Medical Education Department.

SVIMS-SPMCW
Tirupati-517 507.

Basic Course in Medical Education.

13th to 15th June 2024.
Resource material

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SVIMS-SPMCW, TIRUPATI, ANDHRAPRADESH.
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 SVIMS-SPMCW
BCME (13th,14th &15th 2024)
CONTENTS

Day-1
Group dynamics: 1 The Tuckman’s model implementation, Effect,
and analysis & the new Development of the Jones
LSI model on a small group.
Learning process, 2 Interactive lecturing: strategies for increasing
participation in large group presentations.
Learning domains 3 Introduction of Interactive Teaching for
Undergraduate Students
& in Community Medicine.
4 The Flipped Classroom in Medical Education:
Principles of learning Engaging Students to Build Competency
5 Understanding your student: Using the VARK
model
6 Learning Theories: The Basics to Learn in
Medical Education
Goals, roles and 7 Graduate Medical Education Regulations 2019:
Competencies, Competency-driven contextual curriculum
Learning Objectives 8 Competency-Based Medical Education for Indian
(LO) in CBME Undergraduates: Where Do We Stand?
Teaching learning 9 Interactive teaching methods: challenges and
methods (TLM): perspectives
including Interactive 10 Interactive teaching in medical education:
Large Group, Small Experiences and barriers
Group methods 11 Facilitating small group learning in the health
professions
12 Essential Elements of Communication in Medical
Encounters: The Kalamazoo Consensus
Statement
Introduction to 13 Internal Assessment in new MBBS curriculum
Assessment & 14 Assessment System in Medical Education.
Internal assessment 15 The Foundation Programme assessment tools: An
(IA) and Formative opportunity to enhance feedback to trainees?
Assessment 16 Assessment Methods in Undergraduate Medical
Education
17 Assessment in medical education: Evolving
perspectives and contemporary trends.
18 Construct validity and predictive utility of
internal assessment in undergraduate
medical education
 SVIMS-SPMCW
BCME (13th,14th &15th 2024)
CONTENTS

Day-2
AETCOM: Concept 19 Experiential Teaching Learning of Humanities in
and conduct Health Professions Education
SDL: Concept and 20 Triple Cs of self-directed learning: Concept,
Conduct conduct, and curriculum placement
21 Self-directed Learning in Health Professions
Education.
Effective clinical and 22 Implementation of One‑Minute Preceptor for
practical skill teaching Clinical Teaching in Obstetrics and Gynaecology
23 Simulated Patients for Competency-Based
Undergraduate Medical Education Post COVID-
19: A New Normal in India
24 Miller GE. The assessment of clinical skills
/competence/performance.
25 Clinical Skills Laboratory (CSL) - a Modern Tool
of Medical Education
26 Guidelines for the development of skills lab at
medical colleges.
27 Tips for teaching procedural skills
28 The long case and its modifications a literature
review
29 Learning and teaching in the clinical environment
Assessment planning, 30 Preparation of Blueprint for Clinical Assessment
Writing the correct of Undergraduate Medical Students in Psychiatry
essay question and
MCQs
Day-3
Writing a lesson plan 31 TEAL-Effective Lesson Planning
32 Designing a Comprehensive Lesson Plan:
A Crucial Aspect in Improving the Teaching
‑Learning Process
33 How to design a comprehensive lesson plan

Assessment of clinical 34 How to Design and Apply an Objective Structured

and practical skills Clinical Examination (OSCE) in Medical
Education?
Academic growth 35 Networking in medical education: Creating and
& networking connecting.
Aligning assessment to 36 Competency-based undergraduate curriculum for
competency and the Indian Medical Graduate, the new MCI
TLMs curricular document: Positives and areas of
concern
Mentoring 37 Mentoring-Seven Roles and Some Specifics.
38 Twelve tips for developing effective mentors
Journal of Management (JOM)
Volume 6, Issue 4, July– August 2019, pp. 23–28, Article ID: JOM_06_04_005
Available online at http://www.iaeme.com/JOM/issues.asp?JType=JOM&VType=6&IType=4
Journal Impact Factor (2019): 5.3165 (Calculated by GISI) www.jifactor.com
ISSN Print: 2347-3940 and ISSN Online: 2347-3959
© IAEME Publication

THE TUCKMAN’S MODEL IMPLEMENTATION,

EFFECT, AND ANALYSIS & THE NEW
DEVELOPMENT OF JONES LSI MODEL ON A
SMALL GROUP
Dr. Alex Jones
Professor of Leadership, College of Business Administration
American University in the Emirates (AUE)
Dubai, United Arab Emirates

ABSTRACT
This paper presents a practical overview of the implementation of Tuckman model
created by Bruce W. Tuckman in 1965 and revised by Tuckman and Mary Ann
Conover Jensen in 1977. The model reflects the stages of forming, storming, norming,
performing, and adjourning on group dynamics on a small group of graduate students
studying business major at the American University in the Emirates. The stages reflect
the impact of the model while students conducting a negotiation role-play in a class
setting composed of young leaders. The findings reflect the practicality of such a
model to academia and practitioners in the workplace. The outcome of this study has
revealed a new Jones LSI model that has a significant value to organizations facing
the increasing today’s challenges.
Keywords: Tuckman Model, Jones LSI model, Groups, Negotiation
Cite this Article: Dr. Alex Jones, The Tuckman’s Model Implementation, Effect, and
Analysis & the New Development of Jones LSI Model on a Small Group. Journal of
Management, 6(4), 2019, pp. 23-28.
http://www.iaeme.com/jom/issues.asp?JType=JOM&VType=6&IType=4

1. INTRODUCTION
The complexity of our world today is increasing. Organizations are going through lots of
changes. Some of which are transactional and others are transformational. The structure of
organizations varies from one to another. Regardless of such the use of a certain model can
impact the process of implementation to certain extents. Therefore, a use of a specific model
can play a major role in the organization of such tasks.
The Tuckman’s Model has become one of the most influential and well recognized. It was
first published in the year of 1965 and has become the most predominantly referred to and
most widely recognized in organizational literature (Miller 2003). The focus of it was on
group work, collaborative efforts among group members, and group development process.

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 Dr. Alex Jones

This was established essentially through the four stages of forming, storming, norming, and
performing where the fifth was added as a result of research development in the field
(Bonebright, 2010).
The research in this article was conducted on small group of graduate students studying
business major at the college of business administration at the American University in the
Emirates. The focus of this study was to explore the implementation and effect of the
Tuckman’s Model on a small group.

2. REVIEW OF LITERATURE
The study of group dynamics has become the attention of scholars and practitioners.
Organizations across the world has become interested in the development of groups.
Therefore, there was a need to develop a model that can study groups and team dynamics.
There are plethora of resources in the literature talked about groups and group
development. One of the most cited across was the Tuckman’s model. Most popular was the
Tuckman (1965) and Tuckman and Jensen (1977). The research of google scholars has shown
over 20 thousands sources referencing the model between the year of 2015 and 2019 at the
time of conducting this research.
The model itself was described as a mean describing and studying groups, group
dynamics and teams (Rickards & Moger, 2000). The focus of the model is on group
development. It is widely used by educators and practitioners in training programs and group
analysis across organizations (Cassidy, 2007). It was a result of a therapy program from a
meta-analysis study conducted on 50 studies of group development research of sequential
development therapy groups (Tuckman, 1965; Cassidy, 2007).
In the year of 1969, there were data collected from groups of 174 meetings and 12 poverty
programs in Topeka, Kansas over a period of nineteen months resulted of seven stages of
development (1) orientation, (2) catharsis, (3) focus, (4) action, (5) limbo, (6) testing, and (7)
purposive (Tuckman & Jensen, 1977). It was suggested later that Tuckman reduce it to four
stages (Zurcher, 1969).
The result of a thorough literature review concluded with a proposed model that focused
on two dimensions: group development which included the dimension of 1) testing and
dependence, (2) intragroup conflict, (3) development of group cohesion, and (4) functional
role relatedness, and task activity which included the dimensions of (1) orientation to task, (2)
emotional response to task demands, (3) open exchange of relevant interpretations, and (4)
emergence of solutions. It was later summarized as “forming,” “storming,” “norming,” and
“performing,” and a fifth stage “adjourning” was added later as a result of research
development (Tuckman & Jensen, 1977).

3. OBJECTIVES OF THE STUDY

The aim of this study was to answer the following questions:
1. How can the Tuckman Model be implemented in a class setting?
2. What are the implications of it on students on micro scale small groups?
3. Would it be possible to develop a new model out of this study?

4. RESEARCH METHOD
Data was collected on small group of graduate students studying a negotiation course at the
college of business administration at the American university in the Emirates. Participants’
age group ranged from 20 – 35 years old composed of a mixture of males and females. The
sample size was relatively small and there was totally of 25 students composed of 17 males

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 The Tuckman’s Model Implementation, Effect, and Analysis & the New Development of Jones
LSI Model on a Small Group

and 8 females. The highest percentage was Emirati students and the rest from different parts
of the Middle East region. This study was sufficient with the demographics provided and no
other information was required at the time of this study.
Participants in class were divided into small groups. Total number of groups was 5 and
each group was composed of 5 participants. There was no specific instruction given to form a
mixed group of females or males. Participants rather were given the liberty to choose their
own members of the group.
Students were asked to perform a negotiation role-play simulation adopted from (Lewicki,
Barry, & Saunders, 2015). The title of the simulation is called The Used Car. Participants
were asked to negotiate selling/purchasing a used car and were given 30 minutes for
completion of a task. The description of the car is as follows: 2011 Volkswagen Jetta S sedan,
2.5L five-cylinder engine, automatic transmission, power steering, air conditioning, front-
wheel drive, dual air bags, cruise control. Black with gray interior, power door locks, heated
seats, power windows, and AM/FM/CD stereo. Mileage: 51,000 miles; radial tires expected to
last another 30,000 miles. Fuel economy: 24 mpg city, 31 mpg highway; uses regular (87
octane) gasoline. No rust; dent on passenger door barely noticeable. Mechanically perfect
except exhaust system, which may or may not last another 10,000 miles (costs $650 to
replace). Blue book values: retail, $12,100; trade-in, $9,850; private party, $10,500. Car has
been locally owned and driven by one owner (Lewicki, Barry, & Saunders, 2015). Both
buyers and sellers live in the same city.

5. OVERVIEW OF THE MODEL

Tuckman Model is a development model created in 1965 by Bruce W. Tuckman and modified
in 1977 in collaborative efforts of Tuckman and Mary Ann Conover Jensen. The new model
is referred to as Tuckman and Jensen of 1977 revised model of small group development
(Bonebright, 2010). The original model started with four stages: forming, storming, norming
and performing. The fifth stage was added in the revised model: adjourning. The overall focus
of the model is on group functioning within two dimensions: interpersonal relationships and
task activity (Bonebright, 2010). The model was described as “to be used to describe
developing groups for the next 20 years” (Tuckman 1984, 14).

6. ANALYSIS OF THE MODEL

6.1. Forming
The first stage of the model is forming. During this stage participants try to form their own
group choosing their own members into 5 members in each group in this research paper. The
number of participants in each group can vary depends on overall size of the participated
group. This gives students a freedom of choice. It also encourages them to socialize with each
other, getting to know one another, and introduce themselves to new members in the class
they have not met previously. The forming is the initial and important stage in this model.
This is simply because it can lead to create a success and harmony among team members or
leads to the other direction of failure to achieve the desired outcome of the negotiation.
Therefore, a great emphasis should be giving to this stage assuring participants that they are
about to have fun while learning something new that can help them in their practical side of
life. In this stage participants will experience a great deal of dependence through experiencing
a task that has a value to their learning process. This stage develops participants’ interpersonal
skills, measures their behaviors, and enables their leadership skills.

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 Dr. Alex Jones

6.2. Storming
This is the second stage of the model. During this stage participants will experience the agent
of change of experiencing something new. This is due to the nature and complexity of the
task. In this case, the negotiation case study plays the role of the agent of change due to the
nature of it based on the description provided. The storming part happens in this stage is
associated with emotions and behavior and conflict might arise as a result of such. This is
simply because at first students trying to familiarize themselves with each other. That’s what
we refer to as self-understanding. Second, students try to figure out how to work with each
other and work with the case. That’s what we refer to as self-skill abilities. Third, students
might come to agreement and mostly disagreement. That’s what we refer to as the
experienced agent of self-change. Here where the storming happens finding group members
resisting each other. In this case, it can also be a process of stimulating their intellectuality.
Tuckman (1965) stated that ‘group members become hostile toward one another and toward a
therapist or trainer as a means of expressing their individuality and resisting the formation of
group structure’.

6.3. Norming
This is the third stage of the model. This is where group members find ways to create
harmony among each other. At this stage, group members try to accept each other’s opinions
and suggestions. The agent of time limitations plays a major role in this part. This is where
you find a member of the group jumps out of nowhere and settles any issues happening
among each other reminding them that time is passing by and a solution should be presented.
That’s where we notice the best effective ways to work with each, coming up with the best
strategies and seal the deal of the case negotiated. There is less conflict happening in this
stage and more mind streamlining of thoughts and ideas. That’s where cohesion and harmony
prevails.

6.4. Performing
This is the fourth stage of the model. In this stage group members start the actual act of
negotiation trying to come up with the win-win situation. The actual work of implementation
happens in this stage. It is referred to as ‘functional role relatedness’ (Tuckman 1965). This is
where participants get energized supporting each other trying to win and seal the deal. You
would find interaction among participants in this stage is infused with actions and positivity.
Group members tend to bend the roles during this stage for the benefit of all. The focus of all
is channeled towards achieving the ultimate desired goal with the involvement and
participation of all. However, you would find that participants assign one or two members in
the group to negotiate on behalf of the group supported by all group members. That’s where
you find the whole group acting as problem solvers and wear their negotiation hats. That’s
because a robust structure was established in place based on putting personal benefits aside
and success of the whole is the main goal. This is the stage of functionality, flexibility and
performance.

6.5. Adjourning
This is a developed stage in the new Tuckman model of 1977. It is the fifth stage of the
model. The focus of this stage is on the development of the team. Although you would find
the usability of such a stage is less on a class level, but quite popular in an organizational
level. This is where things are taken into the next stage after achieving the desired goals and
objectives of the allocated task to the group. This is pretty much in use during restructuring in
organizations. During this stage it is highly recommended celebrating the success of groups

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 The Tuckman’s Model Implementation, Effect, and Analysis & the New Development of Jones
LSI Model on a Small Group

for their accomplishments, perseverance and hard work. That’s where you make the group
feel that they have achieved the overall success. In this scenario, celebrating the group
negotiation would give a boost of confidence to the group. This, in turn, makes them even
more motivated to negotiate another deal. It, sometimes, referred to as a mourning stage. This
is simply because there is a lot of insecurity and ambiguity associated with the finishing of the
task. Therefore, a transition plan is recommended during this stage to give sense of security
and assurance to group members of the next stage. That, in turn, may reduce the sense of
insecurity and ambiguity that might arise from this stage.

Forming Storming Norming Perfroming Adjourning

Figure 1 Tuckman and Jensen (1977) revised model of small group development.

7. CONCLUSION
The answers to the proposed questions in this study were discovered. The three questions
were 1) how can the Tuckman Model be implemented in a class setting?, 2) what are the
implications of it on students on micro scale small groups?, and 3) would it be possible to
develop a new model out of this study? It was found that the Tuckman Model can be
implemented in a class setting with the stages except the last stage, adjourning, that might not
be applicable in a negotiation role-play setting when conducted in class. However, it is highly
relevant to corporate level and its implication can add a significant value when implemented.
The implication that was found from the use of this model is that it is a great aid in
monitoring student progress, skills, behavior, emotions, flexibility, adaptability and
adjustability to different circumstances, different interaction with different cultures, and
different case scenarios. It is, on a micro level, a tool to observe student’s behavior, problem
solving skills, critical thinking skills, management skills, and leadership attributes.
On a practical side, the analysis of this model come with a proposed new Jones LSI model
that could be much more efficient when used on a smaller scale students or employees. The
new model can be the new phase of group development of this century and the next era. The
proposed new model depicted in the following:

Leading Structuring Implementing

Figure 2 Jones LSI Model.

The new proposed model based on three essential elements: leading (L), structuring (S)
and implementing (I). The beginning part of the simulation starts with the leading. The
leading part includes preparing students to the negotiation case. The orientation part with
introduction to the case is happening during this stage. The leader of the activity, during this
stage, is setting a goal to the group and time frame for accomplishing the task. The focus on
this stage is on two dimensions: goals, tasks and time frame. The second part of this stage is
the structuring. During this stage groups are formed randomly or by choice. This stage
involves getting to know each other through proper introduction and socializing. It can act as

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 Dr. Alex Jones

a factor of developing social skills of individuals of the same group interacting with each
other as well as with other groups. The third part is the implementing stage. During this part,
the actual implementation is happening. There are some challenges faced during this stage.
Some of the most popular ones are conflicts among team, resistance to change, different
opinions, different points of views, different perspectives, clash of thinking and point of
views, emotional attitude, and change in behavior. Therefore, the first stage can eliminate
most of these challenges through proper timely orientation taking into consideration that
ample time might be needed to address most issues arise or might arise in the last stage. That
being said setting goals, tasks, and time can play a significant role in speeding up the process
of achievement and reducing conflict among participants.
The Jones LSI model can be implemented on a corporate level. It serves organizations that
are experiencing a status quo where change is almost difficult to achieve. It can also be
implemented on organizations that are experiencing losses in revenues. The model when
implemented strategically and systemically it can create a paradigm shift in positioning
organizations to the next level to even being able to compete on a larger scale from a macro
and micro level. This model requires further testing. The aim of this new model when
implemented is addressing the macro and micro layers in organizations: improving leadership
in organizations, setting clear vision, reducing ambiguity, focusing on strategic thinking,
improve critical thinking skills, problem solving skills, negotiation skills, reducing conflict,
investigate the current structure, evaluate restructuring, and focus on implementation process
achieving the desired mission. The ultimate goal is saving time, money and efforts addressing
the main issues faced in organizations precisely and concisely.

REFERENCES
[1] Bonebright, D. A. (2010). 40 years of storming: a historical review of Tuckman's model of
small group development. Human Resource Development International, 13(1), 111-120.
[2] Cassidy, K. (2007). Tuckman revisited: Proposing a new model of group development for
practitioners.
[3] Lewicki, R., Barry, B. & Saunders, D. M. 2015. Negotiations: Readings, exercises and
cases (5th ed.). NY: McGraw Hill Higher Education.
[4] Miller, D. (2003). The stages of group development: A retrospective study of dynamic
team processes. Canadian Journal of Administrative Sciences 20, no. 2: 121–43.
[5] Rickards, T., and S. Moger. (2000). Creative leadership processes in project team
development: An alternative to Tuckman’s stage model. British Journal of Management
11, no. 4: 273–83.
[6] Tuckman, B.W. (1965). Developmental sequence in small groups. Psychological Bulletin
65, no. 6: 384–99.
[7] Tuckman, B.W., and M.A. Jensen. (1977). Stages of small-group development revisited.
Group and Organization Studies 2, no. 4: 419–27.
[8] Tuckman, B.W. (1984). Citation classic: Development sequence in small groups. Current
Concerns 34: 14. Retrieved July 23, 2008, from
http://www.garfield.library.upenn.edu/classics1984/A1984TD25600001.pdf
[9] Zurcher, L. A., Jr. (1969). Stages of development in poverty program neighborhood action
committees. The Journal of Applied Behavioral Science, 5(2), 223-258.

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Interactive lecturing: strategies for increasing
participation in large group presentations
YVONNE STEINERT & LINDA S. SNELL
Faculty of Medicine, McGill University, Canada
SUM M AR Y Interactive lecturing involves an increased inter-
change between teachers, students and the lecture content.The use
of interactive lectures can promote active lear ning, heighten atten-
tion and m otivation, g ive feedback to the teacher and the student,
and increase satisfaction for both.This article describes a num ber
of interactive techniques that can be used in large g roup presenta-
tions as well as general strateg ies that can prom ote interactivity
during lectures.
Have you ever given or attended an interactive lecture?
W hat was it that made it interactive? What were your impres-
sions of this method of teaching?
W hereas much has been written about effective lecturing
and presentation skills in m edical education (Cox & Ewan,
1988; Laidlaw, 1988; Newble & Cannon, 1994), little has
been written about the bene® ts and strategies of interactive
lecturing for m edical teachers. The goals of this article are
to describe the advantag es and indications for interactive
lectures, to discuss com mon fears and concerns about using
this method of teaching, to outline a number of interactive
techniques that can be incorporated into medical teaching
at all levels, and to highlight general guidelines for successful
interaction and audience participation.
W hat is interactive lecturing?
Interactive lecturing can be interpreted in a number of
different ways. For som e, interactive lecturing involves a
two-way interaction between the presenter and the
participants. For others, it refers to increased discussion
am ong the participants. Interaction can also refer to a
1
student’ s involvement with the m aterial or the content of a
lecture; it does not necessarily mean that the audience has
to do all of the talking. In all cases, however, interactive
lecturing implies active involvement and participation by
the audience so that students are no longer passive in the
learning process.
Interactive lecturing also implies a different way of
approaching the teacher’s role. In giving this type of presenta-
tion, the `instructor’ frequently becom es a `facilitator’ or
`coach’ , and more often than not, has to modify the lecture
content to allow for discussion and to try new techniques.
For the purpose of this discussion, the term `lecture’ will
refer to any large group presentation, at any level of the
educational system. It is important to note, however, that
the num ber of students in the audience does not dictate
whether the lecture can be interactive. Some very sm all
groups can be non-interactive, and certain interactive
techniques can be incorporated into a class of over 200
stu de nts. M ore over, althoug h larg e classe s are m ost
0142-159X/99/010037-06 $9.00 ½ 1999 Carfax Publishing Ltd
M edical Teacher, Vol. 21, No. 1, 1999
com monly considered the context for interactive lectures,
these techniques can also be used effectively with smaller
groups.
W hy give an interactive lecture?
Lectures as a m ethod of teaching and transm itting inform a-
tion have come under increasing criticism (Bligh, 1972;
Kimmel, 1992; Kroenke, 1984). O ne of the major reasons
for this critique is the observation that lectures are less
effective than other methods when instructional goals involve
the application of inform ation or facts, the development of
thinking skills, or the modi® cation of attitudes (Frederick,
1987; M cKeachie, 1994; Newble and Cannon, 1994). In
addition, students are frequently seen as passive recipients
of information, and as a result, not engaged in the learning
process.
However, while m any teachers accept the notion that
other teaching methods m ight be better than lectures for
encouraging students to be m ore actively involved in
learning , and for promoting the application of knowledge,
few have the time, resources or opportunity to use the sm all
group methods that prom ote such involvement and applica-
tion (Schwartz, 1989). Also, when done effectively, the
lecture can transmit new information in an efficient way,
explain or clarify difficult notions, organize concepts and
thinking, challenge beliefs, model problem solving, and foster
enthusiasm and a motivation for learning (Gage & Berliner,
1991; Foley & Sm ilansky, 1980; Frederick, 1986; Saroyan &
Snell, 1997).
The value of interactive lecturing rests on the premise
that active participation and involvem ent is a prerequisite
for learning beyond the recall of facts, and that students
m ust be attentive and motivated in order for learning to
occur. In sum m ary, interactive lecturing prom otes th e
following characteristics of effective learning.
A ctive involvement
Educational research has shown that students who are
actively involved in the learning activity will learn more than
students who are passive recipients of knowledge (Butler,
1992; Feden, 1994; Kraft, 1985; M urray, 1991). As we have
said earlier, interactive lecturing can promote active involve-
m ent with the m aterial or the content, with the teacher, or
with classmates/peers. Indeed, even students who do not
Correspon dence: Dr Yvonne Steinert, Faculty of M edicine, M cGill University,
3 655 Drummond Street, M ontreal, Q uebec, C anada H 3G 1Y6. Tel: 514-398-
2 698. Fax: 5 14-398-2231. Em ail: steinert@med.mcgill.ca
37
Y. Steinert & L. S. Sn ell
talk in class are often stimulated by questions or problem-
solving exercises as they think about what they would answer
in a particular situation.
Increased attention and motivation
Other studies in education have demonstrated that increased
attention and motivation enhance memory (Gage & Berliner,
1991; M annison et al ., 1994; M eyers & Jones, 1993). In
fact, some authors have said that increased arousal and
motivation are the essential ingredients for learning, and
often are more important to retention than intelligence.
Attention span studies have shown that students’ interest
and attention in the traditional lecture diminishes signi® -
cantly after 20 minutes (Frederick, 1986; Foley & Smilansky,
1980; Stuart & Rutherford, 1978). Energy shiftsÐ or changes
of paceÐ are essential if student attention is to rem ain
focused. By changing pace and incorporating a variety of
techniques that arouse attention, interactive lectures can
stim ulate interest and help to m aintain attention. By
encouraging applications to `real life’ situations or focusing
on controversial issues, interactive lectures also m otivate
students to read and learn more.
A `different’ kind of learning
In addition to increasing student involvem ent, attention
and motivation, interactive lecturing promotes a `higher level’
of thinking (Low m an, 1984; M ichaelsen et al ., 1982;
Ramsden, 1992). This includes the analysis and synthesis of
material, application to other situations and evaluation of
the material presented. Interactive lecturing can facilitate
problem-solving and decision-making, com munication skills
and `thinking on your feet’ . This is particularly important in
medical education where the application and use of informa-
tion is as important as the retention and recall of facts.
FeedbackÐ to the teacher and the student
The importance of feedback to learning has been frequently
noted (Jason & Westberg , 1991; Lowman, 1984). Interac-
tive techniques allow teachers to receive feedback at a
number of levels: on student needs (at the beginning, middle
or end of a lecture), on how the inform ation has been
assimilated, and on future learning directions. Students, on
the other hand, can get feedback on their own knowledge or
performance. For example, computerized audience response
system s allow for the rapid collation and broadcast of
students’ responses to questions (Jason & Westberg, 1995).
Quizzes at various intervals during the lecture also allow for
imm ediate feedback.
Increased studentÐ and teacherÐ satisfaction
In a recent study of surgical teaching, Papp & M iller (1996)
found that faculty who involve students in their lectures by
questioning were perceived m ore favourably by students
than those who did not. These authors also report that
students who attend lectures by faculty who ask many ques-
tions believe that the lecture is more stimulating. Butler
(1992) found that student satisfaction with the lecture format
increased when the students were actively involved in the
teaching session.
38
At the sam e time, experienced teachers will tell you that
once you have tried an interactive lecture, it is difficult to go
back to a more traditional style where the audience is more
passive and less involved. In many ways, interactive lectures
keep the teachers interested and awake as well!
In sum m ary, interactive lecturing encourages active
participation on the part of the teacher and the student.
This method of teaching arouses student attention and allows
for instant feedback on whether the lecture material has
been understood. It also promotes a higher level of thinking,
problem solving and application of material taught. Indeed,
interactive lecturing is a way to capitalize on the strengths of
small group learning in a large group format (Butler, 1992).
W hat prevents us from giving interactive lectures?
Fear
Whereas most teachers accept the theoretical bene® ts of
interactive lectures, m any will not engage in such lectures
for a number of reasons. M ost frequently, teachers report a
fear of losing control when giving such a lecture. They fear
that if the class is allowed to participate actively and ask
questions, the presenter will no longer be `in control’ , of
either the students or the m aterial, and that chaos may
reign. Fear of not covering all of the material , or of sacrificing
impor tant content, is anoth er com m only encountered
lament. It is true that the `num ber of facts’ need to be
reduced in order for a lecture to becom e interactive; we also
know that if we present too much information, students will
retain less (McKeachie, 1994; Newble & Cannon, 1994;
Russell et al ., 1984).
Additional fears include anxiety about not knowing the
answer to a question posed by the students, concern that a
`dominant’ group will take over and apprehension that no
one will respond to a question asked.
The `context’ of lear ning
Time constraints are frequently mentioned as a reason for
not giving an interactive lecture; but again, this concern is
more commonly related to the fear of not `covering’ all of
the material. Audience expectations, the subject m atter and
the physical setting m ay also hinder an attempt to be interac-
tive. M any teachers believe that the basic sciences cannot be
taught interactively, and that it is easier to teach the clinical
sciences using this format. Others believe that undergraduate
students, because of their more lim ited knowledge, cannot
participate in an interactive lecture, which m ay appear more
appropriate for postgra duate students and practicing physi-
cians. A nd yet, teaching experiences and th e relevant
literature do not support this position.
W hat are com m only used interactive tech niques?
The following section provides an overview of the m ost
commonly used interactive techniques in medical educa-
tion. Although the indications and limitations of these diverse
methods may differ, the common ingredient to all is the
goal of increasing student participation, attention and
motivation in the lecture process. These methods include
the following.
 Interactive lecturing

1. B reaking the class into smaller groups tions. It is far more useful to intersperse the lecture with
time for questions, from both the teacher and students.
Small group teaching has distinct advantages over lecturing
· B ra instor m in g : brainstor m ing refe rs to that process
in term s of promoting comprehension, application and
whereby students generate a list of issuesÐ in response to
problem solving (Butler, 1992; M cKeachie, 1994). Yet, for
a sp eci® c question or topicÐ and judgem ent of th e
m any of its proponents, small group teaching is not a cost-
responses is initially suspended (Newble & Cannon, 1994;
effective method of teaching. Incorporating small groups
Schwenk & W hitm an, 198 7). O nly after th e list is
into lectures can, therefore, be bene® cial for promoting the
completed are comm ents or critiques invited.
discussion of ideas and concepts, for exam ining issues and
Brainstorming can be used at different points in the
presenting alternatives, for encouraging the application of
lecture. At the beginning, it can be used to invite everyone
new concepts, and for foster ing problem solving and
in the group to participate and to put them at ease. For
com m unication skills. G roup discussions also give th e
example, the lecturer might start a presentation by asking
teacher an additional way of assessing student attitudes and
the class to list all the possible complications of diabetes.
beliefs.
While this is happening, the teacherÐ or a studentÐ can
Two interesting examples of this technique have been
scribe these responses on a ¯ ipchar t, blackboard or
presented by Schwartz (1989), teaching biochemistry to a
transparency, for critical review after an initial phase of
large number of students, and by Stein et al . (1990), who
accepting all ideas and statem ents. In reviewing the list,
incorporated small group teaching methods in a large group
the lecturer may decide to organize his/her presentation
setting in clinical pharmacology. The general strategy is to
around com ments made or highlight the key issues that
break the class into small groups, using a judicious rearrange-
will be addressed. Brainstorm ing at the beginning of a
m ent of seating if necessary (Gibbs et al ., 1988; Newble &
session has the added bene® t of providing an evaluation
Cannon, 1994). Small groups of between two and four
of the students’ knowledge of a particular area prior to
people may be formed among neighbours without any move-
teaching.
m ent while larger groups can be formed quite quickly. The
Brainstorming in the middle of a lecture can be helpful
selection of the most appropriate grouping will largely
to change the pace, to regain the group’ s attention, or to
depend on what you wish to achieve. Small groups may be
apply certain `facts’ presented so far. For exam ple, the
asked to discuss a limited topic for a few minutes (in what
teacher might ask the following: `What are the common
is often called `buzz groups’ because of the noise in the
side effects of antidepressant medication?’ Brainstorming
room ) or they may consider broader issues for a longer
at the end of a lecture allows the students to summ arize
period of tim e.The sm all groups can also join to form larger
the information discussed, to develop a fram ework for the
groups to further discuss the same topic or to consider a
material covered, and to provide feedback on what was
different approach to the same task (Gibbs et al ., 1988;
understood or learned.
Jackson & Prosser, 1989; M ichaelsen et al ., 1982).
· Rhetorical questions : rhetorical questions have been defined
A lthough breaking the class into sm all g roups is a
as those questions that are asked merely for effect with no
powerful and very effective technique, it is not frequently
answer expected (Webster’s Dictionary, 1977).
attempted. Once tried, however, more traditional lectures
Rhetorical questions stim ulate thought without
seem far too silent!
requiring an answer. They are frequently introduced at
the beginning of a lecture or particular segment of the
lecture, to stimulate interest in the subsequent presenta-
2. Q uestioning the audience
tion. For exam ple, one might start a lecture on Sur viving
Q uestioning the audience is probably one of the most Chan ge by asking the audience whether any of them have
frequently used interactive techniques. It is also the easiest experienced a change in the last yearÐ and whether any
to implement. Questions can stimulate interest, arouse atten- of them have survived.
tion, serve as an `ice breaker’ , and provide valuable feedback · Su rveying the class: this technique is particularly useful for
to the teacher and student alike (Knox, 1986). Q uestioning identifying audience needs and interests, for allowing
can take many forms. teachers to assess the students’ baseline level of knowledge
around a particular topic, and for arousing motivation.
· Straightforward questions: the value of effective questioning
For example, asking the students how many of them have
has been highlighted by many authors (Foley & Smilansky,
ever ha d a fracture at th e beg inning of a class on
1980; Schwenk & W hitman, 1987). Some examples of
orthopaedic trauma gets their attention very quickly!
straightforward questions include the following: `What
· Quizzes and short answers : Q uizzes or short answers can
are the common causes of right lower quadrant pain?’
be used at the beginning or end of a class to provide a
`Which therapy would you choose for the treatm ent of
`check-up’ on learning, to summarize or synthesize the
hypertension, and why?’ In asking questions of the audi-
information presented, and to point out gaps in under-
ence, it is important to remember to pose them in a
standing for both the teacher and the student. Testing
non-threatening way, to wait for a response, and to make
students at the end of a lecture can help to increase their
sure that m ore than one student has an opportunity to
retention of the information covered (Bligh, 1972; Gibbs
respond!
et al ., 1987).
Another way of using questions is to allow students to
ask questions of the teacher. The majority of lecturers
3. U sing audience responses
save time at the end of their presentation for questions
from the audience, and yet, m any of these presenters are Interactive computer systems are one of the newer ways by
often disappointed by the lack ofÐ or quality ofÐ the ques- which to promote interaction in a large group (Jason &

39
Y. Steinert & L. S. Sn ell
Westberg, 1995). By using this method, audience attention
is quickly aroused and the learner can receive immediate
feedback on his/her knowledge in an anonym ous fashion.
Students can also compare their responses to their classmates
in an easy and effective manner (Ytterberg et al ., 1994).
The disadvantage of this method, on the other hand, is
that it can become too `gimm icky’ and some people only see
it as a gadget. It also takes more preparation on the part of
the teacher because the questions have to be carefully
selected and programm ed prior to the presentation. Another
disadvantage to this method is the fact that the questions
are usually closed in nature and spontaneous responses
cannot be easily incorporated into the pre-set format.
An alternative approach to the interactive computer
system, that is much less costly, is the use of ¯ ash cards. For
example, the teacher can project a `multiple choice’ or `true±
false’ question on the overhead projector, and for each
response, the students raise a different coloured card.
4. Use of clinical cases
Clinical cases can be used in different ways to bring relevance
to the discussion (Douglas et al ., 1988; Stein et al ., 1990).
Indeed, this is probably the second most comm on method
(after questioning) used by medical teachers. The use of
cases heightens interest and promotes problem solving in an
effective manner. It also encourages clinical reasoning and
makes the learning of medicine `real’ , important for junior
students with limited clinical experience and for seasoned
practitioners who can easily see application to their own
clinical practices.
During the lecture, students can be asked to analyze or
discuss a case that is presented on paper, on video or live.
Case presentations can be structured in different ways, and
the objectives for its use should be clearly delineated
beforehand. For example, a brief case description can be used
to illustrate a particular point or support certain principles
being addressed, at any time during the lecture. It can also
be used to get students to hypothesize about what is going
on and to problem solve.
Alternatively, students can be asked to work through a
case in class, where the lecturer starts by giving some informa-
tion, asks students for their hypotheses and areas for further
inquiry, provides additional information, and slowly works
through the case with the students. Examples of this include
the following:
· Cliff hanger cases : students are asked to read a case that
outlines a complex situation and that includes a problem
calling for decision. The case narrative stops at the deci-
sion point but students are asked what they would do and
why. In class, students have to defend the factual basis
and reasoning that led to their decision (Segall et al .,
1975; Wilkerson & M iller, 1984).
· Incident type cases: students are presented with a short
description of a problem situation. If they ask the right
questions, they are supplied with m ore information. As a
group, the students take the role of the decision maker
trying to sort out the problem. Sometimes they are divided
into team s and asked to defend their positions. Often they
work alone. The class, however, must come to a decision
that is mutually agreeable (Segall et al ., 1975; W ilkerson
& M iller, 1984).
40
· Inviting patients to class heightens student interest and
m otivation. This is particularly helpful when the learners
can interact with the patient.
5. Use of w ritten materials
Written materials are helpful to assist in the organization of
key concepts, to promote the retention of information, and
to remove pressure on the teacher to `cover everything’ . For
example, handouts of slides (Amato & Quirt, 1990) allow
students to participate m ore in thinking about the concepts
under discussion rather than writing down every word of
the lecture.
The literature on handouts (Beard & Hartley, 1984;
Butler, 1992) suggests that students achieve higher test scores
from lectures accom panied by handouts, that students
appreciate them, and that the design of the handout can
in¯ uence note-taking practices. For example, in one study,
students preferred to write in the space between headings,
and the more space left, the more notes were taken (Newble
& Cannon, 1994). Sim ilarly, Butler (1992) found that
incom plete handouts promoted greater attention and reten-
tion of the material taught. In an interactive lecture, handouts
can also structure the discussion and/or supplement the
lecture content.
The timing of when to distribute the handout often
depends on its purpose. It is useful prior to the lecture if the
student is to come prepared with a fund of knowledge; it is
more effective at the outset of the lecture if the handout is
incom plete; and it is most valuable at the end of the lecture
if the handout contains supplemental information for further
reading. Critical to its success, however, is the use of the
handout in class.
6. Organizing debates, reaction panels and guests
Debates can be conducted in a number of ways. For example,
the class can be divided in two (e.g. along the two sides of
the lecture hall) and the students on either side can be
asked to support two different sides of the issue (Frederick,
1986, 1987;Wilkerson & Miller, 1984). Assignment of `sides’
might take place ahead of tim e or students can be asked to
seat themselves according to their point of view. The class
can then proceed by the instructor asking for several state-
ments from persons seated on each side. Although neither
side may contain the whole truth, it can be energizing to
defend a particular perspective. Students choosing a m iddle
g round sho uld be invite d to de fend th eir reasoning.
Summary arguments could be made by several students
from each `side’ .
Alternatively, a number of students can be chosen from
the class to debate an issue in front of the class (Herbert,
1990). Peer-led debates and discussions have the advantage
of enlisting class support and interest.
7. Using sim ulations and role plays
Simulations and role plays allow students to try out a real
life situation in a `safe setting’ and to receive feedback on
their experiences (Hand® eld-Jones et al ., 1993; Steinert,
1993a). By presenting students with a situation that they
are likely to face in the future, simulations can heighten

attention and clinical relevance, and involve students at a
num ber of levels in the lecture format. Role plays can also
be used creatively in large classes. For example, students
can be asked to role play a doctor± patient encounter and
receive feedback from their peers. Alternatively, the teacher
can role play a particular patient problem (e.g. a 24-year-old
wom an com plaining of painful intercourse) and ask the
students to take a history. Simulations can be used effectively
as well. In a presentation on Parkinson’s Disease, the teacher
can demonstrate a number of abnormal gaits, and students
can be asked to identify the differences am ong them.
8. U sing ® lms and videotapes
Film clips or videotaped vignettes can be used as a trigger to
promote discussion or to stim ulate student thinking. M ost
often, the objective is to elicit an emotional as well as a
cognitive response in the viewer and to `trigger’ meaningful
discussion (Segall et al ., 1975). For example, a short vide-
otaped segment can be used to illustrate a challenging patient
interview and the students m ay be asked to react to what
they saw.
Film s or videotapes used for this purpose should usually
be brief in duration and present only part of a situation in
order to promote further inquiry or discussion. Videotapes
are also useful for examining student attitudes and skills
(Steinert, 1993b).
9. Audiovisual aids
Certain audiovisual aids facilitate interaction m ore than
others. Overhead projectors, for example, allow the presenter
to maintain eye contact with the audience, to record audi-
ence responses, and to change the order of the presentation,
which is not easily achieved when using 35 mm slides. Flip-
charts and whiteboards allow for the creation of diagram s
or content during the lecture and easily perm it the scribing
of students’ answers to questions, problem solving exercises
or d ebates. M ultim edia presenta tion s and com pu ter-
assisted learning also promote interactivity.
10. U sing effective presentation skills
Although the focus of this discussion is not on effective
presentation skills per se, the presence or absence of such
skills can determine the effectiveness of an interactive lecture.
Clearly, if one does not have eye contact with the students
or scan the audience, the lecture cannot be interactive!
Similarly, the physical setting (e.g. a long, steep lecture hall
vs one where members of the audience can see each other)
can hinder or facilitate interaction.
W hat general strategies w ill help us to becom e m ore
interactive?
The previous section outlined a number of speci® c interac-
tive techniques that teachers m ay consider using. The
following general principles m ay help them to become m ore
interactive.
(1) B e w illing to take risks and overcom e your fears . As we
have stated earlier, giving an interactive lecture can be
very risky, but taking the risk is worthwhile if it will
Interactive lecturing
enhance student learning. Identify your fears, be willing
to take a risk and maintain your sense of hum our. M ost
of all, be prepared for the unexpected!
(2) PrepareÐ and practice. M any successful teachers will tell
you that it takes longer to prepare an interactive lecture
than a traditional one because of the need to pare down
the material and to choose your m ethodology carefully.
PreparationÐ and practiceÐ is, therefore, the key.
(3) B e clear in your objectives and cut dow n on your m aterial.
W hereas it is always important to have clear objectives,
this becomes even more important in an interactive
lecture. Remember that less is more; consider your three
most important `points’ and build your lecture around
them . Do not try to cover every topic in com plete detail;
when worried about `leaving out’ too much material, or
not `covering’ everything, provide readings and handouts
to supplement the material. Always ensure that your
methods match your objectives.
(4) Prepare students for their role in interactive lectures. As
teachers, we cannot assume that students will know
how to participate in a lecture or what behaviour is
appropriate. Accustomed to being passive, students must
learn to become active participants in the process of
learning, and we m ust prepare them to do this over
tim e. Setting rules at the beginning of your lecture and
outlining how your session will be conducted is one way
of preparing your students for taking an active role in
the process of learning.
(5) Remain ¯ exibleÐ and do not overdo it. M any teachers,
once introduced to the concept of interactive lecturing,
want to immediately apply their newly acquired skills.
Remember to focus on one new technique at a time,
and to rem ain ¯ exible. Finally, be prepared to abandon
your prepared agenda!
C onclu sion
As Frederick (1986) has said, the lecture method is here to
stay. By using interactive techniques and strategies, students
will becom e more involved in the learning process, retain
m ore information and be more satis® ed. So will the teacher!
A cknowledgem ents
G rateful appreciation is expressed to the members of the
M cGill Faculty Development Advisory Com mittee, Drs
Larry Conochie, Peter M cLeod and Louise Nasm ith, the
group leaders and co-leaders of our workshops on Interac-
tive Lecturing , and the workshop participants, who have all
contributed to the ideas expressed in this m anuscript.
N ote
[1] The word `student’ will be used to represent students at
all levels of medical education, including undergraduate
students, postgraduate students or residents, and prac-
ticing physicians. M oreover, although most of the
examples used in this discussion refer to undergraduate
and postgra duate education, the strategies suggested
apply to continuing medical education and faculty
development activities as well.
41
Y. Steinert & L. S. Sn ell
Notes on contr ibutors
Y VONNE S TEINER T , Ph.D. is a clinical psychologist in the Depart-
ment of Fam ily Medicine at the Sir Mortim er B. Davis Jewish G eneral
Hospital and M cGill University and Associate Dean for Faculty
Developm ent at McGill U niversity in M ontreal, Quebec.
L INDA S N ELL , M.D., M.H.P.E., F.R.C.P.C. is the Director of the
Division of G eneral Internal M edicine and Associate Dean for
Continuing M edical Education at McGill U niversity in M ontreal,
Quebec. Both authors have been actively involved in planning and
presenting program s designed to improve the teaching and lecturing
skills of health care professionals.
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 Original Article

Introduction of Interactive Teaching for Undergraduate Students

in Community Medicine
Jarina Begum, Syed Irfan Ali, Manasee Panda1
Department of Community Medicine, Great Eastern Medical School, Srikakulam, Andhra Pradesh, 1Department of Community Medicine,
Balangir Medical College and Hospital, Balangir, Odisha, India

Abstract
Background: There is lack of interest in the subject of community medicine among undergraduate MBBS students leading to poor understanding
of community problems and drastic fall in preventive, promotive component of health care. Aim: To evaluate effectiveness of interactive
teaching learning (ITL) over traditional teaching learning (TTL) methods in creating interest in the subject. Objectives: 1. To identify the
need of interactive teaching among students. 2. To know the perception of students towards it.3. To know the views and opinion of faculties
towards it. Materials and Methods: An interventional study at NRIIMS, Vishakhapatnam. After need assessment survey, under graduate
MBBS students were randomly allocated to study (A) and control groups (B). 2 topics were taught using ITL 1& 2 in group A and TTL in
group B. After a washout period of 15 days, 2 other topics were taught using ITL3 & 4 in group B and TTL in group A, which was followed by
assessment. Feedback from students and faculties were taken at the end of session. Results: 82% of students felt significant need of interaction
in classroom. There was an increase in performance of students in the intervention group in terms of better scores (>75% score) which was
found to be statistical significant in all the four sessions (P value are 0.0230, 0.0058, 0.0075, 0.0034 for TPS, BS, CBS, PTP respectively).
Students were satisfied, so as the faculties with the implementation of ITL module. Conclusions: Student performance was increased. Overall
satisfaction was good among students and faculties.

Keywords: Buzz sessions, case‑based study, interactive teaching and learning, pass the problem, PowerPoint presentation, randomized
control trial, think‑pair‑share, traditional teaching and learning

Introduction students to take responsibility for their own learning, and

Traditional teaching practice in the current era is found
to little outdated and noninteresting. Using the current
techniques, the lesson taught to students is not skill oriented,
and therefore, although we are producing good number of
health workforce, we are unable to meet the needs of the
community.[1]
One‑way communication in lectures does not influence the
learners’ behavior met in the classroom which in turn fails to
create competent and passionate doctors.[2]
There is a growing concern among medical educators that
conventional modes of teaching medical students neither
encourage the right qualities in students nor impart a life‑long
respect for learning.[3]
Interactive learning actively engages the students, reinvigorates
the classroom for both students and faculty, encourages
Access this article online
Quick Response Code:
Website:
www.ijcm.org.in
DOI:
10.4103/ijcm.IJCM_232_19
promotes characteristics of effective learning.[4‑6]
Interactive teaching methods could be done using large
group, small groups, pairs, and individuals.[7] Methods used
in the study are think‑pair‑share, buzz sessions, case‑based
learning (CBL), and pass the problem. This study highlights
the need and demand of interactive teaching methods in
medical education.
Aim of the study
The aim of the study was to evaluate the effectiveness
of interactive teaching and learning (ITL) methods over
Address for correspondence: Dr. Syed Irfan Ali,
Department of Community Medicine, Great Eastern Medical School, Ragolu,
Srikakulam ‑ 532 484, Andhra Pradesh, India.
E‑mail: irfanrocksmbbs@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Begum J, Ali SI, Panda M. Introduction of
interactive teaching for undergraduate students in community medicine.
Indian J Community Med 2020;45:72-6.
Received: 01-06-19, Accepted: 04-12-19

72 © 2020 Indian Journal of Community Medicine | Published by Wolters Kluwer - Medknow

 Begum, et al.: Introduction of interactive teaching for undergraduate students in community medicine
traditional TL methods in creating interest in the subject
community medicine and effective learning.
Objectives of the study
• To identify the need of interactive teaching among the
undergraduate students in community medicine
• To know the perception of students toward it
• To know the views and opinion of faculties toward the
implementation of ITL methods.
Methodology
• Study design: An educational interventional study
(randomized control trial [RCT] with crossover design)
• Study setting: NRIIMS, Vishakhapatnam
• Study duration: March 2018 to August 2018
• Study participants: Seventh‑semester defaulter
students (28)
• Sampling method: Convenient sampling
• Study tools: Predesigned and prevalidated semi‑structured
needs assessment and feedback questionnaire.
The needs assessment survey had questions regarding
sociodemographic information, perception toward the subject,
difficulty in learning the concepts of community medicine
compared to other parallel subjects (ophthalmology and ENT)
in a scale of 1–5, where 1 is very easy and 5 is very difficult,
reason of missing community medicine classes, and need of
the intervention.
Similarly, feedback questionnaire also had questions on
sociodemographic information, detail information about the
session content, duration, organization, its future implication,
satisfaction of students, and perception of students toward the
effect of interactive teaching sessions in Likert scale.
An in‑depth interview was done with involved faculties
to know their perception toward the intervention and
implementation process.
2 topics were taught using ITL 1 & 2 in group A and TTL in
group B. After a washout period of 15 days, 2 other topics
were taught using ITL 3 & 4 in group B and TTL in group
A, which was followed by assessment of both groups to
compare the results. To decrease the subjective bias the
teachers were also crossed over after each session.
Figure 1: Implementation process
Indian Journal of Community Medicine ¦ Volume 45 ¦ Issue 1 ¦ January-March 2020
After the needs assessment survey, an ITL module was
developed including choosing topics, allocating teachers,
interactive T/L methods, time, and assessment questionnaire
for each topic.
Consent was obtained and both students and teachers were
sensitized. Students were randomly allocated to study and control
groups. Two different topics (analytical study and experimental
study) were taught using two ITL methods (think‑pair‑share
and buzz sessions) in the intervention group (A) and TTL
method (PowerPoint) in another group (B). After a washout
period of 15 days, the crossover of groups was done to reduce
students’ bias, where two different topics (antenatal care and
childcare with integrated management of neonatal & childhood
illnesses (IMNCI)) were taught using two ITL methods (CBL
and pass the problem) in the intervention group (B) and TTL
method (PPT) in other group (A). Each session was followed
by the assessment multiple choice questions and short answer
question (MCQs and SAQ) of both the groups to compare the
results [Figure 1]. To decrease the subjective bias, the teachers
were also crossed over after each session. Feedback of students
and in‑depth interview of the faculty was done at the end of
all the sessions.
Intervention (Interactive T/L methods)
Think‑pair‑share
Students share and compare possible answers to a question
with a partner before addressing the larger class.[7] Study
group A students divided into seven pairs and gave individual
subtopics to discuss (cohort and case–control study: concept
of study and types, steps, relative risk, attributable risk, odds
ratio with some problems, advantages, and disadvantages).
After that, each pair shared their answers in the large group
which was facilitated and compiled by the teacher 1.
Buzz session
First used by Dr. Donald Phillips, it can be applied whenever a
large assembly of people is divided into small groups (usually
of no less than three and no more than eight) which, for a
limited time and simultaneously, discuss separate problems or
various phases of a given problem. If possible, recorders from
each of the groups report their findings to the reassembled
large group.[8] In our study, the study group students were
divided into four subgroups: two groups having three students
each and the other two groups having four students each. Then,
subtopics were given to individual group for discussion (steps
in randomized controlled trial, phases of clinical drug trail,
non‑RCT, association, and causation). Teacher 2 was facilitating
the discussion by visiting each table. At the end, all the group
leaders shared their summary of discussion moderated by teacher.
Case based learning
Using clinical cases to aid teaching has been termed as
CBL. It links theory to practice, through the application
of knowledge to the cases, using inquiry‑based learning
methods (Thistlewaite et al.).[9] An antenatal case scenario was
given for discussion to study group B (four subgroups each
73
 Begum, et al.: Introduction of interactive teaching for undergraduate students in community medicine
having three or four students) (28 weeks of gestation having
anemia and bilateral pitting edema). Students discussed the
case given with different leads (1 – raised blood pressure,
blurring of vision, and headache; 2 – high blood sugar
and excessive weight gain; 3 – history previous abortions,
present s/s of vaginal spotting, and abdominal cramping; and
4 – persistent nausea and vomiting throughout the antenatal
period which has increased recently with signs & symptoms
(s/s) of dehydration and fainting) in groups and presented the
case. Teacher 1 facilitated the presentation afterward discussing
the issues related to it and the management of the given case
in different scenarios.
Pass the problem
Divide students into groups. Give the first group a case or a
problem and ask them to identify (and write down) the first step
in solving the problem or analyzing the case (3 min). Pass the
problem on to the next group and have them identify the next
step. Continue until all groups have contributed.[7] Group B
students were divided into four subgroups each having three or
four students. Four different case scenarios were given related
to childcare as per IMNCI. Each subgroup had to solve part
of the problem given (assessment, classification, management,
advise/counseling, and follow‑up as per IMNCI) by passing the
problem. At the end, the teacher interacted with all discussing
the detail of cases.
Results
A needs assessment survey was conducted out of 33 defaulter
students, of which 28 students participated. Forty percent
were male and 60% were female. Only 38% of the students
were following standard books. None of them like to read
community medicine books and the main reason being (65%)
not able to understand the content followed by other reasons
such as subject being boring (20%) and full of imagination/
stories (11%).
Out of 28, majority (24) of the students stated that they
usually miss the community medicine classes once or twice
a month mainly attributed to factors such as less engagement
in class (100%), followed by noninteresting lectures (91.6%),
preferring self‑study (91.6%), and difficulty in understanding
the subject (83%). Apart from that some other personal,
classroom factors, peer pressure, faster pace, too much stuff,
and monotonous lectures were few important factors affecting
the attendance as mentioned by the students.
Table 1: Needs assessment survey: Difficulty level of
3rd‑year professional MBBS part 1 subjects in a scale of
1-5 (where 1 is very easy and 5 is very difficult)
Subject Difficulty rating scale
1 2 3 4 5 BS, CBL, and PTP, respectively) analyzed using Pearson’s
Ophthalmology (%) 2 60 30 8 0
ENT (%) 0 70 24 6 0
Community medicine (%) 0 0 3 7 90
74 Indian Journal of Community Medicine ¦ Volume 45 ¦ Issue 1 ¦ January-March 2020
Eighty percent of the students were facing difficulty in
understanding the content in community medicine and having
the view of TTL methods being not sufficient for learning
community medicine concepts. Similarly, 84% of the students
felt the need of interesting TLMs for engagement in class
and 92% opined for the requirement of more interaction in
community medicine classes.
Rating the difficulty level of learning the concepts of community
medicine compared to other subjects (ophthalmology and ENT)
of 3rd‑year professional MBBS in a scale of 1–5 showed that
90% felt that community medicine is very difficult compared
to others [Table 1].
The feedback responses were collected from all students who
participated and attended all the ITL sessions (28) and analyzed
with the use of appropriate statistics. The data showed that 60%
of the students were female whereas 40% were male and 58%
were day scholars whereas 42% were hostelites. Around 86%
of the students were not aware of the ITL methods before.
The present study revealed that 92.86%, 50%, and 75% of the
students were satisfied with the appropriateness of content,
adequacy of duration, and planning and implementation of
ITL module among the students, respectively. Around 92% of
the students were overall satisfied with the introduction of ITL
sessions in community medicine classes [Table 2].
Similarly, feedback data of students also revealed that ITL
methods were successful in increasing the interaction (78.57%)
and communication (71.43%) among students along with
interest (57.14%) and understanding (67.85%) of the contents
in community medicine. Around 67.86% of the students found
it helpful for examinations. Students had a 50:50 view toward
ITL methods being a part of curriculum [Figure 2]. It was
observed that 94% of the students wanted to attend other ITL
sessions in the future apart from the four used in the module.
Among four various ITL methods used in the project, pass the
problem (67.86%) was found to be the most enjoyed and liked
one among students, followed by buzz session (BS), think pair
& share (TPS), and CBL based on the ratings of ITL methods
in a scale of 1–10, where 1 is least and 10 is best.
Attendance was increased 7%–10% after each ITL session.
In student performance analysis after introducing ITL
sessions (TPS, BS, CBL, and PTP [pass the problem]), it
was revealed that 39.29%, 32.14%, 35.72%, and 50% of the
students scored >75% in the intervention group compared to
only 14.28%, 3.58%, 7.14%, and 21.42% in the other group
where traditional teaching was carried out [Figure 3].
The association between ITL session and scoring >75% in
assessment was found to be statistically significant in all the
four sessions (P = 0.0230, 0.0058, 0.0075, and 0.0034 for TPS,
Chi‑square test assuming normal distribution.
The in‑depth interview of faculties revealed that there was
an increased teacher–student interaction, student–student
 Begum, et al.: Introduction of interactive teaching for undergraduate students in community medicine

Table 2: Feedback survey: Perception of students on interactive teaching and learning session’s content, duration,
planning, and satisfaction on Likert scale
Statements Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree
Appropriate content (%) 35.71 57.14 7.14 0 0
Adequate duration (%) 10.71 39.28 50 0 0
Well planned (%) 17.86 57.14 25 0 0
Satisfaction (%) 64.28 28.58 7.14 0 0

100% 0%
ITL inclusion in Curriculum 17.86% 32.14% 46.42% 3.57%
90% 10.71%
14.28%
80% 17.86%
Helpful for exam 42.86% 25% 25% 7.14%

AASSESSMENT SCORE
70% 28.58%
Better understanding 67.85% 28.58% 3.57% 35.72%
60%
42.86%
46.42%
50% 50% <75%
Increased Interest 57.14% 35.72% 7.14%
40% 39.29% >75%
35.72%
Improved communication 71.43% 25% 3.57% 30% 32.14%

20% 21.42%
Increased Interaction 78.57% 14.28%
7.14% 14.28%
10%
7.14%
0% 20% 40% 60% 80% 100% 3.58%
0%
Strongly agree Agree Neither agree nor disagree disagree ITL1 TTL1 ITL2 TTL2 ITL3 TTL3 ITL4 TTL4

Figure 2: Perception of students toward the effect of interactive teaching
and learning sessions on the Likert scale
interaction, engagement, communication, and positive attitude
toward community medicine. However, limited time, losing
control, unfinished content, lot of planning, and paperwork
were the big concerns raised by the faculties.
Discussion
The attention span of a medical student was found to be
optimal till 20 min following which it rapidly faded off.[10] To
improve the classic lecture, interactivity between participants
is a must. This promotes active learning, heightens attention
and motivation, gives feedback to the teacher and student,
and increases satisfaction for both.[11] To improve the classical
didactic lecture, numerous methodologies have been devised.
Multimedia has been incorporated in lectures to convey
information. Although this has enabled more content to be
placed intuitively, an inappropriate usage of the presentation
tool can make the students paradoxically more inattentive.[12]
Active involvement students who are actively involved in the
learning activity will learn more than students who are passive
recipients of knowledge (Butler, 1992, and Feden, 1994).
Increased attention and motivation enhance memory. Increased
arousal and motivation are the essential ingredients for
learning (Frederick, 1986, and Foley and Smilansky, 1980).
The present study showed that 86% of the students and 28%
of the faculties were not aware of the ITL methods. It could be
due to the lack of practice of ITL methods in old curriculum
which has been revised in new competency based medical
education (CBME) curriculum which encompasses the use of
various ITL methods.[13]
Figure 3: Comparison of assessment scores between intervention and
control groups which showed significantly more number of students of the
interactive teaching group scored >75% in assessment than the control
group (P < 0.05) analyzed using Pearson’s Chi‑square test assuming
normal distribution
Increased attendance of 7%–10% was observed after each ITL
session although it was not mandatory. However, attendance
is always an issue in normal lectures of community medicine.
Similar facts were observed in another study where traditional
lecturing has been criticized for not being able to hold
students’ (or learners’) attention throughout teaching sessions
and has been associated with relatively low grades and reduced
attendance rates.[14]
It was observed that majority of the students satisfied with
ITL module in terms of increased interaction and improved
communication, interest in the subject, and understanding of
the content. The same findings were observed in a study where
interactive teaching promotes a higher level of thinking which
includes analysis and synthesis of material, application to other
situations, and evaluation of the material presented.[5]
Around 67.86% of the students found it useful for future
examinations although 25% were not sure about it and
7.14% disagree with the statement. It could be due to their
apprehension toward examination, attitude toward the subject,
and lack of knowledge on different ITL methods. Several
challenges may arise during attempts to shift the teaching/
learning method from traditional lecturing to a more interactive
learning style. Challenges can be related to the organization,
resources, staff, and/or the students.[15]
There was a 50:50 view on ITL being a part of routine
lectures. This is attributed to the habit of traditional one‑way
communication, lack of enough time and resources along with

Indian Journal of Community Medicine ¦ Volume 45 ¦ Issue 1 ¦ January-March 2020 75

 Begum, et al.: Introduction of interactive teaching for undergraduate students in community medicine
existing resistance to change, and attitude of finishing up rather
than conceptualizing.
The fear of losing control and the fear of not covering all the
materials along with time constraint prevent a teacher from
giving ITL sessions.[6] It is true that a “number of facts” need
to be reduced in order for a lecture to become interactive; we
also know that if we present too much information, students
will retain less (McKeachie, 1994; Newble and Cannon, 1994;
and Russell et al., 1984).
Ninety‑four percent of the students wanted to attend other
similar ITL sessions in the future. Among various ITL methods
adopted for the project, pass the problem was found to be the
most enjoyed and liked one among students and faculties.
Similar findings were highlighted in a study which stated that
the main strategy of modern education should focus on the
students’ independent activity, the organization of self‑learning
environments, and experimental and practical training,
and interactive teaching which contribute to the complex
competences of future specialists.[16]
In student performance analysis, it was found that the
association between ITL session and scoring >75% in
postassessment was statistically significant in all the four
sessions. Similar findings encountered in a study where it was
observed that true interactivity, both in the interface and in the
presentation methodology, will further enhance learning and
knowledge retention among students.[17]
An in‑depth interview with the faculties showed a positive
response toward ITL although time, resources, lot of planning,
fear of losing control, and not finishing the content in time were
the big concerns for all. Likewise, certain specific obstacles
are associated with the use of interactive learning including
limited class time, a possible increase in preparation time, the
potential difficulty of using active learning in large classes,
and a lack of needed materials, equipment, or resources.[18]
Conclusion
Less favorable attitude and interest in the subject of community
medicine were identified by the needs assessment survey.
After introducing the interactive teaching module, student
performance was increased in terms of knowledge, interaction,
attendance, and engagement in class. Overall satisfaction was
good among students and faculties. Based on the findings of
the study, the author would like to recommend the introduction
of ITL methods in regular classes of undergraduate medical
education curriculum.
Limitations
The limitation of the study was the small sample size and the
inclusion of only four ITL methods.
Acknowledgment
I sincerely acknowledge the guidance of Dr. Tejinder Singh,
Dr. Dinesh Badiyal, Dr. S. K. Mishra, FAIMER faculties,
faculty advisors, all FAIMER 2017 & 2018 fellow colleagues
76 Indian Journal of Community Medicine ¦ Volume 45 ¦ Issue 1 ¦ January-March 2020
of CMC-Ludhiana. I am also thankful to the institution for its
support, all the staff for their cooperation, and students for
their enthusiasm and participation.
Financial support and sponsorship
There was no financial support from institute.
Conflicts of interest
There are no conflicts of interest.
References
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Matthews P, et al. The effectiveness of case based learning in health
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The Flipped Classroom in Medical Education: Engaging
Students to Build Competency
Larry Hurtubise1, Elissa Hall2, Leah Sheridan3 and Heeyoung Han4
1
Department of Family Medicine and Faculty Development, Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA.
2
Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA. 3Department of Biomedical
Sciences, Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA. 4Department of Medical Education, Southern Illinois
University School of Medicine, Springfield, IL, USA.

