be used? It
was then put across that patient feedback was a very important part of 360 degree assessment. Ultimately,
better medical education should translate into better health care; so, the importance of patients' feedback
could never be overemphasized. The reliability of such assessments could be enhanced by using multiple
feedbacks, by multiple patients in multiple settings. After this clarification, one team member shared the
ȞȤȚɂɆȶɄɅȺɀȿȿȲȺɃȶɅɀɅȲȼȶɁȲɅȺȶȿɅɄȷȶȶȵȳȲȴȼȠɅɈȲɄɄȹȲɃȶȵȺȿɅȹȶȸɃɀɆɁ that the performance of a doctor
in the U.S. would be judged by peer assessments and based on criteria such as length of a patient stay in the
hospital, 30 day re-ȲȵȾȺɄɄȺɀȿȾɀɃɅȲȽȺɅɊȴɀȾɁȽȺȴȲɅȺɀȿɄȴɀɄɅɁȶɃȴȲɄȶȲȿȵɁȲɅȺȶȿɅɄȷȶȶȵȳȲȴȼȘȿȲɃɅȺȴȽȶ
was then shared in the group, t hat described the perception of patients and co-relates with the socio-
demographic profile. ȝȺȿȲȽȽɊɅȹȶɅȶȲȾȲȸɃȶȶȵɅȹȲɅɁȲɅȺȶȿɅɄȷȶȶȵȳȲȴȼȴɀɆȽȵȳȶɆɄȶȵ
Later, it was noted that workplace based assessment was just one way of assessing; that would be done
probably during internship or later. What about undergraduate level, at each step while they were building
the competency. Also the team thought about the validity, reliability, feasibility, relevance and educational
impact of each assessment. Various WPBA methods were then enumerated: Mini CEX, case based
discussion, chart-stimulated recall, direct observation of procedural skills and multi-source feedback. Then
it was decided to align the assessment methods with each level on ɅȹȶȤȺȽȽȶɃɄɁɊɃȲȾȺȵȠɅɈȲɄɅȹȶȿȲȵȵȶȵ
that reflections and portfolios were an essential component in teaching and evaluating professionalism.
Also, narratives written by students reflecting their behavior-in real life stories of dealing with patients &
narratives on critical incident (or sentinel events) , when assessed qualitatively by experts and used for
formative assessment could be a useful tool. Then a resource material was shared on teaching and
assessment of professionalism in the Indian context aȿȵɇȲɃȺɀɆɄɅɀɀȽɄȲɅȶȲȴȹȽȶɇȶȽɀȷɅȹȶȤȺȽȽȶɃɄɁɊɃȲȾȺȵ
were noted, including the Professionalism mini-evaluation exercise. The final submission of the team was
as follows:
Final Submission:
ȘɄɄȶɄɄȺȿȸȧɃɀȷȶɄɄȺɀȿȲȽȺɄȾȲȿȵȜɅȹȺȴɄ ȺɄȲȴȹȲȽȽȶȿȸȺȿȸɅȲɄȼȲɄthere is no defined expected behavior of a
medical graduate; professional qualities have to be assessed by multiple methods and multiple assessors
like peers, patients, faculty and also self-assessments. No single method can aptly assess all the skills.
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Hence the assessment methods are in alignment with the Miller's Pyramid.
1. Knows: Multiple Choice Questions (MCQ)/ Short Answer Questions (SAQ)/ Vignettes with
professional conflicts
2. Knows how: Reflective/narrative portfolio, Case based discussion, Narratives written by students
reflecting their behavior-in real life stories of dealing with patients. Narratives could be part of a portfolio
by students. Indeed, reflection is an important component of teaching and assessing professionalism
3. Shows: Observed real or standardized patient encounter (m-CEX; PMEX -Professionalism mini
evaluation exercise); OSCE
4. Does: Multi Source Feedback (MSF) or 360 degree assessment (from multiple sources)
The perception of patients through a questionnaire. Patient feedback is a very important part of 360 degree
assessment. Ultimately, better medical education should translate into better health care. Hence the
importance of patients' feedback can never be overemphasized. The reliability of such assessments can be
enhanced by using multiple feedbacks, by multiple patients in multiple settings.
Workplace based assessment in a real life scenario or simulated scenario
There are various types of WPBA:
a) Direct observation such as Mini CEX, DOPS
b) Multisource or 360 degree feedback such as the peer assessment tool or patient feedback.
c) Record of clinical work: such as logbooks.
· Critical incident reports; Narratives on Critical incident, when assessed qualitatively by experts
Incident reports, in which faculty document notable professional or unprofessional incidents ("sentinel
events") that they observe in trainees.

1) A doubt was raised whether Mini-CEX could be used as a tool to assess Professionalism and Ethics.
It was clarified that Mini CEX could be used to assess professionalism. Depending on the setting,
context and the purpose of the exercise, any one or more of the following could be a focus of the Mini
CEX.: Interview skills, examination skills, communication skills, clinical judgment, and consideration
for patient/professionalism, organization/efficiency and overall clinical competence. A very important
aspect of using the tool was, to provide feedback: what was done well, and what could be done better.
Also, the student's own evaluation and reflection on his/her performance would be a part of this.
2) The assessment methods have been listed along with Miller's pyramid levels. The team has
probably thought of a graded use of the assessment methods based on the level of proficiency of the
candidate.
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Thread 5:
Discussion on challenges in implementing CBME and the future of
CBME
Dear All,
Dr Innovative has presented the very comprehensive modules crafted by the groups to the Dean. Dr
Established gives a pat on the back to Dr Innovative and invites the MEU team to his office for a
meeting. He would like to take this opportunity to applaud the team members for the hard work put in
by all.
It all started with a 2 minute elevator talk, which was followed by a heated debate between Team
CHANGE & PRESERVE. As the teams reached a consensus to develop CBME modules, they joined
hands to discuss and plan a CBME curriculum. The team work displayed by the groups during the
preparation of the modules has been inspirational to Dr Established & Dr Innovative. They are both
highly hopeful and optimistic now.
Dr Established would like the faculty members to discuss:
- The CHALLENGES faced while designing the CBME module; and the challenges likely to be faced
while implementing these modules.
- The FUTURE of CBME.
All have 3 days (26-28th March) to put forth their views.

