|Ahead of print publication
Challenges to new undergraduate medical curriculum due to COVID-19 pandemic and possible solution in India
Ankit Kaushik1, Anamika Jaiswal2, AK Singh2, Ghazala Rizvi1
1 Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Anatomy, Government Medical College, Haldwani, Uttarakhand, India
|Date of Submission||18-May-2020|
|Date of Decision||19-Jul-2020|
|Date of Acceptance||21-Dec-2020|
Assistant professor, Anatomy, Department of Pathology, Government Medical College, Haldwani, Naniatal - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
As the Medical Council of India (MCI) implemented a new undergraduate curriculum from this academic session onward, the aim was to replace knowledge-centric traditional educational model to a more holistic community-based curriculum based on the domains such as knowledge, skills with emphasis on attitude, communication, and ethics. This implementation requires major reforms in the form of faculty development and resource generation for successful implementation of new course. However, COVID-19 pandemic possesses serious challenges to the implementation of curriculum and its success. This review discusses the possible challenges for the implementation of the new MCI curriculum in face of the coronavirus pandemic and possible strategies to counter it.
Keywords: COVID-19, medical education, pandemic
|How to cite this URL:|
Kaushik A, Jaiswal A, Singh A K, Rizvi G. Challenges to new undergraduate medical curriculum due to COVID-19 pandemic and possible solution in India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=316410
| Introduction|| |
Medical education, for long time, in India was following a traditional education model with emphasis on knowledge and to certain extent skill, when neglecting other important domains such as attitude, communication, and skills. This traditional model of education was producing good academicians, but often lacking clinical skills and empathy toward patients. The Indian medical graduates (IMGs) were facing challenges in the form of lack of trust, violence, legal suits, and other multitude of problems. The reforms in medical education in India were long due. In view of newer challenges and to make medical education in India more holistic, community based, and with a goal of health for all, landmark reforms were introduced by the Medical Council of India (MCI) in the form of the new undergraduate curriculum.
While the MCI was grappling for the implementation of the new MCI curriculum, the novel coronavirus emerged as a mysterious pneumonia-like illness in late December 2019; it rapidly spread to affect nearly all countries around the world with as many as 4,525,497 cases documented and 307,395 deaths, as on May 17, 2020. To face and stop the spread of the novel coronavirus pandemic, numerous steps were taken by countries across the world as part of nonpharmaceutical interventions including social distancing, confinement to homes, and closure of academic institutes. As per the UNESCO, nearly 91% of students across the world are affected by this pandemic. In India, all educational institutes including medical colleges are closed since March 24, and there is uncertainty regarding opening of educational institutes.
For the successful implementation of curriculum, the MCI planned and desired a lot including faculty development, training, and development of infrastructure. The novel coronavirus pandemic posed serious challenges to the implementation of the new MCI curriculum.
| Implementation of the New Medical Council of India Curriculum|| |
From this session onward, the MCI introduced revised Graduate Medical Education Regulation 2017. This new curriculum introduced from current session in the first year is a competency-based curriculum with an attempt to introduce all domains of education, namely knowledge, skill, attitude, communication, and ethics (AETCOM) with an attempt to make medical education more community based while still being globally relevant. The aim of the new medical curriculum is to create “IMG possessing requisite knowledge, skill, attitude, values, and responsiveness, so that he/she may function appropriately and effectively as a physician of first contact in community while being globally relevant”.
This curriculum requires learner to achieve national, international, and learner goals that includes broad, exhaustive, yet inclusive list requiring all domains to be learned. The competency-based program is designed, so that the learner at the end should fulfill the roles of being a good clinician, leader, and member of health-care team and system; a communicator with patients and their families including community; and a lifelong learner committed to continuous improvement of skill and knowledge with professionally committed to excellence, ethical, and responsive and accepted to patient and community.,
This new medical curriculum required massive change in teaching, learning, and assessment methods in each subject and across all medical colleges. For the implementation of this new curriculum, each medical college is required to develop capacity to adapt for the implementation of the new guidelines. The approach needed to be sustained and faculty development is a major component of success of this new medical curriculum. The responsibility of the implementation of the new medical curriculum in an effective way lies on medical school leaders, with sensitization of faculty to new competency-based program and assessment methods. The faculty development is critical for success of this new curriculum. The next important change is required in students attitude to not focus merely on knowledge and marks scoring, but acquiring newer AETCOM skills.,
This new curriculum requires a competency-based approach; each competency requires certain domains such as knowledge, skill, attitude, and communication to be addressed with the level of competency required including know, know how, skill, show how, and perform independently. The competency can be core or desirable with suggested teaching method including lectures, small group discussion (SGD), bedside clinic, and demonstrate, observe, assist, and perform (DOAP). The assessment method could be written, viva, or skill assessment that requires clinical skill lab and practical. The competency can be integrated vertically to increase its relevance and basic understanding while horizontally integrated for wholesome understanding.