ABSTR ACT: The flipped classroom represents an essential component in curricular reform. Technological advances enabling asynchronous and distrib-
uted learning are facilitating the movement to a competency-based paradigm in healthcare education. At its most basic level, flipping the classroom is the
practice of assigning students didactic material, traditionally covered in lectures, to be learned before class while using face-to-face time for more engaging
and active learning strategies. The development of more complex learning systems is creating new opportunities for learning across the continuum of medi-
cal education as well as interprofessional education. As medical educators engage in the process of successfully flipping a lecture, they gain new teaching
perspectives, which are foundational to effectively engage in curricular reform. The purpose of this article is to build a pedagogical and technological under-
standing of the flipped classroom framework and to articulate strategies for implementing it in medical education to build competency.

KEY WORDS: competency-based education, educational technology, flipped classroom, formative assessment, active learning

CITATION: Hurtubise et al. The Flipped Classroom in Medical Education: Engaging
Students to Build Competency. Journal of Medical Education and Curricular
Development 2015:2 35–43 doi:10.4137/JMECD.S23895.
RECEIVED: February 5, 2015. RESUBMITTED: March 22, 2015. ACCEPTED FOR
PUBLICATION: March 24, 2015.
ACADEMIC EDITOR: Steven R. Myers, Editor in Chief
TYPE: Review
FUNDING: Authors disclose no funding sources.
COMPETING INTERESTS: Authors disclose no potential conflicts of interest.
CORRESPONDENCE: hurtubis@ohio.edu
Paper subject to independent expert blind peer review by minimum of two reviewers.
All editorial decisions made by independent academic editor. Upon submission
manuscript was subject to anti-plagiarism scanning. Prior to publication all authors
have given signed confirmation of agreement to article publication and compliance
with all applicable ethical and legal requirements, including the accuracy of author
and contributor information, disclosure of competing interests and funding sources,
compliance with ethical requirements relating to human and animal study participants,
and compliance with any copyright requirements of third parties. This journal is a
member of the Committee on Publication Ethics (COPE). Provenance: the authors were
invited to submit this paper.

COPYRIGHT: © the authors, publisher and licensee Libertas Academica Limited. Published by Libertas Academica. Learn more about this journal.
This is an open-access article distributed under the terms of the Creative Commons
CC-BY-NC 3.0 License.

Introduction assessments to determine learning gaps, and 4) using active

For over a decade, medical education has been experiencing a
strong call for transformation.1,2 The current healthcare envi-
ronment requires competent physicians to coordinate with
an interprofessional team to deliver safer, higher quality, and
more cost-effective patient care.3 These factors underlie the
growing trend in medical education reform and make pos-
sible the implementation of learner-centered models as well
as competency-based curricula in which student progression
is achieved by demonstration of “mastery of academic content,
regardless of time, place, or pace of learning.”1–3
Disruptive innovations including social networks, cloud-
based computing, mobile devices, and video recording are
enabling educators at all levels to flip their classrooms to meet
the needs of the 21st century.4 Far from being a fad, the flipped
classroom (FC) has been present in medical education as
early as the mid-1990s with the introduction of team-based
learning. Flipping the classroom, at its most basic level, is
the practice of assigning learners didactic material, tradition-
ally covered in lectures, to be learned before class while using
face-to-face time for more engaged and active learning. The
steps for implementing a flipped classroom include 1) using a
backward instructional design to plan your learning activities,
2) creating opportunities for prelearning (eg, short recordings)
of didactic materials, 3) developing formative and diagnostic
learning strategies and technology to address the learning
gaps and develop competency.5 Additionally, medical educators
should be open to opportunities to develop longitudinal and
interprofessional learning experiences, while being sensitive to
the organizational change required to flip the classroom.
What is the Flipped Classroom
FC is the result of assigning didactic material to learners before
class time while using face-to-face time for more active learn-
ing strategies such as reflection, group projects, or discussions.
Core elements of an FC include assigned preclass content,
formative assessment, working on learning gaps, developing
competency, and the teachers’ role as guide on the side. Each
offers multiple educational advantages.6 For example, online
videos or e-learning modules can be used to teach knowledge,
skills, and attitudes as well as provide content for learners with
various learning styles.7 Learners gain the ability to control
the speed and bookmark sections, as well as review concepts
before and after class. Additionally, formative assessments can
evaluate the development of multiple competencies and elicit
learning gaps. Identifying learning gaps and the developmen-
tal stage of students is a pivotal process.5 Data on learning
gaps enable teachers to mitigate the variance in learners’ com-
petency and recommend self-directed instructional activities.

Journal of Medical Education and Curricular Development 2015:2 35

Hurtubise et al
Theoretical Foundations
The foundations of the FC lie in time-tested educational
theories. According to Dewey’s Reflex Arc Concept, teaching
and learning do not occur in a closed system where a teacher
provides instruction (stimulus) and students simply absorb
what they were told (response) in the classroom.8 Instead,
learning experiences in the FC occur beyond the boundary
of formal class time and place, and resemble a circular and
organic relationship where all activities are connected and
become meaningful and enriched by the previous experi-
ences.8 In this organic learning environment, learners become
the owner of the learning process and can actively engage in
“the iterative process of building mental models from existing
and new information. They can test these models by identify-
ing their learning gaps, seeking resources and assistance, and
interpreting information based on their experiences for fur-
ther development”.9(p6) Learners stay in the zone of proximal
development where they metacognitively manage their learn-
ing process through reflection, and cognitively develop their
own knowledge and skills with expert scaffolding and guid-
ance on the side.10 Teachers’ lectures, in-classroom activities,
and out-of-classroom activities are designed as scaffolding
to facilitate learner-centered environments. In an FC, active
learning is a mechanism for a learner-centered, organic, col-
laborative learning environment.
The purpose of the organic learning environment in the
healthcare community is to meet the challenges of 21st cen-
tury practice.2,11–14 In response, accrediting bodies in gradu-
ate medical education and other healthcare professions require
competency-based medical curricula, and medical school
faculty must ensure “self-directed learning experiences” for
their students to foster the development of lifelong learning
skills.15 Visionary medical educators are proposing a system
that encourages integrative, organic, and collaborative learn-
ing that develops habits of inquiry and improvement and that
advances health and wellness in a holistic way for patients and
patient populations.1
Designing a Flipped Classroom
Medical education, with its year-long courses, hundreds
of instructors, interdisciplinary curriculum, and academic
support systems, poses unique challenges to flipping the
classroom. These challenges require teachers to consider
more deeply the instructional design process.16 Typically,
backward instructional design models suggest first identi-
fying learning goals, then assessment methods, and finally
teaching methods. This process results in an organized
sequence of activities so students spend their time and effort
learning.17–19
One backward design model, Quality Matters© (QM),
was developed for teachers creating online and blended
courses. QM is valuable for flipping the classroom in medi-
cal education because of its consideration of the planning and
communication necessary for students working independently
36 Journal of Medical Education and Curricular Development 2015:2
on Web-based assignments. The foundation of QM is a
comprehensive research-based set of quality standards and
annotations. In addition to traditional backward design mod-
els, QM covers course technologies, learner support, as well
as accessibility and usability.19 The QM standards can serve
both as a formative evaluation in the development of an FC
approach as well as a summative evaluation to ensure instruc-
tional design factors for success.
Learning goals. When identifying learning goals, instruc-
tors should consider the strong movement toward a com-
petency-based model in healthcare education. Recently, the
Association of American Medical Colleges (AAMC) com-
pleted an effort to identify an initial short list of entrustable
professional activities (EPAs) to be expected of all graduates
making the transition from medical school to residency.3 EPAs
refer to professional activities that together constitute the mass
of critical elements that operationally define a profession and
generally require multiple competencies. Similarly, a taxonomy
of competency domains for all the health professions has been
identified by Englander et al.14 These competencies include
patient care, knowledge for practice, practice-based learning
and improvement, interpersonal and communication skills,
professionalism, and systems-based practice, interprofessional
collaboration, as well as personal and professional development.
The agreement, by multiple professions, on the nomenclature of
healthcare competence should result in more effective interpro-
fessional education and better care.
Assessment. Competency-based education also requires
multiple forms of assessment.20 In an FC, learners might be
assessed on a competency such as “use the knowledge of one’s
own role and the roles of other health professionals to appro-
priately assess and address the healthcare needs of the patients
and populations served.” 14(p1092) When the assessment measures
the development of multiple competencies, which align with
EPAs required for practice, the feedback can be more valuable
and lead to learning that endures beyond the course.20,21
Active learning strategies and tactics. Active learning
requires students to have ownership of their learning process
for meaningful learning experiences and outcome.22 The FC
provides time for face-to-face engagement, which aligns prior
knowledge with experiences and prepares learners for practice.
These experiences collectively build learner confidence, pro-
vide opportunities to support development of self-efficacy, and
create an environment of inquiry and open questioning.23,24
There are various teaching tactics and strategies that support
this approach. Tactics require less coordination than strate-
gies and can be used by individual faculty to engage learn-
ers in an FC. Medbiquitous, a standardized vocabulary
for medical education developed in collaboration with the
AAMC, includes tactics applicable to the FC such as case-
based instruction, audience response, peer instruction, as well
as small and large group discussions.20 The FC also provides
an opportunity to engage learners by using class time to hear
new perspectives. These new perspectives include clinicians

with first-hand experience, patients and families with unique
healthcare experiences, and standardized patients trained in
the development of communication skills.
Collaborative learning. Medical education reformers and
other educational leaders highlight the need to develop col-
laboration skills.14,25 Collaborative learning can refer to any
instructional method in which students work together in
small groups toward a common goal and emphasizes group
interactions rather than learning as a solitary activity. 22 Two
flipped curriculum-level strategies, requiring more coordi-
nation, listed by Medbiqutous, are problem-based learning
(PBL) and team-based learning (TBL).
Problem-based learning. PBL is a type of inductive instruc-
tion in which relevant problems are introduced at the begin-
ning of the instruction cycle and used to identify learning
gaps and provide the context and motivation for the learning
that follows. It is always active and usually collaborative. 22
Students determine their own learning gaps and apply newly
acquired knowledge to solve the problem. A tutor, in lieu of
transmitting expert knowledge, guides the group in their
task, monitors the educational progress of each student, and
maintains functionality of the group as a whole. 26 In accor-
dance with a flipped model, PBL students can use online
didactic materials as a resource for foundational medical
knowledge.
Team-based learning. TBL is a model for flipping the
classroom and has been used in medical education since the
1990s. It allows a single instructor to conduct multiple small
groups simultaneously in one classroom. TBL stresses the
importance of out-of-class learning based on learning objec-
tives, emphasizes the importance of holding learners account-
able for attending class prepared to participate, and provides
guidelines for designing group learning tasks to maximize
participation.27,28 Class time is shifted away from learning
facts toward application and integration of information. TBL
also encourages the development of high-performing teams of
5–7 learners. These learning teams develop team skills on the
path to attaining content and/or clinical knowledge and rea-
soning skills. A faculty facilitator provides oral feedback and
corrective instruction, and guides and encourages learners to
articulate their ideas during intragroup work as well as during
intergroup discussions.
Educational technologies for a flipped classroom. In
an FC, educational technology can be leveraged in the design
of engaging prelearning experiences as well as active collab-
orative face-to-face experiences. There are tools available for
content creation, communication, information sharing, col-
laborative inquiry, ongoing assessment, and metacognition to
facilitate teaching and learning.29,30 The exponential growth of
available technologies can prove overwhelming when attempt-
ing to identify the appropriate technology to use. Therefore, it
is essential for medical educators to focus on competency-based
outcomes, interactive learning, and instructional design as the
drivers for technology-related decisions.31 The identification of
Journal of Medical Education and Curricular Development 2015:2
The flipped classroom in medical education
competencies and outcomes ensures that educators implement
technology as a “reliable strategy” versus a “novelty.”29
Content creation. Medical educators have many options
for making prerecorded lectures and distributing on the
Internet.32 Learners use these materials in a variety of ways.
They may watch the video the first time while taking notes in
the PowerPoint file and later download the MP3 on a mobile
device to review materials. Many universities support plat-
forms for recording and distributing lectures, which enable
educators to make the recording once, integrate into existing
systems, and provide students with file types including video,
audio, and PowerPoint.32
Another option is to create engaging e-learning mod-
ules. These modules offer learners the opportunity to interact
with visual content like computed tomography (CT) scans or
ultrasound videos. They can also contain built-in quizzes with
a variety of question types for formative assessment. While
some schools provide the software and equipment for faculty
to develop learning modules, others hire instructional design-
ers to work closely with an educator to transform the lecture
into a high-quality prerecording and engaging classroom
activity. In most cases, instructional designers have expertise
in e-learning authoring tools. These authoring tools create
interactive modules that are viewable on mobile devices and
across operating systems like Windows, IOS, and Android. 33
Communication, information sharing, and collaborative inquiry.
Education technology can be implemented to engage learners
in discussion, collaboration, and inquiry to facilitate social
knowledge construction and problem-solving. For example,
backchannel communication (see Table 1) can be used dur-
ing didactics, real-time group discussions, or asynchronous
discussions to apply knowledge, contribute ideas, and answer
questions. Learners can also share resources such as Websites,
articles, and visuals to explain concepts and support ideas.
Collaborative inquiry, such as brainstorming, affinity dia-
grams, and concept mapping, is another strategy to facilitate
the development of systems-based practice skills used in qual-
ity improvement, decision making, and organization learning
processes.
Ongoing assessment and metacognition. Education tech-
nology can inform both faculty and learners of the acqui-
sition of competencies. Learners can engage in frequent
self-assessments to encourage metacognition and acknowl-
edge practice-based learning and improvement to sustain
personal and professional development.14 When determin-
ing the technologies to utilize for assessment of competen-
cies, educators pinpoint the appropriate cognitive levels to
be assessed. Once pinpointed, the appropriate technologies
are utilized for formative assessment and summative evalua-
tion, including examples such as polling, online quizzes, and
e-portfolios. Technologies implemented to develop compe-
tencies, information sharing, collaboration, communication,
and content curation can also be implemented as authentic
learner assessments.
37
Hurtubise et al

Table 1. Flipped classroom technologies.

CONTENT CREATION
Lecture recording: Minimally this includes an audio recording of the lecturers with voice synchronized with a screen and capture; it can
include video recording of the instructor as well.32
Media Site
Echo 360
Tegrity
Panopto
Camtasia
E-learning module authoring: Minimally this includes an audio recording of the lecturers, with voice synchronized with a screen capture; it
can include graphics capability, animations, interactivity, quizzing, ADA/accessibility, mobile, and software simulations.33
Adobe Captivate
Articulate Storyline
Articulate Studio
iBooks
Lectora
COMMUNICATING AND INFORMATION SHARING
Backchannel: An avenue for synchronous discussion during didactics, lectures, or presentations in which participants, face-to-face or virtual,
can ask questions, post resources, and provide feedback.34 Faculty can use the backchannel to inform content being presented.
Today’s Meet
Twitter
Discussion: Tools are available outside of a dedicated learning management system to promote asynchronous discussion and feedback.
These technologies incorporate written text, video, audio, and voting features.
Idea Scale
VoiceThread
Social bookmarking: Web-based process for saving and tagging websites for both individual and collaborative organization of content.35
Tools vary on extent of annotations, group sharing, and private versus public content.
Delicious
Diigo
Social citation managers: A repository to manage, tag, and annotate scholarly resources.36 Local and/or Web-based applications allow
individual or collaborative sharing of citations.
EndNote
Mendely
Zotero
Social networking: These technologies provide opportunities for information sharing and problem solving with colleagues, access to
expertise and mentors, and peer-to-peer education.
Physician only networks (Doximity)
Professional and Personal (LinkedIn, Facebook)
COLLABORATIVE INQUIRY
Brainstorm and affinity diagrams: Virtual “post-its” to share, rearrange, and to prioritize ideas synchronously in class or asynchronously as
prec-ourse work.
Memosort
NoteApp
Collaborative workspace: Promotes sharing of resources, accessible on multiple devices, from one central location. Additionally, some
workspaces “synch changes from multiple participants” which promotes on-going feedback loops required of competency-based education.37
Dropbox
Google Drive
Concept and mind maps: Web-based resources for creation of individual or collaborative graphic representation of content using words
and/or images. It “involves integration of knowledge and creation of meaning by relating concepts.” 38(p201)
C-Map
MindMeister
Curate content: Resources for visually aggregating hyperlinked content around a central idea(s) or theme(s).39
Pearltrees
Pinterest
ScoopIt

38 Journal of Medical Education and Curricular Development 2015:2

 The flipped classroom in medical education

Table 1. (Continued).

Note-taking: Learners and faculty can create shared notebooks to facilitate collaborative note-taking, sharing of resources, and data and task
management. These tools have exceptional searching capabilities, are accessible on multiple devices, and integrate multiple modes of content
(eg, text, audio, video, ink).
Evernote
OneNote
Web/Virtual conferencing: Provide opportunities for synchronous discussion at a distance. Also consider options for using these
technologies to engage learners at a distance with those in class or facilitate in-class small group presentations using breakout room features.
Adobe Connect
Google Hangouts
Go To Meeting
Join Me (App)
Skype
WebEx
COLLABORATIVE INQUIRY
Whiteboards: Online whiteboard, which includes synchronous conferencing (chat or video) while collaboratively annotating content.
Technologies can integrate pregenerated content, images, or PDFs, as well as facilitate just-in-time teaching and learning.
Baiboard (App)
GroupBoard
Wikis: Content-specific webpages, modifiable by multiple users, utilized for asynchronous collaboration and social content creation.40
Wikis are a dynamic resource requiring contributors to cite references and create connections with other content specific wikis pages.
Wikipedia
Wikispaces
ONGOING ASSESSMENT AND METACOGNITION
Checking for understanding: Technology can facilitate formative and self- assessment of knowledge and learning. These range from
resources in which learners can record content while annotating and flashcards to surveys tools and objective exams.
ePortfolio
ExamSoft
Explain Everything (App)
Google Forms
Mental Case (App)
Online Surveys
Polling: Implemented as a pre-class assessment or face-to-face assessment tool; audience response systems can inform in-class discussion
and teamwork. There are a variety of options available given learner devices and budgets.
Poll Everywhere
Socrative
TurningPoint
Feedback: Crucial to competency-based education is ongoing feedback. There are resources available to help facilitate virtual constructive
feedback without extensive typing or written communication. Examples include the creation of audio files as well as tracking and annotation
features.
Audacity
Google Drive: Documents
iAnnotate PDF (App)

Table 1 is a collection of education technologies for deve­
loping content, facilitating active learning, and assessing
learner competency in an FC. In consideration of backwards
design and QM, the table encourages faculty to integrate
technology as a reliable strategy or activity to achieve learning
goals and scaffold learning experiences.
Below are the instructional design considerations that are
critical for the success of an FC.
• Consider your learners and how they learn. For example,
millennials may have different strengths and needs.
• Make learning goals explicit. Try to cover multiple
competencies.
• Consider the learners’ cognitive load including all their
assessments and assignments.
• Accurately estimate and communicate the amount of
time you expect students will spend on didactic materials

Journal of Medical Education and Curricular Development 2015:2 39

Hurtubise et al
outside of class. Some schools reserve preparation time
on student schedules.
• Provide an online schedule and make learning materials
easy to find and easy to use.
• Ensure assessment methods are competency-based and
match your goals. Use formative assessment and feedback
to identify learning gaps and develop competency during
“richly interactive, compelling, and engaging” sessions.
Plan to “strengthen connections between formal and
experiential knowledge gained across the continuum of medi-
cal education, and promote learners’ ability to work collabora-
tively with other health professionals.”4
Flipping the Classroom to Develop Competency
Example
The flipped model provides opportunities for additional com-
petencies to be addressed during class time. For example, if
the learning goal is the EPA “managing a patient with dia-
betes,” there are a variety of competencies to be addressed.
Leveraging technology to transmit knowledge for practice
before class enables class time to be spent developing the com-
petency to “apply established and emerging principles of clini-
cal sciences to diagnostic and therapeutic decision-making,
clinical problem-solving, and other aspects of evidence-based
health care.”14(p1091)
Table 2 demonstrates how the FC can enable new cohorts
of learners to assemble for collaborative learning. Starting
with a traditional TBL, Table 2 suggests modification to
build and assess a variety of competencies associated with the
EPA “managing a patient with diabetes” as well as the related
competencies.41 While the additional or alternative methods
offered leverage technology, Nishimoto et al suggest an effec-
tive TBL using low-tech assignments and teaching strategies.
The Type 2 Diabetes TBL for M1 students by Nishimoto et al
was downloaded from MedEdPortal, a peer-reviewed clear-
inghouse of health education tools.41
Change Management and the Flipped Classroom
Medical education curricula have had the same structure since
Flexner.16 Our teaching practices with their accompanying
support structures are well established. Flipping the class-
room requires changing these patterns of working and com-
municating. Perhaps the biggest change for medical education
is the initial increase in the amount of administrative coordi-
nation needed. Curricular development teams must facilitate
communication with students and all instructors teaching in
the course. Additionally, including technology and curricu-
lum support units in the development process is critical to sus-
taining any change effort in medical education.
The additional administrative coordination needed to
successfully implement an FC suggests the need for a change
management process. In medical education, the core ele-
ments of FC can be applied to lectures, courses, or an entire
40 Journal of Medical Education and Curricular Development 2015:2
curriculum. Kotter’s42 eight-step process for leading change
has proven to be helpful for organizations seeking to change
in a dynamic environment. Table 3 outlines the success fac-
tors inspired by Kotter’s steps with recommendations for flip-
ping the classroom, course, and/or curriculum in medical
education.3 The recommendations are cumulative as the scope
of change increases.
Implications for Practice and Research
The movement to an FC model has many implications for
educational practice and research. In addition to opportuni-
ties for building and assessing competency for learners, an FC
model also provides opportunities to acquire and assess medi-
cal educator teaching competencies, to implement multifac-
eted continuous learner assessment, and to collaborate across
the continuum with multi-institutional colleagues.
The “Teaching as a competency framework,” intro-
duced by Srinivasan et al in 2011, presents the competency
for program design and implementation, and focuses on a
learner-centered approach in which fundamental principles of
education, learning environment, and advances in instructional
modalities (technologies) are coupled with ongoing assessment
of learners’ needs and effectiveness in achieving outcomes.43
An FC model affords medical educators the opportunity to
build competency in program design and implementation by
1) utilizing situational factors to establish the learning envi-
ronment, 20,24 2) sequencing content for appropriate cognitive
load, 24,29 and 3) scaffolding learning experiences for early
application to scaffold practice. 23,24,29 The program design
and implementation competency applied to FC approaches
can be assessed by using course design frameworks includ-
ing the utilization of the QM rubric as a formative checklist.
A flipped approach also provides educators the opportunity
to engage in multifaceted, continuous learner assessment.
Deliberate assessment has been identified as a shortcoming
in medical education.30,44 Developing educator competency in
FC design and implementation is one avenue to address this.
The flipped model challenges educators to think differently
about assessment, given the availability of analytics to assess
performance. Finally, the FC model affords medical educa-
tors opportunities to develop and integrate recursive, longi-
tudinal, competency-based education to facilitate and assess
teaching and learning across the continuum of UME, GME,
and CME.14,30
For both teaching and learning competency, the FC model
promotes opportunities for multi-institutional collaboration,
mentorship across the continuum, and sharing experiences
through education research and scholarship.4,44 Repurposing
of instructional material across the continuum would result in
enabling opportunities for learning when and where it may not
have been otherwise possible. With this, educators can focus
on role-modeling, facilitating active learning experiences,
and providing feedback to promote a longitudinal learning
experience.24
 Table 2. Flipping the classroom to develop competency example.
TBL COMPONENT
Team formation
Pre-class: learner
preparation for TBL
module
Readiness assurance
test (RAT)
Instructor feedback
and written appeals
In-class team work
and discussion
Peer evaluation
Assessment
and self-assessment
Journal of Medical Education and Curricular Development 2015:2
41
TYPE 2 DIABETES TBL FOR M1 STUDENTS
Organize learners according to
advanced degrees, medical experience,
undergraduate college, geographic origin, gender
Divide into teams of six with equal
representation of the above learner
characteristics
Advanced preparation (made available
2 weeks prior to module):
Pertinent chapters in biochemistry
and anatomy text;
Current evidenced-based journals
and Web-based resources
Individuals (iRAT)
Audience response system to capture
iRAT scores
Team (tRAT)
Scratch off sheets for immediate
feedback and to capture scores
Only team filing appeal is eligible
for rescore
Intra-team
Clinical case and application
questions—team discussion,
progressive reveal of questions
Inter-team
Faculty facilitated
minimal discussion of questions
when consensus among teams
Surveys requiring students to rank
participants
RAT only;
assessment of application-level
objectives not indicated
ADDITIONAL/ALTERNATIVE FC DESIGN RELATED COMPETENCIES
Include interprofessional team members
Interprofessional communi-
Utilize asynchronous discussions technologies cation; collaboration
to form interprofessionally balanced teams around
common interest or experiences
Enable learners to prepare:
Integrate pre-recorded
lectures, podcasts, or e-learning modules
Engage students with formative assessment
Knowledge for practice
and collaborative note-taking technologies:
Use content curation technologies and information-sharing
resources that enable learners to use and contribute to the
resources before and after the FC
Capitalize on in-class time by providing data
to instructors:
Use online forms to assess learner’s prior knowledge
and preparation as well as to inform in-class session Knowledge for practice;
practice-based learning
Implement online testing to capture scores and integrate and improvement;
into student information systems systems-based practice;
patient care
Facilitate collaborative inquiry, using wikis or concept maps,
to develop and share rationale
Develop an interprofessional, practice-based learning
and improvement project related to the case
Knowledge for practice;
professionalism;
systems-based practice;
Use brainstorming and affinity diagramming technologies patient care;
to facilitate collaboration and participatory decision making; interpersonal and
use online whiteboards and backchannel technologies communication skills
to enable an interprofessional panel to participate and
to facilitate inter-team communication
Assess interprofessional teams and case: Interpersonal and
conduct student-conceived evaluation using polling communication skills;
technologies to measure contributions and interprofessional practice-based learning
communication; and improvement;
Utilize collaborative workspaces to facilitate feedback on case patient care
and project from interprofessional panel
Evaluate core competencies: Professionalism;
Rate the efficacy of the project using asynchronous discussion practice-based learning
tools; and improvement;
utilize online forms as critical incident questionnaire to assess professional and professional
FC experience and identify opportunities for continued learning development
The flipped classroom in medical education
 Hurtubise et al

Conclusion

Consider how you will develop, retain, and recruit

Include curricular leaders from across the contin-

developing curricular goals, defining assessment

Gather longitudinal data on curricular outcomes

uum of medical education and interprofessional Flipping the classroom is a building block of curricular

Engage a broad group of faculty in projects like

new skill sets as faculty and staff roles change

Be aware of constituencies who are interested
reform in medical education. It can be implemented in an

in your curriculum. Plan medical education

standards, and selecting technology tools

and share with national and international

educational unit as small as a lecture and as large as the entire
curriculum. It enables educators to learn about competency-
based education while holding promise as a strategy to build

medical education community

bridges across traditional curricular boundaries to develop
meaningful competency. Effectively implementing the model
requires being cognizant of overall curricular goals, the
scholarship projects

underlying theories of education, the active learning strat-

egies they suggest, and the development of new education
CURRICULUM

technologies. However, to fully realize the potential of the

educators

FC will require significant change management strategies

including conducting rigorous medical education research
around new teaching methods and competency-based edu-
cational outcomes.
technology to support new teaching methods

with previous years. Share in education and

Make sure all instructors have talking points
Provide a detailed orientation to the block.

to reinforce the importance of the change

technology publications and conferences

Author Contributions
Include faculty in a course design team.

Compare assessment data from the FC

medical education for example student
Consult all those whose work supports

Modify evaluations, assessments, and

Carefully choose a few people to pilot

Wrote the first draft of the manuscript: LH, EH, LS, HH.
Contributed to the writing of the manuscript: LH, EH, LS,
HH. Agree with manuscript results and conclusions: LH,
and provide specific details

EH, LS, HH. Jointly developed the structure and arguments

affairs and assessment

for the paper: LH, EH, LS, HH. Made critical revisions
flipping their lectures

and approved final version: LH, EH, LS, HH. All authors
reviewed and approved of the final manuscript.
COURSE

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43
Education Forum
Understanding your student: Using the VARK model
Prithishkumar IJ, Michael SA

Department of Anatomy, ABSTRACT

Christian Medical College,
Vellore, Tamil Nadu, India
Address for correspondence:
Dr. Ivan James Prithishkumar,
E-mail: drivanjames@
gmail.com
Received : 31-01-2014
Review completed : 25-03-2014
Accepted : 07-04-2014
Background: Students have different preferences in the assimilation and processing of information. The VARK
learning style model introduced by Fleming includes a questionnaire that identifies a person’s sensory modality
preference in learning. This model classifies students into four different learning modes; visual (V), aural (A),
read/write (R), and kinesthetic (K). Materials and Methods: The 16-point multiple choice VARK questionnaire
version 7.1 was distributed to first year undergraduate medical students after obtaining permission for use.
Results: Seventy-nine students (86.8%) were multimodal in their learning preference, and 12 students (13.8%)
were unimodal. The highest unimodal preference was K-7.7%. Surprisingly, there were no visual unimodal
learners. The commonest learning preference was the bimodal category, of which the highest percentage
was seen in the AK (33%) and AR (16.5%) category. The most common trimodal preference was ARK (8.9%).
The total individual scores in each category were V-371, A-588, R/W-432, and K-581; auditory and kinesthetic
being the highest preference. Visual mode had the lowest overall score. There was no significant difference
in preference between the sexes. Conclusion: Students possess a wide diversity in learning preferences.
This necessitates teachers to effectively deliver according to the needs of the student. Multiple modalities
of information presentation are necessary to keep the attention and motivation of our students requiring
a shift from the traditional large-group teacher-centric lecture method to an interactive, student-centric
multimodal approach.
KEY WORDS: Learning preferences, learning styles, VARK

Introduction intrinsic and extrinsic motivation. Intrinsic motivation is a

stimulation born from within oneself without inducement

T       h e background of the student population in any

university is very diverse. This includes varied socio-
economic background, wide ranging ages of students, varied
cultural background, prior educational experiences, levels
of competency and preparedness, and preferred learning
strategies.[1] Effective teaching in such a set up can be difficult
and challenging. Teaching is a process of knowledge presentation
while learning is often multifactorial and depends on the
mindset of each student.[2] The multiple factors that play an
effective role in the learning process include:[3]
a. Student’s interest in the topic being taught,
b. Student’s motivation to the subject: One of the roles of a
teacher is to establish and maintain motivation in a student.
Two types of motivation have been described, namely
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c.
or coercion from others, while extrinsic motivation is a
stimulation often influenced externally by others.
Individual principle: Every student has different levels
of competency and mastery, each of them having their
own diverse ways of understanding and remembering the
subject.[2]
d. Active student participation and involvement in the
teaching-learning process is crucial to effective learning.
e. Affective domain of the student: Learning also depends on
one’s personality and includes factors such as curiosity, prior
awareness of the subject, emotional status of the individual,
boredom, motivation, concern, and an incentive to study,
if any,[2] and
f. Preferred learning styles: Students have different learning
styles and these affect how they learn. An ‘Individual
learning style’ refers to a ‘style or learning preference or
preferred strategy’ used by the student in the process of
learning and assimilation of information.
Learning style inventories are information-processing models
that aim to identify a student’s preferred intellectual approach
in assimilating and processing information.[4] These include
models described by various educationists such as Dunn and

Journal of Postgraduate Medicine April 2014 Vol 60 Issue 2 183 

 Prithishkumar and Michael: Learning preferences of first year medical students
Dunn, Felder-Silverman, Salmes, Honey and Murnford, Kolb
and VARK.[3] The VARK learning style model was introduced by
Neil Fleming in 2006.[5] VARK is an acronym, which stands for
visual, aural, read/write, and kinesthetic preference modalities.
This learning style classifies students into four different learning
modes, each mode based on different preferred senses used
in information gathering namely visual (V), aural (A), read/
write (R), and kinesthetic (K). The VARK© inventory includes
a questionnaire that identifies a person’s sensory modality
preference. The VARK model has been validated by Dr. Walter
Leite from the Research and Evaluation Methodology program
at the University of Florida.[6] Visual learners (V) learn by looking
at image intense figures, graphics, and videos. They like to use
symbolic tools such as arrows, flowcharts, graphs, models, and
hierarchies, which represent printed information. They teach
concepts to others by drawing an image orpicture.[7] Aural
learners (A) give particular attention to words delivered by
teachers.[2] They prefer to listen than taking down detailed
lecture notes; they like discussions and seminars and like
listening to mp3 recordings of lecturers.[3] Aural learners can
remember information through loud reading or even low volume
mouthing when reading.[8] Read/Write learners (R) read printed
texts to gain information.They like lecture notes, handouts, and
text books. Besides, they are keen note-takers.[2] Kinesthetic
learners (K) prefer hands on experience, practical application,
use of models, and real life experience. They like experiential
learning and prefer to apply touch,movement, and interaction
to their learning environment.[2] They dislike merely listening
even in an image intense environment; typically kinesthetic
students are passive in the classroom setting. The present study
was carried out with the objectives of determining the preferred
learning style of first year undergraduate medical students using
the VARK questionnaire and to compare learning preferences
between sexes.
Materials and Methods
Ethics: The study protocol was approved by the Institutional
Review Board and written, informed consent was obtained from
all participants. Complete anonymity was maintained during
data collection; only the sex of the student had to be indicated
Instrument: The 16 multiple choice VARK questionnaire
version 7.1 [Copyright (2006) held by Neil D. Fleming,
Christchurch, New Zealand and Charles C. Bonwell, Green
Mountain Falls, Colorado 80819, USA] was used after
requisite permissions were obtained from the developer. It was
downloaded from the VARK home page http://www.vark-learn.
com/english/page.asp?p=questionnaire.
Study procedure: During regular working hours, the first year
undergraduate medical students were briefed about the study.
The questionnaire was then distributed in the form of hard
copies to those who consented.
Variables and their evaluation: Students were distributed
into one of the following categories: Unimodal-Having only
of the V, A, R, or K preferences; Multimodal-Having more
than one preference. Multimodal was further classified into
 184
Bimodal-Having two preferences; Trimodal-Having three
preferences; and Quadrimodal-having 4 preferences. Scores
were given accordingly.
Statistical analysis: The data was entered into a Microsoft excel
sheet and the score statistically analyzed to determine the
percentage of students in each category. Difference between
the sexes was analyzed using the Fishers or Chi-square test. All
tests were done at 5% significance.
Results
Demographic data: A total of 91/100 students consented and
completed the questionnaire.
Learning preferences: A total of 79 (86.8%) were multimodal
in their learning preference and only 12 students (13.8%)
were unimodal [Figure 1]. The highest unimodal preference
was K-7.7%, A-3.3%, and R-2.2%. Surprisingly, there were no
visual unimodal learners [Figure 2]. Figure 3 shows the overall
distribution of scores of all modalities of learning styles. The
commonest learning preference was the bimodal category, of
which the highest percentage was seen in the AK (33%) and AR
(16.5%) category. The most common trimodal preference was
ARK (8.9%). Figure 4 shows the total individual scores in each
category. These are V-371, A-588, R/W-432, and K-581. Auditory
and Kinesthetic was the highest preference. Surprisingly, Visual
mode had the lowest overall score. Figure 5 shows the different
modalities grouped under unimodal, bimodal, trimodal, and
quadrimodal categories. There was no quadrimodal group
observed. The commonest learning preference was the bimodal
category, among which the commonest being AK, AR, and VK
category. There was no difference between the sexes (P > 0.05)
[Figure 6].
Discussion
Neil Fleming in his landmark article ‘I’m different; not dumb:
Modes of presentation (V.A.R.K.) in the tertiary classroom’ says
that people learn in different ways using variety of strategies
to convert the educational message into their long term
memories. There is no single best way to teach, but teachers
can diversify their teaching styles to cater to the learning styles
of each distinctive student.[9,10] Awareness of learning styles
will help educators identify and solve learning problems among
students.[11]
In our present study, 86.8% of students were multimodal in their
learning style. A similar study done in the medical University
of Colombo by Samarakoon et al. showed that the majority
(69.9%) of first year medical students had multimodal learning
styles, unimodal being only in 30.1%; among the unimodal
learners, the clear majority were auditory learners (50%); among
the multimodal learners, 30.1% were bimodal learners with
AR(50%) and AK (31.8%) types predominating.[12] As observed
by Samarakoon et al., the similarities observed in our students
may be attributable to the traditional didactic lecture method
in the pre-university education system, where pre-university
education is often supplemented with coaching centers and
Journal of Postgraduate Medicine April 2014 Vol 60 Issue 2
 Prithishkumar and Michael: Learning preferences of first year medical students
Figure 1: Shows the preference for unimodal and multimodal learning.
Seventy-nine students (86.8%) were multimodal, and only 12 students
(13.8%) were unimodal
Figure 3: Shows the overall distribution of scores of all modalities of
learning.The commonest learning preference is AK (33%)
Figure 5: Shows the percentage of unimodal, bimodal, trimodal, and
quadrimodal categories; the commonest being the bimodal
private tuition classes that are often large lecture-based modules
with a strong emphasis on the read/write and aural mode of
information presentation.
A VARK study by Lujan et al. on medical students in Wayne
State University School of Medicine, Michigan showed that
Journal of Postgraduate Medicine April 2014 Vol 60 Issue 2
Figure 2: Shows the different individual unimodal preferences; K-7.7%,
A-3.3%, and R-2.2%
Figure 4: Shows the total individual scores in each category; V-371,
A-588, R/W-432, and K-581
Figure 6: Shows no significant difference in preference between the
sexes
majority (63.8%) had multimodal learning preference with
only 36.1% having a unimodal preference.[13] Among those
with unimodal preferences, 5.4% preferred visual, 4.8%
preferred auditory, 7.8% preferred printed words, and 18.1%
preferred kinesthetic mode; auditory learners were only a
small minority (4.8%). Of the 63.8% of students who preferred
multiple modes of information presentation, 24.5% were
bimodal, 32.1% were trimodal, and the majority preferred all
four modes (quadrimodal, 43.4%). Another study done on
185 
 Prithishkumar and Michael: Learning preferences of first year medical students
medical students by the Department of Medical Education
of Erciyes, Turkeyshowed multimodal preference in 63.9%
and unimodal in 36.1% of students.[11] Among the unimodal,
preferences were V-3.2%, A-7.7%, R-1.9%, and K-23.3%; only
1.9% being auditory learners. Preferred multiple modes were:
Bimodal (30.3%), trimodal (20.7%), and quadrimodal (12.9%).
Both these above studies demonstrate a clear predominance
of kinesthetic learners (18.1% and 23.3% respectively) among
unimodal learners. A similar study among first year nursing
students in Australia demonstrated a predominance of
kinesthetic style of learning.[14] The fundamental difference
between learning preferences in our study and other studies in
USA, Turkey, and Australia may be the pattern of pre-university
education ingrained in our system with a strong emphasis on
the A and R/W mode with little emphasis on the visual (V)
and kinesthetic(K) mode.
A study done among clinical students in a MalaysianMedical
Collegecomprising of a mixed population of Indians, Chinese,
and Malayshowed that 44% were mono-modal and 56% were
multimodal.[15] The latter comprised of all three subgroups,
i.e., quadrimodal, trimodal, and bimodal. In the mono-modal
category, all the four preferences were represented with the
highest preference for kinesthetic. A study in another Malaysian
medical college indicated that 48.6% of undergraduate medical
students were multimodal; kinesthetic preference being the
highest among the mono-modal group (35%).[16] In contrast,
pre-clinical medical students in Saudi Arabia showed multimodal
learning preference in 72.6% with a strong aural preference in the
mono-modal category.[17] Interestingly, a study among musical
students of Thailandshowed 66.1% were multimodal, with aural
preference being the overall highest (62.7%).[18]
Samarakoon et al. on studying the learning preferences of
postgraduate medical doctors found a dramatic shift where
‘Kinesthetic (K)’ learning predominates among postgraduates.
They attribute this to the increased exposure to ‘clinical
teaching’ where the focus changes from didactic lecture
presentations to patient-oriented bedside clinics where one
hones his or her practical kinesthetic clinical examination skills.
There may also be decreased amount of didactic lecture hours
and increased amount of patient-oriented teaching resulting in
development of self-learned skills.[12]
All of the above studies show that multiple modalities of
information presentation are necessary to effectively cater to
student learning preferences. A learning preference is defined
as the most ‘effective and efficient modality,’ in which a learner
has a natural preference to ‘perceive, process, store, and recall
new information.’[19] Awareness of these learning preferences
amongst students necessitates a shift from the traditional
large-group teacher-centric lecture method to an interactive,
small-group student-centric approach incorporating various
teaching-learning strategies. Students at our medical school
have benefitted tremendously with the use of the e-learning
platform, early clinical exposure to patients in wards and
surgical theaters during the first year itself, integrated learning
program of basic sciences, and increased availability of models
and plastinates. Other teaching strategies that could be
 186
meaningfully employed include mp3 recordings of lectures,
audio recordings of power-point presentations, increased
frequency of discussions and seminars, and issuing of lecture
handouts. Since students possess a wide diversity in learning
styles, teachers should combine different educational strategies
to meet the varied learning preferences of students.
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learningstyles. Adv Physiol Educ 2006;30:13-6.
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yearundergraduate nursing and midwifery students: A cross-
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clinical students: A study in a Malaysian medical college. Int J Med
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Latha%20Rajendra.pdf. [Last accessed on 2012 Jun17].
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student: Using the VARK model. J Postgrad Med 2014;60:183-6.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Postgraduate Medicine April 2014 Vol 60 Issue 2
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
 Editorial
Learning Theories: The Basics to Learn in Medical Education
The word “theory” is quite commonly used to represent
the knowledge or cognitive component in our day‑to‑day
work. The various learning theories in the educational field
indicate that it is more like a set of principles/ideas that
provide an explanation of working of a concept or basis
of practical happenings or connections between various
principles in a model or working together. Its like the script
of a movie, i.e., script like a theory provides an explanation
of happenings and movie is like actual happenings. Hence,
movie director can ask questions like why I should make a
movie on this script. The script should be able to explain
why things would work, what are various connections,
even add some evidence to show that these things do work,
etc.
Several theories have been proposed for learning. There
are number of concepts in learning which are essential
components for an understanding of these theories.
Sometimes, there is confusion between concepts, principles,
and theories. Most of us are familiar with adult learning
principles or andragogy. It is also one of the issues most
discussed as the theory behind adult learning. It looks like
a theory based on the fact the discoverer put it forward as
a theory different from pedagogy. Hence, it was taken by
people easily as something different from pedagogy, i.e., a
different point of view for adult learning as compared to
kids. However, if you rethink about how kids learn, they
also learn what is relevant. The learning topics for adults
are always not so free choices, for example, in a medical
undergraduate class the students learn as a group based on
a certain topic, here an individual student has no choice to
learn something else but that topic only. Similarly, not all
adult learners are equally intrinsically motivated, and this
adds another gray area in adult learning.[1,2] The literature
says there is modest evidence that supports andragogy.
Adult learning is more like a concept/model but not
actually a learning theory.
Similarly, experiential learning and work‑based learning
are more like concepts but not theories. In experiential
learning, learning is based on experience. It says that there
is a concrete experience followed by reflection on it, then
abstract conceptualization and further experimentation
or improvement.[3] This is again more of a model than a
theory. However, the learning never happens in the real
world in such a straightforward manner. Hence, experiential
learning does provide us different aspects of learning but
is not a theory per se. Interestingly, these principles (adult
learning, experiential, workplace‑based) do reflect some
of the learning theories, for example, work place‑based
learning has elements of sociocultural theory, experiential
learning has elements of constructivism and humanism
theories. This fact again emphasizes that these are concepts
© 2017 International Journal of Applied and Basic Medical Research | Published by Wolters Kluwer ‑ Medknow
or principles only that can be part of various theories but
are not the learning theories per se.
Let us have a look at the learning theories in brief.
Behaviorism theory says that learning is a “change in
behavior in the desired direction” that happens due to using
various techniques like reward and encouragement for
correct behavior; repetition, feedback and reinforcement for
corrections needed in behavior so that corrections are done
and sustained. This is in response to an external stimulus.
This is based on assumption that number of internal motives
cannot be measured hence behavior which is observable
can be studied. The system relies on continuous repetition
and “skill and drill” exercise. This happens in small chunks
and builds up leading to change in behavior.[4,5]
The second theory, cognitivism theory represents internal
cognitive restructuring due to changes in individual’s
schemata (knowledge). The learner uses cognitive tools,
such as insight, information processing, perceptions, and
memory to facilitate learning. It involves acquiring, storing,
and retrieving information. The learner develops capacity
and skills for effective self‑directed learning. The teacher
facilitates the learner about “learn how to learn.”[6,7]
Constructivism theory explains how new understanding
develops by building on individual’s existing understanding.
Learner constructs knowledge based on their experiences
and that how they do so is related to their biological,
physical, and mental stage of development. Learner
assimilates, accommodates, and adapts knowledge to
develop new understanding. The learning process involves
construction of meaning from experiences through critical
reflection.[5]
Sociocultural theory assumes learning to be a social process
where learning happens in a social context. The learner is
involved in apprenticeship in the community practice or as
a full member in the community. Learning is in relationship
between people and environment. An increasing amount of
medical education occurs in workplace contexts; hence,
this learning theory can be an appropriate explanation in
this setting.[1,5]
Critical theory explains how to change society to make it
equal for all by encouraging participation of all learners
especially those who are marginalized or oppressed.
Humanism theory says that learning is more related to
one’s own growth as a doctor and human being. During
this learning, there are challenges like exploration of one’s
emotions and changing identify of one’s self. The goal
of this approach is for the learner to become autonomous
and self‑directed. Self‑directed learning is one of the most
important principles of this theory.[5]
S1
 Badyal and Singh: Learning theories
There are a lot of similarities as well as differences between
these theories. In a way, they represent learning in context
with stage of learner and situations. They complement each
other or are a part of evolutionary sequences in learning, for
example, as learner memories and understands (cognitivism)
he/she tries to build up connections between various
issues (constructivism), during this process learning is
influenced by context (sociocultural), some behavioral
changes might have happened by this time (behaviorism).
This leads him/her to think about changes in society (critical)
and he/she might start thinking about one’s growth as doctor
as a good human being (humanism). Even at these stages,
more behavioral changes might happen.
In almost all of these theories, learner is actively involved
and hence, this seems to be a common factor. Active
involvement may be reflected in various ways such as
trying to understand, discussing, processing information,
working in community, modulating feelings during
learning, and during corrective actions. The last example,
i.e., corrective actions based on provided feedback is in
concern with behavior theory. Although it is mentioned
that learner is passive in behaviorism theory, it is difficult
to understand how the learner can be passive when he/she
is using feedback to correct their responses. The learner
needs to be actively involved while correcting responses.
Similarly, comprehending/understanding seems to be related
with all theories as without understanding it is very difficult
to construct, and think about sociocultural issues and make
justice in society and to change society for betterment. The
cognition, i.e., knowledge component is involved in all
theories, however the extent and context is different.
Although there are overlaps in these theories, still they
are individual characteristics in these theories which make
them unique as single theories. The humanism theory is
quite specific for thinking about emotions and one’s growth
as human being; critical theory is more inclined for justice
and equality in the society; learning through involvement
in community is quite specific for socioculturalism theory.
The role of teacher also changes in these theories,
e.g., in behaviorism theory the teacher should have a good
knowledge of subject and be active. Teacher arranges the
appropriate learning environment to elicit correct responses.
In cognitivism theory, a teacher structures content of learning
activity. In constructivism theory, teacher acts more like a
facilitator and guides the learning of the students. Therefore,
the behaviorism theory is teacher‑centered; cognitivism,
humanism, and constructivism theory are learner‑centered.
These theories can provide rational basis for the selection
of specific teaching‑learning methods/strategies, framing
learning objectives, and select/design evaluation strategies.
Remember that learners have different interests, different
learning preferences, and different backgrounds. Integrate
various positive aspects of these theories in the classroom
environment to optimize learning.
S2 International Journal of Applied and Basic Medical Research | Volume 7 | Supplement 1 | December 2017
After discussing various learning theories, let us see how
these can be used in various scenarios. In a clinical and
communication skills course, the behaviorism theory
would be appropriate, as during this course the correct
responses in performing skills can be learnt slowly over
time as students are being provided feedback, rewards
and encouragement by teachers. For clinical skills, their
response can be corrected in small chunks and repetitions
are provided so that they are eventually able to learn
correct skills. Behaviorism emphasizes on the mastery of
prerequisite steps before moving to subsequent steps; this
learning orientation is aimed at reinforcing correct skills.
In skills learning, teachers demonstrate specific desired
behaviors, learners observe the manner or technique in
which a desired skill or behavior should be performed, and
some scoring rubric (checklists, rating forms, and direct
observation) can be used to assess performance and provide
reinforcement. This learning theory is most advantageous
when a change in behavior is the desired outcome of an
educational intervention.
For a basic science course, you can think of cognitivism
and constructivism theory. If basic sciences course which
is more conventional and happens more in isolation from
clinical sciences then cognitivism looks appropriate as
they need to process and retrieve information, use new
knowledge, improve the schemata with new knowledge.
This theory can facilitate the acquisition of knowledge and
the development of learning skills that are applicable in
other learning situations regardless of the topic or context.
However, if the basic sciences course is dynamic and
involves the integration with clinical sciences the
constructivism seems more appropriate as they need to
apply this knowledge to clinical cases. The learner needs
to understand the concepts in basic sciences and make
connections with its applicability in clinical sciences. There
should be development of construction of understanding
the relevance of learning basic sciences.
For a community‑based education program sociocultural
theory would be better here as it provides apprenticeship
in the community and experience of working as part of
community. The learning process can be viewed as an
interaction with and observation of others in a social
context. Physicians usually learn in the social context
by observing each other’s techniques and behaviors.
The learner can role model the good health providers
and rehearse it and do it when situation demands. The
unique aspects of this learning theory combine role
modeling behavior with cognitive learning to deepen
the learner’s understanding of how, why and for what
purpose the role model performs a specific task in a
certain way. The teacher is responsible for modeling
new roles, guiding behaviors, and providing learners
with opportunities to practice these new roles and
behaviors.
 Badyal and Singh: Learning theories

Dinesh K Badyal1,2,3, Tejinder Singh2,3,4 cognitive perspective. New Horiz Adult Educ Hum Resour Dev
2006;20:38‑49.
Departments of Pharmacology, Pediatrics, CMCL-FAIMER Regional
1 4 2

Institute, 3MCI Nodal Centre, Christian Medical College and Hospital, 7. Patel VL, Yoskowitz NA, Arocha JF. Towards effective
Ludhiana, Punjab, India evaluation and reform in medical education: A cognitive and
learning sciences perspective. Adv Health Sci Educ Theory Pract
Address for correspondence: 2009;14:791‑812.
Dr. Dinesh K Badyal,
Professor and Head, Department of Pharmacology, Christian Medical
College and Hospital, Ludhiana ‑ 141 008, Punjab, India. This is an open access article distributed under the terms of the Creative Commons
E‑mail: cmcl,faimer2@gmail.com Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the new
References creations are licensed under the identical terms.

1. Abela J. Adult learning theories and medical education: A review. Access this article online
Malta Med J 2009;21:11‑8.
Quick Response Code:
2. McGrath V. Reviewing the evidence on how adult students learn: Website:
An examination of Knowles’ model of andragogy. Irish J Adult www.ijabmr.org
Community Educ 2009;99:110.
3. Kolb DA. Experiential Learning: Experience as the Source of
Learning and Development. Englewood Cliffs, NJ: Prentice Hall; DOI:
1984. 10.4103/ijabmr.IJABMR_385_17
4. Skinner BF. About Behaviourism. London: Cape; 1914.
5. Torre DM, Daley BJ, Sebastian JL, Elnicki DM. Overview
of current learning theories for medical educators. Am J Med How to cite this article: Badyal DK, Singh T. Learning theories:
2006;119:903‑7. The basics to learn in medical education. Int J App Basic Med Res
6. Ponton MK, Rhea NE. Autonomous learning from social 2017;7:S1-3.