Warm Regards,
Contributors:
26th March: Vanita, Juhi, Purnima, Amir, Hem, Shuchi
27th March: Kavita, Shuchi, Sanjoy, Bharti, Juhi, Amir
28th March: Hironmoy, Purnima, Mohit, Kavita, Gokul, Sumanth, Shuchi, Upreet, Snajoy, Soum,
Hem, Gagan, Amir, Sanjoy, Abhijit,
29th March: Clarence, Vijay.
30th March: Sukhinder
31st March: Kavita, Dixit, Gita
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The following discussion took place on this thread:
Challenges in implementing CBME:
The following views were expressed regarding the challenges in implementing CBME:-
1) While applying the CBME curricula, we have to be cautious about its appropriateness. If applied
inappropriately, it can result in demonization and reduction in the educational content. We should
be able to validate its robustness. We should be cautious in applying CBME approach universally:
unless robustly designed /defined higher order of incompetence may result. Occupational
role should be sharply defined. Danger of narrowly or detailed designed CMBE will dominate the
curriculum which may not be suitable for higher education. The checklists approach and passing
and failing candidates could prove superficial and demotivating as it would encourage trainees to
do the right things to pass rather than think critically and excel.
2) Care should be taken while administering OSPEs that it is not a break of an MCQ question. The
meaning of OSPE should be fulfilled. It should be free from political views because it can allow
the Government to influence what is included as important competencies & allocate
resources based on outcomes of the performance. As CBME is not universal and value free, people
who use it shape its meaning. So care should be taken for this too. There should not be person to
person variation in its implementation and interpretation. There is a high lurking fear/ risk that
ȾȶȵȺȴȲȽȶȵɆȴȲɅȺɀȿ ȾȲɊȸȺɇȶɈȲɊɅɀȾȶȵȺȴȲȽɅɃȲȺȿȺȿȸ ȟȲɄɅɀ be resolved before anything apart
from the mainstream is initiated.
3) Some of the challenges are doing a needs assessment, curriculum planning, and getting
administrative support at the institutional level. Lack of trained faculty, planning of logistics such
as skills labs/ modules and modification of teaching-learning and assessment methods would also
be a challenge.
4) In CBME our approach is holistic; we have to keep in mind the various sub- competencies
expected to be attained by the learner during the progress of the course. Therefore, designing
modules considering all factors will not just be brain wrecking but also time consuming. Moreover
if we if we consider flexibility of CBME then the T-L methods and methods of assessment should
be tailored according to the needs of individual student who , we understand, learn differently.
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5) A lack of clarity in the concepts, difficulty in imagining a curriculum that is not limited by time at
all , understanding new teaching-learning and assessment methods which are not frequently used in
our current teaching, no direct support in the immediate environment, competencies relevant in our
context not clearly defined are some of the challenges.
6) It is not easy to develop competency based medical education curriculum. Faculty needs training
for it. The major challenge is the inadequate number of experts in education for medical/public
health/health care organizations and health systems, which has affected the process of
implementation
7) Several of the institutions which have been using teacher centered approaches have had challenges
of introducing innovative, learner centered approaches. The challenge of developing relevant tools
for monitoring and evaluating the implementation of CBME as well as assessment tools for the
learner competencies would be a challenge. Although OSCE, direct student observation and
Portfolio have been identified as methods of assessing student learning of competencies, some of
the medical schools still have a challenge in implementing these methods.
8) Implementing competency-based education requires that curriculum time is reserved for activities
that facilitate competency development. As more time is allocated to the development of
competencies, less time will be devoted to other curricular activities.
9) There are many challenges in designing the CBME curriculum, starting with selection of
competencies, sub-competencies ( differences of opinion in defining them), TL methods,
milestones for each competence and assessments aligned to these milestones and T-L Methods
10) In CBE, even the student's role is changed. Students must have a willingness to join with teachers
in thoughtful discussion, should accept the personal responsibility for learning, and be ready for
frequent assessment.
11) It will take a long time to effect a transition from the present to a completely Competency based
curriculum, because the very concept of CBME is so new and so different that it will require a lot
of understanding to even motivate support. Only a small fraction of faculty really has a basic idea
about the concept. There is a requirement to train all the faculty in these concepts so as to motivate
them accept after critically reflecting on what they have learnt about a CBME system.
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12) The basic challenge to implement CBME is that it does not specify particular learning strategies or
formats, but rather provides a clear description of intended outcomes. With this outcome based
approach, authentic curricula for medical practice could be designed but at the same time this task
requires dedicated time and faculty. The implementation of CBME in undergraduate education
further poses challenges for student assessment practices, teacher preparation, and systemic
institutional change, all of which have implications for student learning.
13) Designing the assessments would be a major challenge with CBME implementation. If the
assessment methods are not diligently and thoughtfully designed, then it can be disastrous.
A very careful planning will have to be done.
14) To ensure a reasonable pace of implementation would be a challenge. Step wise approach should
be used for implementation, so that the problems can be modified early in the course of
implementation. Too swift a pace can hamper the process. A very sound planning is needed.
15) Module development will be time consuming and shall need expertise and very sound knowledge
about the subject. Bringing uniformity across the Nation will be a mammoth task and also the most
essential to keep entire nation together, otherwise all efforts will go waste and medical services will
suffer. Deciding what needs to be changed and all that which needs to be retained would be another
challenge. The sole purpose is to improve the defects in system rather than changing it altogether.
16) Resistance to change: Ȯȶ produce doctors of international standards, so we do not need this.
There is no additional benefit, just added complications!ȠɅɈɀɆȽȵȳȶtime consuming. Resistance
to faculty development ȘɃȶ we running this medical college to train students or train medical
faculty? We did not hire them to train them. If they are eligible to be a faculty, then that's it. We do
not need anything extra from ɅȹȶȾȠɅȾȲɊȿȶȶȵȶɉɅɃȲɃȶɄɀɆɃȴȶɄȲȿȵɅȹȲɅȲȸȲȺȿɈɀɆȽȵȳȶȲ
challenge.
17) Not having a functional MEU and the decision of who would take the lead would be a challenge.
Having to do team work when colleagues do not get along very well and the requirement of
proficiency in English may be additional challenges. Also, the faculty may feel overwhelmed by
having to change almost everything: all the current teaching-learning styles and assessment styles.
18) Being answerable to the university and the question of who will take the responsibility if some
teacher/student/parent/ NGO would go to the court against this, may be a perceived challenge. All
the Universities (The VCs, the Registrars, the Exam Controllers, the Board-of-study members etc.),
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the senior faculties and chair-persons of the Departments (like the HODs) are not sensitized on the
fact of CBME. Even lots of them have never heard the term. So it is very tough for a junior (who
has the ignition and motivation) to make them sensitized and motivated for competency-based
learning.
19) The framing, executing and assessing of the competencies are time-taking and itself requires
competent-cum-sensitized faculties. The motivation for gathering and implementing certain
changes of any faculty often gets masked, when s/he faces some hindrance from the chair-holders,
instead of any praise or appreciations- it needs the Government policies (whether State of Central)
to be rectified.
20) Lack of trained faculties, lack of team approach due to less number of staff, lack of dedication and
motivation in existing staff, resistance to change, lot of integration vertically as well horizontally
might interfere, might take major time and defeat the basic purpose. Intense level of involvement
by everyone is not assured. Clinical departments would find it difficult due to major burden of
patient care. Regulatory body may not provide necessary guidelines and required importance
Bias may come in as there may be a different curriculum in different institutes
21) The students may find it difficult to get oriented to CBME, there may be a discrepancy in
objectives and outcome, a lack of uniformity at national and international levels, validity and
reliability may be questionable due to variable content and structure, may need continuous
rescheduling, might create frustration among staff and students.
22) There is a mammoth task ahead to train/sensitize all the faculty members to CBME, the check lists
for various competencies needs to be prepared and standardized. With the present scenario of post
graduate entrance exams, our students might not show any interest to develop their portfolio, as
formative assessments do not have any place in PG selection. If formative assessments are given a
weight-age during the PG selection, it can be misused easily. The concept of self directed learning
or directed self learning more suits a mature student rather than a teenager who enters the course at
18 years. If we tell a student that these are the list of competencies he has to learn, the student tends
to understand that other procedures are 'not important'. To motivate a student to learn for the sake
of learning and not for the sake of exam is greatest challenge. The infrastructure (number of
student-faculty ratio, facilities for assessment during any time line, additional skill labs) needs
for CBME implementation can shoot the cost of course much higher. This will be a definite
challenge to run a private medical college.
23) A few excerpts from an article were shares to highlight the challenges: Thomas Pellegrino, M.D.,
associate dean for medical education at Eastern Virginia Medical School, said,
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ȮȶȲɃȶɈɃȶɄɅȽȺȿȸɈȺɅȹȺɅȻɆɄɅȽȺȼȶȶɇȶɃɊɀȿȶȶȽɄȶȫȹȶȴȹȲȽȽȶȿȸȶȺɄȿɀɅɄɀȾɆȴȹȲȴȴȶɁɅȺȿȸɅȹȶ
concept, which we think is great, but figuring out how to make it work. Where do we teach? How
do we evaluate performance? How do we remediate students who have not met requirements? The
challenge is to measure the impact of training in terms of improved patient care, and to assess the
extent to which a physician is a self-diɃȶȴɅȶȵɃȶȷȽȶȴɅȺɇȶɅȹȺȿȼȶɃ
24) The challenges faced while designing the CBME module were: comprehending exactly what
Competency referred to; and how it differed from EPA, if at all; and where the milestones fit in;
and how we were to integrate KSA into it; also, what 'competency domains' were as opposed to
'competencies'. It is anticipated that this is exactly how teachers all over the country are going to
react when introduced to CBME for the first time.
25) The challenges likely to be faced while implementing these modules would be convincing the
stakeholders, capacity building, consensus building, motivating students into becoming self-
directed learners and formulating and using appropriate assessment methods
26) Another challenge for us would be to change current model of continuing professional
development into Competency based- Continuing professional development (CPD) model.
Competence is traditionally viewed as the attainment of a static set of attributes rather than a
dynamic process in whiȴȹɁȹɊɄȺȴȺȲȿɄȴɀȿɅȺȿɆɀɆɄȽɊɆɄȶɅȹȶȺɃɁɃȲȴɅȺȴȶȶɉɁȶɃȺȶȿȴȶɄɅɀɁɃɀȸɃȶɄɄȺȿ
ȴɀȾɁȶɅȶȿȴȶɅɀɈȲɃȵɅȹȶȲɅɅȲȺȿȾȶȿɅɀȷȶɉɁȶɃɅȺɄȶȮȶȿȶȶȵɅɀȶȵɆȴȲɅȶɀɆɃȷȲȴɆȽɅȺȶɄȲȳɀɆɅ
competency based- CPD model.
27) Making a module for CBME or implementation of it in our set up is a real problem at this juncture.
Challenges are multifaceted, right from convincing the stakeholders like faculties, administrators,
students, the policy makers to lack of adequate manpower. Then, on the ground of technical issues
Also, there are several challenges starting from identifying the core competencies then to design
the appropriate assessment methods. Another issue of concern is the time flexibility which
definitely is not going to be taken so easily by the stakeholders. We definitely need more
collaborative research to address the major challenges in assessment and also to find out easy ways
of training our faculties for the changed system.
28) The expectation of the community is no longer for a competent "basic" doctor but now for a
specialist. So should CBME be for specialties first followed by the medical students. ? This may
give it more acceptance and help allay the fears and apprehensions of the faculty. This would also
increase the pool of trained and motivated faculty for CBME. Unless the assessment is changed
efforts will be futile. So universities need to change that first or in tandem with
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CBME implementation. Another thing to keep in mind is Intergenerational learning. Each
generation has different expectations and approaches.
29) Although learners will have more freedom to decide how to learn in a CBME model, they may
have less freedom in deciding what to learn as competencies become codified. CBME presents
challenges in the areas of the teaching and learning process, the feasibility of implementation, and
issues around assessment. ȫȹȶɃȶȺɄɁɀɅȶȿɅȺȲȽȷɀɃȾȺɄɄȺȿȸȹȺȵȵȶȿ ȴɀȾɁȶɅȶȿȴȺȶɄȲȿȵȿɀɅȸȲȺȿȺȿȸɅȹȶ
maturation into a professional identity which come from time spent seeing patients. Also
the CBME is said to be overly concerned with training to meet a threshold minimum level of
competency and not with promoting excellence. In an effort to address the challenges of defining
and assessing competencies, some have resorted to breaking them down into the smallest
observable units of behavior, creating endless nested lists of abilities that frustrate learners and
teachers alike.
30) A pure CBME approach is inherently utilitarian, and proposes cutting content and experiences that
do not directly contribute to defined program outcomes. This can be unacceptable to some
stakeholders in the profession. Adopting CBME on a larger scale would require new teaching
techniques, new modules, and new assessment tools to be practical and effective. Adopting
a CBME approach would require significant investments in teaching, infrastructure and
assessment, and perhaps even an augmented workforce.
31) Lack of awareness /sensitization among all medical teachers and administrators, Lack of initiative
/motivation among all faculty members. The system is resource intensive in terms of various
logistical requirements. It needs meticulous planning and execution. It will need integration and
consensus among the 1st, 2nd, 3rd and 4th professional subjects. It will need training in TL and
assessment methods.
The Future of CBME:

The group further discussed how to overcome the various challenges and what to do in the future in
order to implement CBME. On these lines, the following thoughts were shared about the future of
CBME on the thread:
1) The Institutes &Universities partners must bring on board more experts in medical education and
health systems management such us the World Health Organization (WHO), and strengthen the
partnerships with international universities and institutions for faculty development and building
ȽɀȴȲȽȴȲɁȲȴȺɅɊȺȿȹȶȲȽɅȹɁɃɀȷȶɄɄȺɀȿɄȶȵɆȴȲɅȺɀȿ.
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2) Faculty development is identified as a strategy for addressing most of challenges. All the
stakeholders shall have to be engaged in order to ensure a smooth implementation of CBME in the
future.
3) COBES (community based education and service ) programme provides an opportunity for
students to learn vital competencies like population health, leadership and Management skills,
professionalism and ethical practice in a real contextual environment where they are likely to work
upon graduation. Key lessons learnt are institutional collaboration, involvement, empowerment
and engagement of all stakeholders. Such an approach could be one way of initiating and sustaining
changes in medical education.
4) First of all, each faculty should participate in faculty development program for CBME. Once we
have good number of trained faculty at our institution, we can bring reforms in CBME. Only
motivated faculty can bring change. We all must have faced some sort of resistance while
persuading for the change at our place. Force field analysis and people chart analysis is really
helpful. One important role of faculty is to motivate others and form a proactive group.
5) The role of medical teacher is going to be extensive in evaluating students for CBME. We will
have to have a major shift in the knowledge, attitude and practice of all medical teachers. Teacher
training and re-training for the same is required. ȘɄȵȶɄȴɃȺȳȶȵȺȿȮȟȦȾȲȿɆȲȽɀȿȚɀȾɁȶɅȶȿȴɊ
based Curriculum devȶȽɀɁȾȶȿɅȺȿȤȶȵȺȴȲȽȜȵɆȴȲɅȺɀȿ ȲɅɅȲȴȹȶȵȹȶɃȶɈȺɅȹɅȹȶɅȹɃȶȶȺȾɁɀɃɅȲȿɅɃɀȽȶɄ
of teacher in CBME are PlannerȤȲȿȲȸȶɃȲȿȵȜɇȲȽɆȲɅɀɃ
6) In competency-based training, progression through training is linked to the successful attainment

