Medi-Ed - vol.16 no. 1 - January 2016

Andhra  medical  college

Visakhapatnam, Andhra Pradesh, India

Smt. Pallamreddi Seethamma Memorial Medical Education Cell

Shraddhaavaan Labhathe  Jnaanam

MEDI - ED

(Quarterly Bulletin on Medical Education)

Vol. 16                                                                                                        Issue 1

MESSAGE

            I am happy to know that the Medical Education Cell of Andhra Medical College has resumed the publication of this bulletin on Medical Education. Medical Education Technology is making rapid strides in India, thanks to the recent initiatives of the Medical Council of India. It is our duty to help implement the various reforms the MCI is trying to bring about in the training of medical professionals.

            There is an urgent need to train medical students to become clinically competent and confident and not rely on a battery of investigations to tackle even common health problems. They should be trained to develop an analytical, logical and critical approach to patients and view health care as a holistic science.

            Integrated teaching must be given a fillip to help better learning rather than water-tight discipline based teaching with due emphasis on clinical and procedural skills. I am sure that the M.E.Cell of our college and the MCI Regional Centre (which has been actively functioning in our college since two years) will help us in this direction. I wish the M.E.unit all success in its future endeavours.

Dr.G.Venkateswara Reddy, Prof. of Cardiology & Vice Principal, Andhra Medical College

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AN  EDUCATIONIST’S  ‘REFLECTIONS’

Dr.Perala Bala Murali Krishna, Professor of Microbiology, Andhra Medical College, Visakhapatnam

‘I’ is a very important vowel in anyone’s life. If it is ‘less’ you are branded ‘spineless’, and, if it is more, you are dubbed a ‘dictator’ (something similar to immunodeficiency and hypersensitivity complex).

            I am about to retire in August 2016 (courtesy the two year extension) and when I look back and ‘reflect’, many a thought about education in general and medical education in particular, flash across my mind . . . like in any old Telugu, Hindi, or moreso, Tamil movie.

            Was I a good student? – an honest answer is . .  NO. In primary schooling, as far as I remember, I received corporal punishment not too infrequently, of course for nonscholastic deeds like bartering textbooks for toffees and ice-creams (more due to influence of peers)

            The first time I saw my number in the ‘pass’ list of SSC – I heaved a big sigh of relief - that was the first public exam I wrote. I was never a so called first-bencher nor a Self Driven Learner – but I passed my 10^th class exam!  I used to read ‘prepared notes’ rather than text books; maybe I was good in ‘remembering’ and ‘reproducing’ than ‘understanding’ and ‘recalling’. In my 8^th class, I switched over from ‘Composite’ to ‘General’ maths realizing my absolute inability to figure out why the world needs algebra, theorems and such complex ideations. That was the most honest self-assessment I made in my life.

            In my Intermediate, I naturally opted for BiPC (not with the intention to join MBBS but rather to avoid maths!!) . I began to analyze my pluses & minuses. Biology was good for remembering and recalling but when it came to logic, my higher centers did not cooperate , Organic Chemistry was a nightmare.

I passed Inter with a first class, standing first in my peer group – this I attribute to the multiple tuitions I took for all my subjects.

            In those days, my Physics lecturer was my mentor, philosopher and guide . . . he explained and taught me not only Physics but also Chemistry and English! That was my first hand feel of Mentoring and Small group teaching.

            After Inter, I was ‘admitted’ into an MBBS Entrance Coaching Centre – a luxury which my father’s purse did not bear so easily; but my father, though not a doctor, had a love for medical profession .  He wished and blessed me, and I become a doctor. He did everything in and out of his reach and that is why I am here! That test was my first brush with MCQs and I thank my success in that exam to my teachers who designed various sessions and training methods to direct and tune this village bred ‘essay writing’ student into an MCQ oriented entrancer through a one-month crash course. I distinctly remember two ‘discriminating’ MCQs in that exam – which I answered correctly while many were wrong – one was to choose the correct spelling of Gonorrhoea and the other was to select the correct order of the cranial nerves.