International Journal of Applied and Basic Medical Research | Volume 7 | Supplement 1 | December 2017 S3
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 32 , NO. 5, 2019 257

Editorial

Graduate Medical Education Regulations 2019:

Competency-driven contextual curriculum
With modern medicine expanding its horizons, scientific data are becoming robust and
voluminous information is available on various facets of medical practice. Technological
advances have enabled medical ‘hands’ to reach the most intricate interior of the human
body to aid diagnosis and therapeutics. The widespread use of internet and other media
have enabled lay people to become more informed about what is happening to them.
The commercialization of healthcare has resulted in increasing costs as well as a trust
deficit between doctors and patients.
India’s national goal of ‘Health for All’ is guided by multiple factors––economic,
sociocultural, literacy, political will and availability of healthcare service providers. At
the centre of this scheme is the presence of a competent doctor with a caring attitude.
Unlike in other professions, doctors must not only demonstrate a comprehensive
knowledge of their subject but also retain a humane perspective in their conduct. They
should know what is required in terms of ‘appropriate’ diagnostic tests and therapeutic
measures. To reach this goal of a ‘balanced doctor’, who is both knowledgeable and
humane, the first step is to redefine the curriculum of medical students at the
undergraduate and postgraduate levels.
The Medical Council of India (MCI) is responsible for continuously assessing the
needs, aspirations, quality and standards of medical education in India. One of their
initiatives was to standardize the output of graduate medical education in the form of
an ‘Indian Medical Graduate’ (IMG); a skilled, competent and motivated doctor with
five intended roles as ‘Clinician, Leader, Communicator, Professional and Lifelong
learner’ as per ‘Vision 2015’.1 To achieve this, the MCI undertook a huge exercise of
developing a competency-driven contextual curriculum over the past 5 years.
The MCI chose an expert-based approach for curricular change. The factors
considered were: (i) the burden of diseases in India;2 (ii) faculty and graduate
perceptions about curricular deficiencies;3 and (iii) students’ feedback and suggestions
from social and health researchers. The revised World Federation of Medical Education
basic guidelines4 were used to make the IMG globally relevant. The MCI curricular
reforms have systematically addressed these issues and developed strategies to make
medical education more relevant for India in the changing context.
Medical education worldwide is shifting towards competency-based medical
education (CBME). CBME emphasizes domains beyond medical knowledge and
clinical skills, e.g. communication, professionalism and a focus on health systems.
Usually, competency or outcome-based education involves all specialties put together
and is better implemented in a problem-based education system.5
Competency-driven learning includes designing and implementing a medical
education curriculum that focuses on predefined desired and observable abilities in
real-life situations. Competency is an approach to preparing physicians for practice
(i) oriented to the graduate’s abilities and (ii) organized around the requirement of
capabilities based on societal and patient needs.6–8 It de-emphasizes time-based
training (tea bag approach)9 and promises greater accountability, flexibility and
learner-centredness. The MCI along with subject experts across India have prepared
a list of competencies for every discipline.10–12 An expert group has collated all of them
to develop a final list of competencies and possible areas for integration.
258 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 32, NO. 5, 2019

Proposed curriculum
The new proposed curriculum signifies a paradigm shift in acquiring competencies,
skill enhancement and attitude development among prospective medical graduates. It
emphasizes the development of communication skills along with awareness of ethical
issues in medical practice. It retains the total duration of the undergraduate Bachelor
of Medicine and Bachelor of Surgery (MBBS) course of five-and-a-half years (including
internship). However, the restructured course ensures that the student participates
actively in the learning process and becomes competent clinically. A new feature of
this curriculum is a foundation course13 of 1 month at admission to introduce students
to the profession of medicine. This will orient students to national health programmes,
community service, medical ethics, health economics, learning and communication
skills, life support measures, computer learning, sociology and demographics, biohazard
safety and environmental issues. This course will provide an overview of the three core
subjects of anatomy, physiology and biochemistry that are taught in first MBBS.
Some key features of the new curriculum are:
1. Integration:14 horizontal and vertical––the new, innovative curriculum aims to
facilitate horizontal and vertical integration among disciplines, bridging the gaps
between theory and practice of medicine and between hospital-based medicine and
community medicine.
2. Early clinical exposure:15 The purpose of introducing some aspects of clinical and
social contexts of patient care in the first year is to provide a reference to basic
science learning to reinforce comprehension of the normal and altered expression
in disease states. Clinical training on communication and basic clinical skills will be
imparted by the preclinical, paraclinical and clinical faculty.
3. Student doctor method of clinical training: Learning through clerkship/student
doctor method will involve participation of a student as a team member in patient
care including in investigations, management and doing simple procedures.
4. Electives: These will allow flexible learning options such as clinical electives,
laboratory postings or community exposure (not usually a part of the regular
curriculum). Students will be able to do projects and enhance self-directed learning,
critical thinking and research abilities.
5. Skill development and training: The new curriculum recommends the use of
contemporary education technologies such as e-learning and simulation. Certification
of skills would be necessary before licensure.
6. Secondary hospital exposure: Emphasis will be on linking to the local health system
including primary healthcare centres.
7. Attitude, ethics and communication (AETCOM) module:16 The AETCOM module
is based on the principle that changing a person’s attitude can change his or her
behaviour. The cognitive components of attitudes are fundamental and constant
over time. Behavioural attitudes are manifestations of underlying cognitive and
affective attitudes. Ethical dimensions play a crucial role in behavioural evolution,
and the basic building block of good communication is the feeling that every human
being is unique and of value.
The MCI has prepared revised regulations on graduate medical education and
competency-driven contextual undergraduate curriculum, accompanied by guidelines
for its implementation. As the traditional undergraduate curriculum in India is discipline-
based, for feasibility and practical implementation, the proposed competency-driven
approach retains the existing discipline-based format with horizontal and vertical
integration. At the preclinical and paraclinical level, the foundational sub-competencies
will converge to attain the desired clinical competencies (Table I).
Teaching of CBME would need framing of entrustable professional abilities (EPA)
along with milestones for a particular symptom or disease. EPAs are drawn from the
needs of society. For example, if prevention of malaria is a need then along with
diagnosis and treatment, EPAs on prevention need to be framed. The teaching and
assessment method would be designed around the EPAs.16 Though the new curriculum
does not have EPAs, a comprehensive list of competencies and sub-competencies
(Fig. 1) can suffice at this stage to bring the change. Over the years, EPAs and
milestones need to be developed in India as per contextual needs.
A module for assessment17 for the new curriculum has also been prepared, which
would facilitate universities and colleges to develop their assessment plans within a
prescribed framework.
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 32 , NO. 5, 2019 259

TABLE I. Proposed components of competency-based curriculum

Competency
1. Demonstrate understanding
of anatomical and physio-
logical aspects of the thyroid
and its disorders
First professional year
2. Demonstrate an
understanding of the
pathogenesis of thyroid-
related disorders such as
hypothyroidism
Second professional year
3. Able to perform relevant
clinical examination of a
patient with a thyroid-related
disorder and suggest
appropriate management
Third professional year (part I
and II)
Sub-competency
1. Able to draw surface
anatomy of the thyroid gland
2. Able to communicate well
the relationship of iodine
deficiency and
hypothyroidism
1. Able to correlate
pathological specimen and
thyroid case scenario
2. Able to take complete
history of patients with
thyroid-related problems
1. Able to demonstrate
professionalism in the clinical
setting
2. Able to elicit, document
and present an appropriate
history that will establish the
cause of thyroid dysfunction
and its severity
3. Able to write and
communicate to the patient
an appropriate prescription
for thyroxine based on age,
sex and clinical and
biochemical status
Learning experience
1. Museum demonstration/
medical illustration/self-
directed learning
2. Early clinical experience
through regular clinical skills
teaching in the laboratory and
through hospital and
community visits
1. In-depth study of a patient
with a thyroid disorder:
Clinical exposure/pathological
specimen study/analysis of
thyroid profile/case-based or
problem-based learning, etc.
1. Clinical exposure with
formative assessment tools
such as MiniCEX for
improving learning
2. Case-based discussion
3. Clinical clerkship
4. Self-directed learning

Does Discipline competency/Sub-

competency
Medicine Prescribe
appropriate therapy
Shows how based on lipid
profile; counsel the
patient on diet and
lifestyle
Knows how Pathology Interpret laboratory
results of analyses
associated with
metabolism of lipids
Knows
Biochemistry Describe main
classes of lipids

FIG 1. Ascendency of competence—lipid profile abnormalities

Challenges in implementation
Implementing such a curriculum across 532 medical schools with 76 876 seats18 in India
is a major challenge. It cannot be achieved without extensive faculty development,
efficient management, intensive monitoring and evaluation of the programme.
Earlier experience with implementation of curricular changes suggests that a
professionally managed, sustainable approach is necessary for effective implementation.
For faculty development the MCI has established a functional network of 12 regional
and 10 nodal centres19 across the country. These centres have been successfully
running courses in medical education for the past 10 years. Over 43 000 faculty
members have been trained through the basic and revised basic courses and over 900
teachers have been trained through the advanced course in medical education.
In terms of regulation, it was recognized that every medical college needs to develop
a capacity to adapt to the requirements of the new guidelines. The MCI mandated each
medical college to establish a curriculum committee for implementation and monitoring
260 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 32, NO. 5, 2019

of the competency-driven contextual curriculum. For the past 3 years, it also revised
the format of its existing faculty development programme to orient it towards preparing
faculty for implementation of the competency-driven curriculum. An AETCOM forms
a part of this new faculty development curriculum.20 Each member of the curriculum
committee is required to undergo this training as they will lead the change and
implement the competency-driven curriculum. This capacity building work is in
progress at present. Latest articles on CBME in Indian journals indicate rolling out of
a competency-driven curriculum for medical undergraduates in the near future.21–23

Implementation at the institutional level: Expected challenges and possible solutions

Curricular implementation needs involvement and efforts of institutions and teachers.
Both the stakeholders need to keep the outcomes/goals in mind with an emphasis on
skills and performance than on acquisition of knowledge alone. There is a need for
intensive monitoring by the curricular committee. Institutions and policy-makers must
be clear that implementation will be gradual requiring a long-term commitment of time
and resources for evaluation and continuous improvement in the guidelines.
Implementing the new curriculum will involve considerable new learning and some
unlearning for those teachers who will reorient the curriculum. Further, teaching other
faculty and preparing them for implementation will be an added responsibility. The
skills required, besides those related to the CBME approach, include ability to work
together, willingness for change and ability to negotiate resistance. Faculty requires
considerable leadership skills to navigate the complexities of the entire process,
including time and resource constraints. The MCI successfully completed the Curriculum
Implementation Support Programme from January to September 2019 through faculty
development network for training of more than 10 000 faculty members.
Assessment approaches and methodologies with clinical relevance also require an
enormous scale of curricular restructuring. Lastly, the new curriculum needs to be
evaluated for its overall effectiveness over the next 5–10 years. The new assessment
module will facilitate universities and colleges to prepare a plan to overcome the
challenge of multiple-choice questions, which are the basis of entrance examinations
for postgraduate courses.

Conclusion
Medical education in India is on the threshold of a major change. The competency-
driven curriculum developed by the MCI has the potential to address the deficiencies
that have arisen in the training of health professionals in the Indian context. The new
curriculum emphasizes skill enhancement and development of attitudes, ethics and
communication skills to make the future IMG more competent and humane. The
proposed National Medical Commission24 should adopt this well-designed contextual
curriculum to bridge the gaps in the medical curriculum. A well-planned implementation
strategy at the institutional level, faculty development and intensive monitoring by all
stakeholders will ensure improvement in the much-needed educational outcomes and
thereby have a positive impact on healthcare in India.

ACKNOWLEDGEMENTS
I am grateful to the Board of Governors of the MCI and Dr Rajlakshmi, Academic Consultant,
MCI and all members of the expert group for their support.

Conflicts of interest. I continue to be convener of the expert group of the Board of

Governors of the MCI.

REFERENCES
1 Available at https://old.mciindia.org/tools/announcement/MCI_booklet.pdf (accessed on 15 Aug 2019).
2 WHO. The global burden of disease. 2004 update. Available at www.who.int/healthinfo/global_burden_disease/
GBD_report_2004update_full.pdf (accessed on 15 Aug 2019).
3 Supe A, Rege N. Medical curricula. Faculty and graduate perceptions. Indian Pract 2000;53:593–8.
4 World Federation of Medical Education. Basic medical education. Available at http://wfme.org/standards/
bme/ (accessed on 15 Aug 2019).
5 Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based
education in medicine: A systematic review of published definitions. Med Teach 2010;32:631–7.
6 Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education:
Theory to practice. Med Teach 2010;32:638–45.
7 Gruppen LD, Mangrulkar RS, Kolars JC. The promise of competency-based education in the health professions for
improving global health. Hum Resour Health 2012;10:43.
8 Snell LS, Frank JR. Competencies, the tea bag model, and the end of time. Med Teach 2010;32:629–30.
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 32 , NO. 5, 2019 261

9 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Volume-
I (2018). Available at www.mciindia.org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-I.pdf
(accessed on 21 Oct 2019).
10 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Volume-
II (2018). Available at www.mciindia.org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-II.pdf
(accessed on 21 Oct 2019).
11 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Volume-
III (2018). Available at www.mciindia.org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-III.pdf
(accessed on 21 Oct 2019).
12 Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013;5:157–8.
13 Medical Council of India. Available at https://mciindia.org/CMS/wp-content/uploads/2019/10/
Module_Competence_based_02.09.2019pdf (accessed on 21 Oct 2019).
14 Medical Council of India. College and course search. Available at www.mciindia.org/CMS/information-desk/
college-and-course-search (accessed on 21 Oct 2019).
15 Available at https://old.mciindia.org/InformationDesk/ForColleges/NationalFacultyDevelopment
Programme.aspx (accessed on 15 Aug 2019).
16 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Module
1. Foundation course. Available at www.mciindia.org/CMS/wp-content/uploads/2019/08/foundation-
new_compressed.pdf (accessed on 21 Oct 2019).
17 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Module
4. Alignment and integration. Available at www.mciindia.org/CMS/wp-content/uploads/2019/10/Alignment-
and-Integration_03.10.2019.pdf (accessed on 21 Oct 2019).
18 Medical Council of India. Competency based undergraduate curriculum for the Indian medical graduate. Module
2. Early clinical exposure. Available at www.mciindia.org/CMS/wp-content/uploads/2019/08/early-
new_compressed.pdf (accessed on 21 Oct 2019).
19 Medical Council of India. AETCOM. Attitude, ethics and communication. Available at www.mciindia.org/CMS/
wp-content/uploads/2019/01/AETCOM_book.pdf (accessed on 21 Oct 2019).
20 Medical Council of India. Program of the revised basic course workshop. Available at www.mciindia.org/
documents/informationDesk/8.%20Three%20day%20revised%20BCW%20programme.pdf (accessed on
15 Aug 2019).
21 Modi JN, Gupta P, Singh T. Competency-based medical education, entrustment and assessment. Indian Pediatr
2015;52:413–20.
22 Chacko TV. Moving toward competency-based education: Challenges and the way forward. Arch Med Health Sci
2014;2:247–53.
23 Ananthakrishnan N. Competency based undergraduate curriculum for the Indian Medical Graduate, the new MCI
curricular document: Positives and areas of concern. J Basic Clin Appl Health Sci 2018;2:182–90.
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AVINASH SUPE
Department of Surgical Gastroenterology
K.E.M. Hospital
and
Medical Education and Major Hospitals Division
Municipal Corporation of Greater Mumbai
Mumbai
Maharashtra
avisupe@gmail.com

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Competency-Based Medical Education for Indian Undergraduates: Where do we

Stand?

Article in APIK Journal of Internal Medicine · April 2023

DOI: 10.4103/ajim.ajim_161_22

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Competency‑Based Medical Education for Indian

Undergraduates: Where do we Stand?
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Mamta Gehlawat, Goutham Thumati, Priyanka Samala1, Chaganti Lalitha Alekhya2, Are Shailaja2, Anamika Sharma2
Departments of Community Medicine, 1Physiology and 2MBBS Final Part-1, GMC, Siddipet, Telangana, India
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/01/2023

Abstract
The traditional system of medical education was a structure and process‑based system with limited assessment of application of knowledge,
skills, and attitudes. Decades after the World Health Organization gave preliminary guidelines on Competency‑based medical education (CBME)
in 1978, countries around the world are still taking to the newer medical education systems. In India, CBME replaced traditional system of
medical education in 2019 while the National Medical Council replaced Medical Council of India in 2020. The annual intake of medical
undergraduates has reached an all‑time high of one lakh students per year in India and our medical education system is taking baby steps
toward CBME. The implementation of CBME poses different hurdles for medical educators as well as medical students. Medical educators
are yet to develop confidence in the newer teaching learning methods (e.g., Small Group Teaching, Role‑play, Peer group learning etc.), along
with the array of newer assessment methods. There in lies an immense and urgent need of training medical educators with continued hand
holding along with adapting newer teaching learning methods to the students of generation Z who are tech‑savvy but anxious and indulged
yet stressed. This review has tried to articulate the current situation of CBME in the world and in India, acceptance of CBME by faculty and
students and the way forward for India’s medical education system.

Keywords: Competency, competency‑based medical education, medical education, undergraduates

Competency‑Based Medical Education Across the
World
The concept of Competency‑based Medical Education (CBME)
was suggested by the World Health Organization way back in
1978, but it has been truly amalgamated in medical education
only since the last two decades.[1,2] This was the result of
changing regulatory requirements, promotion of competency
frameworks globally, public demand for better health care
quality, and increased answerability of physician and health
system.[3] The adoption of CBME came into being to enhance
the quality of health care, to reduce variation in practices and
with evidence that training received during residency drives
future performance of doctors.[4]
CBME has since become a global phenomenon. In 1998, the
Accreditation Council on Graduate Medical Education, United
States; introduced six domains of clinical competence (patient
care, medical knowledge, practice‑based learning and
Received: 08.12.2022     Reviewed: 01.01.2023
Accepted: 19.01.2023     Published: 13.04.2023
Access this article online
Quick Response Code:
Website:
www.ajim.in
improvement, interpersonal and communication skills,
professionalism, systems‑based practice)[5] which were further
refined through the Next Accreditation System and milestones
were introduced in the residency programs. [6] Likewise,
Canada brought in the Can MEDS Framework that defines
the seven roles (medical expert, communicator, collaborator,
manager, health advocate, scholar, and professional) of a
medical expert.[1] This framework is used in more than 58
jurisdictions in dozens of countries in five continents.[7]
Additional frameworks exist in Australia and Europe, the
United Kingdom (Tomorrow’s Doctor), and Scotland (the
Scottish Doctor).[8,9]
The traditional residency education is a structure and
process‑based system. Within this model, trainees are
exposed to learning content for a specific amount of
Address for correspondence: Dr. Mamta Gehlawat,
Department of Community Medicine, 2nd Floor, GMC Siddipet, Ensanpally,
Siddipet ‑ 501 203, Telangana, India.
E‑mail: drmamtagehlawat@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: How to cite this article: Gehlawat M, Thumati G, Samala P, Alekhya CL,
10.4103/ajim.ajim_161_22 Shailaja A, Sharma A. Competency‑based medical education for Indian
undergraduates: Where do we stand? APIK J Int Med 0;0:0.

© 2023 APIK Journal of Internal Medicine | Published by Wolters Kluwer - Medknow 1

 Gehlawat, et al.: CBME for Indian undergraduates: Where do we stand?
time.[3] Assessment within the system focuses predominantly
on knowledge acquisition. This system rarely assesses
application of knowledge, skills, and attitudes; which may
result in inadequate preparation for independent clinical
practice due to lack of hands‑on experience and its assessment
demonstration. [10] CBME is meant to overcome these
shortcomings of the traditional medical education system.
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Principles of CBME include a shift toward, the use of defined
competencies required for practice, staged progression of
increasing responsibility/independence, tailored learning
and programmatic assessment.[11] The current generation of
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/01/2023
medical faculty will be expected to navigate the challenges
currently faced by healthcare domain, while being called upon
to translate these concepts into workable solutions that meet
the needs of the profession and society.
Competency‑Based Medical Education:
A Medical Education Revolution in India
Indian medical education system continued to be under
influence of western mode of instruction for decades after
independence, rather than focusing on local health needs and
issues.[12] India had only 23 medical colleges at the time of
Independence (yearly 50 students intake per college) while
in 2022 the country has 645 medical colleges (yearly 97,293
medical students in total).[13] Only about half (53%) of these
college belong to the government. The medical colleges
followed a curriculum developed more than a century ago,
which compartmentalized various medical disciplines rather
than giving holistic understanding of the subject and resulted
in preparing doctors capable of curing diseases but failing to
provide comprehensive health care to the people. The erstwhile
syllabus focused mainly on cognitive domain (knowledge),
little of psychomotor domain (clinical skills) with almost zero
attention to affective domain (attitude).[14] The crucial elements
of affective domain such as empathy, professionalism, altruism,
communication skills, ethics, and humanities were only part
of a hidden syllabus. Over time, medical education in India
became a business, with competitive pricing for the provision
of basic and specialized certification.[15]
Medical Council of India was the statutory body to maintain
uniform standards of medical education and to keep check
on basic minimum requirements for the undergraduate
and postgraduate programs in Medicine.[16] After decades
of reforms and transformations [Table 1],[17-20] in 2019,
CBME was introduced in the Indian undergraduate medical
curriculum to fulfill the health needs of society and to train
medical students in a holistic manner.[17] This curricular
revision was essential to address the gaps in Indian medical
education, to put emphasis on the desired and observable
outcomes in day‑to‑day practice of medicine. Introduction of
CBME was the first major revision of the medical curriculum
after a hiatus of two decades, paving the way for subject-wise
competencies along with clearly defined teaching-learning
strategies and assessment methods.
2 APIK Journal of Internal Medicine ¦ Volume XX ¦ Issue XX ¦ Month 2023
How Competency‑Based Medical Education
Differs from Traditional Ways of Medical
Education?
Didactic lectures (DL) were the primary mode of teaching
and formal method of relaying information from instructor
to student before CBME came into the picture. However, this
approach had numerous shortcomings. The passive design
of DL might cause loss of students’ interest in teaching and
learning beyond the classroom setup.[21] Student‑centered
modern approaches are henceforth being implemented to shift
the responsibility of learning upon the learner. There is need
for an educational system that actively engages future doctors.
Students won’t just listen; but will continually be involved in
the learning process through active participation in CBME
[Table 2].[22-23] Modern methods of teaching have shown to
improve long term retention of knowledge and self directed
learning (SDL) skills.[24]
Integration of modern techniques of teaching‑learning
methods acknowledges and adjusts for the differences in
learning style preferences of students, which may affect their
comprehension of basic medical sciences.[24] Techniques like
case‑based learning (CBL), evidence‑based medicine (EBM)
and Problem based learning (PBL), actively involve students
and links medical theory to real life situations. They also
improve competency, logical thinking, and assist better
clinical reasoning of students. Peer Assisted Learning helps
students develop understanding of topic by mutual sharing of
knowledge. Observational learning enhances performance of
medical procedures and allows for immediate feedback from
faculty. Simulation studies allow students to make mistakes
and learn to avoid future medical errors in real life situations.
Through social networking, content‑specific information is
easily disseminated to students and online collaboration is
promoted. YouTube videos from reliable sources provide a
wealth of valuable information to students, particularly for
honing their clinical skills.
Different Modes of Teaching
DL were centered mainly on the professor, who taught large
amounts of information with minimal student engagement in
a classroom. For effective teaching and learning, alternative
methods were introduced in CBME. These can either be a
supplement or alternative to traditional DL.
Figure 1 summarizes ten of the modern methods of teaching
based on research by Challa et al.[25] They are CBL, EBM,
PBL, team‑based learning, simulation‑based learning,
e‑learning, peer‑assisted learning, observational learning,
flipped classroom, and interactive whiteboard.
Implementation by Medical Faculty
Faculty development programs (FDPs) form a crucial step
for evolution of modern‑day medical education.[19] Graduate
 Gehlawat, et al.: CBME for Indian undergraduates: Where do we stand?

Table 1: Milestones in indian medical education system

Year Milestone Initiative or reform made in medical education system
1933 Formation of MCI MCI took over the functions of the General Medical Council of Britain in India
1946 Bhore committee Proposal of 3 months training in preventive and social medicine to prepare “social physicians”
1953 First World Medical Education Conference Review of content of medical curriculum and technique of medical education
1955 1st Medical Education Conference (India) Current methods of examinations and assessment found unsatisfactory and need realised for
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regular assessment of UGs

1959 Mudaliar committee Suggestion of integration of medical and health services
1960 Medical Education committee Proposal of major reforms in selection of students, entrance qualifications, inclusion of
premedical studies, curriculum of medical education, examinations, fulltime teaching units
1975 Shrivastava Committee Proposal for a medical and health education commission to plan and implement the reforms in
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line with University Grants Commission

1975 1st NTTC Establishment of NTTC at JIPMER and bi‑yearly National Courses on Educational Science
for Teachers of Health Professions
1977 ROME scheme Plan to impart community‑oriented training to UGs in primary health care
1983 Medical Education Review committee Suggested measures for overall improvement in the UG and postgraduate medical education,
paying due attention to institutional goals; content, relevance, and quality of teaching and
training and learning settings; and the evaluation systems and standards
1986 Bajaj committee Suggestion of a National Medical and Health Education Policy
1997 GME regulations Continuous Evolution of regulations with periodic amendments
2009 National FDP Longitudinal program to train teachers e.g., BCW in Medical Education technologies,
orientation program for MEU coordinators, CISP
2011 MCI Vision 2015 Proposal of major changes to the existing MBBS curriculum including feedback from all
stakeholders
2014 Ranjit Roy committee Proposal for an umbrella body‑NMC
2016 Justice Lodha committee Recommendation to introduce the NEXT for UGs
2019 GME regulations Regulations for UG competency based medical education
2020 Formation of NMC Dissolution of MCI. NMC formation by NMC Act, 2019
UGs: Undergraduate medical students, GME: Graduate Medical Regulations, MCI: Medical Council of India, NTTC: National Teachers Training Centre,
ROME: Re‑orientation of Medical Education, FDP: Faculty Development Programme, NMC: National Medical Commission, NEXT: National exit test,
CISP: Curriculum Implementation Support Program, MEU: Medical education unit, BCW: Basic Course Workshop

application. Furthermore, when compared to untrained faculty,

Table 2: Traditional versus modern and innovative
Curriculum Implementation Support Program (CISP)‑trained
methods of teaching‑learning in medical education
faculty were found to be more concerned about the impact of
The SPICES model CBME on students. This indicates that CISP training has to be
Traditional method Modern method conducted for all the faculty and continued hand‑holding is
Teacher centered Student centered required for faculty for proper implementation of CBME. Only
Information gathering Problem based with training we can make competent mentors and facilitators
Discipline based Integrated available for students to benefit from CBME. There is no doubt
Hospital based Community based that successful implementation of CBME needs extensive
Standard program Electives training of faculty in all aspects of CBME including newer
Apprenticeship based or opportunistic Systematic methods of assessment.[29]
SPICES: Student centred, problem based, integrated, community based,
electives, systematic New educational roles of the teacher as a facilitator, planner,
manager, performance assessor are huge and a mere 3‑day CISP
medical education regulations include foundation course (FC), cannot provide comprehensive knowledge and competency
early clinical exposure, integrated teaching and, Attitude, development. [30] The deficiency of faculties in most of
ethics, and communication (AETCOM). According to the medical colleges only adds to the challenge of CBME
Gopalakrishnan et al.,[26] 13% faculty showed awareness and implementation by the existing over‑burdened faculties.
57% bear negative attitude toward CBME. More than 4/5th have A study conducted among Foundation for Advancement
felt that they needed training programs to update themselves of International Medical Education and Research fellows
in CBME.[27] Capacity building of faculty is key for successful (FAIMER) [31] showed positive learning attitude about
implementation of curriculum. CBME but also cited lack of knowledge and unwillingness
of faculty to put time and effort into learning newer form of
In a study by Mahajan et al.,[28] stages of concern regarding
teaching‑learning methods as a de‑merit of CBME.
CBME implementation in medical colleges were assessed
among faculty. The results revealed that most of the faculty were Few proponents of CBME recommend that competency‑based
interested in implementing the CBME but find it difficult in actual outcomes alone should not drive the entire curricular experience

APIK Journal of Internal Medicine ¦ Volume XX ¦ Issue XX ¦ Month 2023 3

 Gehlawat, et al.: CBME for Indian undergraduates: Where do we stand?
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Figure 1: Ten modern methods of teaching in CBME.[25] CBME: Competencybased medical education
or define all education goals. Linking faculty development
activities to clinical learning needs or administrative and
regulatory requirements is a way both to provide incentives
for faculty participation and need to enhance efficiency.[29]
Kulkarni et al. found student faculty ratio, poor infrastructure,
time constraints, lack of commitment and human inertia, as
the main hurdles in implementation of CBME.[12]
Acceptance by Medical Students
As evident from previous studies,[32] systematically conducted
FCs found wide acceptance among 1st year medical students
and were helpful in preparing the students to enter the medical
field with confidence. Overall, three‑fourth of the participants
agreed that the FC was necessary at the start of the MBBS
course. Among the different components of the FC, basic life
support training and field visits evoked very high positive
responses (94% and 90%).[27]
DL and small group teaching were the most used mode of
learning and favored by the students. The new curriculum limits
lectures to only one third of total teaching hours allotted to a
particular subject and small group teaching would now account
for two‑thirds of total teaching hours. Allotting only one‑third
for lecture classes is met with great resistance from students.[27]
Students now a days are goal oriented, confident, motivated,
team oriented and high achieving; hence favour the use of
active learning. Active learning is a component of integrated
4 APIK Journal of Internal Medicine ¦ Volume XX ¦ Issue XX ¦ Month 2023
learning in CBME. 78% of the students appreciated the concept
of integrating different subjects and specialties as a good way to
learn medical concepts,[27] but many students still prefer passive
learning which include reading, listening, and viewing over
active learning like designing an experiment or giving a talk.[33]
The concept of SDL has been receiving increasing attention
since CBME was implemented. SDL teaches medical
students independent learning, assertiveness, accountability
and responsibility, but very few students are ready to accept
this concept of teaching as the students feel it to be very
time consuming. Lack of proper information regarding
SDL technique might have made student feel that it is not
useful.[27] They need a proper curriculum to follow SDL. Some
students found SDL helpful as it helped them to identify own
understanding and learning skill.[34]
Attitude, ethics, and communication (AETCOM) was
introduced under CBME for better communication. Most of
the students agreed that AETCOM training must start from
Phase I MBBS itself.[27]
Role‑play as an educational tool leads to better communication
skills and helps students retain information important for future
clinical practice. For example, a study stated that “Over 90%
of the students reported immense confidence in communicating
therapy details, namely, drug name, purpose, mechanism,
dosing details, and precautions. Majority reported a better
retention of concepts and preferred more such sessions.”[35]
 Gehlawat, et al.: CBME for Indian undergraduates: Where do we stand?
Many students preferred early clinical exposure as it improves
basic clinical skills and makes learning medicine easy and
relevant. CBL was also preferred by the students as it made
learning easier and more clinical oriented. According to a study,
80% of students agreed that CBL was an interesting way of
learning, while 64% agreed that a combination of traditional
and CBL would be effective.[36]
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PBL requires students to use their knowledge and skills for the
solution of problem rather than just recalling the facts. PBL
requires less lectures and more of student work like seminars,
small group learning etc. Many students preferred PBL over
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traditional mode of teaching. Though they still felt there is
lack in the curriculum. They faced difficulty in teamwork as
they felt all the group members did not participate equally. But
overall, many students are ready to accept this mode of learning
as they felt it improved their knowledge and clinical skill.[37]
Assessment
According to Ramanathan et al., less than half students (47%)
claimed to have a clear understanding of the assessment
schemes. Around four‑fifth welcomed the addition of
multiple‑choice questions (MCQs).[27] Many students found it
difficult to maintain and write so many logbooks and records.
Students felt too many assessments are burden for them.
Students felt that since the current curriculum required a lot of
exams so they are just studying to pass the exams.[27,34]
A mixed perspective was seen among students. Many students
have accepted CBME curriculum but many of them are
not ready and still prefer traditional way of teaching over
competency based. Students prefer lecture over SDL, small
group learning etc., as many felt that alternative methods of
teaching‑learning are more time‑consuming.[27]
Effect of CBME on medical students: A comparative
study[38] between medical students of 2018 batch (traditional
curriculum) and 2019 batch (CBME) showed a two‑fold
reduction in anxiety levels of students trained under CBME,
thus improving mental health of students. A cross‑sectional
study[39] from Tamil Nadu, India found students performing
well in AETCOM modules assessment proving the usefulness
of teaching AETCOM as part of CBME instead of keeping
it as hidden curriculum as done in the previous traditional
curriculum. As the first batch of Medical students (2019
batch) enters their fourth and major year for clinical training;
upcoming research will show us the effect of CBME on our
Indian Medical Graduates who will complete the training in
the year 2024.
Way Forward for Indian Medical Education
CBME is a method of medical education where students
constitute the basic unit and their learning outcomes and
competencies mark the endpoints. This is a paradigm shift
where the medical curriculum is outlined based on the needs
of society/community. CBME is increasingly understood as a
conceptual framework that is designed to increase transparency
APIK Journal of Internal Medicine ¦ Volume XX ¦ Issue XX ¦ Month 2023
and accountability and improve health care outcomes in
response to societal expectations and community needs by
inclusion of higher order competencies like practice‑based
learnings and improvement, system‑based practice and
professionalism.[29]
CBME provides clarity to the teacher as to what has to be
taught, and to the student as to what will be expected out of
him/her at the end of the learning exercise. More than 50%
of medical teachers in India have been sensitized to medical
education principles of CBME and more than 2000 faculty
mentors are on their way to complete an Advance Course in
Medical education.[19] A paradigm shift from traditional way
of teaching to CBME requires ample amount of time, effort,
resources and patience. Medical colleges and their medical
education units have to bear the responsibility to train the
faculty and to mentor and support the trained faculty, by
providing an educational environment to implement the newly
cultivated methods and skills in their day‑to‑day medical
teaching. Modern methods of teaching like CBL, EBM, and
PBL are good methods for imparting inquisitiveness among
students to test their knowledge and skills. Faculty must gain
experience in these methods, for which we require more
workshops to be conducted with increased resource faculty.
Regularly updating the FDP curriculum will be of paramount
importance to keep the faculty motivated, faculty innovation
and including the global innovations into Indian medical
education.[19] Continuous feedback from the learners (medical
students) will also play a huge role in advancement of medical
education.
A motivated student becomes a lifelong learner. Lifelong
learning is a natural human capacity strengthened by
self‑realization of one’s learning preferences. Self‑initiated
learning techniques are the most persistent and permeative.[40]
Hence, educators should devise activities that meet students’
needs and inculcate motivation. Timely introduction and
exposure to various teaching‑learning strategies strengthen
understanding and help with clinical practice. Medical
fraternity is slowly realizing the significance of vertical
integration between pre, para, and clinical subjects with early
clinical exposure of students. The modern learning methods
will definitely advance the pace of acquisition of knowledge
and skills. These methods will not solely focus on core medical
facts but lead to an overall growth including research and
innovation. There is lack of information on evaluation of
the students in this format of CBME. MCQ are one of the
tools for assessment. But in Clinical practice, this method of
assessment is not adequate for assessing Psychomotor skills.
Role‑play is more suited for assessing Attitudes, Ethics, and
communication. However, its role in assessment is yet to be
defined. A regular appraisal of the modern teaching‑learning
technologies is essential along with timely detection of
an erratic curriculum. An early introduction of alternative
teaching‑learning strategies in the curriculum will set the stage
for optimal teaching and learning environment for the UGs in
educational institutions.
5
 Gehlawat, et al.: CBME for Indian undergraduates: Where do we stand?
Keeping in tune with the phrase‑“Change is the only constant;”
India’s medical education system must actively adapt itself to
the rapid changes happening in the field of medicine and health
care to produce Indian Medical Graduates who excel in reading
the pulse of Indian society, as well as uphold global standards.
Financial support and sponsorship
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Nil.
Conflicts of interest
There are no conflicts of interest.
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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/322056077

INTERACTIVE TEACHING METHODS: CHALLENGES AND PERSPECTIVES

Article in IJAEDU- International E-Journal of Advances in Education · December 2017

DOI: 10.18768/ijaedu.370419

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 IJAEDU- International E-Journal of Advances in Education, Vol. III, Issue 9, December 2017

INTERACTIVE TEACHING METHODS: CHALLENGES AND

PERSPECTIVES

Madona Giorgdze1*, Marine Dgebuadze2

1
Dr., Ilia State University, GEORGIA, madona_giorgadze@iliauni.edu.ge
2
Dr., Ilia State University, GEORGIA, marine_dgebuadze@iliauni.edu.ge
*Corresponding author

Abstract
Georgian educational system has gone through the traditional methods of teaching. One of the main forms of
teaching in high school was a lecture, during which the lecturer was a transmitter and the student was a
recipient of knowledge.
Integration with modern Euro-Atlantic educational space requires modernization of existing learning methods
and the introduction of modern activities in the process of learning that will facilitate the establishment of an
active, independent and free person with critical thinking. Western education system became the main focus
of the Georgian educational policy.
The educational strategy has been changed and its main purpose has become bringing up of free, active,
informed and responsible citizens, equipped with the skills of critical thinking and loyal to the modern
democratic community in order to meet the demands of present-day democratic society.
The analysis of the research results shows that interactive teaching best helps students to get maximum
involvement in the lecturing process. The student is not only a passive recipient of knowledge, who is
constantly in the position of the listener but is actively involved in the lecturing process and gets maximum
knowledge. As a result, the information received is remembered for a longer time.
Recent studies show that interactive learning helps the learner not only to easily acquire new material but to
memorize it for a longer period of time.
The article does not attempt to contrast interactive and traditional methods but rather to highlight advantages
of the interactive method and underline its effectiveness to activate creative thinking, analytic and
argumentation skills in students.
Keywords: Interactive Teaching, traditional methods, teacher’s role

1. INTRODUCTION
A teaching method is formed in the teaching process through the interaction between the teacher and
learner. Within the existing learning conditions, the learning process is considered as an interaction between
the teacher and student, aiming to transfer common knowledge, skills, and values to the student.

http://ijaedu.ocerintjournals.org 544
 IJAEDU- International E-Journal of Advances in Education, Vol. III, Issue 9, December 2017
From the very first day when the teaching situation emerged up today there have been formed only three
widely spread forms of the interaction between a teacher and student:
1. Passive methods;
2. Active methods;
3. Interactive methods.
A passive method of instruction is a form of interaction between the teacher and students with the teacher
being the center of the lesson while the learner remains to be a passive listener. Feedback on such lessons
is conducted through surveys, independent tasks, tests and so on. The passive method is considered as
the most inefficient method in terms of material use, but the advantages of this method include the ability to
prepare less labor-intensive lessons in advance and present a large amount of information in a short time.
For many years the passive method of instruction had been the most popular and the single approach used
in Georgian learning situation. This can be regarded as a defect of that educational period and can be
explained by the logic of totalitarian system - the Soviet school did not aim at bringing up an active, critical
and independent citizen. The role of the pupil in the Soviet school was extremely weakened and this
attitude was obvious at different levels as well – the structure of lessons and the nature of the pedagogical
methods used in the course of the lesson (an active teacher: a passive learner /a teacher presenting: a
learner listening).
After the fall of the Soviet Union, significant changes were made to the Georgian educational system.
Western education system became the main focus of the Georgian educational policy. The educational
strategy has been changed and its main purpose became bringing up of free, active, informed and
responsible citizens, equipped with the skills of critical thinking and loyal to the modern democratic
community in order to meet the demands of present-day democratic society. For Georgia, with its short
tradition of democracy, it has become important to increase citizens' democratic awareness and to actively
engage them in the public life. For this purpose, reform and modernization of the education system have
been initiated, which envisages facilitating the establishment of a genuine knowledge-based society.
2. METHODS REVIEW
An active approach is a form of a teacher-student interaction equally involving both a teacher and students.
In this form of learning, students are not passive listeners anymore but they are active participants in the
learning process. Because of these advantages, a lot of teachers choose this method of instruction. In some
cases, this method is effective if employed by experienced teachers with the learners who have clearly
defined learning objective. If passive lessons represent an authoritative style of instruction, the active
approach is a democratic style (see Fig.1 and Fig 2) Active and interactive approaches have a lot in
common. In general, an interactive method can be considered as a modern version of active methods. In
contrast to the passive approach, active learning is focused on a closer relationship between learners and a
teacher, and students are more active in the learning process (see Fig. 3). The main difference between
active and interactive approach is that, in contrast to active approach, interactive learning involves students’
interaction not only with the teacher but with each other as well.
An interactive approach involves interaction in dialogue mode (“intеr” - reciprocally, “act” – do, perform). In
other words, an interactive teaching method is a form of learning and communicative activity in which
students are involved in the learning process and reflect on what they know and what they are thinking.
Unlike a traditional teaching method oriented on the teacher whose main function is to assist learners and
facilitate, interactive learning focuses on students 'needs, abilities, interests. While in a traditional approach
teacher is a center of the learning process and learners are passive and only receive information, in a
learner-oriented system the teacher and the learner swap their traditional roles enabling the learner to
actively engage in the learning process and be the center of the classroom (Fig. 1.). Based on his knowledge
and experience, learners categorize, analyze, assume opinions, acquire new skills, and develop their
attitudes towards facts and events.

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 IJAEDU- International E-Journal of Advances in Education, Vol. III, Issue 9, December 2017

Fig. 1. Passive methods

The teacher’s role in interactive learning is directed towards achieving the goals of students in the process of
teaching. The teacher makes a lesson plan - interactive activities and assignments, through the working of
which students acquire new information and an individual task is transformed into a group task. Each
member of the group contributes to the whole group's success (Fig. 2.). Interactive exercises and tasks that
students perform are the basic components of interactive lessons. The use of interactive teaching methods
ensures full participation of students in the learning process, and which is a major source of learning. The
fundamental difference between traditional and interactive activities is that the student does not only revise
and strengthen his knowledge but also constructs and completes it with new material.

Fig. 2. Active methods

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 IJAEDU- International E-Journal of Advances in Education, Vol. III, Issue 9, December 2017
Fig. 3. Interactive method
Among widely spread and popular interactive approaches, we can single out the following:
1. Creative tasks;
2. Games (role-plays, imitations, business and development games);
3. Use of human resources (excursions, inviting experts);
4. Social Projects;
5. Use of new material (interactive lectures, video-audio materials, student in the role of a "teacher",
Socratic dialogue, asking questions);
6. Solving tasks (associative maps, brain storming, case analysis).
Practice proves that using the above-mentioned interactive methods helps to achieve the results of modern
education. They help learning process to be conducted in such a way that all students are equally involved in
the cognitive process, each individual contributes to the teaching process, students exchange information
and ideas. This relationship allows students not only to acquire knowledge but also develop communicative
skills: the ability to listen to others, evaluate different points of view, participate in discussions, make joint
decisions, develop tolerance, etc.
Recent studies show that interactive learning helps the learner not only to easily acquire new material but to
memorize it for a longer period of time. The diagram below shows clearly that through passive learning, the
learner can memorize only 30% of the material, while the interactive learning enables us to memorize 90% of
the received information (Fig. 3.).

Fig. 4. Passive and active learning diagram (Edgar Dale’s cone of experience
http://teachernoella.weebly.com/dales-cone-of-experience.html )

3. CONCLUSION
As a conclusion we can say that the article does not attempt to contrast interactive and traditional methods
but rather to highlight advantages of the interactive method and underline its effectiveness to activate
creative thinking, analytic and argumentation skills in students; to develop conversation, discussion, team-
working and effective communication skills as emotional contacts created through interactive learning make
students listen to peers. Interactive methods in multicultural education allow students to have not only
knowledge and compassion for others but also be able to make rational decisions in any situation in order to
develop the most acceptable models of thinking, action, and communication.

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 IJAEDU- International E-Journal of Advances in Education, Vol. III, Issue 9, December 2017

REFERENCE LIST
Atanasescu, C., Dumitru, F. Interactive teaching-learning methods in the interdisciplinary approach of natural
sciences from the mentor-teacher’s perspective. Available at:
https://www.upit.ro/_document/4820/paper_2.pdf (03.09.2017)
Dumitru, Ion Al. (2000) .Developing the critical thinking and efficient learning. Timișoara: West.Pp. 93-95
Edgar Dale’s cone of experience http://teachernoella.weebly.com/dales-cone-of-experience.html Available
at: (07.09.2017)
Interactive Teaching Styles Used in the Classroom. Available at:
http://education.cuportland.edu/blog/tech-ed/5-interactive-teaching-styles-2/ (07.09.2017)
Macarie, C. (2005). Modern methodological alternatives a challenge for the teaching activity. Târgu- Jiu
:Măiastra. Pp. 22-25
Yakovleva, N., Yakovlev E. (2014). Interactive teaching methods in contemporary higher education. Pacific
Science Review 16. www.sciencedirect.com. Pp. 75-80

http://ijaedu.ocerintjournals.org 548

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Adesh University Journal of Medical

Sciences & Research
Article in Press

Review Article

Interactive teaching in medical education: Experiences

and barriers
Anjana Verma1, Ashish Patyal2, Jitendra Kumar Meena3, Medha Mathur1, Navgeet Mathur4
1
Department of Community Medicine, Geetanjali Medical College, Udaipur, Rajasthan, India, 2Department of Neuroanaesthesia, Walton Centre, Liverpool,
United Kingdom, 3Department of Preventive Oncology, National Cancer Institute, Jhajjar, Haryana, All India Institute of Medical Sciences, New Delhi,
4
Department of Medicine, Geetanjali Medical College, Udaipur, Rajasthan, India.

*Corresponding author:
Anjana Verma,
Department of Community
Medicine, Geetanjali Medical
College, Udaipur, Rajasthan,
India.
anjanaverma504@gmail.com
Received: 10 April 2021
Accepted: 27 July 2021
EPub Ahead of Print: 21 Aug 2021
Published:
DOI
10.25259/AUJMSR_13_2021
Quick Response Code:
ABSTRACT
An interactive teaching method is a form of learning and communicative activity, which focuses on students’
needs and allows them to actively participate in the learning process. With the introduction of competency
based medical education (CBME), new teaching methods have been introduced to ensure the attainment of
competencies by medical graduates. Research shows that interactive activity in class is an effective teaching
learning method. There are many studies which have reported that students prefer interactive lectures based on
active learning principles. Despite this, it has been found that many students do not engage with active learning
exercise, which is probably due to the reason that among students, there is an already established culture of
teaching and learning. The interactive lectures need to be designed after exploring student expectations, feedback,
and experiences. Faculty members too have their own skepticism about the use of innovative methods in their
teaching. These challenges need to be addressed for successful implementation of CBME based curriculum in
medical education. With this review, we present the experiences about the use of interactive teaching methods
in the field of medical education and also point out various barriers and challenges on the path of its execution.
Keywords: Interactive teaching, Competency based medical education, Medical education, Barriers, Challenges
INTRODUCTION
Lecture is one of the most commonly used methods of teaching in medical education. However,
the one-way communication during lectures does not influence the students’ behavior. It leads
to loss of interest in the topic among students, who are supposed to be the future competent
doctors. Introducing interactive techniques during lecture can promote learner participation and
as a result, can lead to a higher level of learning. Interaction between teacher and students is must
for improving the traditional teaching methods like lectures. Interactivity can promote active
learning, improves motivation as well as attention and can gives feedback to both teacher and
student.[1] Interactive learning activities actively engage the listener, and encourage the students
for self-directed learning. They will be more attentive and motivated during interactive lectures.[2]
Interactive teaching can be done using large group, small groups, pairs, and individuals. Methods
used in the study are think-pair-share, buzz sessions, case-based learning, and pass the problem.[3]
For decades, educationalists in India have been working towards the introduction of competency
based medical education curriculum in the country. Medical regulatory body has approved the

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 Verma, et al.: Interactive teaching in medical education
transition from traditional to new curriculum starting from
2019 academic year. With this reform in medical education,
there have been challenges and hurdles in its implementation
across all medical colleges in the country. This study
highlights the experiences of interactive teaching in medical
education and various challenges in its implementation.
EXPERIENCES FROM IMPLEMENTATION
OF INTERACTIVE TEACHING IN MEDICAL
EDUCATION
Experiences from abroad
Studies around the world have shown that interactive
teaching is a reform in medical education toward effective
learning. A quasi-experimental study by Ali et al. was
conducted among university students in Jordan to assess the
usefulness of interactive teaching in promoting awareness
about reproductive health. Since health education at teaching
institutes is a cost-effective and ideal method of developing
healthy lifestyles, researchers assessed the effectiveness
of interactive teaching method to educate youth about
reproductive health in conservative societies like Jordan.
The faculty delivering interactive lectures for promoting
reproductive health was trained about the teaching methods
such as brainstorming, group discussion, debate, educational
games, and reflections on real life stories. Interactive teaching
sessions were given to students as 60-min session/day, for
4 weeks. This study revealed a significant improvement in
students’ knowledge and attitudes, when post-test scores
were compared with pre test scores. Authors suggested that
reproductive health should be integrated into university’s
curriculum and should be taught with interactive learning
approach.[4] This study implies that interactive teaching
method is a better way of facilitating higher level of
thinking and extending the learning to affective domain
as well. The affective domain is one of the vital areas of the
learning outcomes of medical students, other than cognitive
and psychomotor domains. Studies in education have
demonstrated that students who are actively involved in the
teaching-learning session learn more than the students who
are just passive recipients of knowledge. Interactive lecturing
encourages the evaluation of the subject content, application
to other types of situations and evaluation of the material
presented. It can facilitate problem-solving, decision-making,
and communication skills. This is particularly important
in medical education where the application of knowledge
is as important as the retention and recall of facts.[5] Apart
from interaction between teacher and students, when there
is interaction within a group of students to define their own
learning objectives, it is called problem-based learning (PBL).
In PBL, students use “triggers” from the presented problem
case or scenario and construct their learning objectives.
Afterward, students independently do self-directed study
Adesh University Journal of Medical Sciences & Research • Article in Press | 2
and gather as a group to discuss and refine their acquired
knowledge.[6] PBL is an active way of learning but its
implementation in developing countries has some hurdles
because large number of students have to be managed with
minimum resources. Alaaqib et al. evaluated and compared
the effectiveness of lectures based on problems (LBP) and
traditional lectures (TLs) in physiology teaching in a medical
college in Sudan. Equal number of lectures was given as LBP
and as TL in the course. Post-test assessment of students was
taken through quiz sessions and scores were used to compare
the effectiveness of the two types of lectures. A structured
questionnaire was used to assess students’ perceptions and
satisfaction about LBP. The results revealed that students had
significantly better retention during LBP and more active role
than TL (P < 0.01). About 64% of students found LBP more
interesting and believed that it improved their understanding
of physiology concepts. The post-test scores of students in
quiz sessions of LBP were significantly better than that of TL
(P < 0.01).[7]
In today’s world, technology is a powerful tool for educators
to make their teaching more creative, interactive, and more
engaging. Flipped classroom (FC) is a teaching approach
in which direct instruction moves from the group learning
space to the individual learning space, and the classroom
is transformed into a dynamic, interactive learning
environment where the teacher guides the students as
they apply concepts and engage creatively in the subject
matter.[8] Traditional teaching method and FC approaches
were compared by Limniou et al., under the perspectives of
Higher Order Thinking Skills (HOTS) development among
1st year psychology students in Liverpool, United Kingdom.
In this study, it was revealed that there was a significant
difference in students’ views about the teachers’ contribution
to teaching learning approach, students’ HOTS development,
and choice of learning material. This study concluded the
importance of the relationship between choice of learning
material and the teacher’s contribution to the FC session and
their attitudes toward technology.[9] A randomized controlled
trial by de Jong was conducted to assess the effectiveness
of interactive seminars or small group tutorials among
undergraduate medical students in Leiden Medical School,
the Netherlands. Educational effectiveness was measured
by comparing the students’ results on the end-of-block test.
Students’ perceptions and satisfaction data were collected by
means of questionnaires. The study revealed that retention
of knowledge through active participation was the most
frequently cited reason for preferring small group tutorials,
a dislike of compulsory course components was mentioned
more frequently by students preferring interactive seminars.
Small group tutorials led to greater satisfaction.[10] Another
research done by McLaughlin et al. used the FC as a course
redesign to foster learning and engagement in a health
professions school. Researchers offloaded all lectures to
 Verma, et al.: Interactive teaching in medical education
self-paced online videos and used the class time to engage
students in active learning exercises. This study revealed that
after participation in FC, class attendance as well as students’
learning improved. The authors concluded that this approach
warrants careful consideration as educators aim to enhance
learning, improve outcomes, and fully equip students
to address present day healthcare needs.[11] A study by
Missildine et al. aimed to determine the effects of innovative
learning activities on academic success and the satisfaction
among nursing students. A quasi-experimental design was
used to compare three teaching learning methods: TL only
(LO), lecture and lecture capture back-up, and FC approach
of lecture capture with innovative classroom activities (LCI).
The study revealed that examination scores were higher
for the FC LCI group (Mean = 81.89 ± SD 5.02) than for
both the LLC group (Mean = 80.70 ± SD 4.25), P = 0.003,
and the LO group (Mean = 79.79 ± SD = 4.51), P < 0.001.
However, it was found that students were less satisfied
with the FC method than with either of the other methods
(P < 0.001). Authors concluded that combining new teaching
approaches with interactive classroom activities can result in
improved learning but not necessarily improved the students’
satisfaction.[12]
Experiences from India
The Medical Council of India recommended new curriculum
for undergraduate medical education emphasizing on
competencies, in a move toward competency based medical
education. It deals with the application of current educational
methodologies to bring about medical educational reforms
and prioritizes learner centric methods of instruction.
In a resource limited country like India, to bring about
reforms in medical education is a difficult process. It has
implications for staffing and learning resources and demands
a different approach to workload and assessment. Findings
of the educational research done in India reinforce the
need to implement learner centric and interactive teaching
methods in medical curriculum. Begum et al. conducted
an interventional study to compare the effectiveness of
interactive teaching learning (ITL) and traditional teaching
learning methods among undergraduate medical students in
Andhra Pradesh. This study also assessed the perception of
students and faculty toward it. Results showed that there was
an increase in performance of students in the intervention
group with significantly better scores than the students
in traditional teaching group. Students and faculty found
interactive teaching better than traditional methods.[13] In
another study from Maharashtra, Buch et al. used a number
of interactive teaching methods such as brain storming,
group discussions, question answer sessions, multiple choice
questions (MCQs), confusion technique, and summaries.
among 150 medical students. A pre validated questionnaire
was used to assess the perceptions of students about new
Adesh University Journal of Medical Sciences & Research • Article in Press |
methods, using the Likert scale. Most (>70%) of the students
liked the sessions. Majority (75%) of the students found
MCQs (76% completely agreed) to be the most popular ITL
method, followed by brainstorming (64% completely agreed)
and confusion technique (53% completely agreed). Most
of the students believed that interactive teaching helped
in improving attention span, communication skills, better
retention of the topic and suggested that such teaching
method should be regularly used during lectures.[14] Roopa
et al. did an evaluation of the type of lectures dental students
prefer in a college in Tamil Nadu. The students were exposed
to both regular and interactive lectures. Out of the total
12 lectures, alternate lectures were interactive. Students’
feedback was obtained at the end of the 12-lecture series.
About 92% students found interactive lectures to be more
useful. Interactive lectures were found to be more useful
than regular lectures by 92% of the students. Majority of the
students either agreed or strongly agreed that they were more
attentive and motivated during interactive lecture. Students
also found interactive teaching to be non-monotonous
and well-defined learning method. Out of the different
techniques, most liked one was use of video clippings
(58.1%).[15] A prospective longitudinal study was conducted
in Maharashtra by Datta et al., among 192 students to
compare the conventional versus interactive teaching with
a series of twenty lectures. An independent observer was
used to keep record of the number of interactions in each
class. After analyzing the results, it was found that pre-
test scores from both the groups were similar and post-
test scores improved in both groups. However, there was a
significant difference in the post-test scores between two
groups (P < 0.05). The post-test score of interactive lectures
was better than conventional post-test score by 9.24% (95%
Confidence Interval: 8.2–10.3%) (P < 0.01). Furthermore,
the retention test score after interactive sessions was better
than conventional retention test score (P < 0.001) by 15–
18.2% (95% Confidence Interval: 15.0–16.64%) (P < 0.01).
There were 51 participative events in the interactive group as
compared to 25 in the conventional group.[16]
Kumar et al. conducted a cross-sectional study among VIIth
semester medical students to study the effectiveness of
tutorials as an interactive method of teaching undergraduate
students in Pondicherry. Students were divided into six
groups and tutorial session was conducted by trained faculty.
Feedback from students was taken through a predesigned
pretested questionnaire using Likert scale. Most of students
(63.4%) revealed that they understood the topic better in
tutorial session. About 69% of students felt time management
was better in a tutorial as compared to lecture.[17]
Another study done by Cheema and Arora among 150
medical students of a medical college in Jalandhar, Punjab to
evaluate the effectiveness of interactive lectures as teaching
3
 Verma, et al.: Interactive teaching in medical education
method in Obstetrics and Gynaecology, demonstrated that
interactive methods stimulate self-directed learning among
students.[18]
A study done in the state of Meghalaya, Panda et al. compared
three types of interactive teaching methods: Flipped class
room; MCQ based interactive teaching; and Confusion
technique Kirkpatrick level 1 evaluation. This academic
study was conducted for a period of 1 year with medical
students. Twelve topics were selected to be included in the
study. Out of the total 12 topics, four topics were taught in
FC technique, another four were taught with MCQs in the
class and remaining four topics were taught using confusion
technique. Feedback was obtained from students with the
post-test questionnaire using Likert chart. The study revealed
that students preferred FC technique of teaching followed by
MCQ technique and confusion technique.[19]
In Karnataka, Angadi et al. did an interventional study with
98 students, divided into two batches of flipped class and
conventional small group teaching. FC involves providing
study resource material to students, outside the class so
that class time is used for instructional activities. This study
was done to assess the effectiveness of FC activity as an
interactive teaching-learning method. For the flipped class,
an online Google group was created. Brief introduction and
pre-recorded videos related to the assigned topic were posted
in the Google group, followed by discussion in the form of
problem-solving exercises. Study showed that there was a
significant difference between the post-test scores of each
session and also the mean scores of summative tests between
two groups (P < 0.001). About 82% of the study participants
strongly agreed that FC session was more engaging and
interesting in comparison to TL. Majority (76%) strongly
agreed that more such classes (FC) should be conducted in
the future.[20]
BARRIERS TO INTERACTIVE TEACHING
The role of teacher is changing from keeper of knowledge
to coordinator of learning which presents a challenge for
educators to dramatically change the way their students learn.
Whereas most teachers agree with theoretical benefits of
interactive lectures, many might not engage in such lectures
for a number of reasons. Most frequently, teachers mention
a scepticism of losing control while delivering the lecture.[3]
Doubts about not covering all of the material, or of losing time
to less important content, is another commonly endured
lament. It is a fact that the “number of facts” or “amount of
information” need to be reduced to deliver an interactive
lecture; another well-known fact is that if we present too much
information, students will retain less.[21] Another common
reason for hesitancy to deliver an interactive lecture is time
constraint. Audience expectations, subject matter and the
physical setting may also hinder an attempt to be interactive.
Adesh University Journal of Medical Sciences & Research • Article in Press | 4
In developing countries, limited resources may pose further
challenges in the implementation of interactive teaching.
Many teachers are of opinion that the basic sciences cannot be
taught interactively, and that it is comparatively easier to teach
the clinical sciences using interactive format. Others believe
that higher order thinking is required for interactive teaching
and undergraduate students, because of their more limited
knowledge, cannot participate in an interactive lecture.[3]
However, the published literature and teaching experiences
do not support this position. The use of educational
technology in medical education is consistently expanding.
The new curriculum mandates integrating new technology
into the teaching methods. However, the exact impact of these
methods on educational outcomes is yet to be determined in
long run. There are many challenges in the practical use of
interactive learning technology despite sufficient research in
the field. There is also the possibility of poor integration of new
technology with other educational activities. Technology can
produce substantial educational benefits when incorporated
in the curriculum in a collaborative manner.
WAYS TO IMPROVE INTERACTIVITY IN
LECTURES
The lecture still is one of the most widely used teaching
methods in classes, and there are strategies teachers can
utilize that will help to engage students around the lecture
content. One of the methods is to incorporate interactivity
into the lecture. Strategies for interactivity can be either
technology based or can be implemented in a shared, real-
time social setting. Technology based strategies range from
using visual cues embedded in PowerPoint to use of social
media platform. On the other hand, simple interaction
strategies that require no use of technology include stopping
for a show of hands or building in time to turn to your
neighbor and discuss. These sorts of strategies balance out
a lecture listening activity with a discreetly placed lecture
responding (interacting) activity. The social dynamics of
learning can be used to enhance the learning experience. The
social interaction directly controls learner engagement and
can be leveraged to enhance learner’s efficiency and to find
solutions to complex learning problems. The interactivity
in teaching can be effective if incorporated with proper
assessment. Where possible, a variety of socially interactive
learning assessments includes group assignments and peer
marking. In socially interactive learning assessments, a self-
reflective element should be included that requires students
to examine the social dynamics of the assessment, and the
impact it has on their learning and thinking.[22]
CONCLUSION
Studying with interactive activities is a great source of
learning especially when they are incorporated with specific
 Verma, et al.: Interactive teaching in medical education
educational components and outcomes. It is accepted by
almost all teacher communities around the world that
interactive teaching methods help in self-directed learning
among students and better retention of topic. Interactive
teaching methods modify the role of a teacher from
provider of information to the facilitator of educational
process. Although there are certain challenges and barriers
in implementation of interactive teaching in medical
curriculum, they can be addressed with proper planning and
training of stake holders.
Acknowledgment
The authors are thankful to the scholars, whose articles are
cited in the text and faculty members of Medical Education
Unit.
Declaration of patient consent
Patient’s consent not required as there are no patients in this
study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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teaching undergraduate medical students. Int J Community
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18. Cheema HK, Arora R. Effectiveness of interactive lectures
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students. J Evol Med Dent Sci 2019;8:1563-72.
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21. McKeachie WJ. Teaching Tips: A Guidebook for the Beginning
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22. Nugent A, Lodge JM, Carroll A, Bagraith R, MacMahon S,
Matthews KE, et al. Higher Education Learning Framework:
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Burgess et al. BMC Medical Education 2020, 20(Suppl 2):457
https://doi.org/10.1186/s12909-020-02282-3

REVIEW Open Access

Facilitating small group learning in the

health professions
Annette Burgess1,2*, Christie van Diggele2,3, Chris Roberts1,2 and Craig Mellis4

Abstract
There is now good evidence that small group teaching provides a fruitful academic environment, which optimises
learning, particularly in the healthcare setting, and especially when compared to lectures. An individual student’s
understanding of knowledge is increased when they are able to actively compare and build on their own understanding
in conjunction with their peers. Small group teaching provides opportunities for learners to work collaboratively, and
promotes team-building skills – skills that are essential to work within healthcare settings. The aim of this paper is to
provide health professional students and early career health professionals involved in peer and near peer teaching, with
an overview of approaches and tips to improve learner engagement when facilitating small groups.
Keywords: Small group learning, Team building skills, Facilitation, Peer assisted learning, Health professional students

Background academic environment, and maximise student learning [10],

Health professional education occurs in a variety of contexts, and remain the preferred approach to pedagogy in health
including those within university, hospital, community-based professional education [5].
and clinical settings. Curricula activities at the university tar- An individual student’s understanding of knowledge is
get development of students’ knowledge of the basic sciences increased when they are able to actively compare and
of healthcare (such as physiology, pathology, and anatomy), build on their own understanding in conjunction with
which are then integrated into the clinical setting, thus con- their peers [11–16]. Small group teaching provides
textualising this knowledge. The clinical setting also plays a opportunities for learners to work collaboratively with
crucial role in developing students’ clinical skills, communi- their peers, and promotes team building skills – skills that
cation skills, and professionalism. The clinical application of are essential to working within healthcare settings [17,
the basic sciences also occurs in case scenario based small 18]. However, all learning experiences are only as effective
group teaching methods, such as problem based learning as the students’ engagement with them. While some small
(PBL), Team-based learning (TBL), Case based learning group learning experiences are inviting and supportive,
(CBL), in the university setting [1–7]; and communication others may impede efforts to learn [19]. The aim of this
skills, clinical skills, and procedural skills teaching in the clin- paper is to provide health professional students and early
ical, patient-based setting [8, 9]. Compared to lecture based career health professionals involved in peer and near peer
teaching, these small group methods provide a more fruitful teaching, with an overview of approaches and tips to im-
prove learner engagement when facilitating small groups.
* Correspondence: Annette.burgess@sydney.edu.au
1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical
School - Education Office, The University of Sydney, Sydney, NSW 2006, What defines small group learning, and what are the
Australia benefits?
2
The University of Sydney, Faculty of Medicine and Health, Sydney Health The suggested ideal group size for small group learning
Professional Education Research Network, The University of Sydney, Sydney,
Australia is between five and eight people, with six often being
Full list of author information is available at the end of the article considered ‘optimal’ [20, 21]. However, small group
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):457 Page 2 of 6

learning is not defined by the number of participants,

and should not be confused with a lecture to small
groups. In order for the lesson to be classed as a small
group learning experience it must involve three key
elements [22]: active participation, ‘face-to-face’ con-
tact between participants, and purposeful activities.
When implemented with all three elements in play,
the small-group context offers many benefits, and en-
hances students’ learning experiences in many ways.
For example, small group learning has the potential
to: [15, 16, 21, 23]