of specific competencies, rather than on the completion of a set period of time. In this context,
competency-ȳȲɄȶȵɅɃȲȺȿȺȿȸȺɄȺȿɅȶȿȵȶȵɅɀȲȽȽɀɈɅȲȺȽɀɃȺȿȸɀȷɅɃȲȺȿȺȿȸɅɀȲȿȺȿȵȺɇȺȵɆȲȽɄɁɃȶ-existing
knowledge and skills and their pace of learning. For those trainees who are able to demonstrate
competence more rapidly than that which relies solely on a set period of time, this will mean
accelerated progression through training; however, it also means that training time could
potentially be lengthened due to a large amount of assessment resulting from the measurement of
each individual area of competency. Hence, there will be a lot of shift in the way a teacher manages
his or her time with CBME.
7) Șȿ ȲɃɅȺȴȽȶ ɅȺɅȽȶȵ The importance of faculty development in the transition to competency-based
ȾȶȵȺȴȲȽ ȶȵɆȴȲɅȺɀȿ ɈȲɄ ɄȹȲɃȶȵ Ʌɀ ȹȺȸȹȽȺȸȹɅ Ʌȹȶ ɃɀȽȶ ɀȷ ȷȲȴɆȽɅɊ ȵȶɇȶȽɀɁȾȶȿɅ ȠɅ ɄȲȺȵ Medical
teachers trained in conventional educational systems need faculty development to prepare them to
function effectively in a competency-based medical education (CBME) system. Faculty
development can provide knowledge about CBME, training in new teaching techniques in different
domains of medical practice, and new strategies for providing the authentic and regular assessment
87 | P a g e
that is an essential aspect of CBME. A systems-wide approach as well as efforts to provide training
in CBME to individual teachers in both the undergraduate and postgraduate systems will be
important. The wide implementation of CBME will be challenging and slow, and will meet with
resistance, but various strategies can be used address these challenges. Faculty development is
fundamental to the efȷȶȴɅȺɇȶȿȶɄɄɀȷɅȹɀɄȶɄɅɃȲɅȶȸȺȶɄ
8) Some faculty (institution wise) can be trained (as in advanced courses) so that they can responsibly
design such curricula. There is a need to have a standard format for training the leader group so that
they are able to convey the concept to other faculty as well as be able to design a program as per
needs. The curricula so designed can be analyzed, standardized, validated and then implemented (if
possible, in a phasic manner). Meanwhile, continuous training and updating needs to be done of all
the stakeholders so as to solicit support, innovation and active contribution. The new program
should be evaluated meticulously and continuation or complete implementation of the program will
depend on the actual outcome of this evaluation. Either we tackle this all at once (so it will be all
success or all failure) or we move ahead gradually (it will take a long time but we can be assured of
some progress).
9) In future, it might be tough to implement and execute CBME until there is any compulsion or
change in Govt. policies. As now-a-days, a doctor is evaluated by his/her degree/specialization and
the entrance in PG depends upon the MCQ mug-up. So hardly anybody bothers for a competent
MBBS graduate, rather every one desires a specialized MD-Postgraduate.
10) The future of CBME looks a little tough. Then again, had it been easy we would not have been
discussing so much. Fate of CBME lies in so many hands as we can see, right from the
policymakers to all those who would be involved in implementation. It is true regulations might
coerce us to implement it but will the essence remain? The herculean task of sensitizing the
stakeholders would be the mainstay in deciding the acceptance of the same. When it is gradually
introduced it would be accepted by all and by nature we are accommodating, once the benefits are
experienced and disseminated, we could be that CBME would see the light of the day.
11) The Vision 2015 statement of the MCI clearly talks of transition to competency based curriculum.
It also suggests the plan. Of course, there are challenges as we can see that these initiatives (Vision
2015) started in year 2010 and yet are far from implementation. But one thing is clear that the need
has been felt seriously and sooner or later we shall be replacing the traditional curriculum
by CBME.
12) In order to have CBME in the future, we need introduction of new teaching elements, like a
foundation course, horizontal and vertical integration, early clinical exposure, student-doctor
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method of clinical training, electives, skill development and training, secondary hospital exposure
and adoption of contemporary education technologies skill lab, simulation, e-learning.
13) In the future we would need newer learning experiences through foundation course, student-doctor
mode of teaching and electives, integration the concept of Family Medicine, greater emphasis on
self-directed learning, integration of ethics, attitudes and professionalism into all phases of
learning, encouragement of learner-centric approaches, ensuring confidence in core competencies
so as to practice independently, assessment of newer learning experiences and acquisition and
certification of essential skills. There are many more challenges which might surface up during the
implementation phase. Meticulous planning, regional task forces, strong support from the council
and political will can ease the implementation challenges of CBME.
14) The future of CMBE is promising. There is much to recommend it. Given a free hand to
extrapolate CBME principles according to regional context and circumstances, Institutions will
land on their feet eventually. Initial employment of a hybrid curriculum - part traditional and
part CBME - should make the transition less traumatic for students, teachers, patients and the
community, alike.
15) The term "CBME" no longer sounds alien (although terms like EPAs, milestones, etc. will still take
some time to be understood by the majority). Workshops are already in vogue where the subject is
being discussed. Even the future Basic Course workshops in MET will have to include various
aspects of this. All this means that a momentum towards transition from traditional to competency
based medical education has actually started. The only fear is that it may not be acceptable to all
stakeholders, if implemented suddenly in one go (all of us felt that way). I agree that if
implemented gradually, in a phasic manner i.e. partly traditional and partly CBME, will score more
votes in acceptability by the stakeholders and be less traumatic to those who oppose.
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16) CBME does not appear to me to be just a transformation but a revolution. It requires a lot of
national level pilot/trial runs to convince the stakeholders about its efficacy, because
introducing CBME without meeting the readiness it requires may lead to chaos and disaster. The
purpose of CBME is very good but the structure appears to be very delicate and complex therefore
even if it is to be introduced tomorrow, it must be kept simple.
17) The recognition of Outcome (or Competency) based medical education by Medical council of India
is not an accident or a blatant attempt to ape the medical education system of other countries. It is
because of the feedback received through various stakeholders to change the medical education
system in the country. The society/community (public, medical students, medical teachers,
administrators) has also become more aware and demand accountability and answers from the
medical education system. So a serious felt need already exists, and CBME will be implemented in
the future.
18) The Medical Education Units of the medical colleges across the country should be connected to
each other as well as globally to other international medical education communities, online and
through administrators/faculty/student exchange programs. There should be a national Medical
Education Association and taskforces must be specially constituted for this purpose at district, state
and national levels. Then we need to allocate a special category of funds. The introduction should
be gradual but in 'pulse' manner i.e. at one time all the medical education units move a small and
simple step. Then after some cooling down, all the MEUs together take the next step. Similarly,
strategies for implementation at the college level by the respective MEUs (decentralization) will be
needed to be done. Medical students, teachers, administrators, policy makers and the community
members should be under one umbrella and interact if this is to move forward. The future
of CBME in this country should be uniform as much as possible, I feel. Investment in Medical
Education units should be sought from the public/private stakeholders.
19) We need to devise a strategy/ies to make it easier for the medical teachers and students to
understand and implement CBME. It should not just become an additional burden on the already
overburdened medical teachers of this country.
20) Being from the community medicine background i feel that i am thinking in terms of creating
something like: National Medical Education Mission with clearly stated goals, objectives, targets,
strategy, budget and monitoring and evaluation. "Nothing is more powerful than an idea whose
time has come". - Victor Hugo; and I think that outcomes based medical education is one of those
ideas. I would like to acknowledge that it is easier said than done when it comes to changing the
deep rooted medical education system of this huge country.
90 | P a g e
21) The first step should be identification of the area into three categories: Must implement, good to
implement and may be implemented. Secondly, three committees can be framed to work on above
three areas however an overlap can be allowed based on interest and expertise. Committee must
have faculties who are innovative and serious to implement and see the change; and not those who
fetch committees by virtue of their seniority as it happens in most colleges.
22) The future of CBME depends on its need, how it has been planned and implemented. It will differ
from college to college. Every college will not give the same result. If the strategy of
implementation is poor, then the future of CBME will be grim and vice versa. We can
introduce CBME modules for post graduates first before moving on to undergraduates. Also, we
can choose a few sub-competencies in one core competence e.g. Professionalism or patient care to
start with.
23) We want that our graduates and postgraduates should have four characteristics: Knows the subject
up to the required standard, can integrate, can develop habits of inquiry and innovations and
formation of a professional identity. The general competencies of a doctor which we are supposed
to produce are patient care, interpersonal and communication skills and professionalism. The
Competency-Based Medical Education is an outcome-based approach to the design,
implementation, assessment and evaluation of a medical education program using an organizing
framework of competencies such as those mentioned above.
24) Competency-Based Education requires a clear definition of expected competencies (things learners
need to know and do), assessment strategies to determine whether these things are done
consistently, and the competencies need to be done within the context of the clinical environment.
Competency-based medical education must be developmental, individualized, and flexible. It must
be able to do things differently and requires different assessment methods.
Other comments:
1) Mohit reported that motivated by the perceived benefits of CBME and challenges in its
implementation, he was planning to device a couple of competencies and implement it in small way to
generate some evidence at local level.
2) Dr Soum suggested to explore the iȾɁȽȶȾȶȿɅȲɅȺɀȿɀȷȤȲɄɅȶɃɊȫȶɄɅȺȿȸ for the core competencies

