Competency-based medical education (CBME) is an outcome-based education. CBME comprises of roles or competency domains or graduate outcomes, which goes beyond the medical knowledge and skills. The CanMEDS competency framework of Canada and ACGME competencies of USA are some well-known outcome-based medical education frameworks. These frameworks listed leadership, collaboration, communication, professionalism, scholarship, advocacy, etc., as the outcomes (terminal competencies) apart from the clinical/medical expert competencies. The Indian Medical Graduate roles also demand the basic doctors trained in India from 2019 to acquire abilities related to leadership, collaboration, communication, life-long learning apart from the role of the clinician. This means a robust and longitudinal process assessment system is required to monitor and evaluate these additional roles among all the Bachelor in Medicine and Bachelor in Surgery (MBBS) students.
The process assessment system is a bit different from the content assessment system as it is done to observe, document the observation, provide feedback, improve performance on the basic of the feedback and take low-stake/high-stake decisions on the roles/competency domains that are not usually assessed in the form of content assessment. The content assessment focuses on the assessment of the competencies, sub-competencies, and outcomes/objectives of individual subject matters using knowledge (cognitive) and skill (psychomotor) domains but it does not regularly assess the behavior/attitude (affective) domain. Hence, process assessment can complement/supplement the student assessment system to fulfill this gap in the medical student assessment system. Therefore, a hybrid integrated teaching learning and assessment systems are required to use formative as well as summative assessment in undergraduate medical education.
The process assessment system can be started in the foundation course, basic sciences phase, and clinical sciences phase of the undergraduate medical education curriculum. Process assessment works well with the small group teaching learning activities and this article aims to share experiences and insights for its use in the basic sciences phase of the MBBS curriculum.
IMPORTANCE OF PROBLEM-BASED CURRICULUM AND PROCESS ASSESSMENT SYSTEM
The process assessment system in small group discussion sessions is required to do continuous monitoring of the competencies and the program evaluation. One of the most widely used small group discussions in medical education is the problem-based learning (PBL), which is a structured teaching learning process where teachers function as the facilitators of the discussion instead of the information provider using a 7-jump process. PBL is well suited to integrate basic science subjects using a “clinical case” as it helps the students to learn in the context.
PBL is either implemented as one of the teaching learning activities (session level) or the main teaching learning tool to integrate the basic science subjects horizontally and clinical science subjects vertically (course/program level). PBL cases for both the cases are normally written by a small team of basic sciences, clinical sciences, and community medicine faculties, which is also validated in a large group of senior faculties. PBL case is structured around “triggers” or the “case vignettes” for the students, whereas it also provides “objectives” and “cues/probes” for each of the triggers for the facilitators. PBL follows adult learning principles and promotes active learning.
Since PBL is mainly used to foster self-directed learning among the learners, facilitators cannot (must not) teach the contents in the PBL tutorials. This means a robust facilitator training program is required to implement it well at the session/course/program level. PBL case also requires a detailed “tutor guide” as the facilitators (faculty) will be from various disciplines and they need to understand the key concepts of other disciplines covered by the case to effectively facilitate the discussions. PBL case objectives of a hybrid integrated basic sciences curriculum must be part of the week objectives, which in turn are part of the integrated organ-system module outcomes and the basic sciences terminal competencies.
PBL facilitators, also known as tutors, can monitor a group of students for a long period of time. They act as a facilitator and provide critical inputs to manage the group dynamics in the PBL tutorials. PBL can also be used to assess the other competencies as various traits/behaviors can be observed during “forming-storming-norming-performing-adjourning” stages of the small group sessions. PBL tutors can observe self-directed learning (preparation and participation), leadership, communication, professionalism, critical thinking, group skills, and reflective thinking. Once these attributes are observed and documented systematically then it can be used to provide focused feedback to the students to foster these competencies during basic sciences phase of the MBBS curriculum. Since the feedback must be given timely to be useful, planning the appropriate time for the feedback session in a suitable setting is absolutely critical.
The PBL approach requires a lot of planning in terms of resources and capacity building. Implementation of the hybrid PBL curriculum requires rooms to conduct small group sessions, which also needs to be equipped with white boards, markers, tables, chairs, and other amenities that will be required for any PBL case such as view box, medical dictionary, etc. It also requires trained faculty and well-oriented students. It needs a strategy for collecting data from tutors as well as students to take formative and summative decision based on the feedbacks and scores.