 Help address gaps in student knowledge

 Encourage self-directed learning
 Allow students to engage with a range of
perspectives from their peers
 Allow students to test their ideas and attitudes with
their peers
 Promote a willingness for students to share their
ideas
 Provide opportunities for students to give and
receive feedback
 Help students to develop skills in critical thinking
and problem solving
 Help students to develop communication, teamwork
and leadership skills.
What is the role of the facilitator in small group teaching?
Rather than being facilitator centred, small group teach-
ing is designed to be learner focused [24]. Actively in-
volving students in learning leads to increased interest,
teamwork ability, improvement in self-directed learning
and better retention of knowledge and skills [23, 24].
There are three main happenings (Fig. 1) that small
group facilitators must manage simultaneously: the
group, the activities and the learning [25, 26].
The role of the facilitator is to ‘facilitate’ the learning:
lead the discussion, ask open-ended questions, guide the
process and ensure active participation from students
[26]. However, a range of roles may need to be adopted
in order to respond to the way small groups function
and interact. During a small group teaching session, the
facilitator’s specific roles include:
 Setting clear goals at the start of the session
 Facilitating the session and ensuring it runs on time
 Maintaining the flow of content, ensuring a logical
sequence of learning, and provision of stimulating
material and questions
 Questioning students to check their understanding
 Encouraging students to ask questions throughout
the session
 Clarifying areas that may cause misunderstanding or
confusion for students
Fig. 1 Three key roles of the facilitator in small groups
 Providing effective feedback
 Managing the group dynamics, including resolving
conflict and unprofessional behaviour
 Critical reflection and lesson evaluation at the
conclusion of the teaching session.
Small group interaction
There is a need to understand the internal dynamics of
the group and how to manage different learners. Tuck-
man’s (1965) framework provides a useful way of think-
ing about the ways in which group dynamics develop
over time [26, 27]. According to Tuckman, there are five
key phases in small group team development:
1. Forming - the initial formation of a group.
Facilitators are responsible for facilitating
introductions, implementing ice-breaker tasks,
explaining the activities and purpose of the group.
2. Norming - ideas are shared within the group and
rules are developed. The facilitator is responsible
for encouraging everyone to participate, clarifying
ground rules, and ideas/suggestions the group may
have regarding the process.
3. Storming - the group actively tries to perform the
task, however some conflict may arise within the
group. The facilitator assists by moderating
conflicts and clarifying ideas.
4. Performing - the group starts to form a team
approach to performing the set tasks. The facilitator
keeps the group focussed.
5. Closure – includes ‘adjourning’ after each session,
or, ‘mourning’, when a group has successfully
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):457
worked together, completed their tasks and
dissolves (the final stage).
Strategies to consider as a facilitator
Initially, an appropriate culture needs to be established
within the group [26]. In getting started, the facilitator
should contribute to the creation of a positive and com-
fortable learning environment by:
 Ensuring the room is set up appropriately (consider
seating, noise, privacy)
 Planning effective introductions (‘ice breakers’)
 Outlining expectations and ground rules (e.g.
maintaining confidentiality)
 Learning and using the students’ names
 Discussing and assigning roles and responsibilities to
group members (eg. timekeeper; scribe)
 Determining the learning needs of individuals by
asking questions or observing performance, and
gaining and understanding of the learner’s level of
knowledge and skills.
Strategies that foster interactions between learners in-
clude: buzz groups, where students are given an oppor-
tunity to discuss a topic for a specific amount of time;
role play/simulation; creation of a poster/drawing; and
break out activities [26]. As demonstrated by comparing
Fig. 2 with Fig. 3, using different forms of questioning to
shift the students’ focus helps to facilitate discussion and
promote interaction [26, 28]. In Fig. 2, the small group is
not working. This is a ‘lecture’ with no interaction be-
tween learners. In Fig. 3, the small group is working
well, with lots of interaction between learners and the
Fig. 2 Didactic interactions between the facilitator (F) and individual
learners. (Adapted from McKimm & Morris, 2009) [26]
Page 3 of 6
Fig. 3 Multiple, active interaction between the facilitator (F),
individual learners and their peers. (Adapted from McKimm & Morris,
2009) [26]
facilitator, but the facilitator does not have a dominant
role (i.e. they are facilitating).
Questioning in small group teaching
The use of frequent questions in small group facilitation
helps to create a learner-centred approach to learning.
This allows the facilitator to gain an understanding of
the learning needs of individual students, enabling them
to pitch their response and interactions at an appropri-
ate level [29]. The use of questioning promotes clinical
reasoning, encourages reflection, and enables the facilita-
tor to monitor the learners’ progress. For example, the
use of closed questions requires only a single answer,
while the use of open questions requires the learner to
combine pieces of information and formulate an answer
[30, 31]. Different questioning strategies promote differ-
ent responses, stimulating deeper thinking, reflection
and discussion. Some examples of questioning strategies
include:
Evidence: ‘What evidence is there to support that?’
Clarification: ‘Can you explain what that means?’
Explanation: ‘Why do you think that would be the
case?’
Linking: ‘How does this idea support what we
mentioned earlier on?’
Hypothetical: ‘What would happen if?’
Summary and synthesis: ‘What are we still uncertain
about?’
The appropriate use of questions has the capacity to
arouse curiosity, and encourage critical thinking [31].
Importantly, questions can assist the facilitator in
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):457
assessing the extent of students’ knowledge, and also
helps the student to identify their own knowledge gaps.
Figure 4 suggests how the use of questions can help
promote synthesis of information.
Generally, there are three types of questions [31]:
1) Yes/No questions: basic form of questioning, very
simple and does not stretch the learner.
2) Closed questions: there is a specific answer, enabling
the questioner to check the knowledge of the
learner, but not their level of understanding.
3) Open questions: there is generally no ‘right’ answer.
Allows the questioner to probe further asking ‘why’
and ‘how’ type questions. This requires a good
understanding of the topic, thinking skills, and
problem solving.
In some circumstances, it can be useful to employ the
technique of “Pose; Pause; Pounce” (Fig. 5) [31]. After
questioning a learner, it is important to pause to allow
the learner to register what you are asking, and to think
about their response. It is important to allow for this
silence and not jump in to rephrase the question imme-
diately, or answer the question yourself [31].
Facilitator reflection
Critical reflection is considered an essential step to ef-
fective education in healthcare, and should be practiced
by facilitators [31]. This involves thinking about the
facilitation strategies used, how well they worked, if
lesson goals were met, and how the teaching session can
be improved in future [25]. Some examples of reflective
questions include [31]:
 What went well during the lesson?
 What can be improved?
 Did the lesson cover the learning objectives I set at
the start of the lesson?
 Was my questioning technique effective?
Fig. 4 The use of open questions promotes synthesis of information
Page 4 of 6
 How well did I engage learners?
 Where can I improve next time?
Gaining feedback from learners can also assist in self-
reflective practices [31]. This can be done verbally, by
asking “what were the key messages” from the session,
and what areas were “confusing” or “least well under-
stood”? Additionally, written feedback may be sought.
Having a peer observe facilitation provides another great
source of feedback [24]. Tips for receiving feedback in-
clude: [26]
◦ Be open to the feedback being given as it is intended
to be helpful
◦ Avoid instantly dismissing feedback that does not
match self-reflection
◦ Avoid becoming defensive - instead engage in
constructive discussion
◦ Ask for specific examples to explain the feedback
being given.
Resolving common problems in small group facilitation
Although small group teaching offers many advantages,
it may pose some difficulties and limitations for the fa-
cilitator and students. Group problems commonly stem
from [19, 26, 32]:
 Students being reluctant to engage in discussion
with each other
 Students are not prepared for small group activities
 Individual ‘free riders’ failing to contribute (may be
shy or disinterested)
 Individual students dominating discussion or being
disruptive
 Attention being directed towards the facilitator, who
is expected to provide answers
 Facilitator’s questions don’t go beyond the level of
recall
 Facilitator’s lack of attempt to get students to
answer their own questions
 Facilitators providing insufficient/poor feedback
 Facilitators talking too much, lecturing rather than
facilitating.
The facilitator should reflect on why the problem is
occurring, what can be done differently to help over-
come the problem, and how accountability for success
can be shared with the student group [32]. Depending
on the specific problem with the group dynamics, some-
times identifying the problem and sharing this percep-
tion with the group may prompt the group to solve the
problem. However, specific and appropriate strategies
may be needed. For example:
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):457
Fig. 5 The 3 Ps of questioning (adapted from Lake, Vickery, Ryan, 2005) [31]
Individual dominant students: summarise points and
divert the discussion to others; indicate time pressure;
give the group specific tasks.
Quiet students: give them time to respond; divide the
group into pairs for a task; positively reinforce any
contribution.
Attention being directed towards the facilitator: build
on students’ responses to a limited extent by sharing
clinical experiences or provide a clinical context where
appropriate to heighten the relevance of the topic.
Students receiving insufficient feedback: schedule a
time for student feedback throughout the session, or
afterward.
Students attending unprepared for small group activ-
ities: ensure student accountability to their team mem-
bers by including short tests at the beginning of class,
which may also help to prevent late arrivals [32].
Conclusion
Small group teaching can be very rewarding, for both
the learners and facilitators. However, successful small
group facilitation requires appropriate facilitation
methods to encourage active and purposeful participa-
tion, and enhance student learning. The facilitator’s role
is crucial in encouraging the learners to interact with the
content, and with their peers. Self-reflective practices
and the use of feedback provide a valuable means to im-
prove small group facilitation skills.
Take-home message
• Ensure small group activities remain learner-centred, with active partici-
pation and purposeful activities.
• Pay attention to group dynamics to ensure achievement of tasks and
effective group work.
• Use open questions to encourage clinical reasoning, and monitor
learners’ progress.
• Reflect on teaching experience, and gain feedback from participants.
Abbreviations
PBL: Problem based learning; TBL: Team-based learning; CBL: Case based
learning
Acknowledgements
The authors have no acknowledgements to declare.
Page 5 of 6
About this supplement
This article has been published as part of BMC Medical Education Volume 20
Supplement 2, 2020: Peer Teacher Training in health professional education.
The full contents of the supplement are available online at URL. https://
bmcmedicaleducation.biomedcentral.com/articles/supplements/volume-20-
supplement-2.
Authors’ contributions
AB, CVD and CM contributed to the drafting and writing of the manuscript.
AB, CVD, CR, CM contributed to critical review of the manuscript. All authors
read and reviewed the final version of the manuscript. The author(s) read
and approved the final manuscript.
Funding
No funding was received.
Availability of data and materials
Not Applicable.
Ethics approval and consent to participate
Not Applicable.
Consent for publication
Not Applicable.
Competing interests
The authors have no competing interests to declare.
Author details
1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical
School - Education Office, The University of Sydney, Sydney, NSW 2006,
Australia. 2The University of Sydney, Faculty of Medicine and Health, Sydney
Health Professional Education Research Network, The University of Sydney,
Sydney, Australia. 3The University of Sydney, Faculty of Medicine and Health,
The University of Sydney, Sydney, Australia. 4The University of Sydney,
Faculty of Medicine and Health, Sydney Medical School, Central Clinical
School, The University of Sydney, Sydney, Australia.
Published: 3 December 2020
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 E S S A Y

Essential Elements of Communication in Medical

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Encounters: The Kalamazoo Consensus Statement

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Participants in the Bayer–Fetzer Conference on Physician–Patient Communication in Medical Education

ABSTRACT

In May 1999, 21 leaders and representatives from major
medical education and professional organizations at-
tended an invitational conference jointly sponsored by
the Bayer Institute for Health Care Communication
and the Fetzer Institute. The participants focused on
delineating a coherent set of essential elements in
physician–patient communication to: (1) facilitate the
development, implementation, and evaluation of com-
munication-oriented curricula in medical education and
(2) inform the development of specific standards in this
domain. Since the group included architects and repre-
sentatives of five currently used models of doctor–patient
communication, participants agreed that the goals might
best be achieved through review and synthesis of the
models. Presentations about the five models encompassed
their research base, overarching views of the medical
encounter, and current applications. All attendees
participated in discussion of the models and common el-
ements. Written proceedings generated during the con-
ference were posted on an electronic listserv for review
and comment by the entire group. A three-person writing
committee synthesized suggestions, resolved questions,
and posted a succession of drafts on a listserv. The current
document was circulated to the entire group for final ap-
proval before it was submitted for publication. The group
identified seven essential sets of communication tasks: (1)
build the doctor–patient relationship; (2) open the dis-
cussion; (3) gather information; (4) understand the pa-
tient’s perspective; (5) share information; (6) reach agree-
ment on problems and plans; and (7) provide closure.
These broadly supported elements provide a useful frame-
work for communication-oriented curricula and stan-
dards.
Acad. Med. 2001;76:390–393.

A growing emphasis on physician–pa-
tient communication in medicine and
medical education is reflected in inter-
national consensus statements,1,2 guide-
lines for medical schools,3–6 and stan-
dards for professional practice and
education.7–12 In May 1999, with work
in these areas and related research13–17
as a backdrop, 21 people from medical
schools, residency programs, continuing
medical education providers, and prom-
inent medical educational organizations
in North America convened for three
The conference participants are listed in a box at the
end of the text.
Correspondence and requests for reprints should be
addressed to the Bayer Institute for Health Care
Communication, 400 Morgan Lane, West Haven,
CT 06516; e-mail: 具bayer.institute@bayer.com典.
days in Kalamazoo, Michigan, for the
Bayer–Fetzer Conference on Physi-
cian–Patient Communication in Med-
ical Education. The aim of this invita-
tional conference was to identify and
specifically articulate ways to facilitate
communication teaching, assessment,
and evaluation.
The group used an open-ended, iter-
ative process to identify and prioritize
topics for discussion. A major topic of
interest to the entire group was deline-
ating a set of essential elements in phy-
sician–patient communication. Partici-
pants expressed three goals for the
discussion:
1. Reaching consensus on a ‘‘short
list’’ of elements that would characterize
effective communication in several
clinical contexts.
2. Providing tangible examples of
skill competencies that would be useful
for licensing bodies, organizations that
accredit medical schools and residency
programs, and directors of medical ed-
ucation programs at all levels.
3. Ensuring that the product gener-
ated by the group would be evidence
based and appropriate for teaching, as-
sessment, and evaluation.
Since the group included architects
and representatives of five currently
used models of doctor–patient com-
munication, participants agreed that
the goals might best be achieved
through review and synthesis of the
models’ essential elements. Toward that
end, brief presentations were delivered
about each of the five models:

390 ACADEMIC MEDICINE, VOL. 76, NO. 4 / APRIL 2001

 䡲 Bayer Institute for Health Care Com-
munication E4 Model18
䡲 make it easier for people working in this
Three Function Model/Brown Inter-
view Checklist19
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䡲 The Calgary–Cambridge Observation
Mi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/26/2024
Guide20
䡲 Patient-centered clinical method21
䡲 SEGUE Framework for teaching and
assessing communication skills22
Each presentation included an ex-
plicit description of the model, encom-
passing its research base, overarching
views of the medical encounter, and
current applications. After discussion of
the models, attendees from the Accred-
itation Council for Graduate Medical
Education (ACGME), the CanMEDS
2000 Project, the Educational Commis-
sion for Foreign Medical Graduates
(ECFMG), and the Macy Health Com-
munication Initiative provided infor-
mation about their efforts to develop
criteria for teaching and evaluating
physician–patient communication. The
group then began looking for common-
alities among the models as well as
points of departure. This process was
enriched by the number and diversity of
organizations represented by conference
participants.
THE ESSENTIAL ELEMENTS
Consensus on the essential elements of
physician–patient communication was
reached by using the three goals out-
lined above to guide and ground dis-
cussion. The group’s perspective on es-
sential elements is consistent with the
task approach, a concept that has been
well supported in communication skills
teaching since the early 1980s.3,18–25 As
noted by Makoul and Schofield,2 ‘‘fo-
cusing on tasks provides a sense of pur-
pose for learning communication skills.
The task approach also preserves the in-
dividuality of [learners] by encouraging
them to develop a repertoire of strate-
gies and skills, and respond to patients
in a flexible way.’’
By identifying specific communica-
tion tasks, the group worked to high-
light behaviors that are embedded in
existing consensus statements, guide-
ACADEMIC MEDICINE, VOL. 76, NO. 4 / APRIL 2001
lines, and standards. While the list is by
no means exhaustive, the intent was to
area to identify not only the key tasks,
but the relevant knowledge, skills, and
attitudes as well. References for the sup-
porting research are listed and discussed
in a number of texts.20,21,23–28
Build a Relationship: The
Fundamental Communication Task
A strong, therapeutic, and effective re-
lationship is the sine qua non of phy-
sician–patient communication.29,30 The
group endorses a patient-centered, or
relationship-centered, approach to care,
which emphasizes both the patient’s dis-
ease and his or her illness experi-
ence.31,32 This requires eliciting the pa-
tient’s story of illness while guiding the
interview through a process of diagnos-
tic reasoning. It also requires an aware-
ness that the ideas, feelings, and values
of both the patient and the physician
influence the relationship.2,15,33 Further,
this approach regards the physician–pa-
tient relationship as a partnership, and
respects patients’ active participation in
decision making.34–36 The task of build-
ing a relationship is also relevant for
work with patients’ families and support
networks. In essence, building a rela-
tionship is an ongoing task within and
across encounters: it undergirds the
more sequentially ordered sets of tasks
identified below.
Open the Discussion
䡲 Allow the patient to complete his or
her opening statement
䡲 Elicit the patient’s full set of concerns
䡲 Establish/maintain a personal connec-
tion
Gather Information
䡲 Use open-ended and closed-ended
questions appropriately
䡲 Structure, clarify, and summarize in-
formation
䡲 Actively listen using nonverbal (e.g.,
eye contact) and verbal (e.g., words
of encouragement) techniques
Understand the Patient’s Perspective
䡲 Explore contextual factors (e.g., fam-
ily, culture, gender, age, socioeco-
nomic status, spirituality)
䡲 Explore beliefs, concerns, and expec-
tations about health and illness
䡲 Acknowledge and respond to the pa-
tient’s ideas, feelings, and values
Share Information
䡲 Use language the patient can under-
stand
䡲 Check for understanding
䡲 Encourage questions
Reach Agreement on Problems
and Plans
䡲 Encourage the patient to participate
in decisions to the extent he or she
desires
䡲 Check the patient’s willingness and
ability to follow the plan
䡲 Identify and enlist resources and sup-
ports
Provide Closure
䡲 Ask whether the patient has other is-
sues or concerns
䡲 Summarize and affirm agreement with
the plan of action
䡲 Discuss follow-up (e.g., next visit,
plan for unexpected outcomes)
CONCLUSION
This outline of essential elements in ef-
fective physician–patient communica-
tion provides a coherent framework for
teaching and assessing communication
skills, determining relevant knowledge
and attitudes, and evaluating educa-
tional programs. In addition, the out-
line can inform the development of spe-
cific standards in this domain. Most of
the elements included in this document
are present in each of the five models
examined during the process of consen-
sus building. A major strength of the
outline is that it represents the collab-
oration and consensus of individuals
with a variety of backgrounds and in-
391
 terests in medical education. Further,
the basic outline can be tailored to
meet the needs of different specialties,
settings, and health problems. Con-
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scientious efforts to address these essen-
tial elements across practice settings
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will help increase the efficiency
and effectiveness of physician–patient
communication,37 enhance patient and
physician satisfaction,38,39 and improve
health outcomes.40
Gregory Makoul, PhD, director of the Program in
Communication and Medicine at Northwestern
University Medical School, provided leadership
in the writing process.
The Bayer–Fetzer Conference on Physician–Pa-
tient Communication in Medical Education was
held May 11–14, 1999. The Bayer Institute for
Health Care Communication is a non-commer-
cial, nonprofit, organization whose mission is to
improve health through education, research, and
advocacy in the area of clinician–patient com-
munication. The Fetzer Institute is a nonprofit,
private operating foundation that supports re-
search, education, and service programs exploring
the integral relationships among body, mind, and
spirit. The conference site was Seasons, A Center
for Renewal, owned and operated by the Fetzer
Institute, in Kalamazoo, Michigan.
This consensus statement reflects the views of the
conference participants; it does not necessarily
imply endorsement by their institutions or asso-
ciations.
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13. Novack DH, Volk G, Drossman DA, Lipkin
M Jr. Medical interviewing and interpersonal
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ture of medical school courses in professional
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48–51.
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19. Novack DH, Dube C, Goldstein MG. Teach-
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20. Kurtz S, Silverman J, Draper J. Teaching and
Learning Communication Skills in Medicine.
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21. Stewart M, Belle Brown J, Weston WW,
McWhinney IR, McWilliam CL, Freeman
TR. Patient-Centered Medicine: Transform-
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23. Riccardi VM, Kurtz SM. Communication and
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24. Pendleton D, Schofield T, Tate P, Havelock
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25. Cohen-Cole SA. The Medical Interview:
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27. Silverman J, Kurtz S, Draper J. Skills for
Communicating with Patients. Abingdon,
Oxon, U.K.: Radcliffe Medical Press, 1998.
28. Stewart M, Roter D. Communicating with
Medical Patients. Thousand Oaks, CA: Sage,
1989.
29. Novack DH. Therapeutic aspects of the clin-
ical encounter. J Gen Intern Med. 1987;2:
346–55.
30. Safran DG, Taira DA, Rogers WH, Kosinski
M, Ware JE, Tarlov AR. Linking primary care
performance to outcomes of care. J Fam
Pract. 1998;47:213–20.
31. Engel GL. The need for a new medical
model: a challenge for biomedicine. Science.
1977;196:129–36.
32. Kleinman A. The Illness Narratives: Suffer-
ing, Healing and the Human Condition. New
York: Basic Books, 1988.
33. Novack DH, Suchman AL, Clark W, Epstein
RM, Najberg E, Kaplan C. Calibrating the
physician: personal awareness and effective
patient care. JAMA. 1997;278:502–9.
34. Williams GC, Freedman ZR, Deci EL. Sup-
porting autonomy to motivate patients with
diabetes for glucose control. Diabetes Care.
1998;21:1644–51.
35. Kaplan SH, Gandek B, Greenfield S, Rogers
W, Ware JE. Patient and visit characteristics
related to physicians’ participatory decision-
making style. Results from the Medical Out-
comes Study. Med Care. 1995;33:1176–87.
36. Gudagnoli E, Ward P. Patient participation in
decision making. Soc Sci Med.1998;47:329–39.
37. Stewart MA. Effective physician–patient
communication and health outcomes: a re-
 view. Can Med Assoc J. 1995;152:1423–33.
38. Williams S, Weinman J, Dale J. Doctor–pa-
tient communication and patient satisfaction:
a review. Fam Pract. 1995;15:480–92.
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fice visits. Collaborative Study Group of the tient involvement in care: effects on patient
American Academy on Physician and Pa- outcomes. Ann Intern Med. 1985;102:520–8.

Participants in the Bayer–Fetzer Conference on Patient–Physician Communication

in Medical Education, May 1999
Patrick H. Brunett, MD Forrest Lang, MD
Assistant Professor of Emergency Medicine, Oregon Health Sciences Vice Chair, Department of Family Medicine, East Tennessee State
University; member of Society for Academic Emergency Medicine University; member of Society of Teachers of Family Medicine

Thomas L. Campbell, MD Anne-Marie MacLellan, MD

Professor of Family Medicine and Psychiatry, University of Rochester
School of Medicine; member of Society of Teachers of Family
Medicine; Advisory Council, Bayer Institute for Health Care
Communication
Kathleen Cole-Kelly, MS, MSW
Associate Professor of Family Medicine, Case Western Reserve
University School of Medicine; Director of Curriculum and Faculty
Development at Case Western for the Macy Health Communication
Initiative
Deborah Danoff, MD
Assistant Vice President, Division of Medical Education, Association
of American Medical Colleges
Robert Frymier, MD
National Director, Educational and Partnerships Division, Veterans
Affairs Learning University; Associate Professor of Family Medicine,
Case Western Reserve University School of Medicine
Michael G. Goldstein, MD
Associate Director, Clinical Education and Research, Bayer Institute
for Health Care Communication; Adjunct Professor of Psychiatry,
Brown University School of Medicine
Geoffrey H. Gordon, MD
Associate Director, Clinical Education and Research, Bayer Institute
for Health Care Communication; Assistant Clinical Professor of
Medicine and Psychiatry, Yale University School of Medicine
Faculty of Medicine, McGill University; member of Association of
Canadian Medical Colleges
Gregory Makoul, PhD
Associate Professor and Director, Program in Communication and
Medicine, Northwestern University Medical School
Steven Miller, MD
Director, Pediatric Medical Student Education, Columbia University
School of Medicine; Council on Medical Student Education in
Pediatrics
Dennis Novack, MD
Professor of Medicine and Associate Dean for Education, Medical
College of Pennsylvania Hahnemann School of Medicine; member of
American Academy on Physician and Patient
Elizabeth A. Rider, MSW, MD
Clinical Instructor in Pediatrics and Instructor in Medical Education,
Harvard Medical School; Office of Educational Development, Harvard
Medical School
Frank A. Simon, MD
Director, Division of Graduate Medical Education, American Medical
Association
David Sluyter, EdD
Vice President for Education, Fetzer Institute

Daniel J. Klass, MD Susan Swing, PhD

Director, Standardized Patient Project, National Board Medical Director of Research, Accreditation Council for Graduate Medical
Examiners Education

Suzanne Kurtz, PhD Wayne Weston, MD

Professor of Communication, Faculties of Medicine and Education, Professor of Family Medicine, University of Western Ontario; member
University of Calgary of College of Family Physicians of Canada

Jack Laidlaw, MD Gerald P. Whelan, MD

Head, Division of Education, Cancer Care Ontario; Advisory Council, Vice President for Clinical Skills Assessment, Educational Commission
Bayer Institute for Health Care Communication for Foreign Medical Graduates

ACADEMIC MEDICINE, VOL. 76, NO. 4 / APRIL 2001 393

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/341641582

Internal Assessment in new MBBS curriculum

Article in International Journal of Applied and Basic Medical Research · April 2020
DOI: 10.4103/ijabmr.IJABMR_70_20

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Educational Forum

Internal Assessment in New MBBS Curriculum: Methods and Logistics

Abstract Dinesh Kumar

Assessment is a pivotal element of competency‑based curriculum. The implementation of Badyal1,2,
competency‑based undergraduate medical curriculum in India requires proper implementation of Monika Sharma3
updates in assessment for which universities, colleges, and teachers need to plan and design internal
Departments of 1Pharmacology
assessment (IA) modules as well as guidelines. IA provides opportunity to assess many competencies
and 2Medical Education,
and hence should be implemented judiciously. Multiple assessment methods should be used to 3
Department of Pediatrics,
improve utility of IA. The process should involve all the teachers of a subject and all competencies. Christian Medical College,
Capacity building trainings should be organized by institutes in basic concepts of assessment as Ludhiana, Punjab, India
well as training in methods such as the objective structured clinical/practical examination, direct
observation of procedural skills, and mini‑clinical evaluation exercises. The culture of providing
regular feedback needs to be instilled at institute levels. The learners who are not able to achieve
competencies and required criteria in university examination should be provided predecided remedial
measures for improving their performance. The article discusses all these aspects in detail.

Keywords: Internal assessment, MBBS, methods, new curriculum

Introduction venues. IA is to be conducted by the

Assessment plays a crucial role in
implementation of competency‑based
curriculum. Assessment in Latin is
“assidere” which means to “to sit with.”
Therefore, it is something we do with or for
students and not to students.[1] Assessment
in competency‑based curriculum focuses
on improving learning as an ongoing and
longitudinal assessment so that facilitators
can identify the needs of the learner, plan
remedial measures, and provide learning
opportunities to improve learning.[2] New
competency‑based curriculum has been
implemented in undergraduate medical
education, i.e., “Bachelor of Medicine,
Bachelor of Surgery (MBBS) from 2019
in India. There are major changes in
assessment and internal assessment (IA)
methods, and logistics are to be decided by
universities and medical colleges.[3]
Internal Assessment: Concept
IA is the assessment, which is conducted
throughout the professional year. The
primary purpose of IA is to provide
constructive feedback for improving
learning. Therefore, this assessment
teachers teaching that particular subject in
a particular institute so that that they can
track the progress of the learner and provide
continuous support.[4] The continuous
nature of IA will help in assessing all
competencies that is postulated to be a
factor in the successful implementation of
competency‑based curriculum.
The garden analogy to compare the growth
of the plant and a learner can provide an
important insight into the implementation
of IA concept.[5] Here, the gardener takes
care of the needs of the plant, observing Submitted: 15-Feb-2020
Revised: 25-Feb-2020
the leaves, branches, and color of the plant.
Accepted: 08-Mar-2020
Same way, the teacher can take care of the Published Online: 02-Apr-2020
growing learner by observing many direct
and indirect markers of growth. In this way, Address for correspondence:
IA has the potential to help the teachers Dr. Dinesh Kumar Badyal,
Department of Pharmacology,
provide timely and appropriate remedial
Christian Medical College,
action and guide learning. Ludhiana ‑ 141 008, Punjab,
India.
Process E‑mail: dineshbadyal@gmail.
com
IA involves a longitudinal process to
assess all competencies. All competencies
need to be assessed. However, it is easier Access this article online
said than done. The assessment can be a Website:
collective effort that assesses a number www.ijabmr.org

continues at various formal and informal
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distributed under the terms of the Creative Commons
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others to remix, tweak, and build upon the work non‑commercially,
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licensed under the identical terms.
For reprints contact: reprints@medknow.com
of competencies together at a time in the DOI:
10.4103/ijabmr.IJABMR_70_20
formal part. Since competencies are a mix
Quick Response Code:
of all domains of learning, assessment
How to cite this article: Badyal DK, Sharma M.
Internal assessment in new MBBS curriculum:
Methods and logistics. Int J App Basic Med Res
2020;10:68-75.

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Badyal and Sharma: Internal assessment in new MBBS curriculum
should also target procedural skills such as intubation,
minor surgeries, and emergency care and soft skills such
as communication skills, professionalism, and ethics.
However, assessing all competencies is not possible on
the day of university (summative) examination but can
be assessed with IA that is continuous. It overcomes the
limitations of day‑to‑day variability and allows larger
sampling to topics, competencies, and skills.[4] It can be
used to provide feedback to students to improve their
performance throughout the course.
Internal assessment in competency‑based curriculum
IA will help the achievement of competencies as continuous
assessment will provide opportunities for feedback. The
feedback will provide directions for remedial measures.
This cycle can be repeated till competency is achieved.[2,6,7]
This means that assessment will help in learning leading
to the achievement of competencies. This is also known as
assessment for learning (AFL).
In the new UG medical curriculum in India apart from
minimum 50% IA marks and a minimum attendance
percentage, certifiable competencies are to be marked
in the logbook by teachers. Each subject has specific
certifiable competencies, for example, pharmacology has
four.[8] The number of assessment opportunities in IA makes
these assessments low stakes, and there is less stress on
students. The nonthreatening environment in assessment
can help learners to perform to the optimum level. In
new curriculum, IA marks will not be added to university
marks.[3] This dissociation takes away the stress on learners
and also teachers. It also empowers learners and at the
same time, asks for greater accountability, flexibility, and
learner contentedness. The importance of IA is retained as a
qualifying criterion and a separate mention on the marksheet.
Type of Methods
IA in competency based curriculum (CBME) should focus
on the assessment of a student’s level of achievement of
competencies, i.e., what the student can do. To target the
multiple competencies and multiple domains of learning,
such as cognitive and behavioral competencies, IA needs to
be frequent and multifaceted. Multiple assessment methods
improve the content‑related evidence for validity and give
more information to the teacher about the learning level
and needs of the students.[9]
Several methods of IA can be utilized for undergraduate
students. Cognitive competencies can be assessed by
constructing modified case vignette‑based multiple‑choice
questions (MCQ) and case‑based discussions targeted
at assessing a student’s ability to analyze and interpret a
clinical or practical problem. Other common methods
usually used include theory tests (including short answer
questions (SAQs), long answer questions (LAQs), and
reasoning questions) and viva voce. All of these methods
should be used in IA. Where competencies are skill based,
International Journal of Applied and Basic Medical Research | Volume 10 | Issue 2 | April-June 2020
assessment must include direct observation of the skill
performance. This followed by feedback, helps involve
the student in identifying his level of achievement and
further learning needs. Some of the methods to assess
practical and clinical skills are objective structured clinical/
practical examination (OSCE/PE), direct observation of
procedural skills (DOPS), and mini‑clinical evaluation
exercises (mini‑CEX). Let us have a look about the utility
of these methods in IA.
Multiple choice questions
The use of MCQ is useful when these questions are
scenario‑based versus single liners. However, avoid
“window dressing” just to make a long statement in stem
to show that it is scenario based. The construction of good
MCQs takes time and can also be interpreted as art. In
new curriculum a part of the assessment of knowledge
can be done with MCQs. Figure 1 shows various parts of
an MCQ. The stem should be aligned with the learning
objective and should have single objective. The language
used in stem should be simple to understand hence avoid
negative and double negative terms as far as possible. Use
common principles for answer choices like ascending/
descending order or sequential order. The quality of an
MCQ is judged by the strength of distractors. If a student
does not know the correct answer after reading questions,
the good distractors should distract the student away from
the right answer. Higher domains in the cognitive domain
can also be assessed by MCQs.
Short answer questions
These provide an opportunity to include more content areas
in a theory test. Care should be take to make sure that the
answer is substantial and dose not finish with few words
only. Therefore, choose the competency/learning objective
carefully for the construction of good SAQs. If SAQ is
vague, students will write all they know irrespective of
what is being asked. Assessors will find it difficult justify
their own criteria generated for the contents of the answer.
Objectively structured clinical examination/Objectively
structured practical examination
One of the most important aspects of the training of a
medical student is the acquisition of practical/clinical
skills. Objective assessment of practical/clinical skills
provides the examiners with an opportunity to objectively
assess the competencies expected of an undergraduate
student. An OSCE/PE consists of set of “stations” with
predesigned objective skills that a student must perform
sequentially. These stations may include psychomotor
skills, such as performing an abdominal examination,
administering intramuscular injections or soft skills such
as communicating treatment, taking history, etc. Stations
can be constructed as observed stations where an examiner
scores the student on a structured checklist or global rating
scale that includes further units of actions a student must
69
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Badyal and Sharma: Internal assessment in new MBBS curriculum

perform to be considered competent on the said skill.
Besides being objective, this method of assessment helps in
standardizing and uniformly assessing all the students.
Utmost care must be taken while designing the station
tasks and the checklists to ensure that one does not
objectify a task to an extent that the assessment becomes
more of a scoring exercise rather than the assessment of
competence. People often misunderstand OSCE/PE as
Table 1: Sample theory paper marks distribution (for
sample questions ref to MCI‑CBA)
Theory paper 100 marks 3hours
Total time 3 hours Suggested Marks
Q. No. 1 MCQs 5 or 10 2 marks each=10 20
Answer sheets of MCQs can be taken
after 15‑20 min
Part ‑I
Q. No. 2 Long essay e.g. 2+4 + 4=10 or 5+5 + 5=15 accordingly
question‑1 change marks of other questions
Q. No. 3 Short notes‑4 5 marks each=20
Q. No. 4 Reasoning 3 marks each=15
Questions‑5
Part‑II
Q. No. 5 Short notes‑4 5 marks each=20
Q. No. 6 Short notes‑5 5 marks each=25
MCI‑Medical council of India; CBA‑Competency based assessment
spotting tests where the student is expected to respond to
a very specific question. While spottingasks the student
to identify specimens/objects or recognize pathological
changes, the OSCE/PE focuses on the assessment of
achievement of competencies or skills. The expert panel
designing the stations needs to ensure that the stations
do not transform into an interesting format of assessing
knowledge. Testing knowledge and its application can be
reserved for other formats of assessment, such as MCQs
or structured essays instead. A set of 12–20 stations can be
optimal for the assessment at UG level. This helps in better
sampling and improves the reliability of the assessment.
However, feasibility restricts this number in medical
colleges according to the availability of infrastructure and
other resources.[10]
OSCE/PEs can be used for skill assessment as ward leaving
or send up examinations. They not only give us inputs on
a student’s skill performance but also provides feedback to
teachers and helps identify gaps in teaching. Designing an
OSPE for pre‑ and para‑clinical subjects is a challenging
exercise. The teachers need to identify the essential
practical skills in their respective subjects and develop a
“station bank” for further use. The problems in OSCE/PE
lie in need for faculty training in the conduct and designing
of the OSCE/PE and the resource‑intensive nature of the
test.[11,12]
Mini‑clinical evaluation exercises

Table 2: Topic wise division of paper A and B of The mini‑CEX is a tool of direct observation of a
first professional theory papers based on new MCI doctor‑patient encounter, during which the observing
curriculum examiner rates the student on various aspects such as
Subject Paper A Paper B history taking, physical examination skills, professional
Anatomy General anatomy Lower limb behavior, analytical skills, communication, and the overall
organization of the patient encounter. This observed
Upper limb Thorax
encounter is followed by a feedback session where
Head & Neck Abdomen
the teacher and student can identify areas in student
Brain (neuroanatomy) Genetics performance that he/she must work on. Within each
General histology General embryology observed encounter, the teacher and student may start with
Physiology General Physiology CVS an agreement on what area of competence the student will
Nerve & Muscle Hematology be assessed on to have better feedback on the specific
physiology Renal area. Multiple such encounters over the period of training,
Neurophysiology Gastrointestinal not only gives a more reliable and valid assessment of
Endocrine, Respiratory
Reproductive physiology Integrated Physiology
Biochemistry Basic biochemistry Nutrition
Enzymes Metabolism and
Chemistry and metabolism homeostasis (6.2‑6.4,
of carbohydrates 6.7‑6.13)
Chemistry and metabolism Molecular biology
of lipids Extracellular matrix
Chemistry and metabolism Oncogenesis and
of proteins immunity
Metabolism and Biochemical
homeostasis (6.1, 6.5, 6.6) laboratory tests
CVS: Cardiovascular system, GI: Gastrointestinal Figure 1: Structure of multiple choice question

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Badyal and Sharma: Internal assessment in new MBBS curriculum

student performance, it also gives ample opportunities for
a student to work upon and improve. Given the multiple
settings available to observe, such as outpatient, ward
or emergency settings, multiple mini‑CEX encounters
will have higher reliability of assessment of student
competence.
As the mini‑CEX focusses less on the specific psychomotor
skills, it is a good tool for assessment of student’s ability
to manage a case along with his/her professional behavior
and communication skills. Mini‑CEX has been studied by
various subject experts and has been found to be a feasible
and acceptable method of assessment.[13]
Direct observation of procedural skills
DOPS is a method of assessing technical skills. Where
OSCE/PE is the assessment of a fragment of skills,
DOPS gives the opportunity to assess the student
perform a complete skill. DOPS was earlier introduced
for surgical programs, but it has now been found useful
in the assessment of skills in medical and para‑clinical
subjects as well. It continues to be frequently used in
postgraduate programs and is being considered useful for
undergraduate programs as well. The student is observed
performing a skill and rated on a structured format. The
feedback following the observation provides inputs to the
student about his/her performance and gaps. The Medical
Council of India (MCI) competency document for all
subjects lists the skills an undergraduate student must
master. Students can be assessed on the skills as part of
a ward leaving examination. Multiple such exams can be
used to assess the various skills required for the subject,
thus ensuring that competence has been achieved. Thus,
wider sampling improves the validity of the assessment.
The issues with the wider use of DOPS lies in need for
observer training.[14]
Components of Internal Assessment
There has to be a minimum number of tests for a learner
for each for theory and practical per subject in preclinical,
para‑clinical subjects, and clinical subjects. An end of
posting clinical assessment should be conducted for each
clinical posting in each professional year.[8]

Figure 2: Internal assessment page for each student in records (page 1)

Figure 3: Division of marks in internal assessment

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Badyal and Sharma: Internal assessment in new MBBS curriculum

Pre‑university send‑ups are to be held in all subjects.
Before university examinations, departments can
conduct additional tests as and when required with the
purpose of providing formative feedback to the students.
In subjects that are taught at more than one phase,
proportionate weightage must be given for IA for each
phase. The most important aspect now is to decide what
to be included for calculating the percentage of IA.
A formal IA plan should be framed by universities for
all affiliated colleges.
intervals to students and the provision of remedial
measures based on feedback for all learners. Faculties, as
well as students, must be trained in giving and receiving
feedback. A culture of feedback in college must be
created. The results of IA should be periodically (and
on demand) shared with students. As far as possible,
the entire faculty of the department should be involved
in IA.[4] The new curriculum emphasizes to make
IA accessible to students so that they get enough
opportunities and time to improve.

Assessment of knowledge can include theory tests, Remedial Actions

send‑ups, seminars, quizzes, interest in subject, scientific
attitude, etc., The assessment of practical/clinical skills
and attitudinal domains can include practical/clinical tests,
OSCE/OSPE, DOPS, and mini‑CEX. Select case‑related
issues for self‑study records maintenance including
logbooks and attitudinal assessment such as sincerity, and
ethics. IA should be a continuous process considering
routine activities and periodic examinations.
Feedback in Internal Assessment
Each department needs to plan a structured feedback
system so that learners get regular feedback about their
leaning. The plan should include feedback at regular
A student whose final IA in a subject is less than required
to appear in university examination should be given a
chance to improve IA. The colleges should provide enough
support to students to implement remedial measures. The
remedial measure should be specific and targeted to the
deficiencies. The colleges should make sure that these
remedial measures are not misused, i.e., extra classes just
to complete attendance where students complete a big
percentage in few days in all subjects. There should be
regular classes for students with deficiencies to improve
their learning. Similarly, tests should be conducted at
appropriate intervals and not one after other to complete
the IA marks.

Table 3: Topic wise division of paper A and B of second professional theory papers based on new MCI curriculum
Subject Paper A Paper B
Pathology Introduction to Pathology; Cell Injury and Adaptation Gastrointestinal tract; Hepatobiliary system
Amyloidosis; Inflammation; Healing and repair Respiratory system
Hemodynamic disorders; Neoplastic disorders Cardiovascular system
Basic diagnostic cytology; Immunopathology and AIDS Urinary Tract; Male Genital Tract; Female Genital Tract
Infections and infestation; Genetic and paediatric diseases Breast
Environmental and nutritional diseases Endocrine system
Introduction to hematology; Microcytic anemia Bone and soft tissue
Macrocytic anemia; Hemolyticanemia; Aplastic anemia SKIN
Leukocyte disorders; Lymph node & spleen Central Nervous System
Plasma cell disorders; Hemorrhagic disorders EYE
Blood Bank & transfusion; Clinical Pathology
Pharmacology General PH 1.1, 1.2, 1.3, 1.4,1.5,1.6, CVS PH 1.24, 1.26,1.28,1.29,1.30
Pharmacology 1.7,1.8,1.9,1.10, 1.11,1.12, Blood PH 1.25. 1.31, 1.35
1.59,1.60, 1.63, 1.64, 3.5, 5.7 GIT PH 1.34
ANS PH 1.13,1.14 Endocrine PH 1.36, 1.37, 1.38,1.39,1.40.1.41
PNS PH 1.15, 1.17 Chemotherapeutics PH 1.42,1.43, 1.44, 1.45,1.46,
CNS PH 1.18,1.19, 1.20,1.21, 1.22, 1.47, 1.48, 1.49,1.50
1.23, 5.5 Miscellaneous PH 1.51,1.52,1.53,1.54, 1.56,
Autacoids PH 1.16 1.57, 1.58, 1.61, 1.62,1.55
Respiratory PH 1.32, 1.33
Microbiology General microbiology and immunity CVS and blood
Musculoskeletal, skin and soft tissue Gastrointestinal and Hepatobiliary infections
Respiratory tract infections CNS
Genitourinary and sexually transmitted infections Zoonotic and Miscellaneous
ANS: Autonomic nervous system, PNS: Peripheral nervous system, CNS: Central nervous system, GI: Gastrointestinal, CVS: Cardiovascular
system, GIT: Gastrointestinal tract

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Badyal and Sharma: Internal assessment in new MBBS curriculum

Table 4: Topic wise division of paper A and B of third professional theory papers based on new MCI curriculum
Subject Paper A Paper B
Community Concept of Health and Disease Principles of health promotion and education
medicine Relationship of social and behavioural to health and Demography and vital statistics
disease Reproductive maternal and child health
Epidemiology; Epidemiology of communicable and non‑ Nutrition; Geriatric services; Mental Health
communicable diseases
Health planning and management
Environmental Health Problems
Health care of the community
Hospital waste management; Disaster Management
International Health; Essential Medicine
Basic statistics and its applications; Occupational Health
Recent advances in Community Medicine
General Medicine Part 1 and 2 Part ‑1Acute Kidney Injury/Chronic Renal failure, Mineral,
(this is being Heart Failure, Acute Myocardial Infarction/IHD, Fluid Electrolyte and Acid Base Disorder, Common
done) Hypertension, Liver disease, GI Bleeding, Diarrhoeal Malignancies, Envenomation, Poisoning, Nutritional and
disorder, Rheumatologic problems, Anemia, Vitamin deficiencies, Geriatrics, Miscellaneous infections,
The role of the physician in the Community
Pneumonia, Fever and Febrile Syndromes, HIV, Diabetes
mellitus, Thyroid dysfunction, Obesity, Headache, Part‑2Psychiatry and Dermatology, Venereology and Leprosy
Cerebrovascular Accident, Movement Disorders (DVL), Respiratory Medicine including Tuberculosis
General surgery Part 1 and 2 Part ‑1Metabolic response to injury; Shock; Blood and
(this needs Surgical infections; Surgical Audit and Research blood components; Burns; Wound healing and wound care;
review) Ethics; Investigation of surgical patient; Pre, intra and post‑
Transplantation; Basic Surgical Skill; Biohazard disposal
operative management; Anaesthesia and pain management;
Minimally invasive General Surgery Nutrition and fluid therapy; Trauma; Skin and subcutaneous
Developmental anomalies of face, mouth and tissue
oropharyngeal cancer; Disorders of salivary glands Part‑2
Endocrine General Surgery: Thyroid and parathyroid Ortho‑Skeletal trauma, poly trauma; Fractures;
Adrenal glands; Pancreas; Breast Musculoskeletal infection; Skeletal tuberculosis.
Rheumatoid arthritis and associated inflammatory disorders;
Cardio‑thoracic General Surgery‑ Chest ‑ Heart and Degenerative disorders; Metabolic bone disorders;
Lungs Poliomyelitis; Cerebral palsy; Bone tumor; Peripheral nerve
Vascular diseases; Abdomen; Urinary System injuries; Congenital lesions
Penis, Testis and scrotum Radiodiagnosis‑Radiological investigations and Radiation
safety
Anaesthesia‑Anaesthesiology as a specialty;
Cardiopulmonary resuscitation; Preoperative evaluation
and medication; General anaesthesia; Regional anaesthesia;
Post‑anaesthesia recovery; Intensive care management; Pain
and its management; Fluids; Patient safety
Gynaecology & Demographic and Vital Statistics Contraception; Vaginal discharge; Normal and abnormal
obstetrics Anatomy of the female reproductive tract (Basic puberty
anatomy and embryology); Physiology of conception; Abnormal uterine bleeding; Amenorrhea; Genital injuries
Development of the fetus and the placenta; and fistulae; Genital infections; Infertility; Uterine fibroids;
Preconception counselling PCOS and hirsutism; Uterine prolapse; Menopause; Benign,
Diagnosis of pregnancy; Maternal Changes in pregnancy Pre‑malignant and Malignant Lesions of the Cervix; Benign
and malignant diseases of the uterus and the ovaries
Antenatal Care; Complications in early pregnancy;
Antepartum haemorrhage; Multiple pregnancies; Obstetrics & Gynecological skills ‑ I
Medical Disorders in pregnancy; Labour; Abnormal Lie Obstetrics & Gynecological skills ‑ II
and presentation; Maternal Pelvis; Operative obstetrics; Obstetrics & Gynecological skills ‑ III
Complications of the third stage; Lactation; Care of the
new born; Normal and abnormal puerperium; Medical
termination of pregnancy
IHD: Ischaemic heart disease, GI: Gastrointestinal, DVL: Dermatology, venereology and leprosy, PCOS: Polycystic ovary syndrome

It is recommended that “Universities shall guide the to any reason.”[8,9] All students who are detained or fail for
colleges regarding formulating policies for remedial various reasons should be provided with:
measures for students who are either not able to score 1. Regular classes in that subjects at appropriate intervals.
qualifying marks or have missed on some assessments due These classes should be spread over time if multiple

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Badyal and Sharma: Internal assessment in new MBBS curriculum

Figure 4: Components and marks of internal assessment for colleges (page 2)

subjects are involved. The students should not be
clubbed with the next batch of students just to make
them sit there and complete attendance. The classes
should be scheduled for improvement in specific
subjects and topics
2. Similarly, regular tests can be planned with 2–3 weeks
intervals in between tests. Tests should include theory
as well as practical/clinical
3. Attendance should be added to previous attendance to
calculate percentage. The absolute number of classes
attended should be added to earlier attended classes.
The denominator should be as given in regulations.
the example of a subject with a total of 100 marks of IA.
Figure 3 shows a model to include various components
in calculating IA. The detailed generic model is given in
Figure 4, which can be used by colleges. It is recommended
to have hard‑bound IA record register having multiple sheets
as per the number of students in each subject in the course.
One page IA sheet should be used for each student.
A SD (detailed data of tests, etc.) will be filled in the SD
sheet by the department. The Main sheet will display IA for
theory and practical. The entire SD used to fill the various
marks on IA form should be maintained properly.

The source data (SD) should be maintained properly. The data
should be accessible to students and also shown regularly
to students as planned by departments. Students should be
asked to sign on IA marks regularly and provided remedial
measures as needed [Figure 2]. The signing at regular
intervals safeguards the departments from legal hurdles later
when students/parents raise objections and make unawareness
as their main reason for not taking remedial actions.
Example of Marks Distribution in Internal
Assessment
The marks for IA can be kept as 100 or 200.[7] Let us take
Theory Examination
MCI document provides detailed changes in theory
question papers in university examinations. These also can
be used for IA theory tests conducted by departments. It
is recommended to use a combination of various types of
questions, for example, structured essays (LAQ), SAQ, and
MCQs.
The marks in all theory papers are 100. If a subject has
two papers, the marks will be 100 + 100 = 200. The
distribution of marks is to be decided by universities. An
example of distribution marks in a theory paper of 100

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Badyal and Sharma: Internal assessment in new MBBS curriculum
marks is provided in Table 1.[9] The distribution of topics
as per the new curriculum must be done by universities.
An example of the distribution of paper A and B topics
is given in Tables 2-4. This has been reviewed by subject
experts.
In Nutshell
Medical colleges and universities need to plan the format
for IA in collaboration for the new MBBS curriculum.
However, the IA is to be conducted by the department
for their subjects in each college and should be displayed
regularly to leaners. Use multiple methods, multiple
teachers, multiple teat items, and multiple venues for
authentic IA. IA methods and logistics planning must
take into consideration the MCI guidelines, infrastructure
available, resources available, and number of trained
faculty available. The faculties in medical colleges must be
trained in assessment so that they use multiple encounters
of AFL.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. A Short Glossary of Assessment Terms. Available from: https://
serc.carleton.edu/introgeo/assessment/glossary.html. [Last
accessed on 2020 Feb 15].
2. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C,
Swing SR, et al. Competency‑based medical education: Theory
to practice. Med Teach 2010;32:638‑45.
3. Badyal DK, Singh T. Internal assessment for medical graduates
in India: Concept and application. CHRISMED J Health Res
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2018;5:253‑8.
4. Rusman E. Growing and Watering Plants. Available from:
https://lilab.eu/growing‑and‑watering‑plants‑assessment‑for‑learn
ing-complex‑skills‑with‑video‑enhanced‑rubrics/. [Last accessed
on 2020 Feb 15].
5. Modi JN, Gupta P, Singh T. Competency‑based Medical
Education, Entrustment and Assessment. Indian Pediatr
2015;52:413‑20.
6. Shah N, Desai C, Jorwekar G, Badyal D, Singh T.
Competency‑based medical education: An overview and
application in pharmacology. Indian J Pharmacol 2016;48:S5‑9.
7. Medical Council of India. Competency Based Assessment
Module for Undergraduate Medical Education; 2019. Available
from: https://www.mciindia.org/CMS/information‑desk/
for‑colleges/ug‑curriculum. [Last accessed on 2020 Feb 15].
8. Medical Council of India. Regulations on Graduate Medical
Education (Amendment). Addition as Part‑II for MBBS
Course Starting from Academic Year 2019‑20 Onwards;
2019. Available from: https://mciindia.org/ActivitiWebClient/
open/getDocument?path=/Documents/Public/Portal/Gazette/
GME‑06.11.2019.pdf. [Last accessed on 2020 Feb 15].
9. Badyal DK, Singh S, Singh T. Construct validity and predictive
utility of internal assessment in undergraduate medical education.
Natl Med J India 2017;30:151‑4.
10. Gruppen LD, Davis WK, Fitzgerald JT, McQuillan MA. Number
of stations, and examination length in an objective structured
clinical examination. In: Scherpbier AJ, van der Vleuten CP,
Rethans JJ, van der Steeg AF, editors. Advances in Medical
Education. Dordrecht: Springer; 1997.
11. Gupta P, Dewan P, Singh T. Objective structured clinical
examination (OSCE) revisited. Indian Pediatr 2010;47:911‑20.
12. Dinesh Badyal. Practical Manual of Pharmacology. 2nd ed.
New Delhi: Jaypee Brothers; 2018.
13. Singh T, Sharma M. Mini‑clinical examination (CEX) as a tool
for formative assessment. Natl Med J India 2010;23:100‑2.
14. Norcini J, Burch Vaneesa. Workplace Based Assessment as An
Educational Tool AMEE Guide No31. Available from: https://
www.researchgate.net/publication/5690073. [Last accessed on
2020 Feb 15].
75
 Journal of Research in Medical Education & Ethics DOI: 10.5958/2231-6728.2018.00046.X
Vol. 8 (Special Issue) December, 2018, pp-S10-S15

EDUCATIONAL FORUM

Assessment System in Medical Education

Ranjana Tiwari1, Binita Goswami2*, Richa Khanna3, Shamsher S. Dalal4, Sanjoy Das5 and
Dinesh Badyal6
*Corresponding author email id: binita.dr@gmail.com

ABSTRACT
Assessment is an integral component of curriculum. It is essential for the assessment of learning as well as assessment for
learning. With time, there have been drastic changes in the assessment system with more emphasis on continual evaluation
instead of two or three assessments throughout the year. With the advent of competency-based medical education, there is an
urgent need to plan assessment for the authentic evaluation of skills and competency of the students. This article describes
the types, advantages and attributes of assessment in medical education.

