The new competency-based medical education in India: Are we going to produce elite quacks?

New competency-based curriculum for medical graduates (competency-based medical education [CBME], 2019) brought about a paradigm shift, which was being planned about a decade back. In the year 2011, erstwhile Medical Council of India published a policy document - VISION-2015, where competency based medical education (CBME) and the term Indian Medical Graduate for a skilled basic doctor was first proposed.[1] Unlike the old curriculum which focused on knowledge, was organized on systems and disciplines, was time based, and had a summative evaluation, competency-based learning emphasizes the skills required for medical practice. It focuses on learning the competencies needed in clinical practice and provides standards and framework for measuring performance.[2] The thrust of the new curriculum attempts to make medical education in India more outcomes oriented. The new curriculum identifies certain skills, describes methods and contexts of teaching, and recognizes standardized measurement of competencies. This outcome-oriented new UG curriculum is intended to provide the orientation and necessary skills for proper care of the patients. In particular, the curriculum provides for early clinical exposure, longitudinal care, and skill acquisition. The acquisition of skills is given utmost importance as an indispensable component of the learning process in medicine, and a detailed procedure of certification in certain essential skills is being prescribed, with the provision of the establishment of skill laboratories in a simulated and guided environment.[3] It lists 412 topics for learning and 2949 outcomes to be mastered. It argues that broad competencies can be achieved in a phased manner while retaining the subject-wise character of the current organization of specialties and integrating teaching and learning across disciplines during the undergraduate course.[2] However, a question has been raised regarding the relative importance given to the element of knowledge acquisition in comparison to that of skill development in the new curriculum. It is also said that the sections of cognitive components covered during the deliberation of basic disciplines are grossly undermined.[4] The basic subjects delve into the fundamental premise of structure and functional homeostasis in human health and disease. A thorough and critical understanding of the subjects is not only essential to comprehend the pathophysiology of the diseases, to know clinical features and to frame therapeutic decision-making; the cognitive foundation of prospective academics in the field of medical science is also created. As per Bloom’s taxonomy, the domains of learning are cognitive, psychomotor, and affective, which broadly signify the knowledge, skill, and attitude components of learning, respectively. In the present curriculum, there is a substantial emphasis on the noncognitive domains with the provision of the foundation course, AETCOM module, early clinical exposure, and a battery of skill development components, but the cognitive domain is rather de-emphasized. In Bloom’s original taxonomy (1956), the cognitive domain was further stratified into six levels such as knowledge-comprehension-application-analysis-synthesis-evaluation,[5,6] whereas the revised taxonomy (2001) espouses a slightly different one with an addition: Remember-understand-apply-analyse-evaluate-create,[7] wherein create is introduced as a higher order of cognitive goal. There are lengthy discussions and critical appraisal on these research areas of educational psychology in a large number of literature in India and abroad for the last several decades.[8] Without going into the details, it can be reasonably implied that intensive and extensive cognitive learning is needed to build up a strong foundation of basic subjects at the outset of UG tenure to develop appropriate acumen for analytical and evaluation proficiency in young enthusiastic minds. This initial preparedness will lead to the development of innovativeness and attitude for inquiry and research among medical graduates. However, relevant research in the field of medical education in our country is surprisingly sparse which indicates that the medical educationists of India are doing little groundwork and imposing certain overseas model to fit in. In the current UG curriculum of medical graduates, the competence classification is leveled as know-know how-show how-perform that indicates an apparent goal of performing ability and skill acquisition of the students.[2] At the lowest level of the pyramid is knowledge (knows), followed by competence (knows how), performance (shows how), and action (performs). This Miller’s (1990) work-based assessment model for clinical competence is practically generalized as the basic model of UG medical education. This is in contradistinction to Bloom’s taxonomy model of cognitive levels, as discussed earlier, which emphasizes the creative and innovative aspects of the learners. Thus, a relative overemphasis on the component of skill and competence than the knowledge component becomes the hallmark of the new CBME. In the absence of meaningful and significant works in this area of education research, it is not really a prudent proposition. It is also well known that CBME focuses on immediate needs and is less focused on preparing learners with the flexibility needed for a more uncertain future and does not suit subject areas, where it is difficult to prescribe specific competencies or where new skills and new knowledge need to be rapidly accommodated. It also takes an objectivist approach to learning and does not suit developing a higher level, more abstract knowledge and skills requiring creativity, high-level problem-solving and decision-making, and critical thinking.[9] Knowledge-based learning is also essential for clinical practice.[10] Another area in the present curriculum where there is an apprehension of potential downslide of the cognitive component is the introduction of too much objectivity in the student evaluation system. For example, the proposition of objectively structured practical examination (OSPE), objectively structured clinical examination (OSCE), and simulated experimentation in virtual platforms is said to substantially replace the conventional pattern of practical and clinical examinations. Practical teaching is one form of active learning or the process of having students engage in an activity that forces them to reflect on ideas and how they are using those ideas. Knowledge is gained through a cycle of hands-on experience with reflection guided to the conceptualization and then returning to the application. When complemented by self-assessment, the students’ understanding and skills are further enhanced. Practical teaching is a student-focused learning rather than a teacher-centric deliberation that leads to increased student interest, attention, and knowledge retention. This facilitates better solutions to problems, increased mastery of conceptual reasoning, and better retention compared to learning alone.[11,12] The practice of conducting scientific investigation even in a small setup of UG laboratory leads to the acquisition of fundamental scientific concepts and is critical in nurturing a lifelong interest in science. It also provides opportunities to develop research skills crucial in science and medicine careers, including precision, accurate measurement, and the mastery of often delicate equipment. It also develops important transferable skills, such as teamwork, resilience, and analysis. Fundamentally, medical science is a practical discipline and, by undertaking good practical science at the UG level, one gains the proper scientific temper that might help the student to adopt a science-related occupation in the future.[13] In conventional practice, the examinee has to perform and conduct the whole experimental procedure or clinical workout under the supervision of the examiner and draw the result and conclusion. However, in OSPE/OSCE setting, the whole experimentation, testing, and clinical examination is not done by the students during the practical examination. It is only a piecemeal portion of the whole experiment is prepared in a highly objective manner in front of an “informed observer,” who may not always be qualified examiner personnel (i.e. non-teaching staffs or lab. technicians of the department etc). It has been observed by the seasoned examiners that, very soon after the onset of the examination the examinees come to know about the OSPE/OSCE items, memorize and mechanically follow suit in a rote manner. Accordingly, the desired objective of the examination is not fulfilled. As a consequence, there may be an adverse and detrimental effect on the practical, clinical, and experimental learning of the students, simply because the major proportion of the students intends to perform in the examination only. The students might lose interest in conducting experimental practical in regular classes, and may fail to learn proper clinical examination procedures. Poor physical examination skills are a threat to patient safety as the probability of diagnostic errors and oversights is increased. Sir William Osler told, “The whole art of medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do.”[14] The age-old module of imparting practical teaching characterized by “causal inference from experiment and observation”[15] is largely ignored. It is well known that a good practical lesson cannot be replaced by a virtual session.[16] As Max Plank wrote, “Experiment is the only means of knowledge at our disposal. The rest is poetry, imagination.” Accordingly, there exists a reasonable apprehension that the cognitive foundation of the budding medicos will be liable to be compromised in the hype of skill training, too much objectivity in assessment protocol, and lack of actual experimentation. The new system would produce more of elite quacks than scientific doctors.