            After joining MBBS, again, the mortal fear of Organic chemistry chilled my spine in the form of Biochemistry which I passed, however, losing in anatomy for poor dissection skills …and losing in physiology for lack of “time management skills” in theory paper.  So to say, I did not concentrate on obtaining practical skills and time management in my preclinical years. That taught me the principles of OSPE & OSCE without the label.

However with that first failure in life, I was branded as a “referred-repeater” with the stigma, trauma, guilt and of course the pain of being separated from my original batch. That taught me two things - never to call someone as a “referred/repeater”.  I identify them by the name of their class rep or roll no.1 or number of students (22 batch, 17 batch etc) – of course now, with the ‘instant’ exam a few months after the initial First MBBS exam, even these students join the main / big batch.

 I started referring to old question papers, peer review, group discussions, self directed learning. Over and above all I used to consult about any doubts/ clarifications with my original batch mates who were ahead of me with whom I would feel comfortable. Needless to say I cleared the rest of my MBBS course with no more failures.

             A word about my post graduation…  After MBBS  I wrote the PG entrance test ( no coaching like SPEED then)..i got MD Microbiology which I did not join, going for an outlandish Offshore job ! After a major fire accident at sea , I left that job, joined AP Government service, and got qualified for service PG quota and again wrote the PG entrance test. I again got MD Microbiology after 13 years. . . peers felt I did not improve, I felt I did not deteriorate even after such a long gap!!! ATTITUDE….!

            During my three years of rural health service as a Civil Asst. Surgeon, I really learnt how to be a real rural doctor. Inspite of myself, I was able to deal with emergency calls, attend routine fevers, minor injuries, even conduct deliveries (obviously normal) successfully; but, when in doubt I used to refer the patients to KGH!! The stint of those three years made me realize that it is not just one’s academic excellence alone that matters to be a successful rural basic doctor - it is your empathy, counsellng skills, character, integrity, honesty, decent behavior more than everything else – it is your “affective domain” that wins the hearts of your patients .

            Proper attention to the “affective domain” right from the day one of entering into the Medical college is a ‘felt need’ of the hour because cognitive and psychomotor skills fill up most of the MBBS agenda, leaving the affective domain defective! Early inception of value education and popularizing the speciality of Family Medicine would be a healthy approach to mould our ‘Process’ to yield a desirable ‘Product’.

            As a medical teacher, I am indebted to the National Teacher Training Centre, JIPMER, Pondicherry – the ten days I spent there, demolished so many myths of mine, about myself and medical education. I was sensitized to the concept of Medical Education Technology. Today, after nearly two decades of teaching, I learn everytime I go to teach my students – they refine my approach towards teaching and help me become a better teacher every day I teach. To teach is learn twice.

            ‘I’ is like the faithful antibody . Don’t let it ‘mutate’ into an ‘autoantibody’ .  We, as a ‘team’ would be more successful to the health of medical education and health care delivery system of our great motherland India. Gold help us become so.

 Reference :

1. Medical Education in India: An introspection.  R.Kumar. Ind. J. Public Admin. Vol.LX no.1 Jan. – Mar 2014.

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COMPETENCY BASED MEDICAL EDUCATION - €“ SOME BASICS
                                                                                                Dr.Ravi Venkatachelam Chitrapu

                                               

Competency Based Medical Education (CBME) is the current buzz word and is likely to be the new paradigm of medical education as enunciated in two MCI documents - Regulations on Graduate Medical Education (MCI-2012) and Vision 2015 (MCI-2011). It would seem that the MCI wishes to implement CBME in imparting communication & attitudinal skills / competencies to MBBS students as a pilot project in some colleges. With the feedback and experience from this exercise, it would extend CBME to the entire graduate medical education system over the ensuing years. This article attempts to provide a basic understanding of what CBME entails.

Need for CBME instead of Traditional Medical Education - 
            The traditional medical education has been blamed to bring out inadequately trained/ competent doctors because it lays emphasis on knowledge acquisition and rote learning with insufficient assessment of more essential practical skills like procedural skills, attitudinal attributes needed for a doctor and soft skills like communication and management skills.