Keywords: Formative assessment, Summative assessment, Internal assessment, Synoptic assessment, Ipsative assessment
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INTRODUCTION having information is not enough. It becomes meaningful

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when teachers make the collected information as an

Assessment is an important component of the educational
integral part of planning instructional activities.
system. It is said that assessment is the tail that wags
the curriculum dog. Assessment may be defined as any The objectives of this article are to define assessment
formal or purported action to obtain information about and to describe the various types of assessment and to
the competence and performance of a student. enumerate the various tools of assessment, their
Traditionally, the term assessment is always used in the advantages and attributes of good assessment.
context of student learning whereas evaluation is used
in the context of educational programs [1]. In this process, NEED FOR ASSESSMENT
the teachers understand the milestones of learning of
The different types of Assessment methods employed
students, their areas of difficulties, their misconceptions
in Medical education could be differentiated from each
or misunderstandings about the topics covered, etc. This
other by two main factors-Purpose and Timing. It could
sort of fine grained information enables teachers to plan
be used not only for certification, but also to provide
programs that challenge students to go beyond what
feed- back to teacher and students. The advantages of
they already know, understand or can do in order to
assessment in medical education are that it provides
build new knowledge and skills.
direction and motivation for future learning by optimising
There are many ways where teachers could find out medical students and practicing physicians, provides a
where students are in their learning by organising basis for choosing competent physicians and identifies
individual meeting, observing students in journal club incompetent physicians to protect the public from any
presentation, seminars and classroom activities. Just harm by their practice.
1
Professor, Department of Community Medicine, G. R. Medical College, Gwalior, Madhya Pradesh, India
2
Professor, Department of Biochemistry, MAMC, New Delhi, India
3
Associate Professor, Department of Paediatric and Preventive Dentistry, King George’s Medical University, Lucknow, Uttar Pradesh
4
Group Captain, Department of Paediatrics, Command Hospital (Air Force), Bangalore, Karnataka, India
5
Professor and Head, Department of Forensic Medicine and Toxicology, Himalayan Institute of Medical Sciences, Dehradun, Uttrakhand
6
Professor and Head, Department of Pharmacology, CMC Ludhiana, Punjab, India

S10 IndianJournals.com
 Assessment System in Medical Education
TYPES OF ASSESSMENT
Based on the purpose and timing of delivery, these
methods are broadly categorised as formative and
summative assessment.
Formative Assessment
It is used as an assessment method to improve learning
(assessment for learning). It provides feedback to the
teacher and student. It should be continuous as often as
possible and it should bring the strengths and
weaknesses of the students with the purpose being
diagnostic and remedial. Formative assessment should
be integral part of the teaching–learning process and
not a separate activity. Various tools used for formative
assessment are given in Box 1.
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Summative Assessment
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It is performed at the end of unit/semester/course, in
contrast to formative assessment, which is periodical.
It generally helps in making promotional decisions, that
is, educational decisions [2] (assessment of learning).
Criterion Referenced Assessment or Criterion
Referenced Testing
It is used for the purpose of grading the students for
selection purposes against some fixed set of standards
[3]
. It is similar to formative assessment in giving
Box 1: Tools of Formative Assessment
Assessment of knowledge
 Written tests
 Quizzes
 Discussions
 Classrooms assignments
 Project work
Methods of competence assessment
 Direct observations of procedural, technical skills, with checklists
 OSPE
 OSCE
 Simulated patients/standardised patients
 Simulations
 Mini CEX
 Chart simulated recall/Case note review
Journal of Research in Medical Education & Ethics
customised feedback and in indicating the learner’s level
of proficiency in the competency concerned [2] .
Learner’s performance is not compared with others.
The difference from formative assessment is that the
learner has to pass/reach the threshold criteria for
passing/selection or any other purpose set for
assessment, which is not there in formative type.
Norm Referenced Assessment or Norm
Referenced Testing
This method of assessment indicates how the students
performed in relation to each other [3]. There is no fixed
standard and ranking can take place only after the
examination. It is different from formative assessment
in being time based and also in grading the individual
learner. It is mainly used to differentiate between high
and low achievers and is used to evaluate basic
academic and cognitive skills.
Internal Assessment (IA)
It is conducted by internal examiners. It is similar to
formative assessment in feedback being given to the
students. In 1997, the Medical Council of India (MCI)
made an important change regarding the assessment
pattern of medical graduates. It made it mandatory for
the undergraduate students to pass their internal
assessment before they could appear for their final
university examinations. These MCI regulations specify
Communication skills
 Viva
 Observations
Methods of overall performance assessment
 Direct observations of procedural, technical skills,
with checklists
 Patient ratings
 Self-assessment
 360 degree assessment
 Portfolios
 Videos-based assessment
 Critical incident technique
S11
 Ranjana Tiwari, Binita Goswami, et al.
that internal assessment shall be based on day to day
assessment, evaluation of student assignment,
preparation and presentation of seminars, clinical case
presentation, etc. The results of internal assessment
should be transparent, that is, they should be available
to the students to help them improve their performance.
In effect, the features which are perceived as
weaknesses of IA are in fact its biggest strengths.
Class Room Assessment
It refers to the use of a variety of techniques called
class room assessment (CAT) techniques or CAT’s to
provide information for instructional improvement and
for monitoring student learning within a course. The CAT
techniques help faculty to obtain useful feedback on
what, how much and how well their students are
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learning. Faculty can then use this information to
refocus/modify their teaching methodologies to help
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students make their efforts more efficient and effective.
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The purpose is to provide the instructor of the course
with a quick way of assessing how students are doing
with the material in order to adjust the instruction. They
are used to identifying areas to revisit or focus on. This
is the similarity to formative assessment. The
information gathered by CAT is useful to the instructor
teaching the class but does not provide information that
could be used for the assessment of the programme or
institutional level student learning outcomes. The most
common example of a CAT is the Muddiest point. It is
different from formative assessment in not being able
to provide student learning outcomes.
Synoptic Assessment
Synoptic assessment normally enables students to show
their ability to integrate and apply their skills, knowledge
and understanding with breadth and depth in the subject
[2]
. It could help to test a student’s capability of applying
the knowledge and understanding gained in one part of
a programme to increase their understanding in other
parts of the programme or across the programme as a
whole. When carefully designed into the curriculum, it
enhances links between modules and reduces
‘compartmentalised’ learning approaches. It encourages
S12
deep learning through its emphasis on vertical and
horizontal integration of the topics being studied. It could
carefully be used to assess two (or more) modules at
one level (either across one or two semesters).
Ipsative Assessment
It measures and compares the performance of a student
against previous performances from that student. The
benchmark against which any change of performance
is measured is student’s own performance [2]. The
student is assessed against his/her previous scores/
grading as a mean to assess his/her progress in a given
course/training. Formative assessment identifies the
performance gap against a set reference (norm/criteria
based) by contrast, ipsative feedback focuses on learner
progress rather than a ‘performance gap’ [4,5]. It is used
to provide feedback for further improvement. Feedback
is the similarity/overlap with formative assessment.
Learners, however, are motivated more by external
rewards such as grades in formative assessment
(extrinsic motivation) and by personal development and
progress in Ipsative assessment (intrinsic motivation).
It can measure how well a particular task has been
undertaken against the student’s average attainment,
against their best work or against their most recent piece
of work. It tends to correlate with effort, to promote
effort-based attributions of success and to enhance
motivation to learn. Within Ipsative assessment, the
student may compare his own performance against the
previous ones, for his own improvement and makes
future goals. This could be accompanied by teacher
feedback [4,5,6].
Diagnostic Assessment
Diagnostic assessment is a distinct from of assessment
which is done prior to giving the instruction. It is a pre-
assessment. Its main purpose is to allow the teacher to
determine the level of students’ prior knowledge, skills,
strengths and weaknesses beforehand and to guide the
lesson plan or curriculum accordingly [2,7,8]. The aspect
of prior information to plan is the overlap with formative
assessment. Formative assessment can be used as
diagnostic assessment if planned at the beginning of any
Vol. 8 (Special Issue) December, 2018
 Assessment System in Medical Education
class/session/module. The advantages are that baseline
setting, curriculum adjustments, instructional planning
and corrective action can be initiated easily.
Authentic Assessment
Assessments which require students to perform complex
tasks representative of activities actually done in out-
of-settings. They could be the assignments that are or
mimic real-world problems and require students to apply
the knowledge they should have learned to solve them.[2]
It differs from formative assessment in being performed
either in class or out of the class settings. Also, in
authentic assessment, feedback is possible only at the
end of the task.
Interim Assessment or Bench Mark
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It is used to gather information about things that are
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relevant to the teaching and learning process such as
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individual and collective student growth, effectiveness
of teaching practices, programs, and initiatives,
projection of whether a student, class, or school is on
track to achieve established proficiency benchmarks,
instructional needs of individual students [9]. Benchmark
or interim assessment is a comparison of student
understanding or performance against a set of uniform
standards within the same school year. It may contain
hybrid elements of formative and summative
assessments, or a summative test of a smaller section
of content, like a unit or semester [9]. When used
formatively, they guide instruction. The difference from
formative assessment is in terms of data aggregation.
The data aggregation is done at critical points in the
learning cycle hence it is the only type of assessment
that provides educators with data for instructional,
predictive and evaluative purposes.
Pre-Assessment
It provides valuable information about what is already
known about a topic and readiness to start new
instruction. If all of our students have a topic or skill
mastered then that lesson can be skipped. If a few
students have a problem, then they can be given separate
sessions. Discovering prior knowledge allows the
Journal of Research in Medical Education & Ethics
teacher to present new information at an appropriate
level for the students. It helps to measure true learning.
By comparing pre-assessments and formative
assessments, we are able to see what the students
actually learned from the lesson. It gives the students a
preview of what would be expected of them and sets
clear expectations and educational objectives. After a
pre-test is given, there may be unexpected knowledge
gaps from which changes to future lessons can be made.
Self-Assessment
Self-assessment is a process of formative assessment
during which students reflect on and evaluate the quality
of their work and their learning, judge the degree to
which they reflect explicitly stated goals or criteria,
identify strengths and weaknesses in their work, and
revise accordingly. Self-assessment as the name implies
means-looking at oneself and figures out your own
strengths and weaknesses, thus identifying areas of
improvement. In medical education this will mean having
an evaluation of your own learning, identifying learning
gaps, making strategies to bridge those gaps, making
learning objectives yourself and thus in the end prosper
as Self-Directed Learner. The self-assessment is an
activity to reflect on the things one did well, and the
things one didn’t do so well and to learn from them for
improvement.
Embedded Assessment
These are assignments, activities or exercises performed
during often at end of class, which provide assessment
data about a specific learning outcome. A rubric is used
to evaluate students and is done by instructor and/or
other evaluators. It has similarities to formative
assessment in being done frequently, being able to
identify learning gaps in required competency and in
improving students learning. It differs from formative
assessment as feedback may or may not be given, rather
marks are given.
Peer Assessment
Peer assessment requires students to provide either
feedback or grades (or both) to their peers on a product
S13
 Ranjana Tiwari, Binita Goswami, et al.
or a performance, based on the criteria of excellence
for that product or event which students may have been
involved in determining’. Peer assessment is where a
fellow student evaluates the performance of other
students in a class/course. It may or may not be against
teacher’s benchmark. Peer assessment is the evaluation
of work by one or more people of similar competence
to the producers of the work here it means the evaluation
of work of a student by other fellow students. Three
processes as modelling, scaffolding and fading are
involved in peer assessment:
Modelling
Before engaging students in self- and peer-assessment,
teachers can provide examples of how they personally
use assessment tools and strategies to improve reliability
Downloaded From IP - 157.47.57.144 on dated 24-May-2024
and accuracy.
Members Copy, Not for Commercial Sale
Scaffolding
www.IndianJournals.com
Encourages teachers to initially start with structured
grading schemes (e.g. rubrics), before moving to less
structured systems where students negotiate the
assessment criteria, before students eventually
developing their own criteria.
Fading
Students achieve greater independence in peer-
assessment as the amount of direction and level of
support offered by the teacher fades, or is withdrawn,
over time.
WHAT IS GOOD ASSESSMENT
 It should motivate for/drive learning and should be
aligned with the learning objectives or at least with
the objectives set for the concerned method of
assessment.
 It should be accompanied with a good descriptive
feedback to help the students to identify his/her
strengths/weaknesses.
 It should be fair, frequent, ongoing, contextual
developmental and consistently administered to the
students.
S14
 It should help the students to compare his own
progression to previous performances and it overall
should use multiple methods and a variety of
environments and contexts to capture different
aspects of performance.
 It should be done using ways/tools that are reliable,
valid, criterion based and that can breakdown
curriculum into significant representing sections/
parts.
 It should include directly observed behaviour
(emphasis on workplace).
 It should assess knowledge, competence and
performance (all levels of miller’s pyramid)
according to the outlined learning objectives and
cover all domains of learning. Timely ongoing
assessments are needed along with comprehensive
periodic reviews to ensure that trainees continue to
progress as per the principles of competency-based
medical education
 It should always be accompanied with prior framing
of learning objectives.
 It should guide future teaching learning.
 It should help teachers and students do a gap
analysis of their objectives.
 It should be honestly done and should help in
creating and maintaining quality standards of
program concerned.
 It should encompass basic ethics and code of
conduct and should be fair in terms of what is
assessed, how it is assessed and when assessed
for all students of same level and done in perceived
safe environment for students.
PRINCIPLES OF ASSESSMENT
Assessment could be planned for competence (knows
how) or of the performance (shows/shows how) of the
students. Competence and performance in any of the
six domains: medical knowledge, patient care,
professionalism, communication and interpersonal skills,
practice-based learning and improvement and systems-
based practice, could be assessed. An outline of
principles is given in Figure 1.
Vol. 8 (Special Issue) December, 2018
 Assessment System in Medical Education
Figure 1: The Principles of Assessment
We are outlining the basic principles for designing
assessment [10]:
 A well-designed assessment method should integrate
different types of assessments into one system.
 Data gathered systematically through assessment
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should be shared deliberately with the learner over
time, ultimately informing the final summative
Members Copy, Not for Commercial Sale
decision.
www.IndianJournals.com
 Multiple assessments by multiple assessors can be
incorporated to inform clinical competency
evaluations
 Specialty-based milestones should be used to give
more granularities about the level of competence
attained.
 Milestones of assessment should be intended to
serve as a framework for assessment and to
promote a longitudinal, developmental approach,
over the course.
 Assessment system should shift attention away from
performance and instead emphasises learning.
CONCLUSION
Assessment in medical education is as important as
teaching. The assessment principles or process is
primarily based on teaching and intended learning guided
by the curriculum [10]. They should be very carefully
constructed so as to be able to understand the student’s
progress in learning and also to contribute to ongoing
learning. Hence, assessment should be designed in such
a way that it should provide information about the fine
details of progress student has been making in learning
that is related to the specific aspects of intended
Journal of Research in Medical Education & Ethics
learning. Teachers should provide equal emphasis on
planning for assessment as they do for planning for
teaching.
BIBLIOGRAPHY
Singh T, Anshu. Principles of assessment in medical
education. Jaypee Brothers Medical; New Delhi 2012.
Principles of assessment Types of assessment - some
definitions [Internet]. University of Exeter. 2018 [cited
3 July 2018]. Available from: http://www.exeter.ac.uk/
staff/development/academic/resources/assessment/
principles/types/.
Lok B, McNaught C, Young K. Criterion-referenced and norm-
referenced assessments: compatibility and complemen-
tarily, Assessment and Evaluation in Higher Education
2016; 41(3):450-465.
Hughes G. Ipsative assessment. Basingstoke, England:
Palgrave Macmillan; 2014.
Hughes G. Ipsative Assessment and Personal Learning Gain.
London: Palgrave Macmillan UK; 2017.
Maths M. Formative Assessment – Norm referenced
assessment and ipsative assessment. Magical Educator
[Internet]. Magical Maths. 2018 [cited 3 July 2018].
Available from: http://www.magicalmaths.org/formative
-assessment-norm-referenced-assessment-and-ipsative
-assessment
Types of Assessment of Learning [Internet]. Teach Thought.
2018 [cited 3 July 2018]. Available from: https://www.
teachthought.com/pedagogy/6-types-assessment-
learning/
Types of Assessment | CCEA [Internet]. Ccea.org.uk. 2018
[cited 3 July 2018]. Available from: http://ccea.org. uk/
curriculum/assess_progress/types_assessment
Perie M, Marion S, Gong B. Moving toward a comprehensive
assessment system: a framework for considering interim
assessments. Educational Measurement: Issues and
Practice 2009;28(3):5–13.
Lockyer J, Carraccio C, Chan MK, Hart D, Smee S, Touchie C
et al. Core principles of assessment in competency-
based medical education. Medical Teacher 2017;39(6):
609–16. doi: 10.1080/0142159X. 2017.1315082.
Received: 03.08.2018
Accepted: 25.10.2018
How to cite this article: Ranjana Tiwari, Binita Goswami, Richa
Khanna, Shamsher S. Dalal, Sanjoy Das and Dinesh Badyal.
Assessment System in Medical Education. Journal of Research
in Medical Education & Ethics 2018;8(Special Issue):S10-S15.
S15
576
REVIEW
The Foundation Programme assessment tools: An
opportunity to enhance feedback to trainees?
S Carr
...............................................................................................................................
Postgrad Med J 2006;82:576–579. doi: 10.1136/pgmj.2005.042366
The recent change in working patterns of doctors in
training has meant that the traditional systems of education
are under increasing pressure and that there is the need to
maximise new opportunities for learning. One new
opportunity may arise after the introduction of the
mandatory assessment systems (Mini-CEX, DOPPS, Multi-
source feedback, and Case based discussion) in the
Foundation Programmes. In this review the new assessment
procedures for the Foundation Programmes are outlined
and the potential of these assessments (using Mini-CEX as
main example) as an opportunity to give feedback to
trainees discussed. The importance of feedback in
professional development and some of the techniques
available for giving feedback are described. The
Foundation Programme assessments will occupy a
significant amount of trainees’ and trainers’ time and it is
important that opportunity for feedback and learning is
maximised.
...........................................................................
T
he introduction of The European Working
Time Directive and the New Deal document1
have had a profound effect on the working
patterns of doctors in training. There has been a
change in working patterns from a traditional
on-call pattern to a shift system of working that
has inevitably led to a reduction in the quantity
of time available for learning. As a result of these
changes in working practices some authors have
reported deterioration in quality of learning
opportunities.2 3 The reduction in hours worked
has increased work intensity and reduced oppor-
tunity for personal reflection and feedback from
colleagues (that is, consultants, registrars, and
fellow senior house officers).
In addition, important changes in the struc-
ture of doctors training have recently occurred
with the introduction of Modernising Medical
.......................
Careers4 5 and the commencement of Foundation
Programmes for all doctors graduating from
Correspondence to: medical school in the UK.
Dr S Carr, University The programmes consist of a two year planned
Hospitals of Leicester NHS
Trust, Leicester General programme of training and assessment:
Hospital, Gwendolen
Road, Leicester LE5 4PW,
UK; sue.carr@uhl-tr.nhs.uk
N Foundation year 1—equating to previous pre-
registration house officer training
Submitted14October2005 N Foundation year 2—(post-registration year)
will incorporate a generic first year of train-
Accepted6December2005
....................... ing.6
www.postgradmedj.com
The tools to assess competency in the
Foundation Programme6 7 and are the Mini-
CEX assessment (Clinical Evaluation Exercise),8
Direct Observation of Procedural Skills (DOPPS),
Case based discussion (CBD), and Multi-source
feedback (MSF). These assessment methods aim
to assess trainees’ performance in a real clinical
setting.
The Mini-CEX was developed, piloted, and
evaluated in the USA and is now widely used to
assess doctors on American Residency pro-
grammes.9–11
The mini-CEX assessment entails direct obser-
vation by an educational supervisor of a trainee’s
performance in real clinical situations (15–
20 minute) and is designed to assess skills such
as history taking, clinical examination, commu-
nication skills, diagnosis, and clinical manage-
ment. The assessment is repeated on multiple
occasions and can occur in various clinical
settings—that is, clinic, ward rounds, GP sur-
geries, etc. The method has been shown to be
reliable and to have construct validity11 and to be
a good method of education as well as an
assessment tool. Mini-CEX has also been eval-
uated in the assessment of clinical skills in
medical students in the USA.12
Direct Observation of procedural Skills
(DOPPS)
Historically, competence in practical procedures
has been assessed using log books and opinion of
educational supervisors. The Royal College of
Physicians developed the DOPPS tools and report
that directly observed performance is likely to be
more valid and reliable than the previous log-
book based system.13–15
Case based discussion (CbD)
Focuses on evaluation of clinical reasoning by
reviewing a case and the trainee’s entries in the
patients’ case notes. This assessment tool was
developed based upon the General Medical
Councils performance procedures and its use
has previously been described in primary care.16
Multi-source feedback (MSF)
This method uses questionnaire data from eight
colleagues medical and non-medical assessing
aspects of performance. MSF has been used
mainly in industry and business13 17–21 to assess
performance and as a means of providing feed-
back to trainees. The mini peer assessment tool
(Mini-PAT) is a multi-source feedback tool that
collates the views from a range of clinical
colleagues and compares with a trainees self
assessment of performance. The rating and free
text comments from the eight assessors are then
Feedback and assessment tools
fed back to the trainee by the educational supervisor.15
The mini-CEX and other assessment tools used in
Foundation Programmes will take trainees and assessors a
significant amount of time to perform. Therefore, it is
essential that in addition to assessment, that we maximise
the potential for education especially in light of the problems
presented by change in working patterns and limited contact
with trainee doctors.
The mini-CEX and other assessments tools entail direct
observation of trainees and as such the assessments offer an
opportunity for regular contact between trainees and trainers
in clinic on ward rounds, etc, that may help to provide
meaningful and timely feedback to trainees about clinical
performance. By such means, we may help redress the
perceived reduction in feedback and mentorship that have
arisen after the introduction of shifts and new working
patterns in hospitals.
In the author’s opinion, some of the assessments are easier
to facilitate than others. The DOPS, CbD, and MSF seem to be
comparatively easy to accommodate into the working day but
the Mini-CEX is more complex requiring more planning and
scheduling into either clinic or ward round time.
Implementing the assessment tools will have significant
effects on clinical service and therefore it is important we use
the time with trainees effectively and negotiate adequate
time to undertake the assessments.
THE ROLE OF FEEDBACK TO TRAINEES AFTER
ASSESSMENTS
In the Foundation Programme curriculum6 the importance of
giving feedback to trainees after each assessment is empha-
sised.
Providing good quality and timely feedback has an
essential role in learning and professional development in
medicine.
In clinical medicine feedback refers to the giving of
information describing a doctor’s performance in an observed
clinical situation. The trainee is given specific, subjective
comments on their observed performance in a way that is
useful for them to consider and use to improve their future
performance.
Feedback presents information and is not intended to be
judgmental, although there is almost inevitably some
judgement attached (boxes 1 and 2).
There are several methods described to help teachers
provide feedback to trainees.21–26 One of the older but more
commonly used feedback techniques in clinical medicine is
that described by Pendleton.22
This technique delivers feedback to the trainee in a
structured way and aims to be non-evaluative.
Pendelton’s series of questions give the opportunity for the
trainee to make observations about their own performance
and to set goals for the future. However, there can be
difficulties delivering feedback to trainees using this rather
Box 1 Pendleton’s rules of feedback 2 2
N Observer clarifies matters of fact
N Trainee identifies what went well
N Trainer highlights what they observed went well
N Trainee discusses what did not go well and how they
could improve this aspect of performance
N Trainer identifies observed areas for improvement
N Trainer and trainee agree areas for improvement and
formulate and action plan
577
Box 2 Useful rules for giving feedback 2 3
N Clarity—be clear about what you want to say
N Be specific—avoid general comments
N Ownership of feedback (use ‘‘I’’ or ‘‘the assessors’’
type statements)
N Emphasise the positive, be constructive
N Comment on behaviour that can be changed, not
personality
N Be descriptive rather than evaluative
N Be careful with advice—help the person come to a
better understanding of their issue and how they can
identify actions to address the issue more effectively
N Timing and environment—agree a time and place
old fashioned and rigid structure. The strict format of the
feedback can become predictable and may inhibit sponta-
neous discussion of points as they occur to the trainee and
trainer. In addition, because the technique contrasts ‘‘what
was done well’’ with ‘‘what could be done differently’’ it is
difficult to avoid the perception that the feedback is
contrasting ‘‘good points’’ with ‘‘bad points’’. The doctor
may feel the opening comments become predictable and
insincere and be bracing themselves for the anticipated
criticism that will follow. The trainee may become defensive
and the learning potential of the feedback will be reduced.
There are many other feedback techniques described in the
literature.26 For example, Silverman et al24 25 described the
ALOBA (or ‘‘SETGO’’ ) technique (agenda led, outcome
based) of feedback that uses the structure shown below:
1. What I (observer) saw—descriptive, specific, non-
judgmental feedback by observer
2. What else did you the learner see?
3. What does learner think?
4. What goals are we trying to achieve?
5. Any offers of how we should get there?
One possible advantage is that this method focuses more
quickly on the trainees’ areas of concern and as a result of
acknowledging difficulties may reduce the trainees’ defen-
siveness and may be less evaluative. A further potential
advantage over the Pendleton’s rules method is that the
trainee is an active participant rather than a passive recipient
of feedback from the facilitators and other group members.
There are other established models of giving feedback
including ‘‘SCOPME model, Chicago model, etc, which are
described further in a recent review article.26 It is important
that a variety of different techniques are used and that the
approach be varied each time so the experience does not
become predictable. The methods described above are quite
dated and hierachical and other newer methods provide a
more real life and multiprofessional approach—that is, 360
degree type appraisals. In the Foundation Programmes
trainees are now involved in a MSF with assessment from
eight raters, both medical and non-medical, which is relevant
to assessing performance in a multidisciplinary workplace.
Feedback is an important part of the process of improving
clinical skills and trainees usually appreciate feedback.23
Giving feedback shows concern and regard for the person
and their professional development and as a result feedback
may also help motivation and satisfaction of trainees. Most
clinicians are familiar with the concept and principles of
giving feedback but often the value of using feedback as a
teaching tool are underused.23 In the past, very little attention
www.postgradmedj.com
578
was given to providing trainees with feedback. A study of
house physicians27 reported that house officers received
almost no feedback and developed their own systems of self
validation to compensate for lack of external feedback. In
such situations some trainees may develop a lack of
confidence but others may develop a misguided sense of
clinical competence.
Feedback has been underused as an educational tool in
clinical medicine for a number of reasons. Firstly, the need to
observe the trainees performance—an opportunity curtailed
by changes in working practices but perhaps refreshed by the
Foundation Programme assessments. Secondly, the teacher
may be concerned about the impact of negative feedback
upon the trainee and upon the trainee-trainer relationship.
The MSF assessment in Foundation Programmes will be
potentially very useful as the technique incorporates feedback
from eight assessors and not just the educational supervisor
who is presenting the feedback.
In addition, it is essential to ensure that trainers are
properly taught the techniques of adult learning and how to
give feedback to trainees. Trainers should preferably be
observed when they give advice and feedback to trainees as
part of training to be an educational supervisor.
We need to continue to use and develop our skills in the
use of feedback in clinical medicine. Without adequate
feedback good performance is not acknowledged and
problems with clinical competence go uncorrected for long
periods of time. We have moved on from the past decade
when in hospital medicine no feedback indicated satisfactory
progress and negative feedback came indirectly in the form of
a poor reference and difficulty getting a new post.
FEEDBACK USING MINI-CEX AND OTHER
FOUNDATION PROGRAMME ASSESSMENT TOOLS
Mini-CEX
There have been a three publications describing Mini-CEX as
a feedback tool. Holomboe et al28 reported upon feedback
given after 107 audiotaped mini-CEX sessions. In 80% of the
sessions the supervisor made at least one recommendation to
the trainee for improvement. The assessor allowed the
trainees to react to the feedback in 61% of sessions but only
34% of assessors asked for the trainees’ self assessment of the
encounter. After the assessment 8% of trainers and trainees
formulated an action plan. The authors concluded that the
educational supervisors were using the encounter to provide
feedback and recommendations but were underusing the
opportunity for other interactive feedback methods including
trainee self assessment and action planning.
Two other studies reported on feedback to medical
students after Mini-CEX assessments. Kogan et al12 found
that after an average of 21 minutes’ assessment feedback was
given for a mean of eight minutes. Similarly, Hauer et al29
studied 30 minute Mini-CEX assessments involving 22
medical students. The feedback given after observations
was on average 15 minutes’ duration. There is no assessment
of quality or usefulness of feedback in either study.
Multisource feedback (MSF) and feedback using other
assessment tools
Many studies have reported use of MSF in business and
industry and concluded that feedback from MSF generally
results in improvements in overall performance.20 However, a
number of factors influencing the success of feedback using
these tools have been identified. Negative feedback can
provoke a variety or responses that may not be beneficial and
people who received feedback discrepant from their own
ratings of themselves tended to believe the feedback was
unhelpful and were likely to react negatively. Another
important finding was that negative feedback can lead to
www.postgradmedj.com
Carr
disillusionment and failure to achieve goals. On the other
hand, positive feedback may lead to over confidence and
reduced efforts. Cynicism and negative attitudes to the MSF
process (ratees and raters) also influenced whether people
were likely to change after the feedback.
There are numerous examples of feedback using these tools
in medicine. In surgery Violato et al18 found MSF to be useful
in making changes in practice but another study reported no
impact of MSF on surgical practice.19 A study of general
practitioners reported that the physicians perceptions of the
feedback process was most important and that feedback
perceived as negative had no value or a negative impact.20 A
recent study involving physicians concluded that ‘‘when
interpersonal, communication, professionalism, or teamwork
behaviors need to be assessed and guidance given, MSF is
one of the better tools that may be adopted and implemented
to provide feedback and guide performance’’.19
There is very little information in the literature regarding
feedback after DOPPS or case based discussion at the present
time and further work will need to be done to assess the
value of feedback given to trainees after these assessments.
CONCLUSIONS
Interactive feedback is important to help doctors improve and
develop professionally. In the light of recent changes in
medical working patterns and changes to the structure of
junior doctors training we need to use new opportunities to
observe trainees and provide good quality, timely feedback to
facilitate learning. The Mini-CEX and other assessment tools
involved in the Foundation Programmes present an oppor-
tunity to observe trainees and to provide immediate and
relevant feedback. The training of educational supervisors in
the use of assessment tools and feedback techniques is
important to maximise this new opportunity for feedback to
trainees.
The Foundation Programme represents an important
change in postgraduate medical education in the UK. The
provision of appropriate time and recognition for educational
supervision and assessment in consultant job plans and
liaison with trusts regarding the implications for clinical
service will be essential.
Funding: none.
Conflicts of interest: none.
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Clinical Evidence—Call for contributors

Clinical Evidence is a regularly updated evidence-based journal available worldwide both as

a paper version and on the internet. Clinical Evidence needs to recruit a number of new
contributors. Contributors are healthcare professionals or epidemiologists with experience in
evidence-based medicine and the ability to write in a concise and structured way.
Areas for which we are currently seeking contributors:
N Pregnancy and childbirth
N Endocrine disorders
N Palliative care
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Assessment Methods in Undergraduate Medical Education

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SQU Med J, August 2010, Vol. 10, Iss. 2, pp. 203-209, Epub. 19th Jun 10
Submitted: 19th Jan 10
Revision Req. 30th Mar 10, Revision Recd. 18th Apr 10
Accepted: 21st Apr 10
r e v i ew

Assessment Methods in Undergraduate

Medical Education
Nadia M Al-Wardy

‫أساليب القياس والتقييم يف التعليم الطيب األولي‬

‫اجلامعي‬
‫نادية بنت حممد الوردية‬
‫ اختيار �أ�سلوب التقييم يعتمد على الغر�ض من �أجل‬.‫ هناك عدة �أ�ساليب لتقييم الكفاءة ال�رسيرية وفقا للنموذج الذي اقرتحه ميلر‬:‫امللخ�ص‬
‫وقد مت حتديد خ�صائ�ص‬.‫ �أو الت�شخي�ص وحت�سني التغذية الراجعة �أو كليهما‬، ‫ فيما �إذا كان لأغرا�ض التعزيز والت�صديق‬، ‫ا�ستخدام ذلك الأ�سلوب‬
‫ فالإ�سلوب الواحد اليكفي لتقييم‬،‫ �أيا كان هذا الغر�ض‬.‫ واجلدوى والتكلفة‬،‫ والأثر التعليمي‬، ‫ امل�صداقية واملوثوقية‬:‫عدة لأداة التقييم وهي‬
‫ وميكن التغلب على �أوجه‬،‫ ولكل �إ�سلوب تقييم مزاياه وعيوبه‬.‫كافة جماالت الكفاءة وهناك ثمة حاجة �إىل جمموعة متنوعة من �أ�ساليب التقييم‬
.‫الق�صور يف �إ�سلوب تقييم ما بوا�سطة مزايا �إ�سلوب تقييم �آخر وذلك �ضمن ا�ستخدام جمموعة متنوعة من �أ�ساليب التقييم‬
.‫ التقييم‬،‫ الدرا�سات اجلامعية الأولية‬،‫ التعليم الطبي‬:‫مفتاح الكلمات‬

abstract: Various assessment methods are available to assess clinical competence according to the model
proposed by Miller. The choice of assessment method will depend on the purpose of its use: whether it is for
summative purposes (promotion and certification), formative purposes (diagnosis, feedback and improvement) or
both. Different characteristics of assessment tools are identified: validity, reliability, educational impact, feasibility
and cost. Whatever the purpose, one assessment method will not assess all domains of competency, as each has
its advantages and disadvantages; therefore a variety of assessment methods is required so that the shortcomings
of one can be overcome by the advantages of another.
Keywords: Medical Education; Undergraduate; Assessment; Educational.

I
n 1990, Miller proposed a hierarchical
model for the assessment of clinical
competence.1 This model starts with the
assessment of cognition and ends with the
assessment of behaviour in practice [Figure 1].
Professional authenticity increases as we move up
the hierarchy and as assessment tasks resemble
real practice. The assessment of cognition deals
with knowledge and its application (knows, knows
how) and this could span the levels of Bloom’s
taxonomy of educational objectives from the level
of comprehension to the level of evaluation.2 The
assessment of behaviour deals with assessment of
competence under controlled conditions (shows
how) and the assessment of competence in practice
or the assessment of performance (does). Different
assessment tools are available which are appropriate
for the different levels of the hierarchy. Van der
Vleuten proposed a conceptual model for defining
the utility of an assessment tool.3 This is derived
by conceptually multiplying several weighted
criteria on which assessment tools can be judged.
These criteria were validity (does it measure what
it is supposed to be measuring?); reliability (does
it consistently measure what it is supposed to be
measuring?); educational impact (what are the
effects on teaching and learning?); acceptability (is it
acceptable to staff, students and other stakeholders?),
and cost. The weighting of the criteria depended
on the purpose for which the tool was used. For
summative purposes, such as selection, promotion
or certification, more weight was given to reliability
while for formative purposes, such as diagnosis,
feedback and improvement, more weight was given
to educational impact.4 Whatever the purpose of
the assessment it is unlikely that one method will
assess all domains of competency. A variety of
assessment methods are, therefore, required. Since

Medical Education Unit, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
Email: naiwardi@squ.edu.om
 Assessment Methods
Does
Professional Authenticity
Shows how
Knows how
Knows
Figure 1: Miller’s hierarchical model for the assessment
of clinical competence1
each assessment method has its own advantages and
disadvantages, by employing a variety of assessment
methods the shortcomings of one can be overcome
by the advantages of another.
This paper will not be an exhaustive review of all
assessment methods reported in the literature, but
only those with clear conclusions about their validity
and reliability in the context of undergraduate
medical education although many of them are
also used in postgraduate medical education also.
Some new trends, although still requiring further
validation, will also be considered.
Assessment of
Knowledge and its
Application
The most common method for the assessment of
knowledge is the written method (which can also
be delivered online). Several written assessment
formats are available to choose from. It should be
noted, however, that in choosing any format, the
question that is asked is more important than the
format in which it is to be answered. In other words,
it is the content of the question that determines
what the question tests.5 For example, sometimes,
it is incorrectly assumed that multiple choice
questions (MCQ) are unsuitable for testing problem
solving ability because they require students to
merely recognise the correct answer, while in open
ended questions they have to generate the answer
spontaneously. Multiple choice questions can test
problem solving ability if constructed properly.5,6,7
This does not exclude the fact that certain question
formats are more suitable than others for asking
certain types questions. For example, when an
204 | QU Medical Journal, August 2010, Volume 10, Issue 2
Nadia
in Undergraduate
M Al-Wardy Medical Education
explanation is required, an essay question will,
obviously, be more suitable than an MCQ.
Every question format has its own advantages
Behaviour
and disadvantages which must be carefully weighed
when a particular question type is chosen. It is
not possible that one type of question will serve
the purpose of testing all the aspects of a topic.
Cognition Therefore, a variety of formats are needed to
counter the possible bias associated with individual
formats and they should be consistent with the
stated objectives of the course or programme.
m u lt i p l e c h o i c e q u e s t i o n s
(a-type: one best answer)
These are the most commonly used question type.
They require examinees to select the single best
response from 3 or more options. They are relatively
easy to construct and enjoy high reliability per hour
of testing since they can be used to sample a broad
content domain. MCQs are often misconstrued as
tests of simple facts, but, if constructed well, they
can test the application of knowledge and problem
solving skills. If questions are context-free, they
almost exclusively test factual knowledge and the
thought process involved is simple.6 Contextualising
the questions by including clinical or laboratory
scenarios not only conveys authenticity and validity,
but, also, is more likely to focus on important
information rather than trivia. The thought process
involved is also more complex with candidates
weighing different units of information against
each other when making a decision.6 Examples of
well constructed one best answer questions and
guidelines about writing such questions can be
found in Case and Swanson.7
m u lt i p l e c h o i c e q u e s t i o n s
(r-type: e x t e n d e d m at c h i n g
items)
One approach to context-rich questions is extended
matching questions or extended matching items
(EMQs or EMIs).8 EMIs are organised into sets of
short clinical vignettes or scenarios that use one
list of options that are aimed at one aspect (e.g. all
diagnoses, all laboratory investigations, etc). These
options can range from 5 to 26 (although 8 options
have been advocated to make more efficient use
of testing time).9 Some options may apply to more
than one vignette while others may not apply at all.
A well-constructed extended matching set includes
 Nadia M Al-Wardy
four components: theme, options list, lead-in
statement, and at least two item stems. An example
and guidelines for writing such questions are shown
in Case and Swanson.7
k e y f e at u r e s q u e s t i o n s
Key features questions are short clinical cases or
scenarios which are followed by questions aimed
at key features or essential decisions of the case.10
These questions can either be multiple choice or
open ended questions. More than one correct
answer can be provided. Key feature questions have
been advocated to test clinical decision-making
skills with demonstrated validity and reliability
when constructed according to certain guidelines.11
Although these questions are used in some “high-
stakes” examinations in places such as Canada and
Australia,11 they are less well known than the other
types and their construction is time consuming,
especially if teachers are inexperienced question
writers.12
short answer questions (saqs)
These are open-ended questions that require
students to generate an answer of no more than
one or two words, rather than to select from a fixed
number of options. Since they require some time to
answer, not many SAQs can be asked in an hour of
testing time. This leads to less reliable tests because
of limited sampling. Also, their requirement to
be marked by a content expert makes them more
costly and time consuming; therefore, they should
only be used when closed formats are excluded.
It is important that the questions are phrased
unambiguously and a well defined answer key is
written before marking the question.13 If multiple
examiners are available, double marking is preferred.
For efficiency, however, each marker should correct
the same question for all candidates. This leads to
more reliable scores than if each marker corrects
all the questions of one group of candidates while
another marker corrects all questions for another
group.5
e s s ay q u e s t i o n s
Essay questions are used when candidates are
required to process, summarise, evaluate, supply or
apply information to new situations. They require
much more time to answer than short answer or
multiple choice questions and, therefore, not quite
as many questions can be used per hour of testing;
hence, their lower reliability. Structuring (but not
overstructuring) the marking process and using
a correction scheme similar to the one used for
short answer questions can improve reliability. The
guidelines for writing short answer questions apply
also to essay questions.13
m o d i f i e d e s s ay q u e s t i o n s (meqs)
This is a special type of essay question that consists of
a case followed by a series of questions that relate to
the case and that must be answered in the sequence
asked. This leads to question interdependency and
a student answering the first question incorrectly is
likely to answer the subsequent questions incorrectly
too. Therefore, no review or possibility of correcting
previous answers is allowed and the case is
reformulated as the reporting process progresses. A
well-written MEQ assesses the approach of students
to solving a problem, their reasoning skills, and their
understanding of concepts, rather than recall of
factual knowledge.14 Due to psychometric problems
associated with question interdependency, MEQs
are being replaced by the key feature questions.13 An
example of an MEQ can be found in Knox.14
script concordance test (sct)
A new format that is slowly gaining acceptance
in health professions education is the script
concordance test (SCT). This format is designed
to test clinical reasoning in uncertain situations15
and is, as the author puts it, based on “the principle
that the multiple judgments made in these clinical
reasoning processes can be probed and their
concordance with those of a panel of reference
experts can be measured.”16 The test has gained face
validity since its content resembles the tasks that
clinicians do every day. SCTs are based on short
case scenarios followed by related questions that
are presented in three parts: the first part ("if you
were thinking of") contains a relevant diagnostic or
management option; the second part ("and then you
were to find") presents a new clinical finding, and
the third part ("this option would become") is a five-
point Likert scale that captures examinees' decisions
as to what effect the new finding has on the status
of the option. An example of an SCT question and
guidelines for their construction can be found in
Demeester and Charlin.17
review | 205
 Assessment Methods in Undergraduate Medical Education
Assessment of
Performance
Assessment of performance can be divided into
two categories; assessment of performance in
vitro, i.e. in simulated or standardised conditions,
and assessment of performance in vivo, i.e. in real
conditions. Both categories involve demonstration
of a skill or behaviour continuously or at a fixed
point in time by a student and observation and
marking of that demonstration by the examiner.
Several tools such as checklists, rating scales,
structured and unstructured reports can be
used to record observations and to assist in the
marking or assessment of such demonstrations.
Checklists and rating scales are used as scoring
methods in various forms of assessments,
including Objective Structured Clinical or Practical
Examinations (OSCE, OSPE), Direct Observation
of Procedural Skills (DOPS), peer assessment, self
assessment, and patient surveys.18
The assessment of actual performance, i.e. what
the doctor does in practice, is the ultimate goal for
a valid assessment of clinical competence. However,
despite the face validity of this “in-training”
assessment, problems of inadequate reliability due
to lack of standardisation, limited observations
and limited sampling of skills are cause of concern
and limits their use as summative “high-stakes” or
qualifying examinations. To mimic real conditions,
assessments in simulated settings have been
designed to assess performance such as OSCE/
OSPE.
checklists
Checklists are useful for assessing any competence
or competency component that can be broken
down into specific behaviours or actions that can
be either done or not done. It is recommended
that over-detailed checklists should be avoided as
they trivialise the task and threaten validity.4 Global
ratings (a rating scale which is used in a single
encounter, for example in an OSCE, in addition to
or instead of a checklist, to provide an overall or
“global” rating of performance across a number of
tasks) provide a better reflection of expertise than
detailed checklists.19
Checklist development requires consensus by
several experts on the essential behaviours, actions,
and criteria for evaluating performance. This is
206 | QU Medical Journal, August 2010, Volume 10, Issue 2
important to ensure validity of content and scoring
rules. Also, in order to obtain consistent scores and
satisfactory reliability, evaluators who are trained in
the use of checklists should be used. An example of
a checklist can be found in Marks and Humphrey-
Murto.20
r at i n g s c a l e s
Rating scales are widely used to assess behaviour
or performance. They are particularly useful for
assessing personal and professional attributes,
generic competencies and attitudes. The essential
feature of a rating scale is that the observer is
required to make a judgement along a scale that
may be continuous or intermittent. An unavoidable
problem of rating scales is the subjectivity and
low reliability of the judgements. To be fair to the
student, however, multiple independent ratings of
the same student undertaking the same activity are
necessary. It is also important to train the observers
to use the rating forms. Guidelines on improving
the quality of rating scales can be found in Davis
and Ponnamperuma.21
objective structured clinical
e x a m i n at i o n (osce)
The OSCE is primarily used to assess basic clinical
skills.22 Students are assessed at a number of
“stations” on discrete focused activities that simulate
different aspects of clinical competence. At each
station standardised patients (SPs), real patients
or simulators may be used,23 and demonstration
of specific skills can be observed and measured.
OSCE stations may also incorporate the assessment
of interpretation, non-patient skills and technical
skills. Each student is exposed to the same stations
and assessment. OSCE stations may be short or
long (5-30 minutes) depending on the complexity
of the task. The number of stations may vary from
as few as eight to more than 20 although an OSCE
with 14-18 stations is recommended to obtain a
reliable measure of performance.18 Reliability is a
function of sampling and, therefore, of the number
of stations and competences tested.24 Scoring is done
with a task specific checklist or a combination of a
checklist and a rating scale. Global ratings produce
equivalent results as compared to checklists.19,25,26
The scoring of the students or trainees may be
done by observers (faculty members, patients, or
standardised patients).
 Nadia M Al-Wardy
Tips on organising OSCE examinations can be
found in Marks and Humphrey-Murto.20
short cases
Short cases assessment is commonly used in several
places27,28 to assess clinical competence.29 In this
type of assessment, students are asked to perform
a supervised focused physical examination of a real
patient, and are then assessed on the examination
technique, the ability to elicit physical signs and
interpret these findings correctly. Several cases
are used in any one assessment to increase the
sample size. Studies on the validity and reliability of
short case assessment, however, are scarce and, as
Epstein30 advocates, their empirical validation must
be done before promoting their use.
long cases
The long case has traditionally been used to assess
clinical competence. In the long case, students
interview and examine a real patient and then
summarise their findings to one or two examiners
who question the students by an unstructured oral
examination on the patient problem and other
relevant topics. The student’s interaction with
the patient is usually unobserved. The long case
has face validity and authenticity since the task
undertaken resembles what the doctor does in real
practice; however, the use of long case assessment
in “high-stakes” summative examinations is
not recommended,31 and, in fact, it has been
discontinued in North America, due to its low
reliability.32 On the other hand, its use in formative
examinations is encouraged because of its perceived
educational impact.33 To increase the validity
and reliability of long cases, several modifications
have been introduced, for example: observing the
candidates while they interact with the patient34,35
(although observing the candidate is not a major
contributor to reliability);36 training the examiners to
a structured examination process,37 and increasing
the number of cases.36,38
360° e va l u at i o n
360° evaluation is a multi-source feedback
assessment system that evaluates an individual’s
competence from multiple perspectives within
their sphere of influence. Feedback is objectively
and systematically collected via a survey or rating
scale that assesses how frequently a behaviour is
performed. Multiple evaluators, who may include
superiors, peers, students, administrative staff,
patients and families, rate trainee performance in
addition to the trainee doing a self-assessment. The
rating scales vary with the assessment context.
360° evaluations have been used to assess a range
of competencies, including professional behaviours,
at undergraduate39 and postgraduate levels.40
However, the use of 360° evaluations in summative
assessment is not advocated until further studies
are conducted to establish their reliability and
validity.40 Their use in formative evaluations might
be more appropriate since evaluators provide more
balanced and honest feedback when the evaluation
is formative and used for developmental purposes
rather than for pass/fail decisions.41 Nonetheless, it
should be borne in mind that this type of evaluation
can be time consuming and administratively
demanding.42 An example of a 360° evaluation form
used in a study can be found in Wood et al.43
m i n i c l i n i c a l e va l u at i o n
exercises (mini-cex)
Mini-CEX are based on tutor observations of
44
routine interactions that supervising clinicians and
trainees have on a daily basis. These trainee-patient
encounters occur on multiple occasions with
different evaluators and in different settings. They
are relatively short observations (15-20 minutes) in
which performance is recorded on a 4 point scale
where 1 is unacceptable, 2 is below expectation, 3 is
met expectations, and 4 is exceeded expectations.
There is an opportunity for noting that a particular
behaviour was unobserved and additional space to
record details about the context of the encounter.
The mini-CEX incorporates an opportunity for
feedback from the evaluator and is mostly used for
formative assessment.39 Evaluators consist mostly
of tutors whose primary role is to teach clerkship
students.39
Several competencies are evaluated by the mini-
CEX: history taking, physical examination, clinical
judgement, counselling, professionalism and other
generic qualities. An example of a mini-CEX tool
can be found in Norcini.44
portfolios
A portfolio is a collection of student work which
provides evidence that learning has taken place. It
includes documentation of learning and progression,
review | 207
 Assessment Methods in Undergraduate Medical Education
but most importantly a reflection on these learning
experiences.45
Portfolios documentation may include case
reports; record of practical procedures undertaken;
videotapes of consultations; project reports;
samples of performance evaluations; learning
plans, and written reflection about the evidence
provided. Scoring methods include checklists and
rating scales developed for a specific learning and
assessment context and are usually carried out by
several examiners who probe students regarding
portfolio contents and decide whether the student
has reached the required standard.45
Portfolio assessment is considered a valid
way of assessing outcomes; however, it has low
to moderate reliability due to the wide variability
in the way portfolios are structured and assessed.
Also, this form of assessment is not considered very
practical due to the time and effort involved in its
compilation and evaluation46 and, perhaps for these
reasons, portfolios are commonly used for formative
assessment and less commonly for summative
purposes.47,48 However, at present, the strength
and extent of the evidence base for the educational
effects of portfolios in the undergraduate setting
is limited.49 Guidelines for portfolio compilation
can be found in Friedman et al.,46 Snadden and
Thomas,50 and Thistlethwaite.51
Conclusion
Various assessment methods that test a range of
competencies are available for examiners. The
choice should be dictated by fitness for purpose and
a number of utility criteria. The importance and
weighting of these criteria depends on the purpose
of the assessment method, i.e. either summative,
formative or both.
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standardized patients. Acad Med 1999; 74:1028–32.
27. Fowell SL, Maudsley G, Maguire P, Leinster SJ, Bligh
J. Student assessment in undergraduate medical
education in the United Kingdom, 1998. Med Educ
2000; 34:S1–49.
28. Hijazi Z, Premadasa IG, Moussa MA. Performance
of students in the final examination in paediatrics:
importance of the "short cases." Arch Dis Child 2002;
86:57–8.
29. Wass V, van der Vleuten C, Shatzer J, Jones R.
Assessment of clinical competence. Lancet 2001;
357:945–9.
30. Epstein RM. Assessment in medical education.
Author’s reply. New Eng J Med 2007; 356:2108–10.
31. Ponnamperuma GG, Karunathilake IM, McAleer
S, Davis MH. The long case and its modifications: a
literature review. Med Educ 2009; 43:936–41.
32. Smee S. Skill based assessment. BMJ 2003; 326:703–6.
33. Wass V, van der Vleuten C. The long case. Med Educ
2004; 38:1176–80.
34. Wass V, Jolly B. Does observation add to the validity of
the long case? Med Educ 2001; 35:729–34.
35. Newble DI. The observed long case in clinical
assessment. Med Educ 1991; 25:369–73.
36. Wilkinson TJ, Campbell PJ, Judd SJ. Reliability of the
long case. Med Educ 2008; 42:887–93.
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of a structured question grid on the validity and
perceived fairness of a medical long case assessment.
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38. Hamdy H, Prasad K, Williams R, Salih FA. Reliability
and validity of the direct observation clinical encounter
examination (DOCEE). Med Educ 2003; 37:205–12.
39. Rees C, Shepherd M. The acceptability of 360-degree
judgements as a method of assessing undergraduate
medical students' personal and professional
behaviours. Med Educ 2005; 39:49–57.
40. Office of Postgraduate Medical Education. Review of
work-based assessment methods, Sydney: University
of Sydney, NSW, Australia, 2008.
41. Higgins RS, Bridges J, Burke JM, O'Donnell MA,
Cohen NM, Wilkes SB. Implementing the ACGME
general competencies in a cardiothoracic surgery
residency program using 360-degree feedback. Annals
Thoracic Surg 2004; 77:12–17.
42. Joshi R, Ling FW, Jaeger J. Assessment of a 360-degree
instrument to evaluate residents' competency in
interpersonal and communication skills. Acad Med
2004; 79:458–63.
43. Wood J, Collins J, Burnside ES, Albanese MA, Propeck
PA, Kelcz F, et al. Patient, faculty, and self-assessment
of radiology resident performance: a 360-egree method
of measuring professionalism and interpersonal/
communication skills. Acad Radiol 2004; 11:931–9.
44. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-
CEX: a method for assessing clinical skills. Annals
Internal Med 2003; 138:476–83.
45. Davis MH, Ponnamperuma GG. Portfolios, projects
and dissertations. In: Dent J, Harden R, Eds. New York:
Elsevier Churchill Livingstone 2005. pp. 346–56.
46. Friedman MB, David MH, Harden RM Howie PW,
Ker J, Pippard MJ. AMEE guide No. 24: Portfolios as
a method of student assessment. Med Teach 2001;
23:535–51.
47. Rees C, Sheard C. The reliability of assessment criteria
for undergraduate medical students' communication
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Educ 2004; 38:138–44.
48. Davis M, Friedman B, Harden R, Howie P, McGhee
C, Pippard M, et al. Portfolio assessment in medical
students’ final examinations. Med Teach 2001;
23:357–66.
49. Buckley S, Coleman J, Davison I, Khan KS, Zamora
J, Malick S, et al. The educational effects of portfolios
on undergraduate student learning: a Best Evidence
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Assessment in medical education: Evolving perspectives and contemporary trends

