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GUEST EDITORIAL
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 101-103  

The Competency-Based Medical Education Curriculum: An Appraisal of the Remedial Measures for Internal Assessment


1 Department of Otorhinolaryngology, Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India
2 Department of Pediatrics, Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India
3 Department of Pharmacology, Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India
4 Department of General Surgery, Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India

Date of Submission24-Jul-2019
Date of Decision15-Oct-2019
Date of Acceptance20-Dec-2019
Date of Web Publication28-Feb-2020

Correspondence Address:
Ajeet Kumar Khilnani
Department of Otorhinolaryngology, Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_216_19

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How to cite this article:
Khilnani AK, Thaddanee R, Khilnani G, Rao G. The Competency-Based Medical Education Curriculum: An Appraisal of the Remedial Measures for Internal Assessment. Med J DY Patil Vidyapeeth 2020;13:101-3

How to cite this URL:
Khilnani AK, Thaddanee R, Khilnani G, Rao G. The Competency-Based Medical Education Curriculum: An Appraisal of the Remedial Measures for Internal Assessment. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Apr 8];13:101-3. Available from: http://www.mjdrdypv.org/text.asp?2020/13/2/101/279624



The competency-based medical education (CBME) curriculum is designed to identify the desired outcomes, define the level of performance for each competency, and develop a framework for assessing competencies. Currently, CBME is adopted by many universities in different countries around the world, and recently, the Medical Council of India (MCI) has recommended its implementation in 2019.[1] CBME is learner-centric and focuses on competencies (outcomes) as end points. In this new form, the curriculum is designed to impart knowledge and skills necessary for an Indian Medical Graduate (IMG). The internal assessment (IA) is embedded in curriculum providing continuous evaluation of student's performance and is given greater emphasis. Despite these advantages, there are many concerns and challenges to the implementation of CBME curricula which include increased administrative requirements and need for faculty development. There is also a concern about the reductionist approach to assessment in CBME.


  How Is Internal Assessment in New Curriculum Different from That in Existing One? Top


The new curriculum emphasizes a cutoff pass level of IA as 50% which is consistent with the CBME curricula in African and other countries.[2],[3] The original Graduate Medical Education Regulations-1997 required that a “student must secure at least 50% marks of the total marks fixed for internal assessment in a particular subject in order to be eligible to appear in final university examination of that subject.”[4] This regulation continued till 2003, wherein it was substituted in terms of Gazette notification dated October 16, 2003 to, “student must secure at least 35% marks of the total marks fixed for internal assessment in a particular subject in order to be eligible to appear in final university examination of that subject.” Thus, the 35% marks of IA became an eligibility criterion to appear in university examination in that subject. The differences between IA in two curricula are stated in [Table 1].
Table 1: Internal assessment - differences between existing and new competency-based medical education curriculum

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From [Table 1], It is clear that there is provision of remedial measures after completion of training for the students who have not scored qualifying marks or have missed on some of the assessments due to any reason. The university shall guide the colleges regarding formulating policies for remedial measures.[5] However, the details of remedial measures to be taken are left to the institution/university.


  When to Take Remedial Measures? Top


The new curriculum envisages taking remedial measures after a student has completed training but has not become eligible for appearing in university examination. Thus, it is important to ascertain the timing of this remedial action.

Example

The first MBBS university examination shall be held in September 2020. The student must have taken third IA in August 2020 so that final IA is announced. In general, a period of 2 weeks is provided to the students for preparation of university examinations. Thus, remedial measures could be taken during this period for students achieving IA marks between 40% and 50% so that student becomes eligible to appear in university examination. There are a few concerns to ponder over. One is that such students would be tensed and stressed to achieve targeted 50% in remedial examination in one to three subjects and simultaneously to prepare for university examination. This would be all the more important during second professional MBBS training, wherein, as per new curriculum, he has already appeared in 19 IA-tests in 11 months![5] There is evidence that examination anxiety interferes with academic performance.[6] Another point is how can one acquire competence and skills during a short span of 15 days which he/she otherwise has not been able to achieve in 12 months?


