Designing a Competency-Based Unified Logbook in Community Medicine for Outcome-Based Learning

The competency-based medical education curriculum (CBME) guidelines were revised by the National Medical Commission (NMC) in September 2024 for implementation in 2024–25 onwards. These guidelines increased the number of competencies. NMC mandated two logbooks—one for CBME and another for Family Adoption Program (FAP). The observations made by the author in 20 medical colleges of India in different states indicate use of multiple logbooks which are poorly designed and do not fulfil the mandate of NMC. “Logbooks are declining despite their value.” This editorial makes a case for revival (modification of traditional logbook) and designing a unified logbook in Community Medicine for outcome-based learning. WHAT IS A LOGBOOK? Logbook is a verified record of the progression of the learner documenting the acquisition of requisite knowledge, skills, attitude, and/or competencies. It forms an integral part of the formative/continuous assessment program. Successful documentation and submission of the logbook is a prerequisite for being allowed to take the final summative examination. Logbook aims primarily at faculty and students. BENEFITS OF A LOGBOOK Logbook is an important tool for self-directed learning Helps in documentation of competency, activity and accreditation. It identifies gap in the curriculum Provides supervisor’s feedback mechanism A tool for formative/continuous assessment ESSENTIAL COMPONENTS OF LOGBOOK These include the name and the number of a specific competency addressed, its learning objectives in behavioral terms, and planning of activities, derivation of components of the activity (tasks) to be performed by the learner to achieve the stated objectives. Criteria for successful completion of an activity, remedial, and constructive feedback are the other key components. Expected learning outcomes of an activity are addressed in the beginning itself by the faculty as it helps in grading the activity and its completion satisfactorily by numerical score/objective criteria. The competency table is an adjunct to logbook; therefore, domains and level of competency required, teaching, and assessment methods form the essential component of the logbook.1–3 IMPLEMENTATION PROCESS The learner is primed and provided learning aids/resource material required to perform an activity effectively. Date of completion of an activity is recorded in the logbook, followed by attempt at activity—First or only (F), Repeat (R), Remedial (Re), as determined by the faculty. Faculty also determines the level of achievement or objective criteria using numerical score that determines satisfactory (meets expectations) completion of an activity that contributes toward acquisition of the competency. The activity performed is rated as Below (B) expectations, Meets (M) expectations, and Exceeds (E) expectations. The faculty also prescribes what a learner should do if he/she does not meet expectations and hence not successfully completed an activity, i.e., should he/she repeat the activity? Should there be remedial training after X number of repeats? As per decision of the faculty if an activity is completed and entered in the logbook is closed and certified (C) or an activity needs to be Repeated (R) without further intervention or an activity needs Remedial (Re) action usually done after repetition did not lead to satisfactory completion. Remedial is thus a planned activity aimed at correcting deficits that prevent the learner from achieving intended outcomes. The mentor signs with date and the learner signs on feedback received if any. Finally, the learner narrates and reflects back his/her feelings and thoughts of experiential learning. Reflective narratives are important educational tools to train and assess competencies related to communication and ethics (soft skills). IMPLEMENTATION STRATEGIES—THEMATIC AREAS Root Community Medicine in the community—have a good look at the community. “Know community you serve before knowing Community Medicine.” Keep liaison with community, i.e., regular contacts and communication. The Department of Community Medicine takes responsibility of or adopts a defined urban slums or villages and allots families to students. Students maintain sustained contacts and communication with families and community at an interval of one month throughout the course curriculum and follow families longitudinally to update their health status. Utilize digital innovation of the healthcare delivery system that links all families and individuals with a dynamic health system. CHALLENGES AND SOLUTIONSTHE WAY FORWARD Department of Community Medicine has a responsibility to identify the key skills in the subject of community medicine and focuses on competency-based learning throughout the course curriculum. Split the complex competency into parts and address one part at a time for better comprehension. Move out of classroom into a real-life field situation for learning or else bring back real field experiences to classroom. Focus on participatory learning, practice integrated teaching, integrated curriculum by system-based learning, community-based and problem-based learning. Mentor prepares community and families well in advance before the visit of the learner and primes him/her with the learning objective of the competency and planning of activities. Plan and organize skill-based learning by adopting a matrix of implementation plan which illustrates as to who will do what