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THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 25, NO. 6, 2012
Medical Education
Assessment in medical education:
Evolving perspectives and contemporary trends
RITA SOOD, TEJINDER SINGH
ABSTRACT
Assessment is an important part of the educational process. It
influences students’ learning. Traditionally, assessment has
been used to measure the achievement of students for
certification or selection. However, increasing attention is
being paid to using formative assessment to improve learning.
Miller’s pyramid provides a good conceptual model to assess
clinical competence by providing tiered levels of assessment.
All levels of the pyramid need to be included in the assessment
process.
To be useful, assessment should be valid (measuring what
it is supposed to measure), reliable (confidence in the results),
acceptable (to various stakeholders), feasible and have a
positive educational impact. The major attributes (validity and
reliability) refer to judgements that we make from the assessment
data and are not the inherent property of any test or tool. All
validity is construct validity. There is often a trade-off between
validity and reliability but an assessment which is low on one
can still be useful by virtue of its being high on the other. No
one tool is enough for assessing students and a combination of
tools is preferred to get a composite picture of students’
attainment.
Assessment of knowledge is largely made by written
assessment. The tests and questions should be contextual and
look for application of knowledge rather than mere recall of
facts. Assessment of clinical skills is done by traditional
methods such as long and short cases and newer methods such
as mini-clinical evaluation exercises, objective-structured clinical
examinations, case-based discussions and portfolios. An
adequate and representative sample of clinical tasks and direct
observation of performance are the key to the validity and
reliability of the assessment process. Faculty training is important
for improving the quality of assessments.
Natl Med J India 2012;25:357–64
INTRODUCTION
‘Examinations drive students’ learning’ describes one of the
strongest relationships in education.1 Of all the different
components of a medical education programme, the assessment
strategies direct and influence the way students learn. A well-
All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029,
India
RITA SOOD Department of Medicine
Christian Medical College, Ludhiana 141008, Punjab, India
TEJINDER SINGH Department of Paediatrics
Correspondence to RITA SOOD, D-II/23, Ansari Nagar (West), AIIMS
Campus, New Delhi 110029, India; ritasood@gmail.com
© The National Medical Journal of India 2012
357
designed assessment sets clear expectations, establishes a
reasonable workload and provides opportunities for students to
self-monitor, rehearse, practise and receive feedback. Conversely,
poorly designed assessments can mar the quality of learning.2 It is
useful to view education as a set of components which interact
with each other to produce the desired effect on student learning.
These components are learning objectives, teaching methodology
and assessment. All three components have a high degree of
interdependence and one cannot sustain without the other.3
For academic staff, assessment is often the final consideration
in their planning of the curriculum.2 Their primary concerns are
designing learning outcomes and planning teaching and learning
activities that will produce these outcomes. How assessment will
be done is often considered once other decisions about the
curriculum have been made. For most students, however, the
curriculum is literally defined by the requirements of assessment.
Students often work ‘backwards’ through the curriculum, focusing
first and foremost on how they will be assessed and what they will
be required to demonstrate.2 Therefore, recognizing the potent
effects of assessment requirements on the study habits of students
and capitalizing on the capacity of assessment for creating preferred
patterns of study is a powerful means of re-conceptualizing and
repositioning the use of assessment.
Assessment provides students with short-term goals, clarifies
the tasks to be learned and provides feedback about learning.3
Since assessments tend to direct students’ learning efforts towards
the intended learning outcomes (ILOs), they can be used as tools
for increasing the transfer and retention of learning. Generally,
learning outcomes at the level of understanding, interpretation
and application are likely to be retained longer and have greater
transfer value than outcomes at the level of recall.3
PURPOSES OF ASSESSMENT
Rowantree4 suggested six purposes of assessment: Selection of
candidates for educational opportunity; maintenance of standards,
particularly in relation to the final output from the system;
motivation of students so that they are encouraged to learn;
provision of feedback to students so that they know how they are
performing; provision of feedback to teachers so that they know
the strengths and weaknesses of their students’ learning (and their
teaching); and preparation of the students for ‘real life’. While
most teachers are well-versed with the summative or certifying
purpose of assessment (assessment of learning), using assessment
as an educational tool (assessment for learning) is a relatively
recent phenomenon.5
EVOLUTION OF ASSESSMENT
There have been many distinct phases in the evolution of assessment
over the past 50 years.6–12 Initially, educational testing focused on
358 THE NATIONAL MEDICAL JOURNAL OF INDIA
measurement alone, with emphasis on objectivity and
reproducibility of results.9,11 The focus then shifted to reliability,
i.e. the degree of confidence that we can place on our results.12 The
wheel of time seems to have gone full circle and now subjective
assessments by experts are no longer viewed as being unreliable.12
This period of innovation left us some important legacies.13
These are: the continuing sensitivity with regard to issues
concerning what it is that a particular test really measures;
recognition that competence is not a simple aggregate of
homogeneous performances, but is multidimensional; willingness
to admit that certain concepts such as generalized problem-
solving ability may be convenient but misleading; and an ongoing
concern with the impact of tests on student learning and the effects
of different types of examinations on students’ priorities and
methods of study.13
Contemporary developments in assessment are based on more
integrative concepts, in which the prominent features are not traits
but roles or competences.14 The key element in this is the successful
completion of a certain task or role, for which different aspects of
medical competence have to come together and be integrated.15,16
Miller’s pyramid marked the beginning of this thinking.17 Miller
introduced a conceptual framework in the form of a pyramid (Fig.
1) wherein various layers of the pyramid are defined not as traits
but as verbs or actions, which are observable and can be judged
and thus used for assessment. These are––‘knows’ (factual
knowledge), ‘knows how’ (analysis, application and interpretation
of knowledge), ‘shows how’ (actual application and practical
demonstration in a simulated situation) and ‘does’ (perform in
real situations).
Clinical competence is defined as the ability to assume a
combination of well-defined roles.18 These roles are: provider of
direct patient care, worker in the healthcare system, scientist,
educator and person.18 In contemporary assessment programmes,
various instruments are used to obtain information about a student’s
competence in each of those roles. The ‘one instrument for one trait’
approach has now become a ‘multi-instrument for multiple roles’
approach.19 The growing interest in quality improvement, bolstered
by increasing demands for public accountability, has shifted the
focus to assessment of work.20 The assessment of actual performance
in practice is essential to quality management. This is what is
referred to as ‘performance’ or ‘work-based assessment’.20
Does
Shows how
Knows how
Knows
FIG 1. Miller’s pyramid17
VOL. 25, NO. 6, 2012
EFFECTIVE STUDENT ASSESSMENT
The following guidelines provide a general framework for effective
student assessment:3
1. Effective assessment requires a clear conception of all intended
learning outcomes.
2. It requires a variety of assessment procedures to be used.
3. The instructional relevance of the procedures is considered.
4. It requires an adequate sample of student performance.
5. It requires that the procedures be fair to everyone.
6. The criteria for judging successful performance need to be
specified.
7. It requires feedback to students that emphasizes strengths of
performance and weaknesses to be corrected.
8. It must be supported by a comprehensive grading and reporting
system.
ATTRIBUTES OF A GOOD ASSESSMENT
Van der Vleuten suggested that the utility of assessment methods
could be conceptualized by looking at the five attributes of the
method––reliability, validity, educational impact, feasibility and
acceptability.14 His argument was to carefully balance the
compromise between these five criteria, rather than focus on any
one of them. The utility is expressed as a product of all the five
attributes. This conceptual model helps to decide on the appropriate
tool. A tool may be low on reliability but can be useful if it is high
on another attribute, say, educational impact.
Validity
Validity is concerned with the interpretation and use of assessment
results. It refers to the evidence presented to support or refute the
meaning or interpretation assigned to the results of assessment.21
The traditional view that there were several different types of
validity has been replaced by the view that validity is a unitary
concept; it is a matter of degree and is inferred from various forms
of evidence.21 It needs to be emphasized here that validity refers
to interpretation of results rather than being an inherent quality of
the tool.
Reliability is now considered a part of validity, although on its
own reliability may not be sufficient to make an assessment valid.
Messick states that all validity is in fact construct validity.22 It
follows that construct irrelevance (e.g. asking a theory question in
an objective-structured clinical examination [OSCE]) or construct
under-representation (e.g. not observing the student during history
taking) are the biggest threats to validity.
Reliability
As for other experimental data, all assessment data must be
reproducible in order to be interpreted meaningfully. Would the
same results be obtained if a different sample of the same type of
task were used, or if the assessment were at a different time? If a
performance assessment is being rated, would different assessors
rate the performance in the same manner? Reliability refers to the
consistency or reproducibility of assessment results over time or
instances.23 Like validity, reliability is a characteristic of the result
or outcome of the assessment and not the measuring instrument
itself.
The factors that lower the reliability of test scores (written
assessments) include too few test items, too easy or too difficult
items, a narrow range of scores, lack of objectivity in scoring and
suboptimal testing conditions.3 In performance assessments, the
greatest threat to reliable measurement is case specificity.
MEDICAL EDUCATION
Increasing the tasks used to assess a student is therefore a very
useful way of improving both validity and reliability.
The reliability must be high (0.80–0.89) in high-stakes
examinations (e.g. certifying or selection examinations). For
assessments with lower consequences (e.g. formative assessments),
a lower reliability (0.70–0.79 or lower) may be acceptable.23
Educational impact
It is known that students are strongly influenced by
assessment.12Assessment should help to guide students towards
better learning. If any assessment method promotes unhealthy
learning or encourages shortcuts in learning, then it may be low on
this attribute of validity. We are all aware of the distorted learning
as a result of postgraduate entrance examinations in India.24,25
Practicability or feasibility
Feasibility is a relative term. Theoretically, every type of test
should be feasible. However, the time and effort involved in
developing, administering, scoring, interpreting and reporting a
test needs to justify its use. There will always be constraints on the
resources available to conduct assessments. Expertise and creativity
are required to develop the best compromise between the ideal and
the practical. Newble stressed that most medical schools will have
to be prepared to spend more time and resources on their
assessments if they are to achieve minimally acceptable standards
of validity and reliability.26 This applies particularly to the
assessment of clinical skills, where much longer or more frequent
observations of student performance are required than for other
assessments.
ASSESSING CLINICAL COMPETENCE
A proper definition of clinical competence and its components is
important to serve as a criterion for validating medical educational
programmes and to assure a minimum level of competence at the
end of medical school and during residency.
Newble defined clinical competence in terms of what a student
or doctor should be able to do at an expected level of achievement
(e.g. at the beginning of an internship) and clinical performance
as what a student or doctor actually does in real clinical practice.26
Epstein and Hundert proposed a definition of professional
competence as the habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning, emotions, values
and reflection in daily practice for the benefit of the individual and
community being served.27 Competence builds on a foundation of
basic clinical skills, scientific knowledge and moral development.
The American Board of Internal Medicine distinguished
between the four different dimensions of clinical competence,
where problem solving was the core aspect.28 These included
abilities (i.e. knowledge, technical skills and interpersonal skills),
problem-solving skills (i.e. data gathering and diagnosis), the
nature of the medical illness (problems encountered by physicians)
and social and psychological aspects of the patients’ problems. In
a later report, more elements were added––communication skills,
professionalism (e.g. ethical practice, understanding diversity,
responsible attitude), and system-based practice (i.e. understanding
of the healthcare system to improve and optimize healthcare).29
In the USA, the assessment of residents, and increasingly of
students as well, is largely based on a model that was developed
by the Accreditation Council for Graduate Medical Education
(ACGME).30 This model uses six areas of competence and some
means of assessing them (ACGME Outcome Project 2000). These
are––medical knowledge, patient care (including clinical
359
reasoning), professionalism, interpersonal and communication
skills, practice-based learning and improvement (including
information management) and systems-based practice (including
health economics and teamwork).31
In India, the Medical Council of India provides broad guidelines
and national and institutional goals for the medical graduate
training programme (Regulations on Graduate Medical Education
1997).32 This document delineates the objectives of training in
various disciplines and skills to be learnt during the course,
including internship. It also gives broad guidelines for teaching–
learning methods and an assessment plan. The document is in the
process of revision. There is a call for making assessments more
reliable and skill-based.33
With this background, we now discuss some of the methods
used for assessment in medical education.
METHODS OF ASSESSMENT
All methods of assessment have strengths as well as limitations.34
Some commonly used methods of assessment in medical education
along with their strengths and weaknesses are described below.
The role of an assessment planner is to use different methods such
that the benefits can be maximized.
Written assessments
Written examination questions are typically classified according
to whether they are the selection type, e.g. multiple choice
questions (MCQ) or the supply type, e.g. short answers or traditional
essays. They can also be ‘context-rich’ or ‘context-poor’.35
Questions with rich descriptions of the clinical context invite
more complex cognitive processes that are characteristic of clinical
practice. On the other hand, context-poor questions can test
factual knowledge but not its transferability to real clinical
problems.36
MCQs
The multiple choice test is a flexible assessment format that can
be used to measure knowledge, abilities, values, thinking skills,
etc. Such a test usually consists of a number of items that pose a
question to which students must select an answer from among a
number of choices. Items can also be statements to which students
must find the best completion.
Various formats of MCQs have been in use. The formats that
ask the students to choose the best answer from a list of possible
answers are most commonly used (‘single or one best option’
type). The other formats are ‘true or false’, ‘multiple true or false’,
‘matching’ and the ‘extended matching’ type questions.
MCQs can provide a large number of examination items that
encompass many content areas, so a broad domain can be covered.
They can be administered in a relatively short period, can be
graded by a computer and have a high reliability per hour of testing
time. MCQs that are rich in context (problem-based) are difficult
to write but can become very effective tests for assessing higher
levels of knowledge. The reliability of an MCQ test is a consequence
of a wider sampling of content.35,37 Guidelines regarding the
content, formatting, style and writing the stem and distractors for
construction of MCQs need to be followed.38
‘True or false’ questions. The main advantage of such questions
is that they can be written easily and cover a wide range of content.
However, there are two major disadvantages. They are difficult to
construct flawlessly––the statements have to be absolutely true or
false. When a student answers a ‘false’ question correctly, we can
only conclude that the student knew the statement was false, not
360 THE NATIONAL MEDICAL JOURNAL OF INDIA
that he or she knew the correct fact. Also, they are weak in
discriminating between high and low performers. Their place in
assessment has been questioned.39
‘Multiple true or false’ questions. In this format, a question
with more than one correct answer can be asked. These take
slightly longer to answer than the previously discussed formats.
The scoring procedure too can be complicated.
Newer formats of MCQs. Certain newer formats of MCQs
allow for a better assessment of diagnostic reasoning. The ‘key
feature’ question focuses on critical decisions in particular clinical
cases.40 These questions are best used for testing the application
of knowledge and problem solving in ‘high stakes’ examinations.
The ‘extended matching items’ consist of several questions, all
with the same long list of possible answers. The elements of
extended matching questions are a list of options, a ‘lead-in’
question, and some case descriptions or vignettes.41 An option
may be correct for more than one vignette, and some options may
not apply to any of the vignettes. This format is in use by the
United States Medical Licensure Examination (USMLE) for
many years.
‘Short answer’ questions
A short answer question (SAQ) is similar to a well-stated MCQ
without the alternatives. Here, the assessee is required to provide
rather than select the answer. These open-ended questions are
more flexible in that they can test issues that require creativity and
spontaneity. However, these have a lower reliability.37 Because
answering open-ended SAQs is much more time-consuming than
answering MCQs, they are less suitable for broad sampling. A
good open-ended question should include a detailed answer key
for the person marking the paper.3
Essay questions
Essays are ideal for assessing how well students can summarize,
hypothesize, find relations and apply known procedures to new
situations. These can provide insights into more complex cognitive
processes, ability to process information, different aspects of the
ability to write and more contextualized answers.37
When constructing essay questions, it is essential to define the
criteria on which the answers will be judged. Essay-type questions
are time-consuming to grade and need more work to establish
inter-rater reliability. As answering them is time-consuming, a
long testing time is required to include a variety of domains. This
may often result in a smaller sample, thereby limiting reliability.
When clear grading guidelines are in place, structured essays can
be psychometrically robust.
Newer formats
The other methods of written assessment that have been used in
the past include modified essay questions (MEQs) and patient
management problems (PMPs) for testing problem-solving and
decision-making.42 A MEQ presents a typical problem faced in
daily practice. The use of both MEQs and PMPs encourage more
complex thinking skills among students and help develop problem-
solving skills. They are especially suitable for emergency or high-
risk problems where a student cannot be allowed to handle real
problems.
Assessments by supervising clinicians
Observation by supervising clinicians and their impression of
students over a specific period remains the most common tool
used to evaluate performance.
VOL. 25, NO. 6, 2012
Long case examination
This has been in use for a long time, is highly valued by many
clinicians and closely resembles some of the tasks doctors undertake
in their everyday practice.43 The format of the long case can vary;
traditionally a student is given an uninterrupted and unobserved
time, usually 30–45 minutes, to interview and examine a real
patient. The student then presents his/her findings and plan to one
or more examiners who then conduct an unstructured oral
examination with the student about the patient’s problem and
related topics. Given the logistics of long case examinations,
medical schools traditionally assess students on a single case. This
limits the generalizability of the results.44 Also, in long cases,
differences among cases appear to contribute more to variation in
scores than differences among examiners.45 The traditional long
case examination has been almost abandoned in most of the
western world.44 However, it is still widely used in India in almost
all clinical assessments of undergraduates and postgraduates.46,47
The reliability of the long case can be improved by increasing
the number of cases seen by each student. 19 Using the
generalizability theory, Wass et al. predicted that examining a
student on 10 cases would achieve a reliability factor of 0.8.19
Another problem in the long case is the unstandardized nature of
the patients. Standardizing patients enables accurate blueprinting
of the test. However, content specificity appears to be more
important than standardization.19
Observation is another strategy to improve the long case
examination.48,49 Rather than relying on the presentation alone,
observation while the candidate is eliciting the history and carrying
out the physical examination would be a more valid assessment of
the candidate’s competence.
Gleeson developed a more structured presentation of an
unobserved long case, the objective-structured long examination
record (OSLER), which includes structuring of the long case and
direct observation of the candidate interacting with the patient for
a small component, e.g. explaining a procedure.50 Gleeson
suggested that reliability would also improve if the number of
judgements within the case are increased. OSLER seems to be a
powerful tool for providing feedback and therefore has great
potential to increase clinical competence.51,52 A study by Gleeson
indicated that OSLER had a profound effect on student learning
in all areas of competence.53 Wass and van der Vleuten made an
argument for the retention of and further research into the long
case clinical examination.43 Its utility for high-stake examinations,
however, remains questionable.43
Objective-structured clinical examination
As a potential solution to the difficulties of adequate sampling and
standardization of cases, the OSCE has gained importance the
world over.9 Candidates rotate through a series of timed stations.
All candidates move from station to station in sequence on the
same schedule. OSCEs have used standardized patients as the
primary assessment tool. However, other assessment items such
as data interpretation exercises using clinical cases and clinical
scenarios with mannequins have also been used to assess technical
skills. The observing faculty or tutor or patient uses either a
checklist of specific behaviours or a global rating form to evaluate
the student’s performance.54,55 OSCEs have been used in most
British and American medical schools, many residency
programmes and by the licensure boards of Canada and USA for
many years. This format provides a standardized means to assess
a variety of clinical skills. These include physical examination
and history-taking skills, communication skills with patients and
MEDICAL EDUCATION
family members, breadth and depth of knowledge, ability to
summarize and document findings, ability to make a differential
diagnosis or plan treatment and clinical judgement based upon
patients’ notes. A separate performance score is derived for each
task performed at a station and scores are combined across
stations or tasks to determine a pass/fail score.
Like MCQs, the reliability of the OSCE stems from its wider
content sampling rather than from its objectivity or standardization.
A minimum of 10 stations, which the student usually visits over
the course of 3–4 hours, is necessary to achieve a reliability of
0.85–0.90.56 There is increasing evidence that global ratings,
especially by physicians, are as reliable as checklists.54,55 However,
extensive training of judges is required to ensure consistency.
OSCEs are very useful for measuring specific clinical skills
and abilities. The performance of a task is actually observed, thus
improving the validity of interpretation. Immediate feedback is
possible, thus helping improvement in learning. OCSEs can also
provide feedback to teachers and help in correcting teaching–
learning errors.57 However, they also have weaknesses. The
examination format is labour-intensive and expensive.58 We found
OSCEs to be unsustainable on a regular basis due to the lack of
resources and faculty time.59 It can also be a challenge when real
patients are used as they can get difficult when the same questions
are asked repeatedly, and standardization is lost.60 Complex skills,
requiring an integrated professional judgement, become
fragmented by the relatively short station length (generally 5–10
minutes), thereby leading to loss of validity at the cost of reliability.61
Aspects of competence such as the ability to perform procedures
and manage life-threatening clinical situations or abilities in
continuity of care cannot be tested using OSCEs.62
Contrary to popular notion, the high reliability of OSCEs do not
depend on their objectivity or structure. It is the wider sampling of
content and skills which help in achieving high reliability. In fact,
the reliability of a one-hour OSCE and a one hour-long case is
almost the same.63 An important implication of this is to use OSCE
for wider sampling rather than keeping only a few stations, and
depend on its objectivity to give a high reliability.12
Multisource or 360-degree assessments
These evaluations consist of measurement tools completed by
several people in a person’s sphere of influence. Evaluators
completing rating forms in a 360-degree evaluation are usually
peers, other members of the clinical team and patients, who can
provide insights into the trainee’s work habits, capacity for teamwork,
and interpersonal sensitivity.64–66 A multisource feedback is most
effective when it includes narrative comments as well as statistical
data, when the sources are recognized as credible, when the
feedback is framed constructively and when the entire process is
accompanied by good monitoring and follow-up.67 Peer assessments
depend on trust and require scrupulous attention to confidentiality,
failing which they can be undermining, destructive and divisive.
The strengths of multisource assessments are that ratings
generally encompass habitual behaviours rated by credible sources,
and assessments often correlate with future academic and clinical
performance. However, in most clinical settings, conducting 360-
degree assessments with large numbers of evaluators, compiling
and reporting confidentially to students/residents is challenging,
though an electronic system may make it feasible.
Portfolio
The portfolio is a framework containing evidence of achievement
of learning outcomes over time. Portfolios have been used to
361
support learning and for assessment purposes, both formative and
summative.68 Reflecting upon what has been learnt forms an
important part of constructing a portfolio.69
A portfolio typically contains written documents but can
include video or audio recordings, photographs and multimedia,
and can be maintained in an electronic format. In a graduate
medical education, a portfolio might include a log of clinical
procedures performed, a summary of research literature reviewed
when selecting a treatment option, ethical dilemmas faced and
how they were handled, etc. Portfolio assessment is intimately
linked to self-directed learning and is most useful for evaluating
mastering of competences that are difficult to evaluate otherwise,
such as practice-based improvement, use of scientific evidence in
patient care, professional behaviour and patient advocacy. Cole
asserts that portfolios can differ in purpose, components and
processes.70
Portfolios are excellent tools for assisting formative assessment
and professional development. They have the potential to assess
clinical performance over a period of time, constituting one form
of authentic assessment.68 However, assessment through portfolios
is labour-intensive and requires staff development. This is also
cumbersome for comparative assessments as they are essentially
non-standardized.
Chart-stimulated recall oral examination (CSR)/case-based
discussions (CbDs)
In a chart-stimulated recall oral examination (CSR) examination,
patients of the examinee are assessed in a standardized oral
examination. A trained and experienced physician examiner
questions the examinee about the care provided, probing for reasons
behind the work-up, diagnosis, interpretation of clinical findings
and treatment plans. The examiner rates the examinee using a well-
established protocol and scoring procedure.30 CSRs are also called
case-based discussions (CbDs) in some settings. A trainee should
be assessed in this manner at least six times in a year. These are
different from the traditional case presentations as the discussion
centres on what the trainee has already done.30 Thus, they test
different skills compared to traditional case presentations.
Checklist evaluation
Checklists consist of essential or desired specific behaviour,
activities or steps that make up a more complex competency.
Typical response options on these form a check or ‘yes’ to indicate
that the behaviour occurred or options to indicate the completeness
or correctness of the action. The forms provide information about
behaviour, but for the purpose of making a judgement about the
adequacy of the overall performance, standards need to be set that
indicate different levels of performance.30 Checklists are useful
for evaluating any competency or its component that can be
broken down into specific behaviours or actions. However, their
use is limited by the fact that checklists assume a fixed sequence
of actions which is not often the case in reality. There may be
different valid sequences to perform the same task effectively. To
ensure the validity of content and scoring rules, checklist
development requires consensus by several experts with agreement
on essential behaviour, sequencing and criteria for evaluating
performance.71
Procedure, operative or case logs
Procedure, operative or case logs document each patient
encountered by the student for the medical conditions seen and
procedures or surgical operations performed. Patient case logs
362 THE NATIONAL MEDICAL JOURNAL OF INDIA
involve recording of some number of consecutive cases in a
designated time frame.72 Case and/or procedure logs are useful for
determining the scope of patient-care experience.
Patient surveys
Patient surveys to assess satisfaction with the hospital or clinic
visits typically include questions about the physician’s care.73 The
questions pertain to general aspects of physicians’ care such as
time spent with the patient, overall quality of care, competence of
the physician, courtesy, interest and empathy shown. Specific
aspects of care would include listening skills, explanation about
the problem, its diagnostic tests, treatment planned and side-
effects of drugs. A patient survey asks the patients to rate their
satisfaction using qualitative rating categories or agreements with
statements describing the scenario. Each rating is given a value
and the final satisfaction score is calculated by averaging scores
across responses to generate a single overall score.30
Patient surveys can be used for formative assessments and
performance improvement. The American Board of Internal
Medicine reports that 20–40 patient responses were needed to
obtain a reliability of 0.70–0.82 on individual resident ratings.29
Record review
A review of patient’s records can provide evidence about clinical
decision-making, follow through in patient management and
appropriate use of clinical facilities and resources.74 However, the
documented care may often not be directly attributable to a single
resident but to the whole clinical team. A sample of 8–10 patient
records is sufficient for a reliable assessment of care for a
diagnosis or procedure.74
Workplace-based assessment (WPBA)
Assessment of a student’s actual performance in the wards or in
the consulting rooms poses a real challenge for teachers. Increasing
attention is being placed on this type of assessment (highest level
of Miller’s pyramid) because of its possible high consequential
and predictive validity. Attempts at performance assessment have
to balance issues of validity and reliability.16,20 Several methods of
assessment have been developed to address these issues and many
of these are variations on the traditional bedside oral examination.
Though these methods have been developed focusing on practising
doctors, they also apply to medical students, particularly to
postgraduates.20 Some of the WPBA methods are described below.
Mini-clinical evaluation exercise (mCEX)
In the mCEX, a faculty member observes a trainee–patient encounter
in any healthcare setting.20 The encounters are intended to be short
(about 15 minutes) and focused. The trainee is expected to conduct
a focused history-taking and/or physical examination during this
time and then provide the assessor with a diagnosis and treatment
plan. The performance is scored using a structured form and
thereafter educational feedback is provided. Trainees are expected
to undertake at least six such encounters during the year, with a
different assessor for each encounter representing a different clinical
problem, appropriately sampled from a list of patient problems.75 A
number of studies have been reported using mCEX and it has been
found to be a useful tool for formative assessment of residents in
medicine.20 Its use in India has also been reported.76
Direct observation of procedural skills (DOPS)
DOPS is a variation on the mCEX in which the assessor observes
while the trainee is doing a procedure (e.g. venepuncture, giving
VOL. 25, NO. 6, 2012
an injection, etc.), rates the performance and then provides
feedback.77 Like mCEX, trainees need to undertake six observed
encounters during the year, each with a different assessor, and the
procedures need to be sampled from an approved list. Research
specific to DOPS is limited but in general four to eight encounters
are sufficient for reasonable confidence in the final results.77
Mini-peer assessment tool (mPAT)
In this method, eight assessors are nominated by the trainee from
among his/her supervisors or peers, including nurses and other
health professionals. The assessors are required to fill out a
questionnaire concerning the technical and interpersonal skills of
the trainee. These data are then shared with the trainee and the
educational supervisor so that there is an agreement about the
strengths and weaknesses of the trainee and a plan for improvement
is developed.77
The use of peer assessment in higher education has been
supported through research.67 Ramsey et al. showed that a
reasonable reliability was obtained with eight to twelve peers and
about five questions.64
The success of WPBA depends on its ability to assess
competencies which are not amenable to testing by conventional
methods and making use of its formative function. With our
present understanding, WPBA is not recommended for summative
or high-stakes examinations due to issues of equivalence (i.e. how
to compare performance of two students on two different cases).77
Students showing unsatisfactory performance on one tool should
be offered other tools for diagnosis and remediation. Assessor
training would go a long way in maintaining the quality of
WPBA.78
CHOOSING THE RIGHT TOOL
Assessments do not happen in a vacuum. All assessments are done
with a context and a purpose. A number of problems related to
assessment because an inappropriate tool is chosen. Many times,
people tend to use certain tools because they are ‘in’ or are being
used by others. The validity or reliability of assessment is not an
inherent property of the tools. Thus, not all knowledge assessment
may happen with essay questions and not all skills may be
assessed by mPAT. A good framework to decide on the suitable
tools is to ask who is going to use the results, when and for what
purpose. If the purpose is selection, then we have to choose more
reliability, but if the purpose is formative, then tools with higher
educational impact should be chosen. Classifying the proposed
use of assessment in relation to the utility criteria (viz. validity,
reliability, acceptability, educational impact and feasibility) can
help in making a useful choice. However, it is important to realize
that not all tools are applicable in all contexts. It is also useful to
keep in mind that in practice, there is always some trade-off
between validity and reliability. Placing too much emphasis on
reliability can take its toll on validity by reducing the authenticity
of assessment. In general, it is better to build validity in the
assessment, even though sometimes it may mean a little
compromise with reliability.
To summarize, assessment requires careful planning. It must
be strategically designed for its educational effects. The assessment
tasks should be in close alignment with the curricular objectives
and the instructional methods. All assessment methods have
limitations and no one method can assess all types of knowledge
and skills. A good assessment uses a mix of methods depending
upon the context. A good assessment must demonstrate validity
and reliability. It should be feasible and must be acceptable to all
MEDICAL EDUCATION
stakeholders, including students, faculty and licensing bodies. To
effectively use some of the newer methods of assessment, there is
a need for training examiners. Assessments that are bad can
promote unhealthy approaches to learning.
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SGPGI-NIH Workshops on ‘Scientific paper writing’,

‘Biostats’ and ‘Observational Studies’
As part of an Indo-US Collaboration, the National Institutes of Health, USA has
sponsored a series of workshops since 2006 on various aspects of clinical research (with
an emphasis on clinical trials), including biostatistics, study design and randomization
issues, data management, research ethics, and regulatory aspects. As a continuation of
this series, three workshops are planned at Sanjay Gandhi Post Graduate Institute of
Medical Sciences (SGPGI), Lucknow during 2013 as follows:
ii(i) Workshop on ‘Scientific Paper Writing’ on April 19–21, 2013,
i(ii) Workshop on ‘Basic Biostatistics’ on July 25–28, 2013, and
(iii) Workshop on ‘Observational Studies’ on September 29 to October 2, 2013.
All the workshops are aimed at active biomedical researchers who hold faculty
positions. Investigators involved in clinical research, who are in a position to lead
clinical research studies, should find this workshop useful.
Only a limited number of applicants will be accepted for each workshop. Applicants
should download an application format (asks for summary of their experience and
expertise in clinical research in a structured format) from https://sites.google.com/site/
sgpginihcourses/ and email it as an email attachment to sgpgi.courses@gmail.com. The last
dates for applications for the three courses are March 3, May 31 and July 31,
respectively. A selection committee will notify the successful applicants of acceptance
about 4 weeks before each course.
A limited number of scholarships for travel and lodging are available for qualified
applicants whose institution cannot cover their expenses.

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Construct validity and predictive utility of internal assessment in undergraduate

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THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 30, NO. 3, 2017 151

Medical Education
Construct validity and predictive utility of internal assessment in
undergraduate medical education

DINESH K. BADYAL, SHEENA SINGH, TEJINDER SINGH

ABSTRACT division includes a theory part of 110 marks (40 theory paper A +
Background. Internal assessment is a partial requirement 40 theory paper B + 15 theory viva + 15 IA) and a practical part
of all medical college examinations in India. It can help of 40 marks (25 practicals + 15 IA).2
teachers provide remedial action and guide learning. But its As per MCI regulations, IA should be based on day-to-day
utility and acceptability is doubted because, with no external assessment, e.g. assessment of student assignments, preparation
for seminars, clinical case presentations, etc.2 However, we are
control, internal assessment is considered prone to misuse. It
not sure that these guidelines are followed in all medical colleges.
is therefore not used as a tool for learning. There is no study
The marks of IA are used as a passport to appear in the university
on the validity of internal assessment from India.
examination, rather than being used as a tool to improve learning
Methods. We use multiple methods and multiple teachers by providing feedback. Hence, IA is not being respected by
to assess students and our records are well maintained. We teachers and students as a tool that can be relied upon
analysed the internal assessment scores at our institute. We confidently.3–5 It is also considered that various components of
correlated the internal assessment marks with the university IA are subjective in nature, making it untrustworthy.6 This brings
marks obtained by students in one of the subjects in each of the in the concept of predictive utility and construct validity of IA.
four professional examinations. Predictive validity is a subtype of criterion-related validity, where
Results. There was a positive correlation of university the criterion is a future test, i.e. university summative examination.
marks with internal assessment marks. The r values ranged If good/poor IA performance score predicts better/poor summative
from +0.426 to +0.685 and were statistically significant scores, respectively, then it indicates that IA has good predictive
(p<0.01). The percentage of internal assessment marks was utility. Our system of using IA throughout the year followed by
higher than the university percentage in all professional summative university examination is a good model to evaluate
examinations except the first. predictive utility of IA.7 In medical education, most concepts are
Conclusions. Internal assessment marks correlate well constructs. A construct is a combination of inputs/evidences,
with marks in university examinations. This provides evidence e.g. content-related evidence, criteria-related evidence, reliability
for construct validity and predictive utility of internal assessment. and other related evidences that contribute to validity. The use
Internal assessment can predict performance at summative of multiple methods including subjective and objective methods,
examinations and allow remedial action. blueprinting, multiple teachers and day-to-day assessment
provides construct-related evidence for validity of IA.7,8
Natl Med J India 2017;30:151–4 Although MCI regulations have guidelines for IA, there has
been no study on the utility or validity of this mode of examination.
INTRODUCTION IA being a useful component, there is a need to study the
In India, student assessment in the undergraduate medical predictive utility of IA and find ways to improve it. Hence, to
curriculum consists of internal assessment (IA) and summative examine the construct validity and predictive utility of IA, we
assessment. The summative assessment, i.e. university examina- compared the IA marks with university marks in the MBBS course
tions at the end of professionals, is used for pass or fail at our institute.
decisions. IA is conducted by teachers who have taught the
students.1 It overcomes the limitations of day-to-day variability METHODS
and allows larger sampling of topics, competencies and skills. In Our study included marks of four MBBS professional
1997, the Medical Council of India (MCI) made IA mandatory for examinations, i.e. first, second, final part-I and final part-II
assessment of undergraduate medical students. Weightage for the professional. The number of students in each batch was 50. Of
IA is 20% of the total marks in each subject. Student must secure the 200 students, the records of 164 students were complete and
at least 35% marks of the total marks fixed for IA in a particular were included in the study. The IA marks of students from one
subject in order to be eligible to appear in the final university arbitrarily selected subject each from all the four professionals
examination of that subject. For example, pharmacology in the were collected. Similarly, the total university marks in these
second professional has a total of 150 university marks. The subjects were also collected from the records. To maintain
————————————————————————————————
Christian Medical College and Hospital, Ludhiana 141008, Punjab, India
anonymity, the subject is not being identified.
DINESH K. BADYAL Department of Pharmacology
SHEENA SINGH Department of Physiology Process of IA
TEJINDER SINGH Department of Paediatrics Our institute has designed a system of IA, which is in use since
·································································································································································· 1997.5,9 This takes into consideration theory tests, practical tests,
Correspondence to DINESH K. BADYAL; dineshbadyal@gmail.com
seminar preparation and presentation, case presentations,
© The National Medical Journal of India 2017
152 THE NATIONAL MEDICAL JOURNAL OF INDIA
research, quiz participation, subjective assessment and
punctuality (Fig. 1). Multiple methods of assessment are used
and all teachers of the subject are involved. The records are
updated and students are provided regular feedback. The IA
marks are calculated as per formula given by our affiliating
university. The formula has the following components:
A (80% [academic marks]) + B (10% [subjective assessment]) +
C (attendance >90%)
For example, the pharmacology IA of 15 marks is composed of
A (12 marks) + B (1.5 marks) + C (1.5 marks) given separately in
each theory and practical.
The calculated IA is shown to students regularly or on demand
throughout the course. Based on the marks in the IA, students are
provided feedback to improve their performance in specific areas.
Students are asked to regularly sign on their IA sheets. The
Principal’s office is informed every 6 months about students
whose IA is low. Students are provided remedial instruction.
Sometimes parental intervention is also included.
FIG 1. Internal assessment record sheet
VOL. 30, NO. 3, 2017
Statistical analysis
The total IA marks were deducted from the university marks of
a particular subject to obtain the marks scored by a student in
the university examination. We labelled these marks as X marks
for calculations. The IA marks and X marks in the subjects are
depicted in actual marks and percentages. The Pearson correlation
between total IA marks and X marks was calculated. The r value
calculated by correlation coefficient is a linear correlation
coefficient and can be used to assess if there is a linear relationship
between two variables.10
RESULTS
The marks of the 164 students from four professional years and
the X marks are shown in Table I. The IA marks show a positive
correlation with X marks, which is statistically significant (p<0.01)
in all professional examinations. The value of correlation varies
from +0.426 to +0.685. The scatter diagram (Fig. 2) shows that the
IA marks are positively correlated to better university marks in
all professionals.
MEDICAL EDUCATION 153

TABLE I. Marks and correlation in one subject of various professional years

Professional examination Marks obtained Maximum marks Percentage Pearson correlation (r value) p value
First (n=50)
Total IA 22.54 40 56.35 +0.426 0.002
X marks 97.44 160 60.90
Second (n=43)
Total IA 21.19 30 70.63 +0.685 <0.001
X marks 77.58 120 64.65
Final Part-I (n=37)
Total IA 14.32 20 71.60 +0.440 0.006
X marks 52.08 80 65.10
Final Part-II (n=34)
Total IA 14.49 20 72.45 +0.442 0.008
X marks 50.77 80 63.46
IA internal assessment Values are means X marks university marks minus total IA marks

Fig 2a Fig 2b
First professional (n=50) Second professional (n=43)
40 30

Subject total internal assessment

Subject total internal assessment

35
25
30
20
25
r=+0.426 15
20 r=+0.685
p<0.01 (0.002) p<0.01 (0.000)
10
15

10 5

5 0
0 20 40 60 80 100 120
0 X marks (University Subject Marks–total IA)
0 20 40 60 80 100 120 140 160
Maximum marks: Total IA=30, X marks=120 (150–30)
X marks (University Subject Marks–total IA)
Maximum marks: Total IA=40, X marks=160 (200–40)

Fig 2c Fig 2d
Final Part-I professional (n=37) Final Part-II professional (n=34)
20 20
Subject total internal assessment

Subject total internal assessment

15 15
r=+0.440 r=+0.442
p<0.01 (0.006) p<0.01 (0.008)
10 10

5 5

0 0
0 20 40 60 80
0 20 40 60 80
X marks (University Subject Marks–total IA) X marks (University Subject Marks–total IA)
Maximum marks: Total IA=20, X marks=80 (100–20) Maximum marks: Total IA=20, X marks=80 (100–20)

FIG 2. The correlation between X marks and total internal assessment (IA) in one subject of first (2a), second (2b), final-I (2c) and final-II
(2d) professionals X marks: Total university marks minus total internal assessment marks in one subject of professional

A comparison of the percentage of marks of IA and X shows than X marks (Fig. 3). However, the difference is not statistically
that in the first professional the X marks (summative assessment) significant in all professionals.
are higher than IA while in other professionals IA marks are lower
 154
Final-II
Professional examination
Final-I
Second
First
0 10 20 30 40 50 60 70
Percentage of marks
FIG 3. Comparison of percentage marks of internal assessment
(IA) and university examination in one subject of various
professionals X marks: Total university marks minus total
internal assessment marks in one subject of professional
DISCUSSION
Our results show that there is a positive linear relationship
between IA and university marks indicating that better marks in
IA are related to better marks in the university examination. This
can also be interpreted as ‘if a student is performing well throughout
the year, he/she is likely to score good marks in summative
assessment’. This indicates the predictive utility of IA, i.e. better
marks in IA predict better marks in summative examinations. This
also provides construct validity evidence for IA, in addition to
suggesting its predictive utility, as predictive-related evidence
contributes to the construct.
The converse is also true for IA marks. If the IA marks are low,
it predicts low marks in the summative assessment. This also
signifies that IA marks can be useful for providing feedback to
students and teachers. Thus, IA identifies areas that should be
targeted for improvement for students who have low IA marks.
The comparison of IA and university marks shows that in the
first professional, university marks are higher than IA, while in
other professionals it is the opposite, i.e. IA marks are higher
than university marks. This is in line with previous reports that IA
View publication stats
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 30, NO. 3, 2017
marks tend to be inflated.4,10 However, despite this variation, there
is a positive correlation.
One of the criticisms of IA is its subjective nature; however,
there is enough evidence in literature to suggest that subjective
assessments can be as reliable as highly objective ones.11–13 Our
IA module uses multiple methods and multiple teachers in
calculating IA, which could have contributed to better future
performance. The use of multiple methods and multiple assessors
improves content-related evidence for validity and also reliability.
Both these evidences contribute to construct validity. These
X marks results indicate that a well-designed IA can have good predictive
Total IA value and construct validity. We could not find any other study
on the correlation of IA marks with university marks to
substantiate the above assumption.
80 90 100 To conclude, despite its limitations of subjectivity and inflated
marks, IA has construct validity and predictive utility. It can be
used to provide corrective feedback to students to improve their
learning.
REFERENCES
1 Singh T, Gupta P, Singh D. Continuous internal assessment. In: Singh T, Gupta P,
Singh D (eds). Principles of medical education. 3rd ed. New Delhi:Jaypee Brothers
Medical Publishers; 2009:10–12.
2 Medical Council of India. Regulations on graduate medical education, 1997 (amended
up to 2012 February). Available at www.mciindia.org/tools/announcement/Revised_
GME_2012.pdf (accessed 15 Feb 2016).
3 Singh T, Anshu, Nath J. The quarter model: A proposed approach for in-training
assessment of undergraduate students in Indian medical schools. Indian Pediatr
2012;49:871–6.
4 Gitanjali B. Academic dishonesty in Indian medical colleges. J Postgrad Med
2004;50:281–4.
5 Singh T, Anshu. Internal assessment revisited. Natl Med J India 2009;22:82–4.
6 Tongia SK. MCI internal assessment system in undergraduate medical education.
Natl Med J India 2010;23:46–7.
7 Downing SM. Validity: On meaningful interpretation of assessment data. Med Educ
2003;37:830–7.
8 Downing SM. Reliability: On the reproducibility of assessment data. Med Educ
2004;38:1006–12.
9 Singh T, Singh D, Natu MV. A suggested model for internal assessment as per MCI
guidelines on graduate medical education, 1997. Medical Council of India. Indian
Pediatr 1997;35:345–7.
10 Mukaka MM. Statistics corner: A guide to appropriate use of correlation coefficient
in medical research. Malawi Med J 2012;24:69–71.
11 Ananthakrishnan N, Shanthi AK. Attempts at regulation of medical education by the
MCI: Issues of unethical and dubious practices for compliance by medical colleges
and some possible solutions. Indian J Med Ethics 2012;9:37–42.
12 Van der Vleuten CPM, Norman GR, De Graff E. Pitfalls in the pursuit of objectivity:
Issues of reliability. Med Educ 1991;25:110–18.
13 Singh T. Student assessment: Issues and dilemmas regarding objectivity. Natl Med
J India 2012;25:287–90.
 Review Article

Experiential Teaching Learning of Humanities in Health Professions

Education

Abstract Anushi Mahajan,

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Humanities are an integral part of health professions. However, with educational focus shifting Purvi Bhagat1,
gradually toward knowledge, information, evidence‑based medicine, and technology, it has taken a Sudhir Babu2,
back seat and become a part of the “hidden curriculum.” Humanities are hardly ever taught upfront
to students of the health profession, let alone its assessment. With the need of its inclusion in health Anuj Singhal3,
professional education now recognized and established through competency‑based education, we Dinesh Badyal4,5,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/24/2024

need to be aware of the tools and strategies which can be used to teach and assess it. In this article, Rajiv Mahajan6
we share selected tools with relevant readily usable examples for teaching humanities to students Department of Periodontology,
of the health profession. Faculty may find it useful to plan sessions around related competencies. Christian Dental College,
Incorporation of such experiential teaching and learning methods can help us achieve the transition CMC, Ludhiana, Punjab,
from “high‑tech” to “high touch” health professions education.
1
Department of Opthalmology,
M & J Western Regional
Keywords: Burn‑out, caregiver’s fatigue, cinemeducation, humanities, medical education, Institute of Opthalmology,
teaching‑learning tools B. J. Medical College and Civil
Hospital, Ahmedaba, Gujarat,
2
Department of Opthalmology.
Kamineni Institute of Medical
Introduction families, societies, and communities. Too
Sciences, Nalgonda, Telangana,
much reliance on scientific knowledge 3
Department of Medicine, Army
Medicine is referred to as “the most
may often get in the way of sound clinical Hospital RR, Delhi, 4Department
humane of sciences, the most empiric of
judgment. Doctors are currently more of Pharmcology, Christian
arts, and the most scientific of humanities” Medical College, 5Department
of “bedside technicians” than “scientific
by Edmund Pellegrino. Engagement into of Medical Education, CMC L
healers.”[4] The clinical encounter between FAIMER Institute, Ludhiana,
humanities offers three benefits essential
a doctor and a patient is something more 6
Department of Pharmacology,
to physicians for their competence:
than a mere diagnosis and treatment of a Adesh Institute of Medical
Methods of inquiry or thought, content of Sciences and Research,
disease; it constitutes a moment between
knowledge, and power to revive the spirit.[1] Bhatinda, Punjab, India
two people to come together in mutual
Humanities has always been an integral part
recognition of all human aspects. This
of medicine since ages; however, as science
insight along with the scientific and
and technology progressed, it was taken for
technical knowledge is indispensable for
granted and became a “hidden curriculum,”
a holistic health profession’s education.
in terms of teaching and assessment. The
The various aspects of humanities include Submitted : 30‑Nov‑2020
value of humanities in medical education
attitude, professionalism, ethics and Revised : 14-Apr-2021
is not challenged but what is of concern
empathy, altruism, and communication Accepted : 07-Jun-2021
is how to fit it into an already loaded Published : 20-Dec-2022
skills.
curriculum.[2] William Osler stated that – “It
is important to know the person who has Furthermore, we also need to consider
Address for correspondence:
the disease as it is to know the disease the sensitizing health professionals to Dr. Anushi Mahajan,
person has.”[3] caregiver’s fatigue (from the point of view Christian Dental College,
of a patient’s family) and the medical burn CMC, Ludhiana ‑ 141 008,
Most doctors fail to realize that our Punjab, India.
out (from doctor’s point of view). A doctor
profession is not only to understand E‑mail: anushimahajan@yahoo.
is considered next to an artist because co.in
the scientific basis of disease and the
serving the ill and the destitute is an art
related technology but also to recognize
coupled with science; to accept destiny and
and appreciate the person who is
not to be a victim of high ambition and Access this article online
affected. Patients cannot be regarded as
hopelessness. Medical students are often
disease‑carrying bodies or individuals Website: www.cjhr.org
prone to burnout due to the real picture
but have to be understood as members of DOI: 10.4103/cjhr.cjhr_161_20
coming alive, facing the grief, the suffering, Quick Response Code:
This is an open access journal, and articles are and the death. They have to accept that life
distributed under the terms of the Creative Commons is not at all perfect and they need to focus
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, How to cite this article: Mahajan A, Bhagat P,
as long as appropriate credit is given and the new creations are Babu S, Singhal A, Badyal D, Mahajan R. Experiential
licensed under the identical terms. teaching learning of humanities in health professions
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com education. CHRISMED J Health Res 2022;9:118-24.

118 © 2022 CHRISMED Journal of Health and Research | Published by Wolters Kluwer - Medknow
 Mahajan, et al.: Humanities in HPE

and keep space for creativity and imagination for relaxation
to prevent burnout. Recently, burnout syndrome has been
recognized as an occupational disease characterized by
emotional exhaustion, feelings of low self‑esteem, and
depersonalization leading to a posttraumatic stress disorder
and even suicide.[5]
Hence, if we wish to create wiser, more tolerant,
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Visual art can enhance clinical practice by breaking
communication barriers and fostering teamwork. The
curiosity aroused when clinicians are presented with an
artwork can ignite a similar curiosity and questioning when
they encounter patients.[10]
Painting‑1 “The Doctor” by Sir Luke Fildes commissioned

by Tate. Content is available under CC BY‑SA

empathetic, resilient and competent physicians, we might
want to reintegrate the dance, poetry, and art (humanities)
in medical education. Keeping these learning objectives
and competencies in mind [Table 1a and b], we introduced
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/24/2024
3.0 [Figure 1].[11]
Setting‑A cottage with humble interiors, with two
unmatching chairs pulled together to make a make‑shift

health professionals to a month‑long process of “experiential
learning,” that is, direct experience outside a traditional
academic setting through the below mentioned methods:
a. Depiction through art
b. Appraisal through case scenarios
c. Reflection through cinemeducation
d. Expression through poetry.
In this article, we discuss the various tools with which
humanities can be taught to students of the health
profession and the above‑mentioned competencies can be
attained.
Depiction through art
It is important to bring the left and the right brains back
together – for the health of the patient and the physician.
bed has a young child lying listless and desperately ill, his
pale face illuminated by a lamp placed on the table.
The doctor, dressed in a well‑tailored suit, sits beside the
makeshift bed and looks down anxiously at his patient, the
child. The boy’s father is standing in the background with his
hand on his wife’s shoulder whose hands are clasped as if in
prayer. A half empty bottle of medicine lies on the table, and
a bowl and jug on the bench, all perhaps to relieve the boy’s
fever or pain. The paper bits lying on the floor could perhaps
be previous prescriptions made by the doctor. The shaft of
daylight perhaps reflects the imminent recovery of the child.
Background – Helpless, grief‑stricken parents.
Doctor – A Victorian family doctor with a furrowed brow,
hand resting on the bearded chin, gazing intently at his

Table 1a: Competencies for humanities already included in undergraduate curriculum with respective learning
Competency
Human anatomy AN82.1:
Demonstrate respect and follow the
correct procedure when handling
cadavers and other biologic tissue[6]
Internal medicine IM26.20:
Demonstrate ability to
communicate to patients in a
patient, respectful, nonthreatening,
nonjudgmental and empathetic
manner[7]
Internal medicine IM26.4: Describe
and discuss the role of autonomy
and shared responsibility as a
guiding principle in patient care[8]
Internal medicine IM26.36:
Demonstrate ability to balance
personal and professional
priorities[9]
objectives
Learning objectives
Describe the importance of compassion with cadavers and biological tissue
Describe the ethical aspects of cadaver dissection
Demonstrate the ethics to be followed while handling cadavers
Demonstrate the preparative steps for cadaver dissection
Enumerate the steps for proper disposal of biological tissues
Demonstrate the steps for proper disposal of biological tissues after dissection
Describe the basic elements of effective communication skills
Describe the importance of good communication skills in medical practice
Describe the importance of listening and empathy while communicating with patients
Demonstrate communication with patients in a language that the patient understands
Understand the common barriers in patient communication
Perform a physical examination without causing any emotional or physical discomfort to the patient
Define “autonomy”
Discuss the rights of patients in making decisions about their own medical care
Discuss the role of physicians in maintaining patient autonomy
Discuss the principle of “shared responsibility” in patient care
Describe the causes and consequences of interpersonal conflict
Describe strategies to manage various conflicts in relation to the health profession
Describe the roles and responsibilities of a health‑care professional
Understand the personal and professional priorities of health‑care professionals
Understand the importance of time management
Understand the ways to maintain work life balance
Describe the leadership qualities in a health‑care professional
Understand the importance of visual arts, meditation, and sports in relieving stress
Demonstrate fairness and professional regard in health care

CHRISMED Journal of Health and Research | Volume 9 | Issue 2 | April-June 2022 119
 Mahajan, et al.: Humanities in HPE

Table 1b: Other possible competencies for humanities with respective learning objectives that can be included in
undergraduate curriculum
Competency Learning objectives
Critically analyze the attributes of a good Describe the health‑care system and its delivery accurately
health‑care professional, relevant to his/her Discuss the attributes of a good health‑care professional precisely
defined role in health‑care system Analyze his/her role as a good health‑care professional in delivering health care to the
society and system specifically
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Appreciate and critically analyze the role
of humanities in patient care, its perceived
under‑utilization in the health‑care system and its
potential benefits for the health‑care professionals
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Define medical humanities accurately
Evaluate the role of medical humanities in patient care and health‑care system
Discuss the reasons for under‑utilization of medical humanities in the health‑care system
Evaluate the potential benefits of medical humanities for health‑care professionals

Demonstrate ability to handle the socioeconomic
and cultural diversity among different patients
with respect and sensitivity
Demonstrate empathy and altruism while
administrating curative and palliative therapy in
patient care after understanding the needs and
preferences of the patients
Demonstrate respect toward diversity among the
community of people with disabilities
Demonstrate ability to break bad news to the
patient effectively and sensitively
Demonstrate respect and care while dealing with
vulnerable population
Demonstrate ability to use exercise, music, and
art in dealing stress and burn‑out in patients/
care‑givers/health‑care professionals
Understand the importance of socioeconomic and cultural diversity in patient care
Demonstrate steps to handle socioeconomic and cultural diversity among different
patients with respect and sensitivity
Understand the needs and preferences of patients while administrating curative and
palliative therapy
Illustrate the concept of empathy and altruism
Demonstrate empathy and altruism while administrating curative and palliative therapy
in patient care
Understand the respect toward diversity among the community of people with
disabilities
Demonstrate respect toward diversity among the community of people with disabilities
Illustrate steps to break bad news to a patient effectively and sensitively
Demonstrate ability to break bad news to a patient effectively and sensitively
Illustrate steps to provide respect and care while dealing with vulnerable population
Demonstrate respect and care while dealing with vulnerable population
Describe the ways to deal with stress and burnout in patients/care givers/health
professionals
Discuss the importance of music, creative arts, and exercise in dealing with stress and
burnout in patients/caregivers/health professionals
Demonstrate the use of music, creative arts, and exercise as a stress buster in patients
and caregivers
Demonstrate the use of music, creative arts, and exercise as a stress buster in health‑care
professionals

relationship. The physician is attending the patient,

Figure 1: A classic Norman Rockwell painting (in 1929)
patient, on his home‑visit. There is nothing much to be done
by him to save the child, but he still is there, just to keep a
vigil as the delicate child’s breath is getting shallower.
Key point: This painting is a strongly expressive portrayal
of what medicine is all about – doctor, patient, and their
apparently observing and waiting. It teaches us the value
of a patient‑centered approach. It signifies the commitment
and dedication to one’s profession.
Practical implications in existing times – Fildes himself
believes that this painting is neither historically accurate
and nor close to reality. With the advent of technology,
there is no longer a need to sit by a patient for extended
vigilance. However, it endures to foster empathetic
relationships between doctor and patient to avoid the
mechanization of medical practice in the present times.
Painting‑2 A classic Norman Rockwell painting (in 1929).[12]
Setting – It is a doctor’s office and the girl is there for a
check‑up as the girl is standing in the doctor’s office. The
doctor’s patient, the little girl, is in turn holding her doll as
a patient for him to examine.
Background – The doctor has a large black bag lying on
the rug on the floor implies doctors made house‑calls to
visit patients. Perched on top of his desk are thick books,

120 CHRISMED Journal of Health and Research | Volume 9 | Issue 2 | April-June 2022
 Mahajan, et al.: Humanities in HPE
brass candlesticks, and pictures. Behind the books, hanging
on the wall, is the doctor’s “registration” document.
Doctor – An old, well‑dressed doctor, seated in his
office, attending a patient from his wooden chair. With
his head craned to the right and upward, he concentrates
on his patient and examines the doll using a stethoscope.
He is pretending to look amused. In fact, the girl has
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removed her doll’s dress to help the doctor closely
examine her doll. The doll’s dress is held close to her
with the elbow.
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Key point: This painting intricately brings about the gaps
between doctor’s perceptions and patients expectations
in their first encounters. The patient, slyly testing the
skills of the doctor by letting him examine her doll first.
Will he pass this test? The doctor is playing it through, to
bridge this gap. Trying to win her trust, he opens up the
channels of communication with her in a playful manner
(Paternalistic model).
Painting‑3 A famous painting of Dr. Gross Clinic, by
Thomas Eakins (in 1875). Content is available under CC
BY‑SA 3.0 [Figure 2].[13]
The painting is based on a surgery in which Dr. Gross had
treated a young man for osteomyelitis of the femur and was
witnessed by Eakins. Dr. Gross is pictured here performing
an operation.
Setting – Gross clinic defines a scene of an on‑going
operation. Anonymous patient with an ether mask placed.
An anesthesiologist at the head of the table. An incision on
the left lateral thigh of the patient to approach the involved
part of the femur.
Background – The patient’s mother, toward the left,
demonstrates her suffering with a raised hand and coiled
fingers like a claw. A few students are seen taking notes as
the surgeon pauses in between to explain the details of the
procedure to his students.
Doctor – The dominating, dignified figure of Dr. Gross,
dressed in black, with bright red blood on his right hand,
holding the scalpel. Something terrible, unutterable going
Figure 2: A famous painting of Dr. Gross Clinic, by Thomas Eakins (in 1875)
CHRISMED Journal of Health and Research | Volume 9 | Issue 2 | April-June 2022
on in his mind, in the shadowed stony hard face. His eyes
reveal the knowledge of sickness and pain.
The assistants look dauntlessly at the wound they are
holding open. The audience watches the process in order
to learn. This is an arena with Eakins portraying Gross as a
modern hero. In the background, a woman claws her hands
horrified, attempting to cover her face. In contrast, the
calm and heroic ability of Dr. Gross to look and see. The
woman cringing in distress is in dramatic contrast with the
composed professional demeanor of the men surrounding
and operating on the patient.
Key point: This painting distinctly exhibits that the
entire burden and responsibility of this crucial moment
between life and death is in Dr. Gross’s slightly
disengaged moment of thought – depicting the life of
a typical surgeon! Eakins purposely puts both hands
(of Dr. Gross and the woman) close to each other
to allow the viewer to compare the rational with the
emotional. It also conveys the importance of team‑work
and collaboration between the doctors to achieve a
common goal of patient well‑being!
Painting‑4 A self‑portrait by Goya (in 1820) expressing
his gratitude for the gift of life, to his friend Dr. Arrieta.
Content is available under CC BY‑SA 3.0 [Figure 3].[14]
Setting ‑ The scene is of Goya’s bedroom. He is sitting
on his bed in a dressing gown, grasping the sheet as if
clinging on to life. He is supported from behind by the arm
of Dr. Arrieta. The portrait is an empathetic representation
not only of Goya but also of the universal patient,
personifying the plight of the ill and sick who, withered,
limp and unkempt, is reduced to an infantile condition to
be comforted, treated and ordered to obey.
Background – Shadowy figures in the background, perhaps
of servants and a priest seem to be indicators of impending
doom. The intruding shadows witnessing his pending
demise.
Figure 3: A self-portrait by Goya (in 1820) expressing his gratitude for the
gift of life, to his friend Dr. Arrieta
121
 Mahajan, et al.: Humanities in HPE
Doctor – He is holding Goya firmly and stoically administers
the medication. The physician is at least kind, warm, and
obliging if not overtly hopeful. His embrace reflects his
instinct to alleviate pain as well as his incognizance of the
risk to himself from proximity to an ill person.
Key point: This painting beautifully portrays the actions of the
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doctor who is aware of his limitations in reversing the course
of illness and who focuses on what is within his ability – to
provide comfort and support. His compassion brings about
probably the silver lining effect in the dark life of the patient.
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Appraisal through case scenarios
The basic aim is to use creativity and self‑expression
for education and clinical practice to develop attributes
of humanities. Practicing medicine requires effective
communication skills, empathy, self‑awareness, judgment,
professionalism, and mastering all contexts of illness
and health. Within medicine, “emotional intelligence” is
thought to be equally important, particularly in perspective
on the cautious administration of feelings required in
patient consideration and practice. Emotional intelligence
is a psychological “construct.”[15] It has been developed
conceptually to represent a characteristic in which
individuals differ. “Profession” is derived from the Latin
word “Professio,” which means a public declaration with
the force of a promise.[16] A professional is someone who
can work best when he/she does not actually feel like doing
so. Hence, certain case‑scenarios were designed to suggest
strategies to resolve certain dilemmas in our professional
life, abiding by professionalism and ethical values.
1. Beneficence - is doing good and what is right for the
patient. Even if one has any interpersonal rivalry or
conflict of interest among his/her colleagues, one needs
to get above personal feelings and give the best to
patients.[17]
Case scenario: “You are the unit head having five
postgraduate (PG) students. One of your PG student
appears to be brilliant and punctual aspiring to take up
post‑PG fellowship in your department. His sincerity
is evident but out of envy, his fellow residents keep
complaining about him for sub‑optimal professional
conduct in managing ward patients. This peer conflict
leads to frequent compromise in patient care. As the unit
head, how will you manage this peer rivalry among PG
students causing potential compromise in departmental
functioning and patient care?”
2. Accountability - is accepting moral responsibility for
one’s own actions. Doctors and nurses are accountable
for the care they provide and their related actions.
They must accept all the professional and personal
consequences resulting from their actions.[18]
“Deception, even by omission, is a powerful betrayer of
trust.”
Case scenario: “You have posted a case for an elective
surgery tomorrow. The patient, though rich and affluent,
122 CHRISMED Journal of Health and Research | Volume 9 | Issue 2 | April-June 2022
wishes to be operated by you in a government setup
because of her faith and trust in you as an expert. In
the evening, you get the news that your father has been
rushed into a hospital in another city with a medical
emergency. He needs to undergo an emergency surgery
and your mother would like you to be with her during
this difficult time. You have the option of requesting
your equally competent departmental colleague to do
your planned surgery. What do you do? How would
you deal with the patient?”
3. Justice is fairness - A doctor must be fair in providing
care i.e., care must be fairly, justly and equitably
distributed among all patients.[19]
Case scenario: “It comes to your notice that one of your
young junior faculty prescribes irrational treatment and
investigations to patients to favor certain pharmaceutical
companies and laboratories. Your students often come
to you to discuss the rationale behind those treatments
and investigations. You realize that the faculty is setting
up a wrong example for the students. How do you deal
with the faculty? What and how do you explain it to the
students?”
4. Nonmaleficence ‑ is doing no harm, neither intentional
or unintentional.[20]
Case scenario: “You are the head of your department.
A few students approach you with a complaint that
one of your senior faculty asks them to help in his
household chores, run his extra errands and take care
of his elderly critically ill mother. The students cannot
refuse the faculty out of fear of his being a potential
examiner. However, they inform that this compromises
their study and extracurricular time. How would you
manage this situation?”
Reflection through cinemeducation
Medical education has often been criticized for not
focusing enough on empathy, altruism, and inter‑relational
skills. The way forward is converting this “high‑tech”
to “high‑touch” medicine, by re‑humanizing medicine.
A humanistic approach “considers people in their intra‑ and
inter personal, cultural, political, economical, spiritual, and
historical contexts.” It is imperative to give importance
to the emotions of both patients and physicians. Patients
should not be considered only as biological bodies but
also as physical and psychological respectful individuals.
Medicine be defined as a “fundamentally inter‑subjective
practice,” bringing a focus to the patient‑care provider
interaction with a tone of “mutual respect,” “empathy,”
and “compassion” between patient and health‑care provider
rather than detachment and dehumanization.
The first report about the use of cinema in medical
education was published in 1979 when viewing of movies
followed by thoughtful discussion was used in psychiatry
residency education. They bring dry content to life and
help convey difficult topics and concepts and stimulate
 Mahajan, et al.: Humanities in HPE

open discussion. The term “cinemeducation” was coined by
Alexander et al. to refer to the use of clips from movies
and videos for educating medical students about the
psychosocial aspects of medicine.[21]
Movies and the health humanities: Cinemeducation has
been mentioned as a unique and enjoyable narrative medical
approach to the teaching‑learning of health humanities. In
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Expression through poetry
Poetry can be a powerful tool in teaching interpersonal
and scientific aspects of medicine. Advantages of using
poetry include emotional intensity, succinct, portable
formulations and communication of encompassing,
“existential” truths. Limitations include learners’ lack
of familiarity with the medium of poetry, and the need

group settings, it can be helpful in brainstorming, creating
useful ideas, and sharing perspectives about the scenes
and characters in the movie from different perspectives.
The experience of films consists of a double empathetic
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/24/2024
to negotiate multiple, complex meanings.[22] Poetry
can be used in active (that is by writing) or in passive
(by analyzing) to express an emotion, develop relations
with patients, their families and future colleagues, convey

sharing: The first with the characters and the second with thoughts and provide emotional and psychological faith,
others present physically or virtually during the screening. reducing physician burn‑out as it is a means of vent‑out.
Furthermore, the ability of films to engage learners in One of the poems written by the one of the authors of this
discussions is a part of the active learning process in which article (AM), in this regard‑
learners build concepts or ideas from preexisting foundations.
Looking through the eyes of cinema
Movies play an important role in the medical humanities and I am in a state of enigma.
have been used to address various subjects such as medical Where is the line …
ethics, professionalism, doctor–patient relationships, clinical Between humanity, technicality and reality?
research, and mental illness. Movies involve the affective Taking a robot out of a human
domain and promote reflection and experiential learning. Or instilling a human into a machine.
Movies can teach empathetic behaviors, self‑reflection, What is that we want to redeem?
compassion, and other skills [Table 2]. Be it “End of life”

Table 2: List of movies that can be used for cinemeducation

Topic Bollywood Hollywood
Empathy Guzaarish, My brother Nikhil, Whose life is it anyway? Terms of endearment, Leaving Las Vegas, Wit,
Munnabhai M.B.B.S. Shadowlands, My life, Dead man walking, The story of us, Gifted hands
Altruism Awakenings, Dallas buyers’ club, The English surgeon
Interpersonal skills Munnabhai M.B.B.S. Doctor in the house, People will talk
Disability Zero, Taare zameen par, Margarita My left foot, The theory of everything, Million dollar baby, What’s eating
with a straw, Pa, Guzaarish Gilbert Grape, The fundamentals of caring, Gattaca
Euthanasia Guzaarish Whose life is it anyway?, Million dollar baby
End of life care Anand, Piku, Waiting End game (Netflix series)
HIV My brother Nikhil, Phir milenge And the band played on, Philadelphia, Longtime companion
Autism Barfi, My name is Khan Please stand by, Snow cake, Change of habit, The boy who could fly, A boy
Called Po, What’s eating Gilbert Grape
Congenital heart disease Once upon a time in Silent cries, Hospital (Episode number 5.3)
Mumbai (2010)
Blindness Black Ichi, At first sight, Blindsight, Proof, The miracle worker
Deafness Koshish (1972) The miracle worker, See what I’m saying: The deaf
Entertainers Documentary, The hammer, Deaf jam, And your name is Jonah
Mental illness Khamoshi (1969) A beautiful mind, One flew over the cuckoo’s nest, Shine, I am Sam,
Infinitely polar bear
Human sexuality/Varied My brother Nikhil Flawless
lifestyles
Toxic pollutants and Toxic price of leather A civil action, Erin Brockovich
Health hazards
Corporate Ethics Kalyug, Corporate, Ankur Arora The constant gardener, Contagion
murder case
Dementia U me aur hum Away from her, Iris, Still Alice
Cultural diversity Rang de basanti, Lagaan Something the Lord made, Miss Evers boys, The legend of 1900, Blood
diamond, Nurse Betty
Ethics Rann, Noor, Nayak Modern times, A man for all seasons, The Shawshank redemption
Medical Professionalism Traffic, Ankur Arora murder case Patch ADAMS, Awakenings, Lorenzo’s oil, The death of Mr. Lazarescu
Listening skills English vinglish The spitfire grill, Dead man walking, Prince of tides, One true thing, Momo

CHRISMED Journal of Health and Research | Volume 9 | Issue 2 | April-June 2022 123
 Mahajan, et al.: Humanities in HPE
Or apprehensions to continue life
Whether it is to relieve them of their physical pain
Or to give them an emotional gain
What comes in a doctor’s domain?
To feel and reduce the suffering the patients contain
A rendezvous of humanism and medicine one can obtain.
A new hope that would be enough.
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for the patients to sustain!!”
Conclusion
Humanities are an integral part of the health profession.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/24/2024
This profession mandates that a humane approach toward
patients is as necessary as is the knowledge and clinical
skill. The month long discussion on the various aspects
of humanities proved fruitful for FAIMER fellows who
were sensitized to train their health profession students and
faculty in their respective institutions. The incorporation
of experiential teaching and learning methods can help us
achieve the transition from “high‑tech” to “high touch”
health professions education.
Acknowledgments
We would like to acknowledge the contribution of all
fellows, advisors, and faculty of CMCL FAIMER during
the moderation month of the fellowship.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Pellegrino, Edmund D. The philosophy of medicine reborn; a
pellegrino reader. In: Jotter F, Tristram Englehard H Jr., editors.
Notre Dame Studies in Medical Ethics. Notre Dame, Indiana:
University of Notre Dame Press; 2008. p. 309.
2. Warner JH. Science in Medicine. 2nd Ser 1 Oriris; 1985. p.38-9.
Available from: https://www.jstor.org/stable/301724.
3. John M. From Osler to the cone technique. HSR Proc Intensive
Care Cardiovasc Anesth 2013;5:57‑8.
4. Feinstein AR. Clinical Judgement. Baltimore: The Williams &
Wilkins Company; 1967. p. 363.
5. A Call for Action against Burn‑Out. Available from: http://
humanizandoloscuidadosintensivos.com/en/a‑call‑for‑action‑
agaist‑burnout/. [Last accessed on 2020 Jul 13].
6. Medical Council of India. Competency Based Undergraduate
Curriculum for the Indian Medical Graduate. Vol. 1. Medical
Council of India; 2018. p. 81. Available from: https://wbuhs.
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ac.in/wp-content/uploads/2019/01/UG-Curriculum-Vol-I.pdf.
[Last accessed on 2022 Nov 29].
7. Medical Council of India. Competency Based Undergraduate
Curriculum for the Indian Medical Graduate. Vol. 2. Medical
Council of India; 2018. p. 103. Available from: https://www.nmc.
org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf.
[Last accessed on 2022 Nov 29].
8. Medical Council of India. Competency Based Undergraduate
Curriculum for the Indian Medical Graduate. Vol. 2. Medical
Council of India; 2018. p. 102. Available from: https://www.nmc.
org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf.
[Last accessed on 2022 Nov 29].
9. Medical Council of India. Competency Based Undergraduate
Curriculum for the Indian Medical Graduate. Vol. 2. Medical
Council of India; 2018. p. 105. Available from: https://www.nmc.
org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf.
[Last accessed on 2022 Nov 29].
10. Miller A, Grohe M, Khoshbin S, Katz JT. From the galleries to
the clinic: Applying art museum lessons to patient care. J Med
Humanit 2013;34:433‑8.
11. Available from: https://en.wikipedia.org/wiki/The_Doctor_
(painting). [Last accessed on 2020 Jul 13].
12. Available from: https://prints.nrm.org/detail/260820/
rockwell‑doctor‑and‑the‑doll‑1929. [Last accessed on
2020 Jul 13].
13. Available from: https://en.wikipedia.org/wiki/The_Gross_
Clinic. [Last accessed on 2020 Jul 13].
14. Available from: https://en.wikipedia.org/wiki/Self‑portrait_with_
Dr_Arrieta. [Last accessed on 2020 Jul 13].
15. Cherry MG, Fletcher I, O’Sullivan H, Dornan T. Emotional
intelligence in medical education: A critical review. Med Educ
2014;48:468‑78.
16. Heller JC, Murphy JE, Meaney ME. A Guide to Professional
Development in Compliance. Ch. 1. Aspen Publishers Inc.,;
2007. p. 3.
17. Kinsinger FS. Beneficence and the professional’s moral
imperative. J Chiropr Humanit 2009;16:44‑6.
18. Aveling EL, Parker M, Woods MD. What is the role of individual
accountability in patient safety? A multi-site ethnographic study.
Sociol Health Illn 2016;38:216‑32.
19. Ambrose AJ, Andaya JM, Yamada S, Maskarinec GG. Social
justice in medical education: Strengths and challenges of a
student‑driven social justice curriculum. Hawaii J Med Public
Health 2014;73:244‑50.
20. Berdine G. The Hippocratic Oath and principles of medical
ethics. Southwest Respir Crit Care Chron 2015;3:28‑32.
21. Alexander M, Lenahan P, Pavlov A. Cinemeducation: A
Comprehensive Guide to Using Film in Medical Education. 2005.
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researchgate.net/publication/237829512_Cinemeducation_A_
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22. Wellbery C. On the use of poetry in medical education. J Learn
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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/350163386

Triple Cs of self-directed learning: Concept, conduct, and curriculum placement

Article in CHRISMED Journal of Health and Research · January 2021

DOI: 10.4103/cjhr.cjhr_13_21

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Review Article

Triple Cs of Self‑Directed Learning: Concept, Conduct, and Curriculum

Placement

Abstract Dinesh Kumar

Self‑directed learning (SDL) is one of the teaching‑learning methods that can be used in medical Badyal1,2,
education at all levels. The use of SDL in undergraduate (UG) teaching is becoming common due to Hem Lata3,
the implementation of competency‑based education in many countries. The new competency‑based
UG medical curriculum in India includes lifelong learning skills as one of the major components. Monika Sharma4,
The SDL method is reported to increase the lifelong learning skills of students. The concept of SDL Anjali Jain5
is based on experiential learning and its conduct needs proper understanding of the concept. The Departments of 1Pharmacology
conduct can include two contact sessions and an intersession or gap period of few days. The contact and 2Medical Education,
sessions focus on introduction, facilitation, and debriefing. The intersession period is the real learning Christian Medical College
and Hospital, 3Department
period for the students. SDL also includes the use of various assessment methods. All SDL sessions
of Physiology, Dayanand
are followed by an evaluation of various stakeholders. Advancements in information technology (IT) Medical College and Hospital,
and the advent of many innovations in teaching can be aptly used in SDL conduct and evaluation. Departments of 4Paediatrics and
The present coronavirus disease 2019 (COVID‑19) pandemic has further provided opportunity to use 5
Anatomy, Christian Medical
IT in the new normal post‑COVID‑19 times. Curriculum placement must be done in alignment with College and Hospital, Ludhiana,
other teaching‑learning methods. Training of facilitators, availability of resources, and preplanning Punjab, India
help in successful SDL conduct. If implemented appropriately, SDL can be a great method to help
students in their postinstitute lives.