The first professional phase is of 13-month duration, preceded by 1 month of foundation course. The subjects included in the first year are human anatomy, physiology, and biochemistry, along with the introduction to community medicine, humanities, and professional development including AETCOM module and early clinical exposure (ECE) for horizontal and vertical integration. A total of 1736 teaching hours are allotted for first professional with 675 h to anatomy, 495 teaching hours for physiology, 250 h for biochemistry, 90 h for ECE, 52 h for community medicine, 54 h for AETCOM module, 60 h for sports and extracurricular activities, and 80 h for formative assessment and term examinations.
| Challenges in Following the New Medical Council of India Curriculum|| |
In the new MCI curriculum, the conventional teaching learning (TL) methods such as didactic lectures are discouraged, and teacher's role as per the new MCI curriculum is more of a facilitator, manager, planner, and performance assessor. This major shift requires teachers to phase out old methods and to implement newer and effective teaching modalities such as SGD and DOAP which are more learner centric. This major shift in teaching modality requires greater number of faculty, along with faculty development and training in the form of Curriculum Implementation Support Program. Various competencies and objectives require domains such as learning of certain skill and AETCOM, which can be acquired only by performing. Furthermore, methods of assessment require one-to-one interaction that is often difficult due to shortage of faculty. In this new MCI curriculum, numerous competencies require horizontal and vertical integration. Already stressed out departments with faculty crunch will rarely be able to spare time and make concept of horizontal and vertical integration successful. Although the concept of ECE is a novel one, with an aim of early familiarization of students to the hospital, the problem of implementation will remain, as this will again need cooperation from faculty or postgraduate students of clinical side. However, faculty or postgraduate students of clinical side will find really difficult to spare out time in peak hours of hospital work as they will be busy in OPD, wards, and their routine clinical works beside teaching students of their respective years.
The competency-based curriculum is not knowledge-based teaching approach and requires large number of competencies to be learned for effective clinical practice. This training module is based on learning and not time based and is more learner and patient centric as well as outcome and context oriented. The curriculum needs to be horizontally and vertically integrated. This curriculum identifies essential skills, teaching methods, and assessment based on essential domains of learning including knowledge, skills, attitudes, values, and responsiveness.
| Challenges Due to COVID-19 Pandemic for the Implementation of the New Medical Council of India Curriculum|| |
This COVID-19 epidemic has a huge socioeconomic impact. The coronavirus pandemic leads to closure of education institutes worldwide, and India is rather no exception. With closure of all educational institutes on March 24, 2020, all educational activities came to halt, although some teaching in the form of e-learning started slowly. In view of much higher risk of infection to medical students by the novel coronavirus due to clinical exposure, medical colleges were also closed. All educational activities including teaching, clinical attachments, essential competencies including skills assessments, and electives were cancelled.
In the recent past, medical education was disrupted due to severe acute respiratory syndrome (SARS) spread. The educational activities in medical colleges of Hong Kong were closed due to the spread of the coronavirus for few days. With suspension of teaching activities, initiatives were taken to integrate information technology and problem-based learning in teaching methods. The SARS spread was contained and educational activities were resumed in a month and in few days' time. The University of Toronto, Canada, also restricted educational activity at the time of SARS spread. However, extent of disruption in medical education at the time of the coronavirus pandemic has already taken months with uncertainty about regular classes are looming ahead.
The developing countries like India are facing serious, never seen challenges in field of medical education due to the coronavirus pandemic. This pandemic compounded challenges in the implementation of the new MCI curriculum this year. The new MCI curriculum is implemented in the current batch with special emphasis on higher domains of learning. In the first year, besides preclinical subjects including anatomy, physiology, and biochemistry, community medicine is also added along with dedicated hours for ECE and AETCOM. This COVID-19 pandemic leads to a huge and different challenge to each subject.