cited. He said that that would probably that would take care of the flexibility of learning & make the
learner attain the desired level of competencies as per different milestones in the modules. He also
shared a resource and quoted Alveno College Faculty 1985¡ 'Programs that employ Mastery testing
systems are oriented towards competency Based education'.
91 | P a g e
Resources:
The following resources were shared on various threads during the month:
1) The effect of implementing undergraduate competency-based medical education on students'

knowledge acquisition, clinical performance and perceived preparedness for practice: a
comparative study
http://www.ncbi.nlm.nih.gov/pubmed/23711403
2) Toward a definition of competency-based education in medicine: a systematic review of published

definitions
3) Conceptual framework for performance assessment: competency, competence and performance in

the context of assessments in healthcare--deciphering the terminology
4) Graduate Medical Education Regulations by the MCI

http://www.mciindia.org/RulesandRegulations/GraduateMedicalEducationRegulations1997.aspx
5) Using a Curriculum Map to Link the Competencies for the PA Profession With Assessment Tools
in PA Education
http://www2.paeaonline.org/index.php?ht=action/GetDocumentAction/i/25268
6) Competency Mapping and Analysis for Public Health Preparedness Training Initiatives
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569994/
7) Modified Delphi technique

http://www.communitydevelopment.uiuc.edu/sp/Step6/Delphi%20Technique.pdf
8) Core competencies for medical education

http://www.utexas.edu/dell-medical-school/academics/core-competencies
9) Minimal clinical experience/competency

file:///C:/Users/HP/Downloads/Clinical%20competency%20-%202014.pdf
10) Core Entrustable Professional Activities for Entering Residency (CEPAER)

http://umsc.org.uic.edu/documents/entrustableprofessionalactivities2014.pdf
92 | P a g e
11) Medical Biochemistry in the Era of Competencies: Is it Time for the Krebs Cycle to go?
http://www.abcd.wildapricot.org/Resources/Documents/Competencies%20Article%20Med%20Sci
%20Educ%202012%20%2022%281%29%2029-32.pdf
12) The role of assessment in Competence based medical education

http://medicine.tufts.edu/~/media/MD/PDFs/Education/assessmentcompetencyeducation.pdf)
13) Competence-based medical education: Systems thinking for assessment

http://medu.au.dk/fileadmin/www.medu.au.dk/centret/PKL/PKL_materiale/Systems_Approach_W
orkshop_Denmark_Version2_4.28.pdf,
14) Building a competency-based workplace curriculum around entrustable professional activities: The
case of physician assistant training
http://informahealthcare.com/doi/pdf/10.3109/0142159X.2010.513719
15) Competence domain for interpersonal and communication skills

http://meded.ucsf.edu/sites/meded.ucsf.edu/files/documents/undergraduate-medical-education/md-
competenciesinterpersonalcommskills.pdf
16) The CanMEDS framework

http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework
17) Implementing Milestones and Clinical Competency Committees

https://www.acgme.org/acgmeweb/Portals/0/PDFs/ACGMEMilestones-CCC-
AssesmentWebinar.pdf
18) Informed consent in Adults