activity, at what time, and at which place with what resources/inputs. This gives an overview of activities against which monitoring can be undertaken. FAMILY ADOPTION PROGRAM AND THE LOGBOOK The NMC envisages that FAP shall include villages not covered under the primary health center (PHC) adopted by the medical college and if travel time is more than 2 hours on weekends, in such a situation, bastis/jhuggis/towns or on outskirts of cities may be adopted. Since 2019, CBME is being implemented in the field practice areas of adopted PHC. Implementation of FAP in a different and new geographical area makes little sense. This dichotomous arrangement of pursuing activities in two locations is a challenging task. This approach jeopardizes the success and achievement of objectives of FAP. Entering in a new territory and an unfamiliar area where the Department of Community Medicine has no infrastructure, and no inputs of manpower or service responsibility is a frustrating experience, leading to administrative and operational problems. The show-how competencies being pursued in the existing PHC need to be integrated with competencies of FAP and pursued in the already adopted field practice area of PHC. This unification is necessary for designing a one unified logbook. Therefore, families must be allotted in the existing field practice area rather than moving to a new unfamiliar territory. Further two or at the most three families be allotted to one student for longitudinal follow-up for maintaining sustained communication and contacts.4 Further FAP needs to be integrated with the existing model of health care at family, household, and community level wherein community health workers make regular home visits and maintain sustained contacts/interactions with the community and target population. These community health workers provide outreach and clinic-based comprehensive primary healthcare services linking families, households, and community with Health and Wellness Centers (HWC). These workers have adopted life cycle approach for continuum of health services and have created a database of all resident households, families, and individuals of the catchment area. They use these data to assess healthcare needs, plan their fixed work schedule for coverage of the area and regular reporting of their work.5 DIAGNOSTIC CAMPS APPROACH/MULTISPECIALTY CAMPS UNDER FAMILY ADOPTION PROGRAM NMC visualizes that every medical college may arrange one multispecialty camp in the villages, followed by annual diagnostic camps by the Preventive and Social Medicine departments, wherein identification of anemia, malnutrition in children, and common NCDs (hypertension, diabetes, ischemic heart disease, kidney diseases, and other local problems) can be addressed. The purpose of these camps is to capture most common illnesses prevalent in the community. The camp approach is a high pitched and short-lived activity. This approach is transitory unsustainable and seldom achieves a continuum of care and linkage of families, households, and community with healthcare delivery system across various life stages. The better alternative to camp approach is capturing monthly/annual outdoor morbidity data of HWC of the area to get seasonal variation of diseases, their trends, and availability of essential medicines and diagnostic services. The other way to determine community health needs and disease burden is to capture mortality data of last one year of HWC area and causes of mortality as recorded by health workers. The problem of anemia can be best captured by participation of learner and faculty in regular ongoing screening program/campaign of anemia in school-going children, adolescents, and pregnant women under Anaemia Mukt Bharat program and the nutritional status of under-five children from anganwadi center and noncommunicable diseases data from community-based screening cum education program by using community based assessment checklist (CBAC) scoring system. Similarly, involvement of learners in regular campaigns like diarrhea fortnight, intensive immunization, national deworming days, mass drug administration under filaria elimination, and adopting behavior change communication model are much more rewarding and memorable experience and learning in real-life situations. CONCLUSION Most of the Community Medicine departments in India are implementing poorly designed logbooks as a matter of compliance only. Revival/modification of traditional logbook to a unified single logbook is an imperative need to pursue CBME program. Implementation of poorly designed logbook does not achieve the purpose/objective of CBME program. It is a serious issue, hence an urgent priority area for research study. HIGH IMPACT RECOMMENDATIONS Design a unified one logbook as per mandate of NMC by including all the essential components as enunciated in the editorial. Implement it in letter and spirit. Frame learning objectives for each competency addressed, in behavioral terms. Identify activity/ies and its components (tasks) and provide adequate learning resource material to carry out the task effectively. Define the expected learning outcomes at the beginning and objective criteria to grade/rate the completed activity. Provide remedial measures and constructive feedback to the learner on a regular basis. Pursue research projects/thesis on the issues of logbook in community medicine, besides upgrading the skill lab within the department with adequate learning resource material. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.