Keywords: Competency, curriculum, facilitator, information technology, self‑directed learning

Introduction Council for Graduate Medical Education

Various methods and strategies in learning
are being implemented in many countries
for undergraduate (UG) medical curriculum.
Self‑directed learning (SDL) is a relevant
and recommended method for UG medical
education.[1‑3] All of us have imbibed a part
of our learning in medical education through
SDL. SDL can be used at all levels of
learning, i.e., UG, postgraduates, and faculty
development. Its most interesting use is at
the UG level as it is an apt time to inculcate
SDL skills that can continue to develop and
help in learning during postgraduation and
beyond as a faculty or professional. SDL
skills have been reported to later on improve
the performance of physicians and patient
care.[4] Therefore, the proper understanding
of SDL skills can play a major role in
improved learning throughout life.
One of the important broader goals of UG
medical education curriculum in many
countries is to create lifelong learning
skills in the students. The Accreditation
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are
licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
has included lifelong learning skills as
one of the major components in resident
teaching. The American Board of Internal
Medicine includes lifelong learning skills
as one of the requirements for physicians.[1]
The new UG curriculum implemented in
India from 2019 has also included the goal
of making students, lifelong learners. It
has been recommended that SDL should Submitted : 24‑Jan‑2021
Revised : 28-Jan-2021
be utilized frequently to develop lifelong
Accepted : 04-Feb-2021
learning skills in UG students.[5] Therefore, Published : 18-Mar-2021
SDL is a goal in many curricula as well as
teaching‑learning methods.
Address for correspondence:
SDL adds variety to teaching‑learning Dr. Hem Lata,
methods and provides an option to Department of Physiology,
Dayanand Medical College and
curriculum makers to choose this method Hospital, Ludhiana ‑ 141 001,
in alignment with some learning objectives. Punjab, India.
The conduct of SDL is quite variable at E‑mail: hembadyaldr@gmail.
different places.[2,6,7] In several instances, it com
is confused with self‑learning or just asking
students to read from books but remaining
Access this article online
unobserved. Students and teachers have
shown apprehension about the freedom in Website: www.cjhr.org
learning in countries where teacher‑oriented DOI: 10.4103/cjhr.cjhr_13_21
learning has been there for a long time. The Quick Response Code:
How to cite this article: Badyal DK, Lata H,
Sharma M, Jain A. Triple Cs of self‑directed learning:
Concept, conduct, and curriculum placement.
CHRISMED J Health Res 0;0:0.

© 2021 CHRISMED Journal of Health and Research | Published by Wolters Kluwer - Medknow1
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Badyal, et al.: Triple Cs of self‑directed learning
placement in the teaching schedule is also quite variable
and often not preplanned.[2,8] Therefore, more clarity on
concept, conduct, and placement in the new curriculum can
play a vital role in the acceptability and implementation of
SDL. In this review, we look at the concept behind SDL
and how it can be conducted and placed in the curriculum.
Concept
Definitions and theories
There have been many quotes as well as definitions for
SDL. One of the most widely used definitions was given
by Knowles. It states that SDL is “a process in which
individuals take the initiative, with or without the help
of others, in diagnosing their learning needs, formulating
learning goals, identifying human and material resources
for learning, choosing and implementing appropriate
learning strategies, and evaluating learning outcomes.”[1]
Collins and Hammond (1987) described SDL as “a process
in which learners take the initiative, with the support and
collaboration of others.”[9]
Various models have been described to give a perspective
to SDL. Some say it is a process where an individual’s
voluntariness is more important than instructions while
others consider it more of a personal perspective where
a mature adult takes responsibility of his/her learning.
However, some relate it to context‑based methods.[10,11]
Two learning theories are involved in the process of SDL,
cognitivism theory and humanism theory. In cognitivism
theory, the student uses cognitive tools, such as information
processing, perceptions, and memory to facilitate learning.
It includes acquiring, storing, and retrieving information.
The learner develops skills for effective SDL. The teacher
facilitates the learner about “learn how to learn.” This
theory represents internal cognition restructuring due to
changes in individual’s knowledge. As per humanism
theory, learning is more related to one’s own growth
as a doctor and human being. There is the exploration
of one’s emotions and changing the identity of one’s
self. Self‑directed learning is one of the most important
principles of this theory.[10] Although there are several
definitions and interpretations, the essence of SDL remains
in its words, i.e., self (learner oriented), directed (facilitated
and monitored), and learning (applicable to lifelong
learning).
The need
Learners are not preprogrammed for SDL. There are
situations where learners need to have a desire to learn
and ability to do so without direct supervision. One of that
scenarios is the recent pandemic that has paralyzed the
entire world. Based on experiential learning, immediate
reactions were that people (leaners here) in all countries
started using masks, handwashing, and social distancing.
Long‑term adaptions which were appropriate led to better
2 CHRISMED Journal of Health and Research | Volume XX | Issue XX | Month 2021
management of pandemic by people/leaders (learner here)
in some countries [Figure 1]. Experiential learning is based
on Kolb’s learning cycle.[12,13]
Various challenges in medical education can be met with
the development of SDL skills in students. Some of these
challenges are:
• Vast curriculum taught by a variety of teachinglearning
methods
• Different learning styles and pace of learning of
students – SDL allows students to learn at their own
pace and with their own learning style
• Shrinking faculty – SDL enables students to take
responsibility of a part of their learning/syllabus
• Need to constantly update knowledge – as we look
at developing students as lifelong learners, SDL is
reported to make them ready to update knowledge on
their own
• Difficulty in understanding relevance of the varied
subjects and memorization – SDL is known to improve
a student’s ability to cross‑link learning context and
improve retention and application of knowledge[4]
• Addressing adult learners – SDL treats medical students
as mature adult learners. This improves their learning[14]
• Need for the globalization of medical education– global
learners are being given similar experiences and
opportunities to learn
• Advent of online learning and virtual universities:
pandemic has made us experience online courses; more
virtual courses and may be virtual universities too can
be a possibility in new normal after pandemic[15]
• Cost of higher education – E‑learning is an excellent
example of SDL that is a cost‑effective solution to
higher education in certain areas of medical education.
Conduct
Several publications are available on the concept and theories
related to SDL.[2,6‑8] However, the design of SDL sessions
and their successful implementation is still a challenge.
One of the major concerns that plague SDL is that teachers/
faculty either start lecturing in SDL session or make students
compulsorily sit in a classroom with their books. The finer
details of the process are often overlooked. SDL is not the
same as asking students to sit down in a room, open books,
and read. It is different from self‑learning too. Self‑regulated
learning is very focused approach with specific tasks, while
SDL is a general approach for learning.[16] Students also find
it challenging and very demanding. As in the number of
countries, students are tuned to spoon‑feeding in the schools,
and hence, it is not easy for them to shift gears for SDL that
needs them to manage their overall learning activities and
monitor their own performance.[2,3]
Various preparations are needed before start of SDL
sessions. These include:
• Faculty training, formation of core committee
• Selection of topics and placement in the curriculum
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Badyal, et al.: Triple Cs of self‑directed learning
Figure 1: Experiential leaning and adaptations
• Orientation of students to SDL program
• Gathering resources necessary for starting SDL
program, i.e., venue, timetable adjustments, computers
with Wi‑Fi connection, computer personnel
• Formation of online group of the students and faculty
• Distributing prereading information to the students
• Actual conduct of SDL session.
Let us discuss few important steps
Selection of topic
Selection of appropriate topic is important to appeal
to a student’s interest and motivate them to learn by
themselves. For example, a person from India might be
more interested to learn French; an American baseball
player might be more interested to learn about cricket.
Choose topics which stimulate thinking of the students.
The topic should be doable in the time frame and should
not just be a collection of huge data or merely a topic
which has minimal information available. Taking into
consideration, the above points now review syllabus or
competencies in the curriculum to identify which topic
is best suited to be learned by SDL. Topic can be in the
form of a competency (s) and can be introduced as a
case, trigger or just as a topic statement, for example,
management of shock, antiplatelet drugs, management of
Parkinson’s disease, pharmacotherapy of tuberculosis, oral
contraceptives, and pharmacovigilance in the subject of
pharmacology in the second phase of MBBS curriculum.
Assess readiness to learn
Students who are autonomous, organized, self‑disciplined,
able to communicate effectively, able to accept constructive
feedback and engage in self‑evaluation and self‑reflection can
be considered as ready to learn by SDL. These components
are also part of other teaching‑learning methods. Studies
show that students in Asian countries where traditional
teaching has been used for a long time need more support
and guidance in the initial years of SDL.[3,17]
CHRISMED Journal of Health and Research | Volume XX | Issue XX | Month 2021
Designing module
This involves finalizing the contents based on the selected
topic. Review the information available/resources for the
students. Decide on the number of contact sessions and
duration of the intervening period. Decide on how many
hours are needed for contact sessions.
Actual conduct of the session
A sample SDL session conduct is described in Figure 2 and
can be used in competency‑based UG medical curriculum.
One topic can have two contact sessions and intersession
period/gap interval of 7 days. Each contact session can be
of 60 min duration [Figure 2].
i. First contact session: it includes instruction to the small
group (8–15 students). Students get a piece of information
on a relevant topic in the form of a case or a trigger.
Students set learning goals and milestones to be achieved
and various modes of their achievement. Learners need
to take responsibility for their learning; remember that in
SDL learner has a very important place.
Every student has to define his/her needs and approach.
This can be through various ways of learning such as deep
approach, superficial approach, or strategic approach. In
SDL, the role of the teacher is as a facilitator. The facilitator
helps in refining goals and finding resources and informs
the time limits. Teachers need to shift gears from being an
information provider to being a facilitator. The facilitator
needs to enhance learning in the process of learning and
enhance their critical thinking.[13,18] This continues in the
intersession period too, and facilitator in a way bakes the
learner to become self‑directed learners. This is not so
easy, as several times, teachers start a minilecture as they
are bubbling with knowledge.
ii. Intersession period: this period extends over days and
students find and explore resources, read and approach
facilitator as needed. Facilitator’s role is to facilitate
learning, guide for resources, and make sure to engage
them in learning. Students learn to manage their own
3
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Badyal, et al.: Triple Cs of self‑directed learning
Figure 2: Plan for conduct of self‑directed learning
time as well as resources. Resources, especially, in
coronavirus disease 2019 (COVID‑19) times can
include YouTube videos, surfing the internet using key
words, e‑journals, and e‑books
iii. Second contact session: this session is for 60 min
and involves debriefing, and during debriefing, there
are many opportunities for learning to be assimilated.
Facilitator needs to guide on those learning points
keeping in view the learning goals. This session also
involves assessment of learning.
Assessment of students in SDL can involve multiple
methods, i.e., grading of project work, grading of the
case presentation, through questionnaires, self‑assessment:
online quizzes, tests, games, Objective Structured Clinical
Examination, Objective Structured Practical Examination,
tutorials, multiple‑choice questions, feedback from peers/
facilitators/experts, and reflections. Learning management
system can be very handy to record these assessments.
Evaluation of SDL is done at the end of all sessions of
a topic. This can be done after few topics have been
covered under SDL. Evaluation considers the overall SDL
program and may involve many methods, i.e., grading
done by facilitator, immediate feedback, logbook entries,
multisource feedback, portfolios, assessments conducted,
number of hits at resources, library visit entries, and
reflections. In one’s institution, one can decide all time
durations as per the curriculum implementation plans.
Curricular Placement of Self‑directed Learning
in Curriculum
Every curriculum uses various methods to teach students.
The use of multiple methods improves learning. Based
on syllabus or competencies, decide how many topics are
4
to be covered with SDL in each subject. Each topic will
need 2–3 SDL slots in timetable in continuity. This spaced
learning to visit the topic after few days is helpful for
long‑term retention and confers to spiral curriculum.[13]
Then, distribute SDL sessions over the entire year for each
subject. Make sure that topics are in alignment with other
topics being covered by other teaching‑learning methods.
Avoid crowding together of SDL session in few months
only. If students are getting exposed to SDL for the first
time, they will need more time for initial SDL sessions.
Once they understand the process, then it would be easier
for students to go through these sessions.
Make sure of the availability of facilitators for SDL
sessions. Spacing SDL sessions can help in that concern.
Apart from faculty, postgraduate students can also be
facilitators but train them in facilitation skills.
Use of media and current technologies in self‑directed
learning
Information technology (IT) plays a big role in medical
education and is very apt to be used in SDL. This is so true
in the COVID‑19 era, where all educational courses have
shifted to online modes using IT throughout the world. In
fact, technology can help a lot in SDL implementation,
especially in the monitoring process. The hits by students
on particular website can be monitored through institutional
servers when students log into institutional library services.
Video recording of sessions can be done. Online resources
can be provided to students on the institutional learning
management system. In case‑designing, various online
videos, cases, etc., can be used.[19]
Students can share the ideas/projects/research/presentations
with peers on Google groups, WhatsApp, Telegram,
CHRISMED Journal of Health and Research | Volume XX | Issue XX | Month 2021
[Downloaded free from http://www.cjhr.org on Saturday, March 20, 2021, IP: 61.2.22.15]
Badyal, et al.: Triple Cs of self‑directed learning
Signal, etc., where they will get feedback and improve
in that field. Online simulations can be used for skills
learning.[20] Advanced technologies such as soft boards,
scanner highlighter, smartphones, and smartwatches
can also be useful. Facilitators can share links to online
resources. Online tools can be used for debriefing.
There are several challenges in designing and implementing
SDL in an institute. Various studies have reported as
motivation to be a leading challenge, as facilitators and
students need to invest a lot of time and resources. Keep
in mind the workload on students and use SDL as one of
the teaching‑learning methods.[8,12,18-21] The time investment
by facilitators in SDL is not a part of the usual teaching
responsibilities of teachers in India. Training of facilitators
and availability of resources have to be planned well before
sessions. Monitoring the intersession period is a challenge
with the existing setup in many institutions in India.
Electronic monitoring, use of IT, and access to reliable
resources are another challenge. One of the models for
SDL describes a three pillars model for SDL that focuses
on these areas. The three pillars include skills, motivation,
and self‑belief, and strengthening these components can
take care of some of these challenges.[13]
To conclude, SDL can have a very high impact role in
medical education if used appropriately. The concept
should be understood entirely to implement it successfully.
The training of the facilitators and readiness of students
must be ensured before starting SDL sessions. The sessions
in an institute can be further improved based on feedback
from stakeholders.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Murad MH, Varkey P. Self‑directed learning in health professions
education. Ann Acad Med Singap 2008;37:580‑90.
2. Leatemia LD, Susilo AP, van Berkel H. Self‑directed learning
readiness of Asian students: Students perspective on a
hybrid problem based learning curriculum. Int J Med Educ
2016;7:385‑92.
3. Premkumar K, Vinod E, Sathishkumar S, Pulimood AB,
Umaefulam V, Samuel PP, et al. Self‑directed learning readiness
of Indian medical students: A mixed method study. BMC Med
Educ 2018;18:134.
4. Boyer SL, Edmondson DR, Artis AB, Fleming D. Self‑directed
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learning: A tool for lifelong learning. J Mark Educ 2014;36:20‑32.
5. Medical Council of India (MCI). Competency Based Undergraduate
Curriculum for the Indian Medical Graduate. Vol. 1. MCI; Medical
Council of India (MCI); 2018. p. 20. Available from: https://www.
nmc.org.in/wp‑content/uploads/2020/01/UG‑Curriculum‑Vol‑I.
pdf. [Last accessed on 2021 Jan 15].
6. Agrawal P, Verma N. Prediscussion and postdiscussion
assessment scores in a self‑directed learning module implemented
in the department of biochemistry: A comparative study. Indian J
Med Spec 2020;11:81‑4.
7. Pai KM, Rao KR, Punja D, Kamath A. The effectiveness of
self‑directed learning (SDL) for teaching physiology to first‑year
medical students. Australas Med J 2014;7:448‑53.
8. Kidane HH, Roebertsen H, van der Vleuten CP. Students’
perceptions towards self‑directed learning in Ethiopian medical
schools with new innovative curriculum: A mixed‑method study.
BMC Med Educ 2020;20:7.
9. Collins R, Hammond M. Self‑directed learning to educate
medical educators, Part 2: Why do we use self‑directed learning?
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10. Badyal DK, Singh T. Learning theories: The basics to learn in
medical education. Int J Appl Basic Med Res 2017;7:S1‑3.
11. Ainoda N, Onishi H, Yasuda Y. Definitions and goals of
“self‑directed learning” in contemporary medical education
literature. Ann Acad Med Singap 2005;34:515‑9.
12. Robinson JD, Persky AM. Developing self‑directed learners. Am
J Pharm Educ 2020;84:847512.
13. Gavriel J. The Self‑Directed Learner in Medical Education.
London, UK: CRC Press, Taylor and Francis Group;
2015. Available from: https://library.oapen.org/bitstream/
handle/20.500.12657/41644/9781785230097.pdf?sequence=1.
[Last accessed on 2021 Jan 15].
14. Goldman S. The Educational Kanban: Promoting effective
self‑directed adult learning in medical education. Acad Med
2009;84:927‑34.
15. Zewail‑Foote M. Using student‑centered approaches to teach
the biochemistry of SARS‑CoV‑2. Biochem Mol Biol Educ
2020;48:655‑6.
16. Siddaiah‑Subramanya M, Nyandowe M, Zubair O. Self‑regulated
learning: Why is it important compared to traditional learning in
medical education? Adv Med Educ Pract 2017;8:243‑6.
17. Harvey BJ, Rothman AI, Frecker RC. Effect of an undergraduate
medical curriculum on students’ self‑directed learning. Acad
Med 2003;78:1259‑65.
18. Jeong D, Presseau J, ElChamaa R, Naumann DN, Mascaro C,
Luconi F, et al. Barriers and facilitators to self‑directed learning
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A scoping review. Acad Med 2018;93:1245‑54.
19. Song L, Hill JR. A conceptual model for understanding
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5
580 Self-directed Learning—M Hassan Murad and Prathibha Varkey
Medical Education – Review Article

Self-directed Learning in Health Professions Education

M Hassan Murad,1MD, MPH, Prathibha Varkey,1MBBS, MPH

Abstract
Introduction: Self-directed learning has been recommended as a promising methodology for
lifelong learning in medicine. However, the concept of self-directed learning continues to be
elusive, with students and educators finding difficulty in defining it and agreeing on its worth.
Methods: In this paper we review the literature of self-directed learning in health professions
education and present a framework based on Malcolm Knowles’ key components of self-directed
learning. Results: The key components of self-directed learning are: the educator as a facilitator,
identification of learning needs, development of learning objectives, identification of appropriate
resources, implementation of the process, commitment to a learning contract and evaluation of
learning. Several but not all of these components are often described in the published literature.
Conclusion: Although the presented framework provides some consistency for educators
interested in applying SDL methods, future studies are needed to standardise self-directed
learning curricula and to determine the effectiveness of these components on educational
outcomes.
Ann Acad Med Singapore 2008;37:580-90

Key words: Independent study, Medical education, Self-assessment, Self-directed learning, Self-
education

Introduction in changing physicians’ behaviour, do not affect patients’

More than 600,000 new citations were published in
MEDLINE in 2005; this raised the total number of indexed
citations to more than 14 million citations.1 In a study be
Williamson et al,2 2 out of 3 primary care physicians
described the volume of literature as unmanageable, and 1
out of 5 reported that they were not using or were unaware
of the 6 selected recent clinical advances in medicine. In
addition, physicians’ knowledge declines with time, which
may result in lower quality of care.3 Ramsey et al4 showed
that the knowledge of internists inversely correlated with
the number of years elapsed since their board certification,
with a sharp decline noted after 15 years.
Textbooks and review articles lag chronologically behind
the current evidence. A meta-analysis by Antman et al5
demonstrates significant discrepancy between treatment
recommendations for myocardial infarction in textbooks
and review articles, compared to the preponderance of
evidence produced by several multicentre randomised
controlled trials. Furthermore, systematic reviews of
continued medical education programmes (CME)
demonstrate that most of these programmes are not effective
outcomes, and are generally not based on learners needs.6-8
Self-directed learning (SDL) has been suggested as a
promising methodology for lifelong learning in medicine.
The Liaison Committee on Medical Education (LCME)
endorsed accreditation standards in 2004 that promote
flexibility and innovation in learning and provide medical
students with skills necessary for self-directed learning.9
The Accreditation Council for Graduate Medical Education
(ACGME) recommended that residents should become
self-directed learners, evaluate their learning with innovative
tools such as computerised diaries and portfolios, and
facilitate the learning of others.10 The American Board of
Internal Medicine (ABIM) recommends that a basic
component of the maintenance of certification programme
is that physicians become lifelong learners and be involved
in a periodic self-assessment process to guide continuing
learning.11
However, the concept of self-directed learning continues
to be elusive, with students and educators finding difficulty
in defining it and agreeing on its worth.12,13 Only 8% of SDL
articles published between 2000 and 2004 provided a clear

1
Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
Address for Correspondence: Dr M Hassan Murad, Division of Preventive and Occupational Medicine, Mayo Clinic College of Medicine, 200 1st Street SW,
Rochester, MN, 55905, USA.
Email: Murad.Mohammad@mayo.edu

Annals Academy of Medicine


working definition of SDL.14 The term SDL has been used
widely in the literature to describe various concepts in
learning such as self-planned learning, learning projects,
self-education, self-teaching, autonomous learning,
autodidaxy, independent study, and open learning.15 In
addition, SDL has been frequently used interchangeably
with problem-based learning (PBL).16-21 By means of this
paper, we aim to: a) review the literature of self-directed
learning in health professions education, and b) recommend
a framework for the application of SDL in medical education.
Methods
We searched MEDLINE through the OVID interface
using the keywords self-directed learning, adult education
and self-assessment. Articles were eligible for inclusion in
this review when: 1) authors explicitly identified their
methodology as self-directed learning, 2) educational
interventions targeted health professionals, 3) articles were
published in English, and 4) articles were original research
(review articles, commentaries and letters were excluded).
We considered SDL to consist of 7 key components as
described by Malcolm Knowles (Table 1). Knowles22
defined SDL as a process, in which individuals take the
initiative, with or without the help of others, in diagnosing
their learning needs, formulating goals, identifying human
and material resources for learning, choosing and
implementing appropriate learning strategies, and
evaluating learning outcomes. We evaluated the included
articles to determine how often educators applied these
SDL components in their programmes and whether these
components were effective compared with traditional
didactics.
Results
We identified 926 articles that met eligibility criteria.
The abstracts, titles and keywords of these articles were
reviewed and 106 of them were deemed relevant and
reviewed in full text. Twenty articles were included and
qualitatively described in this review.23-42 These articles are
described in Table 2 and categorised by level of learner
training, curriculum content, results, and components of
SDL present in the educational intervention.
Key Principles of Self-directed Learning
The educator as a facilitator: Although self-directed
learning may imply the lack of the need for an educator,
learners often need an expert to introduce them to the basics
of SDL including the appraisal of educational needs,
adoption of a theoretical construct and development of
learning goals.43 Therefore, teachers in SDL programmes
are seen as a source for skills rather than a source of content,
and they assume the role of facilitators or consultants to the
learner.44 There are several examples of this in the medical
July 2008, Vol. 37 No. 7
Self-directed Learning—M Hassan Murad and Prathibha Varkey 581
Table 1. Key Components of Self-Directed Learning
1. The educator as a facilitator
2. Identification of learning needs
3. Development of learning objectives
4. Identification of appropriate resources
5. Implementation of process
6. Commitment to a learning contract
7. Evaluation of learning process
education literature. Abraham et al23 described a self-
directed physiology course designed for medical students,
in which a subject expert served as a course facilitator and
guided the students to focus on learning objectives when
they deviated from them. Allen et al24 designed a self-
directed systems-based practice curriculum for Internal
Medicine residents, in which a faculty mentor spent 1 to 5
hours per mentee to assist with formulation of learning
objectives and allocation of appropriate resources and
relevant contacts. Students’ knowledge as measured by
exam scores in the first course and self-reported knowledge
in the second curriculum increased as a result of the
interventions.
Identification of learning needs: Educational needs are
the discrepancy between the present level of competency
and the required level of competency (or the difference
between aspiration and reality).45 Identification of learning
needs is an integral component of SDL. Beckert et al46
demonstrated that learning activities based on student’s
needs and self-drive are more likely to be successful than
activities dictated by extrinsic sources. Knowles45 also
suggested that the more explicitly learners identify learning
needs and the more harmonious their needs are with
societal, organisational or academic aspirations, the more
likely effective learning will take place. Borduas et al27
utilised questionnaires given to over 200 participants in
previous CME activities to identify learning needs for a
self-directed interactive workshop about the topic of arterial
hypertension. General practitioners who participated in
this activity demonstrated increased knowledge scores
(from 5.5 to 8.3 out of 10; P <0.05) and reported a high
satisfaction rate for the event.
Development of learning objectives: Learning objectives
are the desired outcomes of learning and are derived from
the pool of needs generated by learners. Learners translate
needs into objectives and ideally, would choose the ones
that are higher on their priority list and are measurable to
facilitate learning evaluation.45 Stuart et al34 described a
pilot programme in which paediatric residents and faculty
utilised individualised written commitments to learning to
record their own learning goals and objectives for self-
directed learning. Despite facing difficulties in establishing
and working with learning goals, residents who utilised this
582 Self-directed Learning—M Hassan Murad and Prathibha Varkey
learning method reported that it was helpful in providing a
framework or a focus for learning and increased their
awareness of the learning process.
Commitment to a learning contract: A learning contract
is a formal document prepared by learners in consultation
with a subject expert to demonstrate “what is to be learned,
how it is to be learned, and how learning will be verified”.40
Thus, learning contracts acknowledge learners’ self-
directedness and specify learning objectives, resources,
strategies and evidence of accomplishment.22 In a study by
Parker et al,41 a learning contract-based intervention
increased the knowledge of physicians practising in
community hospitals (correct answers increased from 64%
to 87%; P <0.01) and made more than 50% of them institute
changes in patient care. Statistical significance of knowledge
gains was again demonstrated with repeat testing 3 months
after the intervention. Similarly, Pereles et al42 reported
geriatricians who made a written commitment to change
their practice after an educational course made more changes
and affected more patients when compared with counterparts
in a control group. In undergraduate medical education,
first- and second-year medical students who used learning
contracts were able to accomplish more SDL tasks,
demonstrated more positive attitudes regarding SDL, and
scored higher on the self-directed learning readiness scale
(SDLRS).40
Resource identification: Knowles22 advocated direct
involvement of learners in the allocation of learning
resources. Learners in consultation with a subject expert,
choose the appropriate resources based on their preferred
method of learning and the type of learning objectives. He
suggested that cognitive objectives are best learned by
lectures, written resources, interviews, colloquy and panel
discussions; behavioural objectives are best learned by
experience-sharing, role-playing, sensitivity training and
case-based learning and psychomotor objectives are best
learned by skill practice exercises, role-playing, simulation
and drills. SDL interventions designed for health professions
education describe the use of written materials (e.g. articles,
workbooks), computerised modules, web sites, audio-visual
aids (e.g. videos) and mannequins for teaching procedural
skills.28,30,33,43,47 Beckert et al46 showed that when medical
students designed and ran their own OSCE’s (objective
structured clinical examination), they scored higher on the
end of year examinations compared with previous years,
and compared with students from other schools who took
identical examinations in the same year. Similarly, in 2
other studies, Internal Medicine and Pediatric residents
undertook self-directed curricula in systems-based practice
and ambulatory medicine, consulted their mentors and
chose the learning resources that they considered suitable
for their learning styles and learning contents.24,34 Although
the studies did not report learning outcomes, through open-
ended qualitative questionnaires, residents commented
that their learning experiences were positive.
Implementation process: To build rapport and set the
climate for SDL, facilitators should conduct introductory
meetings with learners. These meetings emphasise the
partnership between learners and educators, rather than
dependency of students on teachers. Subsequent meetings
can be utilised to identify learning needs, goals, learning
plan and evaluation means.22 Learners may experience
initial negative feelings such as confusion and
dissatisfaction; however, transformation to positive feelings
as SDL progresses is expected. 48 Coombe et al 49
recommended an incremental approach to SDL to allow
gradual acquisition of SDL skills prior to graduation; they
considered the need for SDL is more critical after graduation.
They routinely conducted workshops for nursing students
to ease their transition from pedagogic learning methods,
with which students are familiar, to andragogic methods. In
graduate medical education, spontaneous incremental
utilisation of SDL activities has been noted by paediatric
residents as they progressed from interns to senior
residents.50 For learners who lack SDL skills, a cooperative
model, as described in the nursing literature, can be
considered. The educator in this model adopts a proactive
role to enable introduction of SDL skills using pedagogic
methods.51
Learning evaluation: Learning portfolios that demonstrate
the acquisition of knowledge, skills, attitudes and
achievements have been recommended for health
professionals undertaking SDL.52 Learning portfolios enable
learners to control the educational process, maintain
autonomy, promote reflective thinking, increase SDL skills
and evaluate learning outcomes.52 Portfolio computerisation
can further enhance their role by providing better
accessibility, ease of use and security features for
confidential information.38,39 Fung et al39 described the use
of an Internet-based learning portfolio by residents in
obstetric and gynaecology to record patient encounters
(e.g. a procedure), critical incidents of learning (elements
of surprise outside the area of knowledge and experience),
the domain of learning (e.g. cognitive), and the stimulus of
learning (e.g. patient interaction). Residents were assessed
by 2 instruments (the SDLRS and another instrument
designed to assess future learning practices) and were
compared with residents in 3 other programmes that did not
utilise portfolios. Residents that used the portfolio reported
higher perception of SDL, believed that future learning
would less likely be derived from didactics, CME or
textbooks; and more likely from online resources (P values
<0.05).
In addition to portfolios, SDL can be evaluated by
Annals Academy of Medicine

multiple choice questions, OSCE, and qualitative and
quantitative self-reported measures of competency.22,34,35,49,53
Trevena et al35 designed a self-directed course in population
health for third year medical students that consisted of
student-led group discussions, web-based resources and
field experiences. Students were assessed formatively and
summatively by multiple-choice and modified-essay
questions. In addition, instructors assessed the students’
ability to explore a population health topic by evaluating
the student-led tutorials they presented to their peers on
their selected topics. In a study of 4 different measures of
self-directed clinical learning in undergraduate medical
education, Dornan et al53 compared a quantitative instrument
measuring satisfaction with the learning process and
environment; free text responses to questions about the
quality of students’ learning experiences; a quantitative
self-report measure of real patient learning; and OSCE
with written progress test results. They concluded that free
text responses about the quality of learning experiences
and quantitative self-report of real patient learning had the
best evidence of validity.
Effectiveness of SDL
Educational programmes that utilised SDL methodologies
have been described in various health professions such as
medicine, nursing and dentistry, as well as other non-
medical disciplines such as engineering54 and K-12
classrooms55 (kindergarten through 12th grade). In health
professions education, SDL has been used in a variety of
content areas including Chemistry, Physiology,
Microbiology, Anatomy, Pharmacy, Evidence-based
Medicine, Systems-Based Practice and Population Health
(Table 2). In general, there is paucity of evidence to
document the efficacy of SDL compared with traditional
didactics. In this review, we found most studies to be
mainly focused on evaluating learner’s acceptability and
satisfaction with SDL as well as feasibility of SDL projects
rather than studies providing information on the impact of
SDL learning outcomes. The 2 papers that had all the 7
components of SDL as described by Knowles were non-
controlled and did not report learning outcomes.34,37 Some
of the studies that documented educational outcomes are
described below.
Abraham et al23 described a self-directed course in
physiology that consisted of presentations and group
discussions led by medical students; exam scores of SDL
sessions were significantly higher than lecture exam scores
(76 ± 0.21 vs.72 ± 0.40; P not reported). Arroyo-Jimenez et
al26 designed a course in anatomy for medical students in
Spain that included self-study, presentations to peers, and
laboratory time. The course resulted in a trend of increased
mean percentage of successfully dissected items that did
July 2008, Vol. 37 No. 7
Self-directed Learning—M Hassan Murad and Prathibha Varkey 583
not reach statistical significance. Bradley et al28 randomised
medical students undertaking a course in evidence-based
medicine to a self-directed group (computer-assisted
independent study) and a workshop format group. Both
groups were similar in scores of knowledge, skills and
attitudes. Peng31 randomised students admitted to a medical
school in China to a self-directed group (limited didactics
to less than 30%, open library access, self-study and
group discussions) and a control group (didactics, limited
library access). Students in the SDL group had significantly
higher exam scores in basic knowledge in Inorganic
Chemistry, Biochemistry and Microbiology, applied
knowledge in Human Anatomy, and total knowledge in
Biochemistry. In all other classes, the two groups scored
similarly.
Education Theory and SDL
SDL is consistent with several educational concepts and
theories including the theory of adult education, humanism,
constructivism, empowerment, the Schön model, and the
Kolb learning cycle.44 The theory of adult education assumes
that adult learners display attributes of maturity,
independence, self-direction, responsibility and
individuality; and that their learning is related to their social
roles and previous experiences. Thus, it may be more
appropriate for adult learners to use less paternalistic
learning models that promote partnership between the
learner and the teacher, such as SDL.44,45,56
The humanist approach to learning is consistent with
SDL in that the locus of learning relates to the needs of the
learners and the motivation for learning is self-actualisation
and self-fulfillment.44,57 SDL is also consistent with
constructivism in that learning is not acquired by
transplanting knowledge in an empty reservoir; it is rather
built by learners based on their prior knowledge,
experiences, cultural and psychosocial background.58 In
addition, SDL empowers learners. Learners who have been
personally, educationally, socially or politically oppressed,
take control of their own learning and experience a liberating
effect by using SDL.59,60
The Schön and the Kolb learning models resonate well
with the philosophy of SDL. After encountering a question
that requires knowledge, skills or attitudes that learners do
not possess in their “zone of mastery”, learners face a
“surprise” that provokes learning. The problem that
instigates learning can be a specific problem (a question
that pertains to an individual situation) or a general problem
(a gap in knowledge or skill that can be applied to in a
variety of situations). Learners then progress through stages
of acquiring the new knowledge or skill and return to the
first stage to start a new cycle.27,44,61,62
 Table 2. Review of key components of SDL in health professions education 584

Study Learners Study design Learning Educational Findings Explicit Described key principles of SDL
content strategies SDL Learner’s Learner’s Learning Learners Well-defined Self- Educator
definition assess formulate contract identify Implementation assessment as a
needs objectives resources plan facilitator
Process Content
Practicing physicians (CME)
Borduas Practicing Descriptive, Knowledge Interactive Increased knowledge X X X X X X
et al physicians non controlled about workshop, about hypertension
200127 hypertension group on pre- and post-
discussion intervention
questionnaires

Campbell Practicing Descriptive Patient care Computerised 49% of X X X

et al 199638 physicians learning participants stated
(various portfolio they will change
specialties) their practice
(patient
management,
practice audit,
review literature,
teach, research)
Self-directed Learning—M Hassan Murad and Prathibha Varkey

Parker et al Practicing Descriptive, Various Learning Intervention X X X X X X X

199241 physicians non controlled topics in contract increased
in Internal participants’
community Medicine knowledge and
hospital caused change in
patient care

Perles et al Practicing Randomised Geriatric Learning Participants made

199642 physicians controlled medicine contract more changes in X
patient care and
affected more
patients at 3
months after
intervention
Strasberg Practicing Non controlled Clinical Computerised Programme was X
et al 200333 physicians questions search for successful and
clinical queries feasible. No
comparison group
Graduate medical education
Allen et al Senior Descriptive, Systems Meetings with Residents reported X X X X X X X
200524 residents non controlled based mentors, increased
practice presentations, knowledge of
independent content and SDL
study skills

Annals Academy of Medicine

 Table 2. Contd.

Described key principles of SDL

Study Learners Study design Learning Educational Findings Explicit
content strategies SDL Learner’s Learner’s Learning Learners Well-defined Self- Educator
definition assess formulate contract identify Implementation assessment as a
needs objectives resources plan Process Content facilitator

Bravata Residents Randomised- Acquisition Independent Increased X X X X X X X

July 2008, Vol. 37 No. 7

et al and controlled of SDL study, group learners’ ability
200329 Faculty skills study, to identify
identification of learning goal
role models (P = 0.001),
building
learning plan
(P = 0.04)

Fung et al Residents Controlled, Obstetrical Computerised Intervention X X X

200039 in non- and learning increased residents’
Obstetrics randomised gynaecologic portfolio perceptions of their
and skills SDL (P <0.05)
Gynecology
Stuart et al Pediatric Descriptive, Clinical Individualised 60-90% of X X X X X X X X
200534 residents non-controlled topics learning plan residents
and faculty utilised
programme;
barriers
identified

Undergraduate Medical Education

Abraham Medical Descriptive, Physiology Presentations SDL sessions X X X X X
et al students non-controlled and group Exam scores were
200523 discussions significantly (no P
value reported) higher
than lecture exam
scores

Arroyo- Medical Descriptive, Anatomy Self-study, Increased number X X X X X

group of successful
Jimenez students non-controlled
discussions, dissections
et al
lab time, between first and
200526 second year
presentations
to peers (P <0.001)

Bradley Medical Randomised Evidence- Computer SDL and non-SDL X

et al students controlled based assisted groups were
200528 medicine independent similar in EBM
(EBM) study knowledge, skills
compared to and attitudes (P
Self-directed Learning—M Hassan Murad and Prathibha Varkey

workshops values 0.8, 0.5,

0.5, respectively)
585
 Table 2. Contd.
586

Described key principles of SDL

Study Learners Study design Learning Educational Findings Explicit
content strategies SDL Learner’s Learner’s Learning Learners Well-defined Self- Educator
definition assess formulate contract identify implementation assessment as a
needs objectives resources plan Process Content facilitator

Done et al Medical Descriptive, Basic life Reading Programme was X X

200230 students non-controlled support skills materials, video successful and
tapes, manikins, feasible. No
practice in pairs comparison group.

Fox et al Medical Descriptive, Gerontology Learning Increased X X X X X X X X

1983 40 students non-controlled contracts motivation to learn
about gerontology,
attitudes regarding
SDL and ability to
execute SDL
Peng Medical Randomised Basic Reduce didactics Scores of SDL group X X
198931 students controlled sciences for intervention were equal or better
group by 30% to than control group
allow library use;
group
Self-directed Learning—M Hassan Murad and Prathibha Varkey

discussions,
review questions
and exercises

Trevena Medical Non-controlled Population Student-led Programme was X X X X X

et al students health group successful and
200235 discussion; web- feasible. No
based resources; comparison group.
field experience

Annals Academy of Medicine

 Study Learners Study design Learning Educational Findings Explicit Described key principles of SDL
content strategies SDL Learner’s Learner’s Learning Learners Well-defined Self- Educator
definition assess formulate contract identify Implementation assessment as a
needs objectives resources plan Process Content facilitator
Other Health Professions Education

July 2008, Vol. 37 No. 7

St. Clair Nurses Non-controlled Basic critical Independent Improved X X X X
199032 care nursing study knowledge on post-
test compared to
pre-test (P = 0.01)

Yunek Nurses Non-controlled Diabetes Written and Programme was X X X X X X X X X

198037 patient audiovisual successful and
education references; feasible. No
workshops comparison group.

Aly et al Undergraduate Descriptive, Dental Software package 98% of learners X X X

200325 and non-controlled curriculum that enables self- favoured the
postgraduate study and self- educational strategy
dental evaluation to traditional
students didactics
Villani Students in Non-controlled Physiology Self-study; 80% of students X X X X
199636 chiropractic, feedback preferred SDL to
osteopathy, tutorials; traditional didactics
health frequent testing
education
and human
movement
SDL: self-directed leaning; PBL: problem-based learning; SDLRS: self-directed learning readiness scale; CME: continued medical education
Self-directed Learning—M Hassan Murad and Prathibha Varkey
587
588 Self-directed Learning—M Hassan Murad and Prathibha Varkey
Limitations of SDL
The application of SDL in health professions education
is limited by the heterogeneity in the implementation and
definitions of SDL by educators. In addition, only a few
randomised studies document the efficacy of SDL. There
is also a lack of evidence on the content that is most
appropriate for SDL.
Furthermore, there is no standardised method to assess
learners’ readiness for SDL. The most widely used and
studied scale is the SDLRS, developed by Guglielmino in
1977. Despite the good convergent, divergent and criterion
validity, the SDLRS is criticised for reliance on self-report
instead of objective data and for its inability to predict
future learning behaviour.44,63 Other readiness scales, such
as the Oddi continuing learning inventory (OCLI), which
emphasises personality traits enabling for SDL, and the
Ryan’s questionnaire, which emphasises students’
perceptions of SDL, have little evidence of validity.63-65
The accuracy of learners’ self-assessment of learning needs
and learning outcomes has been doubted repeatedly in the
literature. Inaccurate self-assessment was described in
medical students, residents and practising physicians and
has been demonstrated across the various medical specialties
and in different task formats.66-71
SDL and PBL have often been used interchangeably in
the literature, often erroneously. Since SDL is often initiated
after encountering an educational challenge or a
“problem”,27 SDL has been linked with problem-based
learning (PBL) in the literature. PBL is defined by Barrows
et al72 as learning that results from the process of working
towards the understanding of a resolution of a problem; the
problem is encountered first in the learning process.72
Therefore, PBL curricula often include components of
SDL. This occurs when the teacher assumes the role of
facilitating learning process rather than being a content
source, when the teacher fosters SDL skills and behaviours,
when learners’ formulate their own objectives, identify
learning resources and perform self-assessment. However,
this is not always the case, and PBL curricula can contain
learning objectives dictated by teachers and course
organisers and can also include didactics.73,74
In addition, the evidence regarding SDL activities in PBL
curricula is conflicting. On one hand, some studies showed
that medical students16,19 and paediatric residents18 who
participated in PBL curricula exhibited more SDL skills
and behaviours. They had higher scores on the SDLRS
scale, utilised learning resources such as libraries and
electronic medical databases more frequently, and spent
more time on independent study. On the other hand, a study
by Lloyd-Jones et al17 concluded that the learning experience
of medical students using a PBL curriculum was not self-
directed and was dependent on faculty resources. Similarly,
pharmacy and nursing students’ readiness for SDL as
measured by the SDLRS scale did not improve or even
declined after participating in PBL curricula.20,21
SDL has been advocated within conventional educational
settings in rigid institutions as well as when access to
academic settings is limited32 and despite scarcity of
evidence, we believe it is compatible with several
educational frameworks, particularly, PBL and experiential
learning. Moreover, there is a debate regarding whether
SDL can be taught or is it an inherent personal trait. We
found ample evidence to show that SDL can be taught. In
fact, in at least 4 of the studies included in this review, it was
clearly demonstrated that the interventions used led to
increase in learner’s knowledge about SDL, SDL skills,
ability to identify learning goals, develop learning contracts,
execute SDL, as well as improved perceptions and attitudes
about SDL.24,29,39,40
There is no high-quality evidence to determine learner’s
characteristics most suitable for SDL. Knowles and others
implied that it is more suitable for adult learners who
already have a reservoir of knowledge and can apply their
learning immediately to their practices, and recommended
it for heterogeneous groups of learners with different past
experiences.22,45,60 Similarly, it was found that the more
residents advanced in training, the more they utilised SDL
resources.50 Yet, SDL is described as effective in children
and in preliminary and secondary education.55 Therefore,
the issue of learner characteristics most suitable for SDL is
in need for further studies.
We acknowledge several limitations of this review paper.
Studies that did not overtly describe SDL were not included
in this review. Since our intention was to describe what
educators considered to be SDL, we used a search strategy
that was more specific and less sensitive than what would
be typically used in a systematic review of the literature.
Therefore, we did not search for keywords such as
autodidaxy, independent study or open learning. The second
limitation relates to the fact that none of the 20 articles
included showed SDL to be inferior to traditional didactics.
Hence, publication bias has clearly affected the results of
this review making it difficult to determine which strategies
are not effective in SDL and should be avoided.
Conclusion
SDL is a potential methodology to promote lifelong
learning in medical education. With the explosion of new
content, competency based education that requires SDL,
e.g., the Practice-Based Learning and Improvement
competency (PBLI) and the requirements for the
Maintenance of Certification by the ABIM,10,11 there has
been increasing interest in SDL among educators. To date,
the most comprehensive description of SDL is the one by
Annals Academy of Medicine

Malcolm Knowles, which includes the components of the
educator as a facilitator, identification of learning needs,
development of learning objectives, identification of
appropriate resources, implementation of the process,
commitment to a learning contract and evaluation of learning
process. Numerous medical educational programmes have
applied some or all of these components, although in
general there is a lack of evidence to document the efficacy
and salience of the individual components of SDL. Further
research is necessary to evaluate the effectiveness of SDL
in medical education, to establish the content and learner
characteristics that are most appropriate for SDL (level of
training, prior experience and skills), and to assess learners’
readiness for SDL.
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Annals Academy of Medicine
The Journal of Obstetrics and Gynecology of India (January–February 2023) 73(1):69–76
https://doi.org/10.1007/s13224-022-01718-8

ORIGINAL ARTICLE

Implementation of One‑Minute Preceptor for Clinical Teaching

in Obstetrics and Gynaecology
Ritu Sharma1 · Dinesh K. Badyal2 · Rakhee Sharma1 · Shikha Seth1 · Monika Singh1

Received: 8 February 2022 / Accepted: 5 October 2022 / Published online: 21 October 2022
© Federation of Obstetric & Gynecological Societies of India 2022

Abstract
Background In absence of a dedicated teaching curriculum for non-PG residents in Obstetrics and Gynecology department, a
concise teaching learning method, One-Minute Preceptor (OMP) with feedback being its core component may be introduced
to translate their theoretical knowledge into clinical practice.
Methods This descriptive cross-sectional study included four faculty members and 20 residents. Each resident was exposed
to three OMP sessions pertaining to common gynecological case scenarios with a gap of at least two days in between the
sessions with faculties acting as preceptor and as observer. After three OMP sessions, feedback from residents and faculty
regarding their teaching and learning experience after implementing this tool was obtained through separate pre-validated
questionnaires graded on Likert’s scale.
Results The satisfaction index of the residents and faculties for OMP was found to be 96.3% and 95%, respectively. All
residents and faculty members had consensus that OMP addressed the learning gaps (mean score 4.45 ± 0.51 and mean score
4.5 ± 0.57, respectively) and expressed being highly satisfied with OMP in busy clinical settings as compared to traditional
method of teaching with mean score of 4.9 ± 0.30 and 4.75 ± 0.5, respectively. The faculties had consensuses that OMP can
assess all domains of learning (mean score 4.75 ± 0.5). All residents and faculties opined that the time allotted to address all
micro-skills was less and 60% residents advocated allotting at least 5 min time to the teaching encounter.
Conclusion Our study indicates the beneficial role of OMP in time-constraint clinical environment and warrants further
research to review the time frame keeping in view the learners’ needs and the discipline.

Keywords OMP · One-minute preceptor · Non-PG residents · Obstetrics and Gynaecology · Teaching-learning method

Dr. Ritu Sharma (MD, FICMCH) is a Professor, Department of

Obstetrics and Gynaecology, Government Institute of Medical Introduction
Sciences, Greater Noida, UP, India; Dr. Dinesh K Badyal (MD,
MHPE, Fellow FAIMER, Dip Clinical Research) is a Professor, Competency-based medical education (CBME) coming into
Department of Pharmacology and Medical Education, Christian
effect from 2019 is a welcome long-awaited landmark in
Medial College, Ludhiana, India; Dr. Rakhee Sharma (MS) is an
Assistant Professor, Department of Obstetrics and Gynaecology, undergraduate (UG) medical education in India. This pro-
Government Institute of Medical Sciences, Greater Noida, UP, gram aims to create an ‘Indian Medical Graduate’ (IMG)
India; Dr. Shikha Seth (MD, FICOG) is a Professor and Head, possessing the requisite KSAC domains i.e., Knowledge,
Department of Obstetrics and Gynaecology, Government Institute
Skill, Attitude and Communication, so that the outcome
of Medical Sciences, Greater Noida, UP, India; Dr. Monika
Singh (MS) is a Senior Resident, Department of Obstetrics and is the physician of first contact [1]. Similarly Postgraduate
Gynaecology, Government Institute of Medical Sciences, Greater curricula have also been revised. These new competency-
Noida, UP, India. based curricula, advocating utilizing different active teach-
ing learning methods (TLM) to achieve the above-mentioned
* Ritu Sharma
drritu661@gmail.com skills are likely to benefit henceforth undergraduate and
postgraduate (PG) medical students. However, lack of time
1
Department of Obstetrics & Gynecology, Government and traditional teaching methods may not have encouraged
Institute of Medical Sciences, Greater Noida, UP 201310, inculcation of these essential qualities among the non-
India
PG residents who are struggling to translate theoretical
2
Department of Pharmacology& Medical Education, Christian
Medial College, Ludhiana 141008, India

13
Vol.:(0123456789)
70
knowledge into clinical skills. Also, exclusive teaching pro-
grams for them are limited.
The traditional clinical teaching encounter takes on an
average 5–8 min including case presentation by learner (half
of time), questioning by the preceptor (one-fourth) and dis-
cussion (rest of time) i.e., three-fourth of the interaction time
is dedicated to patient care issues rather than learner issues
with practically no time being left for invoking thought pro-
cess in the learner and giving feedback, thereby questioning
to its relevance as a teaching tool especially in busy clinical
branches (Fig. 1) [2].
Emergency departments like Obstetrics and Gynecology
struggle to allocate sufficient time for implementing innova-
tive clinical teaching methodologies. To address this need,
learner centered educational tool- Five Step Micro Skill
Model also known as one-minute preceptor (OMP) was
introduced in 1992 [3]. This tool focuses to make most of
the time spent in actual discussion to optimize the teaching.
Being time-sensitive tool, it soon became popular with many
busy subjects. OMP originally included five micro-skills
with addition of sixth micro skill later on; the first two deal
with cognitive domain while next three deal with feedback
and last deals with self-directed learning (SDL) (Fig. 1) [4,
5]. Its efficacy has been evaluated with varied results [6–8].
In absence of dedicated teaching programs for non-PG
residents, we proposed to use OMP to evaluate its role in
enhancing their skills. This project was also planned in view
of the fact that most of the studies on OMP have been done
in the West and there is a scarcity of evidence on its use in
non-PG resident teaching in the Indian context.
Fig. 1  Traditional preceptor model and One-minute preceptor model
13
R. Sharma et al.
This educational research project was designed with
the aim to evaluate the effectiveness of OMP as a teaching
method for non-PG residents and to implement it in routine
clinical teaching in busy clinical branches like Obstetrics
and Gynecology, if found effective.
Objectives were to introduce OMP as teaching tool in
Obstetrics and Gynecology department and to analyze the
perception of faculty and residents about the OMP as an
effective TLM.
Materials and Methods
Study Design
This descriptive cross-sectional study was conducted in the
department of Obstetrics and Gynecology after obtaining
ethical clearance (GIMS/IEC/HR/2021/08).
Study Participants
Twenty non-PG residents posted in the department of
Obstetrics and Gynecology on rotational basis with no pre-
vious OMP exposure were included in the study via conveni-
ent non-probability sampling technique after their consent.
Four faculty members who consented and were available for
the study were included.
Faculty and non-PG residents were sensitized to OMP via
interactive session using power point presentation and video
presentation. Then the module was prepared with selection
Implementation of One-Minute Preceptor 71

of common Gynecology cases e.g., Abnormal Uterine

Bleeding (AUB), vaginal discharge and uterovaginal pro-
lapse. This was followed by charting out a schedule for OMP
sessions and allotting the role of preceptor and observer to
the faculty. Each non-PG resident was exposed to three OMP
sessions with a gap of at least two days in between the ses-
sions. In each session, residents were instructed to obtain
relevant history and perform pertinent examination quickly
reaching the logical provisional diagnosis by effective rea-
soning. For students these competencies have been placed
under core competencies with domain addressed being
“Knowledge and Skill” and level required being “Show
how”. But for non-PG residents, expected to be competent
IMG, we addressed all domains i.e., “Knowledge, Skill, Atti-
tude and Communication” and level addressed was “Does/
Perform” in accordance with Dreyfus model of skill acqui-
sition. In each session one of the faculties was preceptor
and one was observer. After three OMP sessions, feedback
from non-PG residents and faculty regarding their teaching
and learning experience after implementing this tool was
obtained through pre-validated 13-item questionnaire and
11-item questionnaire, respectively. The feedback question-
naire for faculty and residents contained all closed-ended
questions graded on Likert’s scale (1-Strongly disagree,
2- disagree, 3-not sure, 4- agree, 5- strongly agree) except
one open-ended question in each. The open-ended question
pertained to the suggested time frame for OMP. The ques-
tionnaire for residents and faculty contained questions on
three themes: perception on teaching efficacy of OMP (8 and
6 questions, respectively); perception on feedback provided
(3 and 2 questions, respectively); and perception on the time
frame (2 and 3 questions. respectively). The validation of
questionnaire was done by experts. Fig. 2  Flow chart of Study design
The categorical variables were summarized using per-
centages and frequencies and continuous data were analyzed
using mean (standard deviation) and median (range). Data diagnosis by effective reasoning. Almost all of them (95%)
were analyzed by using SPSS version 21(Fig. 2). believed that their presentation skills had improved and
they feel more confident in managing common Gynecol-
ogy cases after the sessions. Though 20% residents were
Results not sure that they received relevant knowledge during
OMP sessions; 90% residents were highly satisfied with
Among 20 non-PG residents, 18 were females, and 2 were OMP in busy clinical settings as compared to traditional
males. All faculty members were females. method of teaching with mean score of 4.9 ± 0.30. All
advocated to include OMP as a part of regular clinical
Perception of Non‑PG Residents for One‑Minute teaching in Obstetrics and Gynecology department.
Preceptor All residents perceived that their learning gaps were iden-
tified and well addressed; 75% strongly attributing this to
The satisfaction index of the non-PG residents for OMP the feedback provided during the sessions which as per all
was found to be 96.3%. While majority (80%) of the resi- directed them to study and rectify the mistakes (Table 1).
dents felt that OMP improved their interaction with the It is worth mentioning that all residents opined that the
teachers, 20% were not sure of the same. All residents time allotted to address all micro-skills was less, the mean
perceived that OMP has improved their clinical reasoning score being 4.7 ± 0.47; and 60% advocated allotting at least
and analytical skills; and inculcated the habit to reach the 5 min time to the teaching encounter (Fig. 3 and Fig. 4).

13
72 R. Sharma et al.