CBME aims at ensuring that the final product (graduate doctor) comes out sufficiently competent (in predefined skills and attributes) - to this end, the student can take however much time they require depending on their learning abilities and pace of learning. (This second clause is important - time is flexible and not fixed unlike the traditional discipline based curriculum where we have fixed time -  semester / 1 ½ years etc. for the skills to be acquired. Since CBME is time bound, it ensures learner centredness and more accountability.

 Didn’t the conventional system ensure they were competent, one may ask -  the answer is not a definite no but, unfortunately, our assessment systems have been reduced to knowledge/ memory testing, and in some instances, to farcical exercises. Maybe this could have been rectified by reforming the examination system but our educationists thought otherwise -  world over, the shift is to CBME - so why not we too shift to CBME - this would also make our doctors more familiar and comfortable when they move out to foreign lands and work there.

Since the CBME will be a new system being put in place, the assessment system would be suitably reformed to ensure competent doctors. (but maybe we Indians will still find a way out!!! but we can spare that skepticism to a later date).

                                                                                                 

                        Traditional curriculum                                     Competency based
Aim                              Knowledge acquisition                            Knowledge application
                                    Single subjective measure                        Multiple objective measures
Evaluation                     Norm referenced                                               Criterion referenced
Emphasis on                  Summative                                            Formative

                        Time bound                                           competency bound (time flexible)

What is CBME ? -  some definitions/ terminology
            CBME is an OUTCOMES - BASED approach to the design, implementation and assessment and evaluation of a medical education program using an organizational FRAMEWORK OF COMPETENCIES.
            The key words here are COMPETENCIES and OUTCOME-BASED. So, firstly, you have a set of competencies (abilities) in which you have to train the student, and, assess them at the end - €“ so you will have to prepare your curriculum / training methodology and assessment plan accordingly. Secondly, the goal focuses on the outcome or end-product - so, you would ensure that the product or outcome meets some criteria before certifying them competent or passed or fit to practise medicine. The student would master one level of competency before proceeding to the next higher level of competency – e.g. only after achieving competency in the anatomy of the inguinal region, would the student go to the next level of assisting, then performing under supervision, and, finally performing independently, a hernia repair.
            The 3 key steps to CBME are –

-          Identification of competencies (that the student should be trained in)

-          Organising teaching – learning program

-          Assessment planning & program evaluation

Now coming to describe some terms such as goals, roles, competencies, objectives, etc.
            The GOALS of graduate medical education remain the same -  to create basic doctors or physicians of first contact for the community, who will practise preventive, promotive, curative, palliative and holistic health care that is rational, relevant, scientific and affordable / accessible. Thus, a goal is a broad aim or a general statement (usually long-range) of the achievement / result towards which the program/ course is directed -  e.g. Health for all, eradication of measles, elimination of malnutrition, effective control of hypertension and diabetes in 80 or 90% of patients in the community, training a first contact physician, etc.
            OBJECTIVES are more specific / concise (usually in the short term) -  they are brief, clear statements of the desired learning outcome of a given program / educational experience -  e.g. immunizing 90% of infants, giving free drugs to all diabetic and hypertensive patients, conducting a normal labor, performing a tracheostomy, writing a prescription for a case of uncomplicated malaria, etc.
            Learning OUTCOMES are clear statements of the essential learning (knowledge, skills, attitudes) that learners achieve and can demonstrate by the end of a course / program – one key word here is DEMONSTRATE - it must be demonstrable to be assessable ain’t it?
            COMPETENCIES, I feel, come in between goals and objectives - they are the true reflection of learner outcomes - they are defined as the Observable Ability of a doctor, integrating multiple components such as knowledge, skills, values and abilities. (to perform the said task, to the desired level of proficiency, in a real life context) - (words in italics /parenthesis added by me).

 These competencies help the professional to perform KEY OCCUPATIONAL TASKS which are characteristic tasks for their profession.
            Competencies can be Domain specific which are clusters of knowledge, skills and attitudes in one specific domain, or, they can be Generic i.e. needed in all contents and transferable to new situations.
            COMPETENCE is the ability to perform a requisite range of skills.  
            The ACGME (Accreditation Council for Graduate Medical Education) enunciated Six core competencies for physicians - 

Medical knowledge / Patient care / Professionalism /  Interpersonal communication / Practice based learning & improvement / System based practice.