The anatomy subject has the highest number of topics (82) and the highest number of outcomes (409). In anatomy, nearly 170 competencies have domain level of above knowledge (K) and nearly 160 competencies needed skill assessment. Further considering the number of objectives within the abovementioned competencies, the task gets more challenging. The subject of anatomy is based on visual and skill-based learning involving dissection to learn about course, relations of organs, their arteries, veins and nerves, bones, joints, radiological anatomy, surface anatomy, and histology. The cadaveric dissection is an indispensable aspect of anatomy and still considered the most effective way of teaching anatomy. Discontinuation in regular teaching modalities leads to a loss of practical-based learning materials including cadaveric teachings, three-dimensional (3D) models, viscera and soft specimen, skeleton, and others.
In physiology subject, the number of topics is 11 and the number of outcomes is 137. In physiology, nearly 20 competencies have domain level of skill and needed skill assessment by objective-structured clinical examination (OSCE) and objective structured practical examination (OSPE). All the twenty competencies are based on basic hematology, nerve muscle physiology, gastrointestinal physiology, cardiovascular system, and respiratory system with skills required to assess physiology of different organ system and effect of various physiological conditions on these systems. All the competencies and subcompetencies represent core clinical activities needed for the diagnosis and clinical care of the patient and therefore cannot be compromised. Loss of mastering on these essential competencies will be detrimental to student.
In biochemistry subject, the number of topics is 11 and the number of outcomes is 89. In biochemistry, nearly 12 competencies have domain level of skill and needed skill assessment of OSCE and OSPE. All the 12 competencies requires exercise such as urine analysis, estimation of serum levels of various proteins, enzymes, metabolites, and various commonly used equipment and techniques essential to assess function of different organs and systems. All the competencies and subcompetencies are needed to be acquired by the first-year medical students to understand clinical application of medical biochemistry in the context of diagnosis and management of the patient. The loss of acquiring these essential competencies will create lacunae in long-term performance of students.
With MCI emphasizing on community aspects of health care, early introduction of community medicine orient student about management, communication, counseling, assessment of the population health, and determinants of health and disease, concept of prevention of diseases which becomes unquestionably relevant in prevention of spread of infectious diseases pandemic like COVID-19.
The ECE was introduced in the new curriculum with objectives of while enhancing recognizing and enhancing basic science learning and recognizing their clinical context with patients motivation to learn. Loss of regular classes due to pandemic is leading to loss of clinical correlation to basic sciences, authentic human contact, and introduction to AETCOM, a novel and essential concept introduced in this curriculum.
Although e-learning started in the form of online lectures, numerous challenges must be addressed to achieve competency-based learning according to the new MCI curriculum. First, the concept of e-learning was present in few medical colleges across India and most of the medical colleges were short of infrastructure needed. The challenges associated with e-learning in India including lack of infrastructure such as hardware, software, poor internet speed, frequent disruption, and poorly skilled technical staff. These technical challenges can lead to a poor yielding lecture for students. The teachers were also not trained for a good online lecture that may lead to lack of confidence, limited dedication, poor communication, and lack of motivation on student's part. On part of medical students, the issues remain more or less same like lack of infrastructure in their home, poor internet speed, and not used to e-learning; this may render them unenthusiastic regarding online teaching.,, This curriculum is a competency-based curriculum, and except for few competencies which are based on knowledge domain and few hours dedicated to self-directed learning, large number of competencies with their objectives cannot be achieved by e-learning. This failure of achieving higher levels of learning as directed to be achieved in competencies will lead to failure of implementation of the new curriculum. The online assessment of competencies is another major challenge. The horizontal and vertical integrations are rarely possible by e-learning because of either shortage of faculty, especially from clinical side who are more involved in COVID-19 management.
Other notable challenges are faculty development and infrastructure development. One important part of COVID-19 management is faculty development including training of faculty in view of the new MCI curriculum such as Curriculum Implementation Support Programme. This pandemic leads to stoppage of training activity, which can be a major roadblock in curriculum implementation. Infrastructure development is also essential for the new MCI curriculum; economic impact of COVID-19 will certainly reduce infrastructure development because of financial difficulty, especially in developing countries like India.
| Possible Steps Can Be Taken|| |
The unprecedented nature of this pandemic created uncertainty and anxiety among medical students and requires flexible, comprehensive, yet compassionate mitigating strategies. In India, with resource-limiting settings in most of medical colleges, practical yet effective mitigating strategies are required.
This pandemic compelled educational institutes to adjust with new reality and requires new teaching approaches that may not be best but still be an alternative to carry out educational activities. Earlier in SARS pandemic of 2003, the web-based learning was used for minimizing impact on medical education, but providing only online didactic lectures, books, and Atlas More Details is not suffice to understand human body. The web-based learning is now the only possible solution. There is an urgent need for the formulation of online course that can provide best solution for pause in regular teaching. Both teaching and self-directed learning are needed. Novel teaching modalities are required to counter disruption in medical education. Online webinars with high student engagement were found to be useful. Inclusion of clinical conditions and case-based study and clinical examination with active involvement of students can enhance learning experience.