file:///C:/Users/HP/Downloads/Informed%20consent%20%20adults%20%20MedlinePlus%20Med
ical%20Encyclopedia%20(1).htm
19) MD competencies by University of California, San Francisco

http://meded.ucsf.edu/ume/md-competencies
20) Portfolio based learning and assessment

http://www.indianpediatrics.net/mar2015/231.pdf
93 | P a g e
21) Competence based medical education: theory to practice
22) ȧȲɅȺȶȿɅɄȲɄɄȶɄɄȾȶȿɅɀȷɁɃɀȷȶɄɄȺɀȿȲȽȺɄȾȲȿȵȴɀȾȾɆȿȺȴȲɅȺɀȿɄȼȺȽȽɄɀȷȾȶȵȺȴȲȽȸɃȲȵɆȲɅȶɄ
23) The General Medical Council patient-feedback questionnaire

http://www.gmc-uk.org/patient_questionnaire.pdf_48210488.pdf
24) Teaching and assessing professionalism in the Indian context

http://www.indianpediatrics.net/nov2014/881.pdf
25) The importance of faculty development in the transition to competency-based medical education.
94 | P a g e
Medical Humanities
Dr. Navjeevan Singh, Professor of Pathology,

University College of Medical Sciences (University of Delhi).
Delhi 110 095
Medical humanities’ (MH) is an inter-disciplinary way of looking at medicine through the lens of
philosophy, theology, art, history, literature, anthropology, and other humanities subjects. We need
doctors who will respond sensitively to both the physical and the emotional needs of their patients.
The doctor must consider the patient as a whole; in equal measure, doctors must engage with
patients with all of themselves – their minds, their hearts and their emotions – engage as persons
who are able not only to heal, but also to feel and think, explain and understand and cope.
Medical students in India are focused from an early age on science subjects; this hasty dissociation
from the humanities stream results in an unbalanced world-view. With the ever-expanding
curriculum in medical education, students end up being actively trained in the core curriculum of
diagnostics and therapeutics while important attitudinal skills such as behaviour, communication,
empathy and ethics and understanding cultural diversity remain unaddressed.
A variety of interventions comprising history, literature, various forms of theater - such as street
theater and Augusto Boal's 'theater of the oppressed', - film, poetry, graphic medicine, and disability
studies to help health professionals explore health and illness from multiple perspectives, that of the
health care-provider, of the health seeker, and of the care-giver can be developed.
Through sharing illness narratives doctors can become aware of the range of experiences resulting
from illnesses; they can begin to see the patient’s view-point; through the social sciences they can
learn about cultural and personal circumstances and beliefs that impact health care practices. Such
awareness is expected to result in fostering empathy, which, in turn, can lead to the doctor learning
the importance of providing a safe environment in which patients can communicate freely and
effectively.
Exposing the medical fraternity to art, dance, theater, and films are known to bring about attitudinal
change by enhancing skills which are important for healers. Music for dance, and music per se,
have been known to help medical practitioners in the fields of cognitive functioning and emotional
development. Being a good doctor not only entails mastery of medical skills and keeping abreast of
medical developments; what is required is much more than mere academic and professional
excellence. It is also about being aware of one's own limitations, and of having the right attitude,
character, aptitude, commitment and demeanour; and above all, a heart that is sensitive,
compassionate and understanding.
The development of tools that allow better - better in the sense that they are culturally relevant and
guided by reflective and experiential practice - engagement between patients and medical
practitioners have been shown to hone communication skills, judgment, professionalism, and
reflective practice. The six years since the launch of the Medical Humanities Group at the
University College of Medical Sciences, Delhi, have been both challenging and rewarding. In this
session we shall attempt to share some of the tools of MH that we have used during this time.

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On the wards and in our clinics each day in KEM, we helped everything and my thirst for knowledge and search for the
out in procedures or assisted in surgeries and watched art in medicine and the medicine in art continues to become
various physicians take consent, discuss prognoses or answer keener. A formal curriculum in medical humanities surely
questions posed by families to the attending physicians in provides a wide array of choices, and increases awareness; but
front of the whole medical team and we learned each day how compassion, sincerity and humility we all learn by example,
to communicate with patients; how to comfort their worried whether by setting our own or from our peers and teachers
family members, how to inspire confidence in them; how to
alike.
be gentle and how to be firm with patients who continually
posed a challenge by being non-compliant or defiant. Now We are fortunate to be living in a world where knowledge is
when I look back at those times I can clearly remember the freely available just like the air we breathe; it is only a matter of
god-like worship in the eyes of patients and their family seeking it out. This availability of knowledge has also inundated
members; and my memory doesn’t fail to echo the words: “We’ll us with surplus knowledge which we will find difficult to
do whatever you say, doctor saheb.” Was it a simplistic belief navigate and make the best of without the help of proper
that the physician is always right? I wonder now: where did all guidance. A well-structured curriculum in medical humanities
that faith come from? How did physicians get elevated to god-
will help decrease the reliance on experience alone; for
like status? Does dealing with matters of life and death make
instance, I was fortunate enough to train at the Seth GS Medical
us even half as omnipotent as the Creator? Was it the lack of
College, Mumbai, with some great teachers, but would I be as
awareness or lack of education or a matter of faith which defied
reason? The adoration which patients and families had for their conscientious a physician if I hadn’t seen good medicine being
physicians was not something we were taught to expect as practised as much? We need to increase standardisation among
part of any formal curricula, but we just saw it each day, and medical schools across India, so no matter where you train, you
that faith inspired us to strive to do our best, as someone was can avail of at least a good standard well-rounded medical
always counting on us to come through. education. Of course, the curricula should have enough scope
for each institution to incorporate its own philosophy. There is
Do I feel that I missed out on something by not having a formal
no substitute for exemplary teaching but a formal curriculum
curriculum to help me learn about medical humanities? To
dealing with medical humanities will enrich the time spent in
a certain extent I do. I wish I had taken the time to read and
medical schools in learning core concepts. I believe this kind
admire poetry and literature dealing with medicine; or learn
about Leonardo da Vinci’s artistic renderings of scientific of teaching, coupled with the current system of education, will
concepts. I felt that the emphasis on mastering concepts on enable us to produce more well-rounded physicians in India.
which questions would be set deprived us of the time to stop Reference
and think about how we got here. Did that make me less 1. Medical Humanities [Internet]. New York: New York University; c
compassionate or less appreciative of the wonders of modern 1993-2012. Medical Humanities Mission Statement;1994 [cited 2012 Jul
medicine? It did not. Somehow, I managed to learn a little of 3];[about 1 screen]. Available from: http://medhum.med.nyu.edu/
Whither medical humanities?