IMPLEMENTATION OF THE PROBLEM-BASED LEARNING CURRICULUM AND PROCESS ASSESSMENT SYSTEM
Patan Academy of Health Sciences (PAHS), established in 2008 by the act of Nepali parliament, is an autonomous health science university of Nepal. The PAHS School of Medicine (PAHS-SOM) is using a hybrid PBL curriculum and the community-based learning and education program in the basic sciences phase of the MBBS curriculum since 2010. PBL was also used in the 6-month long introductory (foundation) course to teach medically relevant physics, chemistry, biology, mathematics, computer, etc., for the first 5 years before it was replaced with a 2 months long foundation course with strong emphasis on the medical humanities, ethics, and communication.
PBL is the main teaching learning methodology of the 2-year long basic sciences phase of the MBBS curriculum of PAHS-SOM, which covers nearly 60% of the contents of all the basic science subjects. The syllabus of six basic science subjects, namely human anatomy, human physiology, medical biochemistry, medical microbiology and immunology, clinical pharmacology, and pathology along with community medicine and early clinical exposure from Nepal and abroad were reviewed critically and discussed widely with national and international faculty for more than 3 years.
After a long discussion, it was decided to use Nepali-Canadian model of hybrid PBL curriculum where contents (learning outcomes/objectives) of each basic science subjects were mapped to the various organ-system modules (blocks), for example, hemopoetic, respiratory, cardiovascular, gastrointestinal, musculoskeletal, etc., blocks [Table 1].
These learning outcomes/objectives were then mapped to the weekly objectives of each block staring from the basics to complex situations for that organ-system block in a spread sheet [Table 2]. The first two blocks were designed to provide foundation knowledge and skills on six basic science subjects and organ-system based blocks started thereafter [Table 1]. The Principal of Human Biology II block, shown in Table 1, focused on the autonomic nervous system, immunology, and genetics.
The duration of some of the blocks was modified based on the continuous feedback from the faculty and the students. Some blocks were separated out, for example, endrocrine metabolism and reproductive block was divided into two separate blocks: Endocrine and metabolism and reproductive system blocks, respectively, as per the feedback from the students, faculty, and exam section.
The first basic sciences PBL case was on “body ache/fever” in a child and it covered only three subjects: Anatomy, Physiology, and Pharmacology in a “Principals of Human Biology I” block whereas the “upper respiratory tract infection” in an adult man covered most of the basic sciences and community medicine contents in the respiratory block [Table 2]. Each PBL case of this hybrid PBL curriculum was identified to cover the weekly objectives and not more than five didactic sessions were planned for the basic sciences subjects along with 2–3 practical sessions to teach basic sciences skills to the medical students.
During this process, many “nice to know” and some “better to know” basic science contents were removed/dropped from the PAHS-SOM MBBS curriculum with active involvement of the founding dean and team of clinical faculty.
Table 2 also shows how the weekly contents were mapped and a PBL case was selected for that particular week. Some of the contents were shifted to succeeding weeks based on group discussion and consensus. Each PBL case of the week was selected based on the weekly contents but it was also selected using one of these three criteria: Common case (e.g., tuberculosis) or critical case (e.g., cancer) or exemplary case (e.g., osteogenesis imperfecta).
Since PBL cases covered nearly 60% of the basic sciences objectives each week, it was decided to provide 9–12 h of self-study time within the weekly academic schedules for self-directed learning. This was based on the 6 h of PBL sessions (three PBL tutorial sessions of 2 h each) planned for each week. PBL tutorials are still running for 2 h each on Sunday, Tuesday, and Thursday 8–10 am for 1st year and 10–12 am for 2nd year students since 2010 [Table 3].
PAHS-SOM PBL tutors not only facilitate the tutorials, they also observe each student in their room to observe and assess the noncognitive competencies. They quietly document all the specific incidences/behaviors/traits in their diary so that they can use it while providing specific feedback to the individual students. PBL tutors then fill out the tutor assessment of students (TAS) tool, which is used for formative as well as summative purposes. TAS tool is an integral part of the process assessment system of PAHS-SOM. PBL tutors receive focused trainings at PAHS-SOM and other medical colleges of Nepal, which is described in details elsewhere.