According to the author's view, a dedicated approach is required to counter this disruption in regular teaching. The formulation of dedicated teams in medical colleges including representation from deans, various department, faculty, technical staff, and students across all professional can formulate effective strategies. This faculty–student-driven approach can lead to effective change. A well-charted approach and multimodal effective communication by E-mail alerts about course formulation and assessment can provide clarity to students and teachers. A web-based course should be designed including designing of modules based on concept of “think-pair-share” with short 10-15 minute lecture by faculty, intermittent multiple choice question(mcq),critical thinking exercises to encourage student interactivity and discussion. the web based course can be designed comprising of syllabus, lecture notes aided with online communication tools (discussion tool), practice question bank, programmed feedback, and online assessment. The students should submit their online response by mail or class website, and further follow-up questions will enhance student knowledge.
Advanced technological tools, including dedicated online software programs, are present for subjects such as anatomy and home-based learning by virtual reality is possible and availability of smart phones with required software can be used for these virtual reality program. However, besides cost factor, technological issues such as lack of teachers and students training to use these programmes, difficulty in manipulating online 3d models and to focus on point of interest during use of software, will be the major challanges in using these online tools. The department can provide teachers prerecorded videos, explaining stepwise dissection in addition, students can access online dissection videos to enhance their learning. Online digital cadaveric photographs, interactive images, and self-testing tools along with one-to-one interaction in the form of chats and tutorials will improve online teaching quality., The use of virtual slide-based learning in histology can be used for learning. This virtual-based mode of learning histology was found to be successful by various authors with high level of acceptance among students and teachers with nearly same performance levels as achieved by conventional microscopy.
The suspension of all clinical activities leads to stopping of ECE; the possible solution to ECE can be simulated clinical experience, formulation of new webinars, online clinical skill posting, flexible self-designed case studies and skill-based projects, and involvement of students in skill demonstration.
With discontinuation in regular teaching and use of e-learning, there can be problems in assessing knowledge, skills and other higher learning domains like attitude and communication. The assessment framework needed to be modified according to the curricular adaptations done in the current pandemic. Certain medical institutes have adopted open-book examination approach as an effective way of assessment with reduced student anxiety., The formative and summative assessment needs to be flexible. The formative assessment of students can be structured into multiple opportunities divided into various smaller and larger teaching–learning activities. The feedback and formative assessment in all first-year subjects can be done in the form of MCQ, short-answer question, online tutorials, structured viva, and video-specific tasks for competencies requiring knowledge as assessment. The assessment of skills requiring workplace-based assessments in the first year with suggested TL method being DOAP sessions and suggested assessment methods being practical/OSPE needed to be deferred till regular classes resumes or can be assessed later with subjects with which first year competencies are vertically integrated.
In anatomy, the topics such as radiological anatomy, surface anatomy, and histology can be assessed by online viva of radiological, body image, and virtual slides. The bones and models assessment can be done by 3D images and models to be labeled by thr student during the online tutorials. The assessment of competencies that requires laboratory procedures and skills to be performed like blood pressure measurement, of blood pressure, hemoglobin estimation, and system-specific DOAP session needs to be deferred or should be merged with vertical competencies and can be assessed later.
In pre-COVID ties, written examinations were done with large numbers of students in examination halls and practical halls, but during COVID-19 pandemic, increased numbers of examination venues with lesser number of students will be needed.
The monitoring of task such as history taking and clinical reasoning of virtual patients can be done by Entrustable Professional Activities., The mini-clinical evaluation exercise tool can be used (remotely) for assessment. E-portfolios with activities such as video-specific tasks can be used for formative and summative assessment.
Although numerous promising online tools are available for assessment, overzealous compromise on the assessment of first-year students can lead to far reaching consequences, so according to the author view, assessment of students should not be compromised and possible delay in session or assessment of competencies in the next semester or professional may be an answer.
One possible solution is extension of first professional duration for further 2 months, as haphazard and excessive teaching on resumption of studies will only lead to undue stress on students. Although not a possible replacement, online training can be given to faculty by the MCI till resumption of training is possible by the MCI.
The higher education, especially medical education, is much needed for nation development; government should find way to maintain or increase funding of government medical colleges for infrastructure development and simultaneously develop resources and training of faculty for more effective e-learning. With unpredictable course of this pandemic, there is a need of formulating assessment strategies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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