Navjeevan Singh
Professor of Pathology and Coordinator, Medical Education Unit, University College of Medical Sciences, New Delhi 110 095 INDIA e-mail: [email protected]
Abstract The author reviews the various strategies used and the challenges
Understanding the Medical Humanities (MH) and their role in of introducing the subject to the current generation of medical
medical education is in its infancy in India. Students are initiated students.
into professional (medical) education too early in life, usually at
the expense of a basic grounding in the humanities, resulting Don’t you ask yourself why you are being educated?
in warped intellectual growth. The author, arguing against the Do you know why you are being educated and what
wholesale import of foreign systems, advocates free inquiry that education means? As we know, education is
by medical educators to evolve a humanities programme going to school to learn how to read and write, to pass
for medical students derived from our own cultural context. examinations, and to play a few games; and after you
This essay describes the early experiences of efforts to make a leave school, you go to college, there again to study
beginning at the University College of Medical Sciences, Delhi. very, very hard for a few months or a few years, pass an
[ 166 ]
examination and then get a job; and then you forget all course, to crack the postgraduate entrance exam. Success does
about what you have learned. Do you understand what not necessarily earn the right to pursue a postgraduate career
I am talking about? Isn’t that what we all do? in a subject of one’s choice. Depending on performance, a
person wanting to become a gynaecologist may well have to
-J Krishnamurti (1)
settle for being a pathologist. There is a hierarchy to the choice
of subject, which is often determined by considerations of
Background monetary returns from the workplace.
Why do we need to educate medical students in the
humanities? Let me begin with an outline of the path to higher It is not uncommon in our medical institutions for postgraduate
education in India. Consider a child’s trajectory from early trainees, untutored and unskilled in the nuances of teaching, to
school to higher professional education. The school-going child shoulder all teaching responsibilities in small groups, where
is encouraged to learn by rote. The ability to recite or reproduce teaching is said to be most effective: tutorials, demonstrations,
memorised text is rewarded at each step. Little effort goes into practicals, and at the bedside. The faculty recruited to “teach’”
developing the higher cognitive abilities of comprehension, confines itself to the least effective form of teaching - taking
analysis, synthesis, and evaluation of knowledge. lectures, often speaking to large crowds of 150 or more bored,
listless students. Small wonder then that the commonest
At barely 15 years of age, the need to make a career choice is graffiti etched indelibly into the wooden desks, and in the
thrust upon the hapless child. Our educational system assumes minds of the students, reads “In memory of those poor souls
precocity beyond the ability of most 15 year olds to decide who died waiting for this lecture to finish.” Taking teaching
career paths for themselves. Perforce, ambitious parents make beyond the classroom is viewed as an esoteric pursuit best
the surrogate decision to prepare the child for a professional confined to philosophers and the unbalanced. To ensure full
career of their choice. Parents may know what is best for their classes, institutions resort to compulsory attendance, resulting
child in matters relating to food and friends, but they may make in vicious cycles of frustrated teachers and increasingly
the wrong choice considering the long-term consequences uninterested students. Oppression is the name of the game.
that a professional career entails. On the other hand, few
adolescents are equipped for such a choice either. That many of our students survive the ordeal that we call a
medical education, and actually go on to become outstanding
Often, a child’s preparation for a professional career begins physicians and compassionate human beings, is a tribute to
with enrolment in a coaching institution whose aim is to their resilience, strength of will, and indomitable spirit.
equip aspiring young minds with a solitary skill: how to crack
the entrance examination of their choosing by honing their The need for humanities in the medical curriculum
ability to memorise. Then follows a hectic round of classes
Nowhere in the scheme outlined above is there a place for the
tailored to the nuances of each separate entrance examination.
growing adolescent to be exposed to the humanities. Even
For the next four years, from the age of 15 to 18, when these
a passing acquaintance with subjects like languages, history,
children should have been discovering themselves and their
philosophy, and the arts is simply not possible for those who
world, their likes and dislikes, inclinations and attitudes, they
are herded into professional education by this route which,
lead a blinkered existence with the solitary goal of entering
unfortunately, is the rule rather than the exception. Language
an engineering or a medical college regardless of the aptitude
skills suffer the most. One has only to struggle through identical
required for these careers. We, the parents, teachers, and policy
written answers, mistakes and all, in hundreds of answer
makers, never inquire about our children’s true vocation or
sheets at any examination to comprehend the extent of the
interests. At 18, the rigours and demands of professional
problem. The phenomenon is neither new, nor unrecognised.
education deny our adolescents the chance to grow, to
In an interview (2) with a prominent newspaper, Venkataraman
understand themselves, to come to terms with the world
Ramakrishnan, winner of the Nobel Prize in Chemistry in 2009,
around them, and to decide on their own course.
said it all: “I grew up in the Indian system and I, unfortunately,
Far from bringing relief, the joy of those who succeed in had to choose between humanities and science in high school.
entering a professional course is destined to be short-lived. I’m making up for it. I’m learning Spanish. I’ve to take an exam
Soon the realisation comes that the years of self-denial are in January. “
going to last a lifetime. The struggle worsens when parental
Is introduction of humanities during the MBBS course a way
pressure to perform mounts. Many are told, “Now that you are
to correct the imbalance created by several years of mindless
here, at least continue and finish the undergraduate course.”
pursuit of a single, mindless goal: to obtain a professional
There is no way out for the unfortunate trapped soul but to
degree in as few years, and as early in life, as possible? How
continue. The heavy investments in intense coaching cannot
do we take our students beyond the defined curriculum, into
simply be discarded for a new career choice.
pursuits which at first appear to have no tangible benefits to
The misery does not end there. Three years into the MBBS their immediate, short-term goals? Force, as in structuring a
course, the spectre looms again post-graduate admissions humanities curriculum into the medical, creating yet another
are on the horizon. Then follow another two-and-a-half years examination to pass, yet another hurdle to clear, marks,
of intense coaching, beginning in a critical phase of the MBBS evaluations, the fear of failure, cannot be an option. In the
[ 167 ]
words of the eminent thinker, philosopher and educationist J gradually giving way to hesitant curiosity. Strangely, members
Krishnamurti, “we should create a school where the student is of the group seemed to have no misgivings.
not pressed, is not enclosed, is not squeezed by our ideas, by our
One of the earliest activities that we indulged in was to try and
stupidity, by our fears, so that as he grows, he will understand
bring about awareness and respect for the environment. An
his own affairs, he will be able to meet life intelligently. “(1) We
undergraduate student took the initiative. Being a singer, he
are at a stage where we have the unparalleled opportunity to
wrote and sang a song bemoaning the plight of the polluted
do the right thing. Transplanting other’s ideas of the medical
river Yamuna in Delhi, likening the river to a life-giving mother.
humanities into the Indian cultural context may appear to be
He followed this up by organising a tree plantation exercise in
the easy way out, but is likely to be counter-productive in the
the campus. Three people planted saplings, while two others
long run. The onus is on us to think this one out for ourselves.
looked on! It was the wrong time of year to be planting, and
How is it possible to awaken the over-burdened mind to new the saplings were in the shade of a large tree, in the path of
thinking, to new horizons? At the University College of Medical pedestrians taking a shortcut from the college canteen to the
Sciences (UCMS) we have been asking these questions and car park. The plants did not survive the week. It was our first
seeking answers. Clearly, it is not easy to decide what to do. lesson in learning the odds that faced us.
To change established thinking and behaviours is a time
The Society for Promotion of Indian Classical Music and
consuming, uphill task calling for the patience of Job. We
Culture among Youth (SPIC-MACAY), a well-known volunteer
need committed people, a conducive environment, and the
organisation that facilitates performances in educational
understanding that we may not see the result of our labour in
institutions worldwide by eminent artists, began small. A
our lifetimes.
role model for the success that volunteerism can achieve, it
graciously provided us with our first real opportunity. We are
“Medical”? humanities
inspired by the selfless quality and quantity of its members
My hope and wish is that one day, formal education will contributions to their cause, which is very similar to promoting
pay attention to what I call “education of the heart”. Just humanities in medical education. Awareness and appreciation
as we take for granted the need to acquire proficiency of the performing arts by Indian classical artistes is gradually
in the basic academic subjects, I am hopeful that a time increasing at UCMS. In the first year, the main hurdle that we
will come when we can take it for granted that children faced was finding an audience for the performances. Our
will learn, as part of the curriculum, the indispensability students and faculty were indifferent, simply not interested.
of inner values: love, compassion, justice, and With time that is changing too, as successive batches of
forgiveness (3). students volunteer in and contribute to organising these
What is meant by medical humanities (MH)? MH is an events, the numbers are beginning to add up.
unfortunate term that suggests that medical humanities During this period we explored other avenues. Our students
are different from the humanities taught in general arts wrote and performed a street play, under a banyan tree in
colleges. Use of this phrase propels us to find a medical angle the college compound, for the MHG. Titled “We all have AIDS”,
to everything that the medical student may have to do with the acronym standing for “academics-induced degeneration
the humanities. In that sense, it is restrictive, and only serves syndrome”, the play took a clever dig at the difficulties faced by
to perpetuate the myth that study of the humanities is not students trapped in the rat race of gaining a medical education.
essential to the student of medicine. That the medical student’s A small number of students attended a reading session, where
interest in the performing arts, music, literature, history, culture, everyone was required to read a literary passage or poem. The
and other similar subjects can only flourish when given a participants had never realised that reading could be an art
medical twist is rather irrational thinking. Arguably, if the form. Listening to an audio recording by Zia Mohiuddin, famed
learner has a basic foundation in the study of humanities, the Pakistani performer and exponent of the art, quickly dispelled
experience can be directed to unravelling the mysteries of that notion.
medical relationships. Currently there is a void in the students’
minds created by the missing humanities education in their There is always hidden talent within the community. We
school and college years. We need to fill this void. To grow, the stumbled upon a painter and a photographer of uncommon
learner must be provided with a steady stream of knowledge, ability in one of our residents. He obliged the MHG by
the luxury of choice, and a non-threatening environment. exhibiting a collection of his work at the institution. In our
effort to spread awareness of the humanities we have invited
Our experiments with the humanities speakers from diverse fields, including a linguist, a rationalist,
a prominent journalist proponent of the Tibetan people’s
At our institution, we took our first baby steps three years ago.
struggle for freedom, and a leading role model for persons with
Using subliminal advertising and guerrilla tactics, we began by
disability. Infinite Ability, a support group for disabled students,
setting up a small group of interested students and faculty. In
conceived and established by a prominent member of the
deference to the prevailing wisdom of the time we called it our
MHG, is currently engaged in this area.
Medical Humanities Group (MHG). We have experienced much
scepticism, even derision, in the community, but it seems to be Early in 2011, we had Dr Radha Ramaswamy facilitate a two-
[ 168 ]

