Competency-based Medical Education

Shakti Kumar Gupta

Shakti Kumar Gupta

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Shakti Kumar Gupta hails from a border Village Ari (LOC), Dist. Poonch, J&K. Commencing his medical career at grass-root levels as an Assistant Surgeon in J&K Health Services, he provided curative, preventive, promotive and rehabilitative services at dispensary and primary healthcare centres. His quest for achieving professional excellence propelled him to relocate to AIIMS New Delhi where he joined as a faculty. He was Medical Superintendent at Doctor RP Centre for Ophthalmic Sciences, New Delhi for fifteen years. He is Fellow of National Academy of Medical Sciences, International Medical Sciences Academy, Academy of Hospital Administration, and Institute of Hospital Engineering. He has been the recipient of WHO Fellowship to study accident and emergency services at USA, and Management Development Programme of National University, Singapore. He is presently ED & CEO of AIIMS, Jammu.

Medical education aims to train graduates to take care of the health needs of the society. The existing curriculum is subject-centered and time-based. Most evaluations are summative & focus more on knowledge than on attitude and skills. Thus, graduates lack the basic required skills. CBME is targeted to achieve this paradigm shift in Medical education.

Medical education is metamorphosing into objectivity and every detail needs to be captured and replicated. To achieve the national goal of “health for all,” it is an inescapable need to understand the felt needs of the society they serve in. Medical education in India, however, has lot to be desiredto meet this expectation. It is time to reengineer the traditional medical education to competency based education. There is a huge challenge in converting it to deliverables. The aim of imparting medical education is to train graduates to efficiently take care of the health needs of the society. The current medical education system is based on a curriculum that is subject-centred and time-based. Most  valuations are ummative, with little opportunity for feedback. The teaching–learning activities and the assessment methods focus more on knowledge than on attitude and skills. Thus, graduates may have extraordinary knowledge, but may lack the basic clinical skills   required in practice. In addition, they may also lack the soft skills related to communication, doctor– patient relationship, ethics, and professionalism (EPA’s). Change is inevitable and more so the management of change is a huge issue.

The need of the hour is to allay this apprehension and address the key issues that are hindering the implementation of CBME. There are three Components of CBME, Competency, Entrustable Professional Activity (EPA) and Milestones.

The term “competency” refers to a combination of skills, attributes and behaviours that are directly related to successful performance on the job. Core competencies are the skills, attributes and behaviours which are considered important for all staff of the organisation, regardless of their function or level. Managerial competencies are the skills, attributes and behaviours which are considered essential for staff with managerial or supervisory responsibilities.

This refers to the application of skills in an actual setting, and an individual who is able to do so is considered competent. The Medical Council of India (MCI) (Presently National Medical Commission, NMC) has also suggested that competencybased learning must be implemented in all the medical colleges. It would include designing and implementing a curriculum that would focus on the desired and observable ability in real life situations. The criteria of change is in changing people’s behavior.

Entrustable Professional Activity (EPA)

EPA helps bridge the gap between the theory and practice of CBME. While competencies are the abilities of a physician, EPAs are descriptors of work that define a profession. The process and outcomes of EPAs are observable and measurable. They require multiple competencies in an integrative, holistic nature. For example, let us consider Oncological assessment as the EPA. It would require a definite set of knowledge (the clinical presentation, the investigations needed, and the treatment protocol), skill (clinical interviewing, general and systemic examination, and interpretation of the reports), and attitude (communicating with empathy, inviting questions, and offering appropriate guidance and advice). The core competencies reflected here would be those of a clinician, a communicator, and a professional.


A competency is achieved gradually, step-by-step. These steps are designated as milestones. The Dreyfus model as applied to education would have five such steps or milestones. These are a novice, advanced beginner, competent, proficient, and expert.

CBME will help tody’s learners to become better physicians of tomorrow by providing a holistic experience. Radical educational thinking and new medical program accreditation process in India provides us an opportunityto reconsider  existing approaches to medical education.

CBME will focus on individualised customisation and level playing field of teaching. Individualised learning facilitated through CBME will ensure that competencies are being met for each stage. Students will receive more personal upervision, mentorship and day-today assessment. Increased flexibility may provide additional opportunities for enrichment of knowledge during electives. Students will get equal opportunity of learning and performing the task at their own pace without being compared to other fellow learners avoiding peer pressure in particular. Mastering essential clinical skills will provide necessary impetus by enhancing preparedness for practice.

Faculty will see and feel the paradigm shift in their role while implementing CBME. They will help the teachers to handhold and be a part of the teaching learning process rather than just deliver lectures. The incorporation of different instructional methods, namely small group discussions, early clinical exposures and linkers allows the teachers to facilitate active learning. Teaching will be based on well-defined learning outcomes; hence, they can focus on specific observable competencies. Thus, teacher centered approach will be properly aligned with student centred teaching without replacing each other.

CBME has been suggested and tried to tackle these concerns. This means that teaching–learning and assessment would focus on the development of competencies and would continue till the desired competency is achieved. The training would continue not for a fixed duration, but till the time the standard of desired competency is attained. Assessments would be frequent and formative in nature, and feedback would be inbuilt in the process of training. Furthermore, each student would be assessed by a measurable standard which is objective and independent of the performance of other students. Thus, it is an approach in which the focus of teaching–learning and assessment is on real-life medical practice.

Despite the broad endorsement of CBME as a core strategy to educate and assess the next generation of physicians, major concern is about reductionist approaches in CBME, lack of standardisation and assessments. We have to take little steps towards this change in education system. CBME remains the best possible solution for most of the problems inherent to conventional system of medical education in India. Hence, a systemic collaborative approach and dedicated involvement of all the stakeholders; medical educators, students and policy makers will ensure successful implementation of CBME.

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