TAS tool scores are triangulated with peer assessment of students (PAS) and self-assessment of students (SAS) tools to validate this score as it is not only used for the formative but also for the summative purpose at PAHS [Figure 1]. TAS, PAS, and SAS tools are assessed in the same eight noncognitive competencies (preparation, participation, self-directed learning, critical thinking, professionalism, communication skills, group skills, and reflectiveness). PAS and SAS tools were filled in papers by the medical students earlier, but it is now filled using Google Forms, which allowed the quick analysis and feedback to the students and the faculty by the PBL coordinator.
TAS tool has certain number of items for each of these eight competencies, which was prevalidated with 10 + 2 science students (47 items) in 2009 followed by pioneer batch of PAHS medical students during introductory course (32 items) in 2010. TAS tool with 32-item and 4-point rating scale is used for the PBL process assessment since 2010 at PAHS-SOM. The local validation of TAS tool was done to take formative and summative decisions based on the TAS tools scores and this is recommended for other medical college/schools who are or will be using process assessment for the competency assessment.
Students also fill the student assessment of tutor and student assessment of case tool, which provides continuous feedback to the tutors, block directors/case writers, PBL coordinator, basic sciences coordinator, dean and the health professions education unit chaired by the rector. These tools which also have open-ended questions helped the PAHS-SOM to continuously monitor and evaluate the hybrid PBL curriculum and make the informed changes in the MBBS curriculum.
LESSON LEARNT AND WAY FORWARD
Seven PBL rooms at basic sciences complex of PAHS-SOM accommodated 9–11 students and a facilitator in each room, which is enough for the class size of 60–70 medical students. Since PAHS-SOM focused in the quality rather than quantity, the intake has always been low compared to other public and private medical colleges where a maximum of 100 students are admitted annually now unlike the 150–200 students admitted in medical colleges in Nepal earlier.
The longitudinal assessment of noncognitive competencies has helped the medical students to develop a learning attitude after acquiring the self-directed learning competency. They have also become more open minded due to their active participation and are not afraid to ask questions to the faculty not only during the PBL wrap-up session but also during lectures and practical sessions in general. Facilitator feedback helped the medical students to acquire noncognitive abilities, which was lacking in the traditional lecture dominated curriculum. Research done at PAHS revealed that students showed positive reaction to the PBL, irrespective of gender or educational background in providing contextual learning and retention of knowledge. Students agreed that it fostered generic skills (communication, group work, critical thinking, reasoning, reflectiveness, and self-directed learning). Students wished for more such sessions in more subjects in the foundation course with the short content assessment at the end of the sessions.
The hybrid PBL curriculum has helped the faculty to develop effective facilitation and feedback skills. They also learned who to refrain from delivering the contents in the PBL tutorials and observe the minute details required to document the noncognitive competencies. Faculty facilitators also learnt the art and science of giving timely and constructive feedback to the students. Since PBL facilitators are trained in the regular faculty development workshops and sit in the PBL tutorials as co-tutors first as observer of the entire process, it helped them to gain confidence to run the PBL tutorials independently later.
Some students were flagged by the formative process assessment and they underwent a structured remedial system of PAHS-SOM. None of the students “failed” in the summative PBL process assessment in 10 years (2010–2020) of MBBS program at PAHS-SOM, which shows that medical students acquired the eight noncognitive competencies from the robust process assessment system that was tightly integrated with the PBL curriculum in Nepal.
The hybrid PBL curriculum and process assessment system can be implemented in other medical colleges in Nepal and other South Asian countries to integrate the basic sciences subjects and provide avenue for students to learn in context with clinical cases and assess the noncognitive competencies among the undergraduate medical students in the first 2 years of the MBBS curriculum. Since undergraduate CBME is already rolled out in India, the hybrid PBL curriculum and the process assessment system can be implemented, monitored and evaluated even for the large group of students with proper planning, resources, and faculty development programs. Finally, the hybrid PBL curriculum is also an ideal system for integrated content assessment given that basic sciences faculty work as a team and believe in the integrated basic sciences department rather than stand-alone departments to produce basic doctors for Nepal, India, and other South Asian countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors would like to thank Founding basic sciences faculty and leadership of Patan Academy of Health Sciences.
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