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MCI Regional Centre in MET

Himalayan Institute of Medical Science, Dehradun

AT-COM Sensitization programme

Medical Council of India

As per MCI recommendation

Prepared for the Academic Committee of

The Medical Council of India has prepared revised Regulations on Graduate

The Medical Council of India has decided to implement Attitude and

It is proposed that the existing network of MCI Nodal/Regional Centers and

Dr Vedprakash Mishra Dr. M. Rajalakshmi

Medical Council of India

2. Dr. Krishna G. Seshadri

3. Dr. Tejinder Singh

4. Dr. R. Sajith Kumar

5. Dr. Sanjiv Lewin

7. Dr. P.V Chalam

8. Dr. Praveen Singh

9. Dr. Subir Maulick

4 Section I: Extract from the revised Regulations on Graduate Medical 7-14

8 Appendix 1: List of ATCOM competencies approved by the 79-82

The overall goal of undergraduate medical education programme as envisaged in

Role modeling and mentoring associated with classical approach to professional

This document is a guide to facilitate institutions and faculty in implementing a

The document is divided in to the following:

5. Appendix 1: consists of the entire set of competencies as approved by the Academic

1. Goal: A projected state of affairs that a person or system plans to achieve

Knowledge Skill Attitude/communicate

Enumerate Identify Counsel

List Demonstrate Inform

Describe Perform under Demonstrate understanding of

Discuss Perform independently

Lecture Any instructional large group method including traditional lecture

DOAP (Demonstration- A practical session that allows the student to observe a

Core A competency that is necessary in order to complete the

Non Core A competency that is optional in order to complete the

K Knows A knowledge attribute - Usually enumerates or describes

KH Knows how A higher level of knowledge - is able to discuss or

2.3. Communicator with patients, families, colleagues and community.

2.4. Lifelong learner committed to continuous improvement of skills and knowledge.

2.5. Professional, who is committed to excellence, is ethical, responsive and accountable

4. Competencies: Competency based learning would include designing and implementing

3.1.1. Demonstrate knowledge of normal human structure, function and development

3.1.2. Demonstrate knowledge of abnormal human structure, function and development

3.1.3. Demonstrate knowledge of medico-legal, societal, ethical and humanitarian

3.1.7. Demonstrate ability to perform a physical examination that is complete and

3.1.8. Demonstrate ability to perform a physical examination that is contextual to gender,

3.1.12. Demonstrate ability to prescribe and safely administer appropriate therapies

3.1.13 Demonstrate ability to provide a continuum of care at the primary and/or

3.2.1 Work effectively and appropriately with colleagues in an inter-professional health

3.3. Communicator with patients, families, colleagues and community

3.3.1 Demonstrate ability to communicate adequately, sensitively, effectively and

3.3.2 Demonstrate ability to establish professional relationships with patients and

3.3.3 Demonstrate ability to communicate with patients in a manner respectful of

3.4.1 Demonstrate ability to perform an objective self-assessment of knowledge and

3.5. Professional who is committed to excellence, is ethical, responsive and accountable to

3.5.1 Practice selflessness, integrity responsibility, accountability and respect.

3.5.5 Demonstrate a commitment to the growth of the medical profession as a whole.

Assessment is a vital component of competency based education. In addition to make

1. What does it mean to be a doctor?