  Whom to Administer Remedial Test? Top


[Table 2] shows the possible outcomes of the IA taken by the students. There could be a number of situations. A student may get <40% marks, assigned for IA, in theory, practicals (Case-C), or both (Case-D). Thus, the remedial tests will have to be arranged for theory, practicals, or both, for all those who scored <40% in theory and/or practicals/clinicals in one or more subjects in a phase.
Table 2: Remedial tests

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  What Constitutes Remedial Measure? Top


In simple terms, a remedial measure is done to improve or correct performance and to assist students in order to achieve expected competencies. The new curriculum has left the onus of taking such measures to the institution/university. Does it mean to administer a full-fledged examination annulling the previous low score or a forme fruste of such examination to make up for the deficiency? In other words, will it be a supplementary IA or complementary IA? The Rajiv Gandhi University of Health Sciences has recommended another IA as remedial measure to secure aggregate 50% marks.[7] This recommendation was in consonance with the recommendations in curriculum implementation support program (CISP) document before publication of MCI's Assessment Module-3. Similarly, Maharashtra University of Health Sciences, Nasik, in its first professional MBBS curriculum advocates a remedial IA examination for students who did not score aggregate 50% (combined in theory and practical) for the subject. The remedial IA should be organized by the college immediately after the completion of university examination of the affected students. Such a remedial examination shall be conducted by allocating only 3 days per subject without any gap (2 days for theory and 1 day for practical). This recommendation was also made before release of MCI Assessment Module-3.[8]

Potential remedial measures include written test (SAQs, MCQs), OSPE/OSCE stations, structured viva voce, and bedside assessment. Badyal and Singh opine that remedial measures be predecided and individualized based on students' requirements.[9] However, individualization would lead to tailor-making of test and more faculty requirement and commitment. Measures would depend on the number of subjects and timing of such measures as described above. It is feared that such individualized tests may not be valid or objective. The retest for remedy shall be an extra effort, and the department has to make necessary arrangements for theory and practical retests during teaching hours, and this is likely to affect the completion of curricula as prescribed in CBME. It would be more challenging in clinical subjects. To avoid such extra efforts, institutions and faculty may assume a perfunctory role in just fulfilling the requirement of 50% by devising viva voce or small group discussions. Viva voce is subjective and includes errors relating to halo effects, central tendency (judgments cluster in the middle), a general tendency toward leniency, and errors of contrast. Viva voce examinations test lower taxonomic levels, mostly recall of facts.[10] It is also known that written examinations during periodic and continuous assessments improve performance in summative examinations in anatomy.[11] However, students will have to appear in yet another written examination and skill testing would be left as such. Therefore, introduction of remedial examination may not serve the objectives as envisaged in CBME.

There must have been an objective evidence for increasing cutoff from 35% to 40%, but this small increase may not offer advantage over the existing traditional curriculum. For example, as per GME-97, students who get 35% in IA become eligible for appearing in university examinations, but a good number of them finally fail because of poor performance in IA. Studies have shown a positive correlation between continuous IA and final university marks.[12],[13] IA also reflects achieving degree of competence and skills. Introduction of remedial measures, which to us is less likely to substantially improve their competence and skills, may lead to less competent students to pass the university examination.


  What Is Way Forward? Top


The university may decide to do away with remedial measures. However, this would deprive the deserving students of the opportunity to achieve qualifying marks in IA due to unavoidable reason/s. Provision for remedial measure for number of students who have not qualified in final IA implicates meticulous preparation of structured module for the assessment of knowledge and skills in a short spell of time of 1–2 weeks. To enhance utility of remedial measures, it would be prudent to administer them after administration of every test at term end and periodic examinations (during formative assessment). Providing structured feedback and remedial action will result in improvement of performance.[9] However, the exact modalities and timings remain to be finalized by the institution in close consultation with university. We are concerned about identifying the real utility of remedial measures in improving performance and producing competent IMGs.