The MCI Graduate Regulations document assigns five ROLES to the Indian Medical Graduate -  Clinician / Leader & member of health care team / Communicator / Lifelong learner / Professional.
            To fulfil each of these Roles, the MCI document lists a set of competencies - 15 for the Clinician, 6 for leadership / teamwork, 4 competencies for communication, 5 for lifelong learning and 5 for professionalism. Some of these are - (see MCI document for full set of competencies)
- Demonstrate the ability to perform a physical examination that is contextual to gender, social and economic status, patient preference and values
- Recognise and function effectively, responsibly and appropriately as a health care team leader in primary and secondary health care settings
- Demonstrate ability to communicate with patients, colleagues and families in a manner that encourages participation and shared decision making
- Demonstrate ability to apply newly gained knowledge or skills to the care of the patient
- Abide by prescribed ethical and legal codes of conduct and practice

            Thus, we must link our goals to outcomes / competencies and ensure that
- we provide the appropriate teaching / learning opportunities for the student to acquire the competencies
- devise appropriate methods to assess these competencies
- define the minimum level of successful achievement of these competencies
            Some educational programs use the term MILESTONES to provide a more explicit definition of the expected competencies a Milestone is a significant point in the development and includes the skill and knowledge based developments that commonly occur by a specific time and that must be demonstrated by the resident.
            Depending on the level of expectation / achievement, the student passes through different phases in training (Dreyfus & Dreyfus) - 
Novice à  Advanced beginner à  Competent à  Proficient à  Expert
           

A novice has little background experience and completes assigned tasks, going rigidly by rules, and under extensive guidance and cannot exercise discretionary judgement . . .
            An advanced beginner completes assigned tasks and can connect the context and rules, but still requires guidance in unfamiliar circumstances . .
            A competent person . . . can identify circumstances and make judgements and prioritise & seek guidance in unfamiliar circumstances
            A proficient person . . . can make situational discrimination and select the best approach for the particular problem with less conscious planning . . .
            An expert . . . has an intuitive grasp of the problem / situation and does not need an analytical process to act, and is recognized as a source of guidance by peers / subordinates . . .
EPA  -  ENTRUSTABLE PROFESSIONAL ACTIVITY
            EPA refers to a set of professional work activities that the trainee can be entrusted with, to carry out with the required competence and responsibility. It means that we can trust him/her to perform that given task or level of task, independently.
            Assessment in CBME will be planned depending on the nature of the competency and at which level – e.g. using Miller’s pyramid, we may assess the student by the following means – Knows, Knows how, Shows and Does. While ‘Show’ would be a test for Competence, ‘Does’ would be a test for Performance. We have to set the criteria beforehand to certify competence. For competencies that need ‘Does’ level, it will have to be done during work – i.e. Work Place Based Assessment – which can be DOPS (Directly Observed Procedural Skill), mini-CEX (Clinical Examination) Global Rating Scale, or 360 degree feedback, logbook, check-off sheets. Competencies of Shows how can tested by Observation of procedure performed on manikin or simulated patient, OSCE/ OSPE, etc.

            Changing to CBME is not going to be a cakewalk -  because, we need to train the educators and students about the methodology and assessment methods and there would be the usual resistance to change. But the merits of CBME i.e. ensuring competency, accountability, integrated learning, global acceptance, learner centred approach and learner freedom should make this an attractive, useful and effective T/L paradigm to produce competent doctors.

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Mark Van Doren – ‘The art of teaching is the art of assisting discovery’.

John Dewey – ‘We don’t learn from experience. We learn from reflecting on experience’.

Feedback is the fuel that drives performamnce.

Please do write for the Medi-Ed bulletin. Please mail your articles or any other write-ups (on educational issues to mecell@rediffmail.com) or send to Dr.KVV Vijaya Kumar, Prof. of Pulmonary Medicine, T.B.Hospital, Chinna Waltair, Visakhapatnam.  

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