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|Year : 2021
: 63 | Issue : 2 | Page
|Competency-based medical education: Relevance to psychiatry
Sujata Sethi1, Dinesh Kataria2, Vivek Srivastava1
1 Department of Psychiatry, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
2 Department of Psychiatry, Lady Harding Medical College, New Delhi, India
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|Date of Submission||09-Jun-2020|
|Date of Decision||01-Sep-2020|
|Date of Acceptance||25-Feb-2021|
|Date of Web Publication||14-Apr-2021|
|How to cite this article:|
Sethi S, Kataria D, Srivastava V. Competency-based medical education: Relevance to psychiatry. Indian J Psychiatry 2021;63:189-91
| Introduction|| |
To achieve the national goal of “health for all,” it is necessary that Indian medical graduates are competent enough to cater to the needs of the society they serve in. Medical education in India, however, has been unable to meet this expectation.
It is hoped that the introduction of a restructured curriculum such as competency-based medical education (CBME) might prove remedial.
Models of CBME are geared toward better accountability to the stakeholders including the society and are based on the latest scientific information and changing needs of medical practice.,, Competency-based frameworks accomplish these by focusing on the achievement of prespecified individual competencies and by using appropriate methods of assessment of patient care and performance-based education outcomes, rather than just being knowledge-based examinations and global ratings. By doing so, CBME intends to produce physicians whose skills match the needs of the communities they serve and meet the demands of the healthcare systems and communities in which they practice.
These goals of medical education seem feasible by adoption of CBME as it is student- and patient-centric, outcome-oriented, and provides learning environment appropriate with prespecified objectives and clearly defined methods of imparting education and of assessment and regulation.,
Keeping with the recent global trends, the Medical Council of India (MCI) implemented CBME in all medical colleges in India in August 2019. In the context of CBME, competency is “the ability of a health professional that can be observed.” Apart from knowledge, it embraces other components as well such as skills, values, and attitudes. The core competencies required of a medical graduate are predetermined in the curriculum and are contextual to the environment in which the medical graduate would eventually practice his/her profession. In simple words, competencies help us to ascertain that students know the skills laid in the curriculum and articulated in the form of learning objectives.
Having said that CBME is learner-centric and it focuses on all the three domains of learning, i.e., knowledge, attitude, and skills simultaneously; teaching–learning methods are aligned in such a way that it is more clinical and skill-based approach. Early clinical exposure has been integrated right from the phase 1 to work toward this goal. Similarly, assessment constitutes an important component of CBME to ensure that predefined outcomes are achieved. Assessment methods have been revised from traditional knowledge-based assessment at the end of term to a varied, diversified, observation-based assessment approach that lays a lot of importance on formative assessment.
| How does Competency-Based Medical Education Translate for Psychiatry?|| |
As discussed above, the curriculum for MBBS is in the form of competencies and outcomes. Psychiatry has been assigned a separate subject code and competencies related to psychiatry are divided into 19 topics: (1) doctor–patient relationship, (2) mental health, (3) introduction to psychiatry, (4) alcohol and substance use, (5) psychotic disorders, (6) depression, (7) bipolar disorders, (8) anxiety disorders, (9) stress-related disorders, (10) somatoform disorders, (11) personality disorders, (12) psychosomatic disorders, (13) psychosexual and gender identity disorders, (14) psychiatric disorders in childhood and adolescence, (15) mental retardation, (16) psychiatric disorders in the elderly, (17) psychiatric emergencies, (18) therapeutics, and (19) miscellaneous. These topics are broad and are more or less the same as currently being taught in psychiatry to medical graduates.
Each topic has specific competencies to be learned, resulting in a total of 117 outcomes. Further, through 45 competencies, psychiatry is either vertically or horizontally integrated with nine other subjects, especially with general medicine, pediatrics, and community health. Another area of focus is the emphasis laid on the acquisition of skills and their assessment. Undergraduates (UG) get to rotate through psychiatry for 2 weeks right after Phase 1, i.e., in their 2nd year (5 days a week; 3 hours/day), and then again in Phase 3 Part I (6 days a week; 3 hours/day), thus making a total 1 month (66 hours) of clinical clerkship as compared to 2 weeks (36 hours) of clerkship pre-CBME. Number of total teaching hours also has increased to 40 hours with a caveat that theory lectures shall not exceed one-third of the total time allotted for the subject; two-thirds of the teaching shall include interactive sessions, tutorials, and practical, clinical, or/and group discussions; and the learning process should include more of problem-based approach, clinical case discussions, and community-based activities, thus focusing more on skills and clinical exposure.