Since IA can have construct validity and high predictive value for success in university examinations, we recommend that the eligibility as well as passing cutoff percentage marks for IA should be fixed at 50% without any provision of remedial measures. It will encourage the students to work harder throughout the course to achieve 50% marks, rather than depending on the remedial measures, thus producing a more competent IMG. Another advantage is that student shall not exert too much in university examination to compensate for the deficiency of IA marks to reach 50% passing criteria in summative examinations. With the likelihood of introduction of National Exit Test as a licentiate examination in near future, setting 50% IA marks as a passing criterion will provide a fillip for the students to work hard throughout the training period.



 
  References Top

1.
Competency Based Undergraduate Curriculum. Available from: https://www.mciindia.org/CMS/information-desk/for-colleges/ug-curriculum. [Last accessed on 2019 Jul 16].  Back to cited text no. 1
    
2.
Olopade FE, Adaramoye OA, Raji Y, Fasola AO, Olapade-Olaopa EO. Developing a competency-based medical education curriculum for the core basic medical sciences in an African medical school. Adv Med Educ Pract 2016;7:389-98.  Back to cited text no. 2
    
3.
Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: Theory to practice. Med Teach 2010;32:638-45.  Back to cited text no. 3
    
4.
Salient Features of Regulations on Graduate Medical Education; 1997. Available from: https://mciindia.org/ActivitiWebClient/rulesnregulations/graduateMedicalEducationRegulations1997. [Last accessed on 2019 Jul 15].  Back to cited text no. 4
    
5.
Medical Council of India. Competency Based Assessment Module for Undergraduate Medical Education Training Program; 2019. p. 1-30. Available from: https://mciindia.org/CMS/wpcontent/uploads/2019/10/Module_Competence_based_02.09.2019.pdf. [Last accessed on 2019 Sep 30].  Back to cited text no. 5
    
6.
Triphoni A, Shahini M. How does exam anxiety affect performance of university students? Mediterranean J Soc Sci 2011;2:93-100.  Back to cited text no. 6
    
7.
Available from: http://www.rguhs.ac.in/courses_rguhs/medical_ordinances/mbbs%20rs4%20with%20logbooks.pdf. [Last accessed on 2019 Oct 08].  Back to cited text no. 7
    
8.
Available from: https://www.muhs.ac.in/showpdf.aspx?src1=upload/syllabus/Anatomy%20090819.pdf. [Last accessed on 2019 Oct 08].  Back to cited text no. 8
    
9.
Badyal DK, Singh T. Internal assessment for medical graduates in India: Concept and application. CHRISMED J Health Res 2018;5:253-8.  Back to cited text no. 9
  [Full text]  
10.
Khilnani AK, Charan J, Thaddanee R, Pathak RR, Makwana S, Khilnani G. Structured oral examination in pharmacology for undergraduate medical students: Factors influencing its implementation. Indian J Pharmacol 2015;47:546-50.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Rani A, Chopra J, Rani A, Diwan RK, Verma RK, Yadav S. Effect of introducing written tests in continuous assessment for improving performance in terminal exam of anatomy. IOSR J Dent Med Sci 2016;11:69-74.  Back to cited text no. 11
    
12.
Santra R, Pramanik S, Mandal A, Sengupta P, Das N, Raychaudhuri P. A study on the performance of medical students in internal assessment and its correlates to final examinations of 2nd MBBS pharmacology curriculum in a medical college of Eastern India. J Clin Diagn Res 2014;8:HC01-2.  Back to cited text no. 12
    
13.
Badyal DK, Singh S, Singh T. Construct validity and predictive utility of internal assessment in undergraduate medical education. Natl Med J India 2017;30:151-4.  Back to cited text no. 13
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