Further electives provide extra opportunities for more engaging learning experience in the subject through the clinical clerkship. Although it is mandatory for the UG students to do an elective (4 weeks) in a clinical subject, it is not necessary that each and every student should take up psychiatry for an elective. Internship also offers 2 weeks of mandatory rotation and 2 weeks of elective/optional exposure in psychiatry.
| Is This Enough?|| |
With outcome-driven curriculum, increased theory and clinical clerkship hours, and a handsome number of competencies, one needs to ponder whether this curriculum is really geared toward producing physicians of first contact.
While the focus on competencies is a prominent change, the new curriculum is no different from its predecessor in its context. It remains tertiary hospital- and specialty-centered in its approach, ignoring its relevance to general medical practice. There is not much focus on common mental disorders that form the bulk of patients presenting to general physicians. The CBME approach is more suited for tertiary care psychiatry.
While the overall curriculum argues for formative evaluations during the clinical postings in psychiatric facilities, the majority of psychiatric competencies continue to focus on the transmission and recall of knowledge, rather than the evaluation of skills required to recognize and manage such problems in busy general medical settings.
Although all the competencies in psychiatry are core (desirable) competencies, none of these is certifiable or mandatory, hoping that students will be able to perform these independently during the internship, as is the pattern with pre-CBME curriculum. Indian Psychiatric Society UG Committee recognizes this as a major gap between perceived importance and ultimate implementation. The concerned committee intends to discuss with the Government of India and the MCI (now National Medical Council [NMC]) about the importance of certification of skills toward successful completion of UG training. Further, the committee recommends that faculty be sensitized and trained in teaching–learning and assessment methods in accordance with the CBME requirements.
The new curriculum, while emphasizing for vertical and horizontal integrations with other specialties, does it vaguely, arbitrarily, and superficially. The purpose of integration, i.e., interconnectedness between subjects and wholesomeness of education, is not served to full extent.
The new curriculum advocates for formative assessments during the psychiatry clerkship, but it is not clear how it will contribute toward the internal assessment. As for the summative assessment, psychiatry is included under medicine and allied subjects, so it shares its presence in summative examination with skin and respiratory medicine as a part of Medicine Theory Paper II with 50 marks for all three allied subjects. There is no indication regarding clinical/practical examination for psychiatry. Further, a gap of more than 1 year between psychiatry training and final examination undermines the importance of subject and might not be successful in engaging the students with the subject.
| The Future of Competency-Based Medical Education|| |
The NMC (earlier MCI) has been determined though gently, moving toward a competency-based curriculum as evident in its Vision 2015 document., Integration with other subjects will reduce stigma and feeling of “alienation” about psychiatry. Emphasis on UG education of psychiatry and opportunities in new competency-based curriculum of NMC can help narrowing the treatment gap of psychiatric disorders in the country. Onus rests now with subject experts/teachers to impart quality UG training in psychiatry taking cognizance of the fact that how it is different from postgraduate training both in conceptualization and delivery.
However, much depends how the new curriculum is designed and implemented. Taking local context and needs into consideration while designing the curriculum as well as using a blended approach in implementation, i.e., using a combination of both traditional and CBME to start with, may be more rewarding.
Further, the purpose may be defeated if the implementation of CBME is limited to medical colleges governed by NMC as autonomous institutions in the country, such as All India Institute of Medical Sciences (AIIMS), however are not in any bind to implement competency-based curriculum at UG level. It is encouraging that AIIMS, Rishikesh, has introduced psychiatry as mandatory subject of examination for 100 marks in UG, leading as a model for other institutions to follow.
| Conclusion|| |
The new CBME curriculum is paradigmatic shift from just knowledge to competencies, i.e., skills. It is envisaged that with clearly articulated competencies and increased emphasis on clinical skills (patient oriented) along with increased proportion of time spent with the subject of psychiatry, we may accomplish the goal of producing the physicians of first contact competent enough to provide basic psychiatric services to the community. However, the stilted focus of curriculum, no need for certification of any of the core competencies, and ambiguity regarding assessment dilute the projected importance of the subject.
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Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatry, Pt. B.D. Sharma PGIMS, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None