Table 1  Perception of non-PG residents for OMP in Obstetrics and Gynecology clinical teaching
S.No Statement Response on Likert’s Scale (N = 20) Mean score ± SD
1 (Strongly 2 (Disa- 3 (Not 4 (Agree) N (%) 5 (Strongly
disagree) N gree) N sure) N agree) N
(%) (%) (%) (%)

1 OMP improved student teacher interaction 0 (0) 0 (0) 4 (20) 9 (45) 7 (35) 4.15 ± 0.74
2 OMP has improved my presentation skills 0 (0) 0 (0) 1 (5) 11 (55) 8 (40) 4.35 ± 0.58
3 OMP has inculcated the habit to reach to the 0 (0) 0 (0) 0 (0) 9 (45) 11 (55) 4.55 ± 0.51
provisional diagnosis
4 OMP helped to improve clinical reasoning and 0 (0) 0 (0) 0 (0) 10 (50) 10 (50) 4.5 ± 0.51
analytical skills
5 OMP increased my confidence in managing 0 (0) 0 (0) 0 (0) 10 (50) 10 (50) 4.5 ± 0.51
common gynecological cases
6 Relevant knowledge is delivered in OMP 0 (0) 0 (0) 4 (20) 15 (75) 1 (5) 3.85 ± 0.49
teaching
7 Residents are more satisfied with OMP in 0 (0) 0 (0) 0 (0) 2 (10) 18 (90) 4.9 ± 0.30
busy clinical settings compared to traditional
method
8 OMP should be a part of regular clinical teach- 0 (0) 0 (0) 0 (0) 8 (40) 12 (60) 4.6 ± 0.50
ing in Obstetrics and Gynecology department
9 Feedback during OMP sessions was very 0 (0) 0 (0) 0 (0) 5 (25) 15 (75) 4.75 ± 0.44
useful
10 OMP helped to identify and address specific 0 (0) 0 (0) 0 (0) 11 (55) 9 (45) 4.45 ± 0.51
learning gaps
11 OMP motivated me to study and rectify mis- 0 (0) 0 (0) 0 (0) 15 (75) 5 (25) 4.25 ± 0.44
takes (SDL)
12 Time allotted to address all micro-skills of 0 (0) 0 (0) 0 (0) 6 (30) 14 (70) 4.7 ± 0.47
OMP teaching was less
13 If you feel scarcity of time, what is the time Median (range): 5 (3–5)
frame suggested by you

Fig. 3  Perception of non-PG residents and faculty (%) on the shortage of allocated time to address all micro-skills of OMP

13
Implementation of One-Minute Preceptor
Fig. 4  Suggested time frames (in minutes) to address the micro-skills of OMP by non-PG residents (N = 20) and faculty (n = 4) (R, Response)
Perception of Faculty for One‑Minute Preceptor
The satisfaction index of the faculty for OMP was found to
be 95%. All faculty members were of the view that OMP
improved student–teacher interaction. Though three fac-
ulty members (75%) perceived that OMP improved clinical
reasoning skills of students, one faculty member (25%)
was not sure of the same. However, all felt that the overall
performance of residents was improved after its introduc-
tion. Faculty was also more satisfied with OMP in busy
clinical settings as compared to traditional method; the
mean score being 4.75 ± 0.5. There was a consensus among
the faculty that OMP should be a part of regular clinical
teaching in Obstetrics and Gynecology department.
Further as an educational tool, all faculty had con-
sensuses on the fact that using OMP they can assess all
domains of learning (mean score 4.75 ± 0.5) and can rec-
ognize and address specific learning gaps via immediate
feedback which is its most useful component (mean score
4.5 ± 0.57) (Table 2).
Further OMP was perceived as a well-structured time-
sensitive tool by faculty. Although three (75%) faculty
members felt that the time allotted to address all micro-
skills of OMP teaching was less yet they suggested 2 to
4 min time only. One (25%) faculty member didn't want
any change in the time allotted (Figs. 3 and 4).
Overall, the tool was well accepted by the faculty and
residents alike for efficacy and feedback except the short-
age of time which was stated as the prime limitation for
the methodology.
73
Discussion
The results have been discussed under three themes: percep-
tion on its teaching efficacy; perception on feedback pro-
vided; and perception on the time frame.
Perception on Teaching Efficacy
In our study, the satisfaction index of the residents and facul-
ties for OMP was found to be 96.3% and 95%, respectively.
All residents and faculty expressed their satisfaction with
OMP over traditional method (mean scores 4.9 ± 0.30 and
4.75 ± 0.5, respectively) and advocated including it in rou-
tine clinical teaching. Previous studies confirm its efficacy
with some supporting replacing traditional clinical teaching
with OMP [6, 9]; while some advocated its incorporation to
supplement traditional case presentation [7, 10].
In our study all faculty members agreed that all domains
of learning can be assessed via OMP and all perceived its
role in improving the performance of students. The simi-
lar perceptions were mentioned in other studies as well [9].
Other studies have also registered that OMP enhances clini-
cal reasoning skills [7, 9]. In our study though 75% faculty
perceived that OMP improved clinical reasoning skills of
non-PG residents, 25% was not sure of the same; also, 20%
residents were not sure about the improvement in teacher-
resident interaction. This may be due to short exposure to
OMP sessions in this study.
In our study, 20% residents were not sure of receiving
relevant information during OMP sessions. This may have
13
74 R. Sharma et al.

Table 2  Perception of faculty for OMP in Obstetrics and Gynecology clinical teaching
S.No Statement Response on Likert’s Scale (N = 4) Mean score ± SD
1 (Strongly 2 (Disa- 3 (Not 4 (Agree) N (%) 5 (Strongly
disagree) N gree) N sure) N agree) N
(%) (%) (%) (%)

1 OMP improved student teacher interaction 0 (0) 0 (0) 0 (0) 2 (50) 2 (50) 4.5 ± 0.57
2 OMP improved clinical reasoning skills of 0 (0) 0 (0) 1(25) 2 (50) 1 (25) 4.0 ± 0.8
residents
3 Preceptor can assess all domains using OMP 0 (0) 0 (0) 0 (0) 1 (25) 3 (75) 4.75 ± 0.5
KSAC (Knowledge, Skills, Attitudes, Com-
munication)
4 OMP improves overall performance of residents 0 (0) 0 (0) 0 (0) 4 (100) 0 (0) 4.0 ± 0.00
5 Preceptors are more satisfied with OMP in busy 0 (0) 0 (0) 0 (0) 1 (25) 3 (75) 4.75 ± 0.5
clinical settings as compared to traditional
method
6 OMP should be a part of regular clinical teach- 0 (0) 0 (0) 0 (0) 0 4 (100) 5.0 ± 0.00
ing in Obstetrics and Gynecology department
7 OMP helps to recognize and address specific 0 (0) 0 (0) 0 (0) 4 (100) 0 (0) 4.0 ± 0.00
learning gaps of residents
8 Feedback during OMP sessions was very useful 0 (0) 0 (0) 0 (0) 2 (50) 2 (50) 4.5 ± 0.57
9 OMP is well-structured time-sensitive tool 0 (0) 0 (0) 0 (0) 1 (25) 3 (75) 4.75 ± 0.5
10 Time allotted to address all micro-skills of 0 (0) 1 (25) 0 (0) 3 (75) 0 (0) 3.5 ± 1.00
OMP teaching was less
11 If you feel scarcity of time, what is the time Median (range): 2.5 (1–4)
frame suggested by you

resulted due to the recent implementation of this tool by the
faculty with the case discussions having a tendency to run
off topic. This implies that a sustained effort and not one-
time OMP workshop for faculty members will be required to
improve clinical teaching. Our view is based on the results
of a study from National Dental Centre Singapore where
residents rated no change in quantity as well as quality of
clinical teaching after single workshop on OMP (76.5%,
p = 0.480 and 61.8%, p = 0.134, respectively) [8]. Sustained
exposure to OMP also increases the ability of preceptors to
correctly diagnose patients’ medical problems and improves
self-confidence in rating students [11].
OMP was perceived as a well-structured time-sensitive
tool by faculty in our study. This is in line with the best prac-
tice recommendations provided for busy pharmacy precep-
tors where considering time scarcity as an important barrier
to perception, OMP was unanimously recognized as more
time-efficient tool than the subjective–objective-assessment-
plan (SOAP) [12].
Though in our study OMP was well accepted in Obstet-
rics and Gynecology department, in other studies it has
been received variedly in different specialties. In a com-
parative analytical study, the family medicine residents were
reported to be more familiar (55 vs. 25%) and significantly
more confident than psychiatry residents (p =  < 0.01) [13].
Thus the results from one department specific study cannot
be generalized.
Perception on Feedback
All non-PG residents and faculty in our study perceived that
OMP is an important educational tool with ability to identify
and address the learning gaps, attributing this to the immedi-
ate feedback provided during the sessions which inculcates
self-directed learning. This is in consensus with earlier stud-
ies where faculty members acknowledged that OMP helped
them to address weak areas of residents; and residents val-
ued the beneficial key points and timely feedback provided
through OMP [7, 9, 10, 12]. The observations recorded by
different studies vary with regard to the micro-skill that
reflected maximum improvement. In a survey the residents
perceived a significant improvement (p = 0.035) in the micro-
skill “Teaching general rules” which was also rated as the most
important micro-skill both pre and post faculty workshop on
OMP (35.3% and 38.2%, respectively) [8]. On the contrary in
a randomized control trial the residents revealed significant
improvement in all micro-skills except “teaching general rule”
[14]. In another study conducted with the aim to evaluate train-
ing of health professionals who teach nurse practitioner stu-
dents using OMP, the authors reported statistically significant
increase in intended use of positive and corrective feedback
[15]. A systematic review on OMP use for nurse practitioners,
including 12 experimental quantitative studies in analysis and
20 descriptive studies in discussion, concluded that available
literature supports the efficacy of OMP clinical teaching model

13
Implementation of One-Minute Preceptor
which has the potential to improve feedback and clinical rea-
soning skills [16].
Perception on the Time Frame
Shortage of time allotted to address all micro-skills of OMP
teaching was identified by all the non-PG residents in our
study. Although 75% faculty members also shared simi-
lar view, 25% didn't want any change in the time allotted.
While the faculty suggested 1–4 min time for the teaching
encounter, 60% of residents suggested increasing the time
to at least 5 min. Our findings corroborate with previous
study where though 53.8% residents felt shortage of time
allotted to OMP, only one faculty member (16.6%) had the
same perception [7]. This may be due to already overworked
clinical faculty.
We favor scheduling the time frame of OMP depending
on learner’s needs and the target case. In the initial model
introduced by Neher JO et al. in 1992 [3], the time allotted
for clinical encounter was 5 min or less which later got lim-
ited to one minute. The model was modified and renamed
in 2011 by Bott G et al. [17] as 5-min preceptor realizing
different needs of nursing students who require at least
5 min for the encounter. Later in 2015 Hu YC et al. [18]
went further to compare the perception of 5-min preceptor
with its modified version, the 10-min preceptor among 107
new nurse graduates and found that in comparison with the
former, satisfaction with 10-min preceptor was significantly
higher (p = 0.025). We propose to review the time frame by
comparative prospective studies for maximizing the benefits.
Limitations and Strengths
The small sample size, short study period and not includ-
ing a control group to assess the actual impact attributed to
introducing OMP are the limitations of our study. Further
inclusion of only non-PG residents may limit generalization
of the findings and large studies are necessary testing the
scientific validity before including OMP in routine clinical
teaching. The strength of our study is well planned meth-
odology and giving due consideration to three important
aspects of OMP while framing the questionnaires which
helped in generating the robust evidence of well acceptance
of this tool in Obstetrics and Gynecology clinical teaching as
well as the emerging need to revise the timeframes suggested
for imparting micro-skills in OMP.
Conclusion
Owing to the increased work load in major clinical branches,
a time-efficient, student-centered TLM is the need of the
hour. Further due to unavailability of regular teaching
75
sessions for non-PG residents, a TLM that polishes their
theoretical knowledge and translates it into clinical practice
without putting much burden on clinical faculty is urgently
required. The results of our study endorse the efficacy and
worthiness of OMP in Obstetrics and Gynecology for teach-
ing non-PG residents, thereby advocating its inclusion in
undergraduate and postgraduate clinical teaching as well.
Prospective longitudinal studies are required to assess the
expected intermediate and long-term outcomes.
The results also exhibit the perception of time crunch;
hence opening up another area to be researched involving
prospective comparative studies focusing on the effective-
ness of various timeframes suggested for imparting micro-
skills in OMP so that the time can be revised for maximizing
benefits.
Acknowledgements I am highly thankful and indebted to ACME fac-
ulty for mentoring throughout this study on medical education. I am
also thankful to the residents and departmental faculty for their support
and participation in the study. The study was part of National Medical
Commissions’ ACME-full course.
Author Contributions *RS and SS initially conceptualized the study,
RS and MS added their inputs; DB helped in finalizing the study
design. Material preparation, data collection and analysis were per-
formed by *RS, RS and MS. The first draft of the manuscript was
written by *RS and all authors commented on previous versions of the
manuscript. Final review and editing was done by DB. All authors read
and approved the final manuscript.
Funding Not required.
Declarations
Conflict of interest All the authors declare that they have no conflict
of interest.
Ethical Approval The institutional ethical committee clearance was
obtained for the study GIMS/IEC/HR/2021/08).
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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 MEDICAL EDUCATION

Simulated Patients for Competency-Based Undergraduate Medical

Education Post COVID-19: A New Normal in India
ANIL KAPOOR,1 ANJU KAPOOR,2 DINESH K BADYAL3
From Departments of 1Medicine and 2Pediatrics, People’s College of Medical Sciences and Research Centre, Bhopal, Madhya
Pradesh; and 3Department of Pharmacology, Christian Medical College, Ludhiana, Punjab.
Correspondence to: Dr. Anil Kapoor, Professor of Medicine, HIG, C/10, PCMS Campus, Bhanpur, Bhopal 462037, Madhya Pradesh.
anil.faimer@gmail.com

The conventional medical curriculum in India needed more focus on explicit teaching and assessment of interpersonal and
communication skills, professionalism, team-work and reflection for prevention and better management of increasing incidences of
violence against doctors by building good doctor-patient relationships. Increasing number of seats in Indian medical colleges,
decreasing hospital stay of patients, and decrease in faculty requirements will hamper adequate supervised authentic clinical
experiences of undergraduates for developing clinical skills. The recent COVID-19 pandemic has led to a significant decrease in
student-patient encounters. Simulated patients are being used in many countries to address many of these issues. To make the Indian
medical graduates competent to function as primary physician of first contact, competency-based medical education along with
guidelines for use of skill-lab and simulation has been introduced from 2019. The current review is focused on the need and use of
simulated patients; their advantages, limitations and role in students’ teaching and assessment. It also gives a brief outline of their
training process. Simulated patients should be used to supplement day-to-day learning, help in transition to attending real patients and
also save enormous faculty time in the post-COVID-19 new normal. However, simulated patients are unlikely to completely replace real
patients’ experiences.
Keywords: Clinical skill assessment, Competency-based assessment, Medical education, Simulation, Standardized patient.

Published online: May 20, 2021; PII: S097475591600331

T
here has been an increase in incidences of
violence against doctors in last few years in
India, which had been partly attributed to lack
of explicit teaching and assessment of inter-
personal and communication skills, ethics, professiona-
lism, team-work and reflection during the undergraduate
(UG) training program [1,2]. UG students often miss to
develop competence in soft-skills. There is a need to
improve doctor-patient relationship with more trust and
respect for each other. In order to address these issues
and to make the Indian Medical Graduates (IMG)
competent to function as a primary physician of first
contact, Graduate Medical Education Regulations
(GMER) amendment, 2019 has implemented major reforms
by introducing competency-based medical education
(CBME) [3]. It has emphasized more on knowledge
application than knowledge acquisition and recommen-
ded use of simulations and simulated patients (SPs) for
teaching clinical skills to achieve competencies in a safer
environment; simulation labs have been made mandatory
in all medical colleges [4].
Since there have been sufficient number of patients
available, use of SPs is not a routine practice for teaching
UG students in India. However, the times are changing
and coronavirus disease 2019 (COVID-19) pandemic has
led to significant decrease in student-patient interactions
and it seems that SPs are the need of the hour. The current
review is focused on the need and use of simulated
patients, and their advantages, limitations and role in
student’s training and assessment. It also gives a brief
outline of their training process.
HISTORICAL PERSPECTIVE
The concept of ‘simulated patient’ (SP) was introduced
by Barrows and Abrahamson in 1964 for teaching clinical
skills to medical students [5], which was later also expanded
to their assessment [6]. During a board examination in
psychiatry and neurology, Barrows observed that one
patient with syringomyelia became uncomfortable with
the way of examination by a resident and tried to fix him by
providing wrong information and changing his sensory
findings! He also noticed lack of direct observation of
students during their encounters with patients; and
students committing many mistakes during examinations.
This led him to an idea of introducing trained persons,
who can be used instead of real patients on whom medical
students can do repeated practice and receive corrective
feedback to learn the desired skills [7].

INDIAN PEDIATRICS 881 VOLUME 58__SEPTEMBER 15, 2021

KAPOOR, ET AL.
The American Board of Pediatrics (1978) has defined
five clinical skills (attitude, factual knowledge,
interpersonal skill, technical skill and clinical judgment) in
which pediatric residents should be competent [8].
Factual knowledge can be assessed by various valid and
reliable assessment tools, while assessment of other skills
relies more on using standardized patients [7,9,10].
American Board of Internal Medicine, Medical Council of
Canada and Educational Commission for Foreign Medical
Graduates have also supported the use of standardized
patients for assessment of clinical skills [10,11,12].
WHAT ARE SIMULATED PATIENTS?
Barrows initially introduced the term ‘the programmed
patient’ [5] for a normal person who had been trained to
act and react like a real patient with an illness and later
revised it as ‘simulated patient’; while Norman coined the
term ‘standardized patient’ [7,13]. The concept of SP is
based on the philosophy of learning by doing and
receiving immediate constructive feedback to have
authentic experiential learning. Though the terms
simulated patient and standardized patient have been
used interchangeably, different educationists have
described them differently. With simulated patients, the
emphasis is on simulation (presenting the symptoms and
signs of real patients) while “standardized patients are
those simulated patients who present the patients
problem in standardized unvarying way to different
students; therefore, they can also be termed as
standardized simulated patients” [14].
Later, standardized patients was used as an umbrella
term, covering both the SPs as well as real patients, who
have been coached carefully to present their problems
consistently in a standardized way, to prevent students
from knowing whether they are facing a real patient or a
SP [7].
‘REAL’ PATIENTS IN MEDICAL EDUCATION IN
INDIA
Till date, medical students are being trained and assessed
on real patients. The greatest advantage of real patients is
their availability with real symptoms and abnormal
findings e.g., koilonychia, pallor, jaundice, hypertension,
cardiac murmurs, irregular pulse, goiter, exophthalmos,
pregnancy, edema, ascites, hepatomegaly, splenomegaly,
crepitations over lungs etc. They are authentic and well
accepted by teachers and students. They do not require
any training or added cost for teaching-learning purpose.
However, using real patients can lead to opportunistic
teaching; students are taught only those diseases whose
patients are available. They are difficult to use in
emergency or emotionally charged situations (e.g. HIV
INDIAN PEDIATRICS
SIMULATED PATIENTS FOR CBME IN COVID-19 ERA
positive patients, recently diagnosed cancer patients,
dying patients, rape victims, acute exacerbation of
psychiatric disorders etc.). Some patients are reluctant to
be examined by trainee students; some feel uncomfortable
by repeated interrogation and physical examination and
become non-cooperative. They may pose different
problems to different students; thus making the assess-
ment less reliable [15]. It is difficult to standardize them as
they see the situation from their own perspective.
Students can not be allowed to examine very sick patients.
With increasing number of UG seats in Indian medical
colleges, decreasing hospital stay owing to rapid
diagnosis with better management, day care facilities and
apprehension after COVID-19, we are going to face a
shortage of variety of patients in proportion to number of
students for providing adequate clinical experiences.
NEED FOR SPs IN CBME
Similar to Barrows’ observations, students in India also
are mostly not observed while eliciting the history and
clinical examination of patients and their mistakes and
deficiencies often go unnoticed till they perform poorly in
examinations as well as in real life situations. Regular
supervision and feedback culture is sub-optimal at most
of the medical colleges. Due to decrease in the official
requirements of faculty in various departments, it will be
difficult to supervise, provide feedback and certify all the
students for acquiring all the competencies prescribed in
the CBME curriculum, without using SPs. COVID-19
pandemic leading to a significant decrease in student-
patient interactions is now a major reason for us to
introduce SPs for clinical teaching and it might continue
to be a supplement method in the ‘new normal.’ A scoping
review of 33 studies related to use of the SP methodology
found 24 studies to be effective in developing clinical
skills of students in many countries [16]. Advantages of
using SPs are enlisted in Box I [7,14,15,17,18].
SPs AS A TEACHING TOOL
SPs are trained to follow a script to reproduce a particular
problem or symptoms, and are given a set of guidelines to
follow for certain responses and provide specific patient-
centered feedback. They are helpful in developing all
three domains of learning; technical, communication and
cognitive skills.
Technical skills: SPs are effective in improving students’
examination skills as students can actually perform
various maneuvers on cooperative real human beings.
Many physical findings have been simulated with proper
training (Box II) [7,19]. Make-up or moulage is being
used to make realistic portraying of wounds. Some
specially trained SPs, known as ‘intimate examination
882 VOLUME 58__SEPTEMBER 15, 2021
KAPOOR, ET AL. SIMULATED PATIENTS FOR CBME IN COVID-19 ERA

Box I Advantages of Using Simulated Patients

• SPs provide high fidelity learning environment that realistically replicates a patient encounter in a predetermined clinical scenario.
• They can be trained to be mentally prepared to co-operate and examined by numerous students and respond uniformly in every
student encounter.
• They provide a safe and non-threatening learning environment that allows mistakes and interruptions to be made.
• Medical students can practice history-taking, clinical examination and counselling skills repeatedly with SPs till they feel ready to
face the complex and unpredictable encounters in real world.
• Once trained on SPs, students feel more competent and confident while encountering real patients and patients too feel that an
expert is examining them rather than a novice.
• SPs can be used in teaching and assessing critical illnesses and emotionally charged situations, which is practically not feasible with
real patients; e.g. confronting with a dying patient, sexually abused patient, psychiatric patient etc.
• They can be manipulated as per educational needs. Complications can be added or deleted in the ‘case scripts’ based on students’ level
of training.
• They can be trained to change their presentation quickly so as to demonstrate the response to treatment and course of chronic
illnesses in the same setting.
• They can be trained to provide assessment scores and specific patient-centered feedback that students require in order to further
enhance their learning in cognitive, psychomotor and affective domains, thus saving enormous faculty time.
• As they are standardized, a criteria referenced assessment of students can be formulated.
• By using SPs in place of real patients, real patients’ safety and privacy are maintained; thus avoiding risk of legal issues.
• They can be enrolled in a ‘SP bank’ and are available for use any time, as and when required.

Box II Some Physical Findings That Can Be Simulated

stressful and non-threatening environment [21]. Thus,
Central Nervous System
SPs promote self-directed and collaborative learning.
• coma/altered sensorium/confusion Communication and teamwork skills: Interpersonal and
• gait abnormalities/hearing loss/vision loss communication skills and professionalism are core
• hyperactive tendon reflexes competencies as per Accreditation Council of Graduate
• neck rigidity/Kernig sign/Babinski sign Medical Education (ACGME) and are must for successful
• muscle spasm/muscle weakness interaction between doctors and patients. However,
• sensory losses standard norms were not set for teaching and assessment
• incoordination/abnormal movements etc. of these skills in traditional curriculum [17,22,23]. Poor
Abdominal examination communication with patients and caretakers may lead to
• abdominal tenderness/rebound tenderness
dissatisfaction and risk of violence against doctors [24].
• acute abdomen
SPs provide a unique opportunity to students to learn
and practice these soft skills; and also receive
Respiratory system
constructive feedback from them [17,18,25].
• cough/abnormal breathing pattern
Joint examination Cognitive skills: SPs are helpful in developing students’
• movement restriction clinical reasoning and decision making skills and can
• tenderness/warmth/redness address higher levels in cognitive domain. ‘Time in - time
Psychological out’ and ‘stimulated recall’ are two powerful tools to
• depression/agitation develop competence in clinical reasoning and decision-
making [7]. In ‘time in - time out’ technique, once a group
of students had interacted with a SP, teacher calls ‘time
associates’ (IEA) or ‘teaching associates’ allow for out’ and the SP goes into suspended animation (as if he/
female (gynecological teaching associate) and male she is not there). Meanwhile, teacher discusses with the
(urological teaching associate) intimate examinations students what they think is happening with the patient
(breast, pelvic, rectal, testicular), thus avoiding risk of and future course of action then and there only. Once
mistreatment to real patients; and these IEAs are discussion is over, teacher calls ‘time in’ for the SP to join
reasonably paid for that [20]. Trained SPs provide back and participate in the discussion. This method gives
corrective feedback which allows students to reflect on the opportunity to discuss freely regarding differential
their performance and improve on weaker areas in a non- diagnosis, management, prognosis and sensitive issues

INDIAN PEDIATRICS 883 VOLUME 58__SEPTEMBER 15, 2021

KAPOOR, ET AL.
that can not be discussed in front of real patients. In
‘stimulated recall’, interaction between student and SP is
video-recorded and discussed later with the teacher.
Hybrid model: Integrating SPs with mannequins provide
opportunities to practice procedural skills on the
mannequin while communicating with SPs simultan-
eously; thus enhancing their technical and interpersonal
skills in same sitting [26, 27]. Few examples are wound
suturing, giving injections, catheter insertion and con-
ducting delivery, which can be performed side by side on
inanimate models attached to SPs.
SPs AS AN ASSESSMENT TOOL
Written examination and viva-voce do not assess clinical
competence. Interpersonal skills and clinical performance
is rarely observed during students’ assessment [10]. Real
patients used for clinical assessment of students are
usually not standardized, which may affect the reliability
of result. In a study, no significant difference was found
between undergraduate students’ performance on real
and simulated patients; students favored use of SPs over
real patients for assessment of communication skills [28].
Objective Structured Clinical Examination (OSCE) and
Clinical Skill Assessment (CSA) both use SPs as
assessment tool. While OSCE assesses discrete skills or
small set of skills at one station, CSA assesses a group of
clinical skills (history taking, physical examination and
patient education) in one encounter [29]. Good reliability
and validity of CSA is ensured by using three different
types of encounters, as described here [10,30]:
i) History cases: are used to assess history taking and
interviewing skills of the students.
ii) History and focused physical examination cases: are
used to assess physical examination skill in addition
to history taking and interviewing skills.
iii) Patient education-counselling cases: are used to
assess the ability to educate patients on common
topics (breast/complementary feeding, vaccination,
oral rehydration therapy, diabetes education, use of
metered-dose inhaler etc.) or counselling in critical or
emotionally charged situations.
SPs assess students objectively by filling the case
specific content checklists which are pre-designed to
determine ‘What relevant history questions were asked?
Based on that, what physical examination maneuvers
were selected to perform? Whether performance was
done correctly?’
Before entering into the examination room, each
student is given an opening-scenario (basic information
INDIAN PEDIATRICS
SIMULATED PATIENTS FOR CBME IN COVID-19 ERA
of the patient) and examinee’s-task (which student has to
perform in that station). Time allotted for each station is
10-15 minutes. After every encounter, 5 minutes are given
to the student to write a summary of information gathered
from the SP, make differential diagnosis and complete
other post-encounter exercises. Simultaneously, SP fills
two forms: a case specific content checklist (up to 30-35
items) and an interview rating scale. Arizona Clinical
Interview Rating scale (ACIR) or Kalamazoo Essential
Elements Communication Checklist - Adapted (KEECC-
A) are commonly used for assessing the interviewing skill
[31,32]. SPs are trained about the criteria on which they
have to judge and assess the student’s performance and
they are found to be precise and consistent in filling the
checklists [33].
USE OF CHILDREN AS SPs
Children have been used as SPs since 1980s [34]. A focus
group discussion with child SPs (6-18 years) reported that
play-acting (simulation) was found to be fun; they
learned how to differentiate between a ‘bad’ and a ‘good’
doctor. Children and their parents unanimously told that
simulation had overall positive effect on them [34]. A
pediatric clinical skill assessment (PCSA) of the residents
using children (7-11 years) reported child SPs’ experience
to be quite positive; they could memorize the checklists
and rate the residents’ performance fairly well and
consistently [35]. Another study on the feasibility of
using school children (8-10 years) for OSCE showed that
these children can score/mark the examinees reasonably
well with a reasonable correlation between their scores
and examiners’ predictions of their scores [36]. Use of
child SPs can be very effective in developing ‘soft skills’
and humanistic values to acknowledge and address
children’s special needs as patients [37]. The benefits of
being a SP (including a child SP) have been reported
apparently to outweigh the known risks [38]. A systematic
review suggested involvement of adolescent and
younger children as SPs to be feasible and valuable;
however, it doubted about their reliability to portray the
SPs’ role and provide feedback [39].
TRAINING OF SPs
It has been stated that “simulated patients, if
appropriately trained, should not be distinguishable
from a real patient even by experienced clinicians” [40].
Medical colleges in many countries have developed dedi-
cated simulated patients training programs. The Asso-
ciation of Standardized Patient Educators (ASPE) has
also published standards of best practice (SOBP) [41].
Steps for training SPs are summarized in Web Box I
[15]. Case scenarios prepared can be totally fictional or
884 VOLUME 58__SEPTEMBER 15, 2021
KAPOOR, ET AL. SIMULATED PATIENTS FOR CBME IN COVID-19 ERA

drafted from the case histories of real patients. Patients’
own laboratory results and clinical course can be used for
discussion [7]. Script of the case scenario, objectives of
the case encounter, instructions for the students, time for
interaction, scoring system (marks or rating scale),
relevant laboratory reports, ECGs, X-rays, CT/MRI
reports etc. with their interpretation and abnormalities are
given and explained to the SPs. Depending on the need,
SPs are either required to follow strictly as per the script or
given some freedom to tell some of their personal
information during the interaction with students. They
are trained to act and react in a specific and predictable
way, according to the goals of the program (teaching,
assessment or both). For doing so, they should be able to
observe and memorize the student’s verbal and non-
verbal actions apart from role-playing [13].
After going through the script, SPs prepare
themselves for their role by watching relevant videos,
observing previously trained SPs and/or meeting real
patients suffering with the same problem [42]. Two to four
training sessions, each of 2-3 hours may be needed
depending on the scenario and time required for the SP to
develop the desired level of competence in performing the
role and use of checklists. They are monitored for
‘accuracy’ (how accurately they portray a given patient)
and ‘replicability’ (how consistent they are in portraying
the same patient to different students); and provided
further training if needed.
EXPERIENCE WITH SPs IN INDIA
Till date, there is limited documentation of use of SPs for
teaching and assessment of students in India. A study on
teaching patient interviewing, communication and
counseling skills to UGs using Calgary–Cambridge guide
format recommended to conduct regular courses on
effective communication in the MBBS curriculum [25].
Another study reported use of simulated interviews and
role play for training PGs in psychiatry; trainees who
performed as SPs reported the need of more clarity on
their roles as SPs [43]. A study from dentistry assessed
the effect of introducing a ‘communication skills course’
using interns to role play as SPs, reported improvement in
communication skills of dental undergraduates [44].
The standardized patient methodology has also been
used to assess standard for quality of care in healthcare
settings [45].
SET-UP REQUIRED FOR TRAINING SPs
CBME curricular reforms have recommended every
medical college to develop ‘Skills laboratory’ with
dedicated rooms, equipped with facility of video
recordings and debriefing [4].These labs can be used by
trained faculty of the institute to develop and implement
SP training program. People willing to work as SPs can be
recruited by advertising in local newspaper, internet or
through word of mouth; local actors can also be hired.
Persons who are willing to become SPs should be able to
act, memorize roles and checklists, good in communi-
cation skill, valid and reliable (accuracy and replicability),
available at any time and setting (portability), able to
adapt to many/different patients’ roles and motivated to
help educate students [4,11].
To reduce the cost, departmental staff, post-
graduates, interns, senior medical students, or even
mothers of admitted babies can be trained to participate in
the SP program [43,46]. Additionally, nursing and other
non-teaching staff, undergraduates, patients with genetic
disorders or chronic stable illness like thalassemia, sickle

Box III Limitations of Using Simulated Patients (Adults and Children)

• Difficulty in finding people to work as SPs, especially for intimate examinations.

• Only a limited range of physical findings can be simulated using SPs; we can not teach and assess for organomegaly, heart murmurs
etc. in healthy SPs.
• Training of SPs is costly in terms of money and time required, more so with child SPs; SPs have to be paid for every clinical encounter
with students.
• Ethical issues in using children as SPs - In accordance with the Constitution of India (The Child Labour (prohibition and regulation)
Amendment Act 2012), the minimum age for employment is 14 years; and violation of this rule can result in fine or even
imprisonment. Written consent of parents and assent of children from 14-18 years has to be taken before recruiting them.
• Training children as SPs can be more challenging; younger children may have difficulty in understanding what is expected out of them
and how to provide feedback. Their behavior may be inconsistent and difficult to control.
• Working long hours for child SPs can be taxing and may have negative psychological effects. They may get bored with repeated
encounters leading to non-cooperation, inconsistency in their responses with poor feedback.
• Difficulty in getting child SPs because children are more likely to have acute illnesses, so their clinical findings will change or resolve
over a short period of time.
• Parents may be too much concerned about their children’s feelings during the SP encounters, and may not allow their child to miss
school even for a day.

INDIAN PEDIATRICS 885 VOLUME 58__SEPTEMBER 15, 2021

KAPOOR, ET AL. SIMULATED PATIENTS FOR CBME IN COVID-19 ERA

Box IV Overcoming Problems in Using Child Simulated Patients

• Create scenarios where the adult SPs can be used to portray role of parent of a sick child, to assess history-taking skills of students.
• Take care of child SP’s emotional and physical well-being; consider participation of the child SP’s family/chaperones during
encounters.
• Use adult SPs along with their healthy or sick children (6-14 years) as parents and pediatric SPs and ask students to elicit a complete
history of child from parent including parent’s concerns. Subsequently, ask students to do physical examination of child OR it is
either presumed to be done and normal OR abnormal findings (as per the need of the case) are given on a piece of paper.
• After eliciting the history and a brief clinical examination, include interpretation of relevant laboratory reports, pulmonary
function tests, ECGs, X-rays, CT scans etc.
• Select children for SPs roles who are cooperative and preferably have interest in acting/drama.
• Use Child SPs for situations/issues that cannot be adequately assessed using other methods.
• Assign the roles to child SPs which match with their personalities, developmental age, and actual complaints/physical problems they
might have/had e.g. headache, abdominal pain.
• Older children (>14 y) can be coached to simulate complicated behaviors or emotional problem they themselves have not
encountered.
• Organize SPs-led sessions outside school hours/on holidays with regular breaks for rest and snacks.
• Limit SP encounters up to 10 or less at a time or till the child is comfortable.
• Consider use of patient substitutes such as photos (skin disorders), videos (abnormal movements, gait disorders), mannequins, and
computer simulation (audio-visual cardiac/respiratory system findings) for training and assessment of students.

cell disease, cerebral palsy, down syndrome, bronchial
asthma, diabetes mellitus, chronic obstructive pulmonary
disease, irritable bowel syndrome etc. can also be utilized
if they are willing to participate. Limitations of using SPs
(adult and children) with Indian perspectives are
summarized in Box III [15,47-49]. Suggestions to
overcome challenges in using child SPs have been
presented in Box IV [37,49].
Trained SPs are a valuable resource, and retaining
them in the SP program requires adequate remuneration,
respect and recognition of their efforts, appropriate
freedom to teach and give feedback to students [15].
CONCLUSION
SPs are being used for clinical skills’ teaching, observing,
assessing and giving feedback to medical students in
many countries for more than 50 years. They act out
scenarios (history, physical examination, inter-personal
communication skills, counseling and patient education),
can simulate abnormal physical findings, use checklists
to assess trainees objectively and give corrective feed-
back. Encounters with SPs have been found to be bene-
ficial in developing cognitive, technical and communi-
cation skills and self-confidence in medical students. SPs
are not going to replace real patients but help in transition
to real patients. With the implementation of CBME
curriculum in India, introducing SPs for training medical
students, especially undergraduates, will be an effective
approach for developing the desired competencies under
supervision and also saving faculty time. If ethical and
practical issues are addressed properly, use of child SPs
also can be feasible and rewarding. It is recommended to
introduce simulated patients in regular practice as a
supplement method for teaching and assessment of
clinical skills in the post-COVID-19 new normal.
Note: Additional material related to this study is available with
the online version at www.indianpediatrics.net
Contributors: Anil K: conceptualized the draft, drafted the initial
manuscript, did literature search, revised the manuscript and
approved the final manuscript before submission and act as
guarantor of the paper; Anju K: literature search, initial drafting
of manuscript, reviewed the manuscript and approved the final
manuscript before submission DKB: reviewed the manuscript,
provided critical comments, and approved the final manuscript
before submission.
Funding; None; Competing interests: None stated.
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Clinical Skills Laboratory (CSL) - a Modern Tool of Medical Education

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Journal of Sylhet Women’s Medical College (JSWMC)
Journal.swmc.edu.bd
Editorial
Clinical Skills Laboratory (CSL) - a Modern Tool of Medical Education
Introduction:
Clinical skills laboratory (CSL) is a type of
medical educational tool which proved its
beneficial effect in undergraduate and
postgraduate medical education. CSL provides a
safe and protected facility to the learner in which
they can practice the procedures before applying
it on real patient. The CSL includes physical
examination, procedural training, history-taking,
building team work, effective communication
and learning professionalism.1 This teaching tool
was first started in the Netherlands Limburg
University of Maastrich in the year of 1976.
After that the Universities of Liverpool, Dublin,
Dundee, Southampton, Imperial College and
Leeds have incorporated CSL in their medical
curriculum. In the Asia, United Arab Emirates
University first established CSL in their
curriculum in the year of 1988.2
Table 1: Different skills practiced in CSL.
Name of the skills practiced in CSL
- Procedural techniques
- Patient management
- Physical examinations
- History taking
- Building team work
- Interpreting investigational team
- Communication skill
- Teaching and learning methodology
- Attitudinal awareness and professionalism.
In the modern medical education system CSL is
also called as clinical and communication skill
center. Apart from skill teaching,
communication practice is also taught in CSL.
According to the educational strategy the CSL
could be of different types.3 They are:
ISSN: 2708-2857 (P), 2710-0405 (O)
2022 January; Volume 12; Issue 01
1. Self-directed learning
2. Student-centered
3. Problem-based learning
4. Outcome based education
5. Community oriented
6. Multi-professional
Different methods and resources are used in
CSL. Audio and video components are
important in the communication teaching. The
participant groups could be small group or large
groups. The skill teaching resource are of
various types. Such as-
1. Role play
2. Simulated patients
3. Real
4. Standardized
5. Manikin
Structure of CSL area:
The CSL setups are mostly established in
medical schools / colleges and Universities. In
the year 1996, proposal was made to launch
satellite centers of CSL in peripheral clinics and
community based setup with the linking with the
higher centers.4
Usually large area is required for an ideal
laboratory which comprises of seminar area
along with small rooms for interviews. Different
types of clinical setting such as emergency
room, ICU cubicle, counselling room, procedure
practice rooms are to be included in the clinical
skills laboratory apart from the simulations or
manikins. There should be flexibility in the
structure so that the floor area can be converted
to different set up if required. This is very
important that the set up should look very much
realistic for the clinical scenarios.
9
Journal of Sylhet Women’s Medical College (JSWMC)
Journal.swmc.edu.bd
Four types of simulators are usually used-
1. Part-time trainer
2. Simulated patients and environments
3. Integrated simulators
4. Computer-based system
- Multimedia program
- Interactive system
- Virtual reality
Advantages and disadvantages:
The advantages of CSL in modern medical
education is enormous. This provides a great
opportunity to the medical students to learn the
procedures in protected and safe environment. It
reduces the gap between the classroom and
clinical setup. The theoretical component is
integrated with the skill by this procedure.
During the skill training no patients feel stressed
or embarrassed which makes the trainee more
comfortable. Computer assisted programs gives
detail audio visual information to the trainee
which helps to build strong residual knowledge.
This can be used as modern assessment tool like
objective structured clinical examination
(OSCE) all through the year as well as during
the examination. Private part examinations
learning are performed without disturbing the
patients and compromising cultural barrier.5
There are few disadvantages also. Full time well
groomed trainer to be appointed for smooth
running of CSL. The training manikins and other
simulator resources are expensive and
sometimes are not affordable to many
institutions. As the examination and procedures
are taught without real patients so the holistic or
spiritual relationship between physician and
patients are not addressed here.6
Different type of simulators:
The commonly used simulation-based resources
are-
1. Plastic model for partial task training
(intubation, catheterization etc.)
2. Mannequin type simulators (ATLS, physical
examination etc.)
3. Live or inert animals with isolated organs.
4. Human cadavers for surgical training
(mastoid surgery, skull base surgery etc.)
ISSN: 2708-2857 (P), 2710-0405 (O)
2022 January; Volume 12; Issue 01
5. Simulated and standardized patients (history
taking, physical examination, counselling
etc.).
6. Screen based software based virtual reality
simulators.
Mannequin simulators were invented in 1950s
mainly to teach resuscitation. There are of two
types of mannequin simulators, dummy-type and
high-fidelity type. Dummy type mannequins are
used in teaching basic life support (BLS),
advanced trauma life support (ATLS),
endotracheal intubation and cardiac
defibrillation training mainly. The high-fidelity
simulators are mainly computer software
controlled. They capable in showing some
physical status like blood pressure, heart rate,
respiratory and heart sound, pupillary diameter
and movement of upper limbs. Modern high-
fidelity mannequins can display the change of
the vitals like heart rate, blood pressure, pulse,
bowel sounds after any physiological or
pharmacological stimulation.7
Conclusion:
Clinical skills laboratory is a unique addition to
the modern medical education. Developing skill
in safer way can be obtained by this teaching
tool. In the Bangladesh context basic skills are
scheduled to be taught in the third year MBBS
course curriculum. Incorporating CSL in the
third year bed-side ward placement rotation can
improve the quality of skill/ procedure teaching
in the undergraduate medical education.
Correspondence: Khandaker Abu Talha
MBBS, MCPS (Surgery), MPH, MS (Neurosurgery),
Diploma in Clinical Research (Canada)
Associate Professor and Head, Neurosurgery
Department, Sylhet Women’s Medical College,
Sylhet 3100, Bangladesh.
Email: katalha@yahoo.com
References:
1. Boulay CD, Medway C. The clinical skills
resource: a review of current practice.
Medical Education 1999; 33:185-191.
2. Bradley P, Postlethwaite K. Setting up a
clinical skills learning facility. Medical
Education 2003; 37(1):6-13.
10
View publication stats

Journal of Sylhet Women’s Medical College (JSWMC) ISSN: 2708-2857 (P), 2710-0405 (O)
Journal.swmc.edu.bd 2022 January; Volume 12; Issue 01

3. Dacre J, Nicol M, Holroyed D, Ingram D.

The development of a clinical skills centre.
J. R. Coll. Physicians Lond. 1996; 30(4):
318-324.
4. Bradley P. The history of simulation in
medical education and possible future
directions. Medical Education
2006;40:254- 262.
5. O’Connor HM. Training undergraduate
medical students in procedural skills.
Emergency Medicine 2002;14:131-135.
6. KorndorfferJr JR, Stefanidis D, Scott DJ.
Laparoscopic skills laboratories: current
assessment and a call for resident training
standards. The American Journal of
Surgery 2006;191:17-22.
7. KorndorfferJr JR, Stefanidis D, Scott DJ.
Laparoscopic skills laboratories: current
assessment and a call for resident training
standards. The American Journal of
Surgery 2006;191:17-22.

11
 SKILLS MODULE

1
2
 Annexure B
Examples of Task Training Modules
Example 1: Module for Recording Blood Pressure
Competency in Phase-I:
PY5.12: Record blood pressure & pulse at rest and in different grades of exercise and
postures in a volunteer or simulated environment.
Skill training: Recording of blood pressure.
Objectives:
By the completion of this module, the student will be able to:
Record blood pressure of volunteer by palpatory and Auscultatory method, with
sphygmomanometer in right / left upper limb, step wise in sitting / lying down /
standing position at rest.
Suggested Teaching Learning Method: DOAP sessions
Background Knowledge:
PY5.3 Discuss the events occurring during the cardiac cycle
PY5.7 Describe and discuss hemodynamics of circulatory system
PY5.8 Describe and discuss local and systemic cardiovascular regulatory
mechanisms
PY5.9 Describe the factors affecting heart rate, regulation of cardiac output & blood
pressure
Knowledge about the equipment = Sphygmomanometer, its parts, appropriate size
selection and placement.
Equipment/ Instrument/ Other requirement:
Sphygmomanometer
Stethoscope
Volunteer / mannequin
Hand-outs / check list
Bed/Couch
3
Steps in Blood Pressure Recording:
Patient counselling and consent. Explain to the patient the need for Blood
Pressure recording and the procedure. Assess patient's understanding and
answer any questions they may have. Respond to the patient’s concerns
throughout the procedure.
Check the sphygmomanometer and stethoscope.
Ensure the equipment mercury column is at zero mark.
Ensure appropriate position of the patient (sitting on a chair with back supported,
feet on the floor, legs uncrossed or lying supine).
Record Blood Pressure after 5 mins. of inactivity.
Expose the arm and support it at the level of the heart.
Palpate the brachial artery in cubital fossa.
Choose appropriately sized cuff & position the center of cuff’s bladder over the
brachial artery.
Wrap the cuff smoothly and snugly around the arm. Cuff should be wrapped in a
circular manner one-inch above the level of elbow.
Correctly palpate the radial artery of the volunteer / or the mannequin with 3
fingers.
Close the sphygmomanometer valve and inflate the cuff to determine mm Hg at
which arterial pulsation can no longer be felt.
Slowly deflate the cuff by opening the sphygmomanometer valve and note the
point where arterial pulsation can be felt again (this is estimated systolic BP).
Inflate the cuff again to a level 20 – 30 mm Hg more than estimated systolic BP.

Place diaphragm head of the stethoscope lightly over the brachial artery.
Deflate the cuff slowly by opening the sphygmomanometer valve so that the
pressure falls at 2–3 mm Hg / second.

4
 Note the mm of Hg pressure at which arterial pulsation / beats can be heard (this
is systolic BP).
Continue deflation and note the mm of Hg pressure at which the last arterial beat
is heard (this is diastolic BP).
Continue deflation for another 10 – 20 mm of Hg past the last heard beat to
ensure that the absence of sound is not due to skipped beat.
Deflate the cuff rapidly and completely.
If necessary to re-record, wait at least 2 minutes.
Document the recording in terms of patient position, arm used, cuff size, blood
pressure recording.
Inform the patient of your findings and conclude.
Skill assessment:
OSCE type stations, where observer can observe and assess communication skill
(counseling), psychomotor skill and attitude (respond to the patient’s concerns,
inform
the patient of the findings and conclude). This can be done either with check lists or
using global ratings.
Suggested Reading:
Books Recommended (latest edition)
1. AC Guyton – Text book of Medical Physiology
2. WF Ganong – Review of Medical Physiology

5
 Annexure C
6.1 Guidelines for development of skills lab at medical colleges:
1. Every medical institution must provide students access to a skills laboratory
where they can practice and improve skills pre-specified in the curriculum.
2. The purpose of the skills lab is to provide a safe and non-threatening
environment for students to learn, practice and be observed performing skills in
a simulated environment thus mitigating the risks involved in direct patient
exposure without adequate preparation and supervision.
3. The skills lab attempts to recreate the clinical environment and tasks which
future health care workers have to perform with various levels of complexity and
fidelity.
4. Skills labs are used to enhance - clinical, psychomotor and communication
skills - as well as teamwork.
5. The skills lab that fulfills the requirements of the outcomes in undergraduate
curriculum should contain, at the minimum, the following:
a. The skills lab should have a total area of at least 2000 sqft for 100 students,
there must be a facility for minimum of 04 rooms (preferably 08) for
examination of patients or standardized/ simulated patients.
b. The skills lab should be equipped with a facility for video recording and
review of the interaction. This is vital for teaching communication skills.
c. A room for demonstration of skills to small groups,
d. A review or debriefing area,
e. Stations for practicing skills individually or in groups,
f. Trainers or mannequins required to achieve skills outlined in the
competency based undergraduate curriculum document,
g. Adequate storage space for storage of mannequins and/or other
equipments,

6
h. A room for faculty coordinator, and for support staff.
i. Dedicated technical officer and support staff must be available.
6.2 Suggested facilities in Skill Labs (for 100 students) by the start of Phase 1 in
all medical colleges
Part Time task trainer simulators / models / mannequins for:
o First aid, Bandaging, splinting; n=4
o Basic Life Support (BLS), CPR (Cardio Pulmonary Resuscitation)
mannequin: n=4
o Various types of injections- Subcutaneous, Intra-muscular, Intra-venous;
n=5
o Urine Catheter insertion; n =4
o Skin & Fascia suturing n=5
o Breast examination model /mannequin
o Gynecological examination model / mannequin including IUCD (Intra
Uterine Contraceptive Device) Training model
o Obstetrics mannequins including Obstetric examination, conduct and
management of vaginal delivery.
o Neonatal & Pediatric resuscitation mannequins
o Whole body mannequins, Trauma mannequin (Optional)
Each model (Low or High Fidelity) should have a module for training including
objectives, methods and assessment. Modules can also have hybrid models
where real patients or standardized/simulated patients/ computer simulations
can be used.

7
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
https://doi.org/10.1186/s12909-020-02284-1

REVIEW Open Access

Tips for teaching procedural skills

Annette Burgess1,2*, Christie van Diggele2,3, Chris Roberts1,2 and Craig Mellis4

Abstract
The teaching of procedural skills required for clinical practice remains an ongoing challenge in healthcare education. Health
professionals must be competent to perform a wide range of clinical skills, and are also regularly required to teach these
clinical skills to their peers, junior staff, and students. Teaching of procedural skills through the use of frameworks, observation
and provision of feedback, with opportunities for repeated practice assists in the learners’ acquisition and retention of skills.
With a focus on the teaching of non-complex skills, this paper explores how skills are learned; ways to improve skill
performance; determining competency; and the provision of effective feedback.
Keywords: Procedural skills teaching, Peyton’s four-step approach, Determining competency, Provision of feedback,
Deliberate practice

Background procedural skills, this paper aims to explore how skills are
Health professionals must have the ability to perform a learned; ways to improve skills performance; determining
wide range of clinical skills competently. These generally competency; and the provision of effective feedback.
include history taking, physical examination, and proced-
ural skills. While some procedural skills are specific to
particular disciplines, competency in the performance of How are skills learned?
skills is required to ensure the delivery of safe patient care. In the last half of the twentieth century, many motor
Examples include correct hand washing technique, gastric learning theorists posited the required steps to teach a
tube insertion, cannulation, resuscitation, correct use of psychomotor skill [3–6]. Building on this work, re-
crutches, bedside dysphagia assessment, bed-to-chair searchers have since proposed motor learning models
transfer, and gait analysis. A skill that is learned and for teaching and learning procedural skills [7, 8]. Com-
retained beyond the period of practice, can be recalled mon to most skills teaching literature is that skills are
and competently performed in a variety of clinical settings best learned by following a sequenced and stepped ap-
[1]. Health professionals are regularly required to teach proach to teaching – whether a simple or complex task.
these clinical skills to their peers, junior staff, and stu- However, the majority of skills required in healthcare
dents. However, the effectiveness of skills teaching is un- are complex, requiring more than seven skill elements
certain, and there is evidence suggesting junior health [9], and are difficult to teach, learn and retain. It has
professionals are overconfident in their ability to teach been reported that when using George and Doto’s
practical skills [2]. With a focus on non-complex (2001) five-step model to teach a simple dental skill,
novices were able to perform the task after one attempt
[10]. Similarly it has been reported that use of Peyton's
* Correspondence: Annette.burgess@sydney.edu.au [7] four-step model enhanced medical students' aquisi-
1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical
School - Education Office, The University of Sydney, Edward Ford Building tion of simple skills when learning suturing [11]. When
A27, Sydney, NSW 2006, Australia teaching complex tasks, however, the four- and five- step
2
The University of Sydney, Faculty of Medicine and Health, Sydney Health models may have limited utility to assist skill acquisition
Professional Education Research Network, The University of Sydney, Sydney,
Australia and retention. For example, some studies have reported
Full list of author information is available at the end of the article no difference in learning outcomes when using a two
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
step, four step or five step approach to teaching complex
skills, such as simulated manual defibrillation [12], laryn-
geal mask airway insertion [13], and simulated gastric
tub insertion [14]. Nicholls et al. (2016), in their review
of contemporary motor learning, suggest an integrated
instructional model to teach multi-part psychomotor
skills provides a more effective approach to teaching
complex skills required for clinical practice. The authors
have provided the educational steps required to teach
complex psychomotor skills [9].
The method used for teaching skills differs from that
for teaching content. Teaching of procedural skills utilis-
ing frameworks, observation and feedback, with oppor-
tunities for repeated practice assists in the learner's
acquisition and retention of skills [7, 8, 15, 16]. Clinical
skills, such as taking a patient history, performing a
physical examination, synthesising and presenting data,
require multiple cognitive and psychomotor skills. As
such, clinical skills are more readily demonstrated than
described. One of the difficulties is that once a skill is
performed regularly – as an expert – it is performed
subconsciously. As a result, it is not easy to break it
down into structural steps to clearly communicate the
process to others [2]. There are many ways to teach a
skill, including the use of simulated patients, manikins,
videos, virtual reality and computers. The use of proced-
ural skills labs in teaching provides opportunities for safe
practice before performing these procedures on patients.
This gives learners the opportunity for practice, to re-
ceive immediate feedback, and to further refine their
competence and confidence - before undertaking the
procedure on a patient. Although some skills, such as re-
suscitation, can be taught in skills labs, students will
Fig. 1 The three main components of skill competency [2, 17]
Page 2 of 6
generally need to practise carrying out safe procedures
in the clinical setting. Generally, a skill:
 is learned, and not innate
 is able to be broken into explicit steps
 requires practice in order to improve
 has a specific goal or outcome, that is measurable
Learning a skill involves more than just performing the
skill manually. There are other considerations, including
knowledge of the procedure (such as why it is being done,
how, and what are potential risks) and communication
skills. Becoming competent in a skill involves three main
components: knowledge, communication and perform-
ance [2, 17], as displayed in Fig. 1.
Tips for teaching clinical skills
When teaching a skill, even the most basic of steps
should be included, such as handwashing. No assump-
tions should be made, and every detail needs to be dem-
onstrated. Some tips for teaching clinical skills are listed
below [7]:
 Include the fundamentals: for example, handwashing
 Demonstration: provide clear demonstrations for
learners to see
 Integrate theory with practice: learners can see the
evidence behind the action, which promotes clinical
reasoning
 Break skills/procedures down into steps: find out
what the learners already know, and proceed from
there
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
 Use collaborative problem solving: allow learners to
work together towards a solution
 Provide feedback: that is clear and constructive, in
an appropriate environment
Skills as structural steps
Skills need to be broken down into small, discrete steps
when teaching others in order to demonstrate and com-
municate exactly what is required. Although there are
many models, a useful, well researched method is Pey-
ton’s four step approach [7], displayed in Table 1, which
can successfully be applied to teaching in the clinical set-
ting. A controlled trial by Krautter et al. (2011) found
that using Peyton’s four step approach to teach a tech-
nical skill was superior to standard instruction, with
benefits in the areas of professionalism, communication
and faster performance of the skill [14].
Provision of immediate feedback
The acquisition of procedural skills is reliant on task
practice and feedback [2]. As well as repetition, Peyton’s
four-step approach allows learners to see the skill being
performed in real time, from beginning to end, and re-
peated by the instructor, before attempting performance
of the skill themselves. This allows for the reinforcement
of learning and opportunities to correct any errors and
provide feedback. Immediate feedback and error correc-
tion avoids the risk of the skill being performed and
practiced incorrectly, stored in long term memory,
recalled and performed incorrectly [1, 18]. Provision of
constructive feedback on the learners’ performance is an
essential part of skills acquisition. Salmoni and col-
leagues (1984) suggest that feedback should be withheld
until the conclusion of the skill to allow the learner to
practice while focussing on each element of the skill,
without excessive verbal information [19]. Feedback
should be given immediately in order for the learner to
correctly practice areas requiring improvement. The
learner should also be provided with opportunities to
ask questions at the end of the skill session. A
participant-driven method, such as Pendleton’s feedback
Table 1 Peyton’s four step approach to skills teaching [7]
Peyton’s four step approach
1. Demonstration: Instructor demonstrates the skill at normal speed
and without additional comments.
2. Deconstruction: Instructor demonstrates the skill by breaking it
down into simple steps, while describing each step.
3. Formulation: Instructor demonstrates the skills whilst being ‘talked
through’ the steps by the learner.
4. Performance: Student demonstrates the skill, while describing each
step.
Page 3 of 6
model [20], displayed in Fig. 2, is useful to ensure the
learner reflects first on their own performance.
When training learners in skills teaching, Peyton’s
four-step approach method [7], followed by provision of
peer and teacher feedback can be modelled. For ex-
ample, in small groups of three to five learners, each
learner teaches a skill to another learner, using Peyton’s
four-step approach. Each learner also takes responsibility
for providing feedback to a peer on their teaching, using
Pendleton’s feedback model. The activity (teaching a skill
and providing feedback) may be formatively assessed by
the facilitator using marking guides. However, it should
be noted that as well as there being different models that
may be used to teach a skill, there are also many
models of feedback that can be applied to skills
teaching. These include models such as Silverman’s
SET-GO and ALOBA [21] methods, which can be
usefully applied to bedside teaching. It is important to
find suitable methods that you are comfortable and
familiar with using.
Development of competency
Learners move through a series of stages before be-
coming competent at a skill (see Fig. 3) [22]. There
are four levels in skill acquisition: 1) Unconsciously
incompetent, 2) Consciously incompetent, 3) Con-
sciously competent, 4) Unconsciously competent. To
appreciate these stages it is useful to reflect on acqui-
sition of an everyday skill, for example, on how you
learnt to drive a car. Novices will start initially as be-
ing ‘unconsciously incompetent’ (not aware of the
knowledge and skills needed to competently drive),
moving through the stages of competence (until they
have the knowledge and skills to competently drive a
car). However, there is the long-term potential of
again becoming ‘unconsciously incompetent’ (for ex-
ample, over-estimating their driving ability, and/or
not staying up to date on new recommendations or
road rules).
Determining competency
Knowing when someone is competent can be difficult to
assess. Learners are generally deemed competent once
they can perform the procedure or skill alone, or with-
out supervision. Competence is sometimes determined
simply by noting the number of times the learner has
performed the procedure (for example, bronchoscopy),
or after completing a formal, observed assessment. Each
skill may require a different approach to determining
competence [23]. The important aspects of ensuring
someone is competent are [23]:
 Setting and knowing the outcomes
 Setting and knowing expectations
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
Fig. 2 Feedback Model (adapted from Pendleton et al, 1984) [20]
 Multiple observations of skill performance
 Looking for common errors
Miller’s pyramid [24] provides a useful hierarchy to
determine a learner’s competency in performing a
skill (see Fig. 4). The bottom of the pyramid is based
on knowledge (taught didactically and assessed by
multiple choice questions (MCQs)), moving to ‘knows
how’ (taught clinically and assessed with Objective
Structured Clinical Examinations (OSCEs) or clinical
Fig. 3 Development of Competency (adapted from Peyton, 1998) [22]
Page 4 of 6
long cases), to demonstrating how to carry out the
skill by “on the job” performance. Most assessments
that clinicians undertake are based on the upper
levels of the pyramid and are carried out in the
workplace.
Maintaining a skill and improving performance
Skills are acquired through diligent practice [15].
Nicholls and colleagues (2016) suggest skill practice is
reliant upon multiple, spaced, short duration, and
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
variable tasks, with practice opportunities to promote
skill acquisition and long-term retention by the learner
[9]. In order to avoid natural skill decay, it is important
for health professionals to maintain their skills once ac-
quired. This can only be achieved through regular prac-
tice. According to Ericsson & Charness (2004), those
that attain high skill levels do so because they continu-
ally reflect on their own performance [15]. They tend to
focus on the areas in which they are not doing well and
practice that competence. This is what is known as de-
liberate practice and is highly relevant for clinical skills
training, as well as elite sportspersons and musicians.
The key elements to deliberate practice are:
 Well defined tasks
 Opportunities to practice and improve
 Opportunities to repeat and reflect
 Regular feedback from an observer
The use of simulation in teaching procedural skills
It is important to note that the use of simulation-
based healthcare education has been associated with
better patient care and improved patient safety [25].
The frequency and repetition with which a task is
practiced impacts skill retention, recall, and transfer-
ability from the simulated to real clinical environment
[1, 18]. Simulation offers the opportunity to practice
procedures without any risk of patient harm, and is
widely used as both a training and assessment tool.
Goal-orientated learning using competency-based in-
struction, is a characteristic of adult learning. It rein-
forces a standard of training, rather than assuming
that everyone who has been taught the skill can per-
form the skill. A recent systematic review showed
strong evidence for the use of simulation and
Fig. 4 Framework for clinical assessment (adapted from Miller, 1990) [24]
Page 5 of 6
competency-based teaching paradigms in the effective
teaching of procedural skills [26]. The systematic re-
view found that the most effective approach in align-
ing procedural skills training with the needs of the
adult learners is high-quality simulation that includes
repetitive practice, mastery of learning, and deliberate
practice, supplemented by visual aids, such as videos
[26]. Sawyer et al. (2016) developed a six- step ap-
proach to teaching a skill that combines preparation,
skill acquisition, and maintenance of the skill: “Learn,
See, Practice, Prove, Do, Maintain” [25]. This six-step
approach uses adult learning theory to reinforce the
need for the development, assessment and mainten-
ance of procedural skills:
1. Learn: knowledge acquisition
2. See: observation of the procedure
3. Practice: deliberate practice using simulation
4. Prove: competency is assessed
5. Do: the procedure is performed on a patient, with
direct supervision until the learner is entrusted to
perform the procedure independently
6. Maintain: continued clinical practice, supplemented
by simulation-based training.
Conclusion
Acquisition of competency in clinical and procedural
skills is fundamental to healthcare training. In the clin-
ical setting, there is a requirement to teach skills to
others, so it is important to learn how to do this most
effectively. Simulation offers the opportunity to practice
procedures without any risk of patient harm, and is
commonly used as both a training and assessment tool.
It has long been posited that using a stepped structural
approach best guides skills acquisition and retention. A
Burgess et al. BMC Medical Education 2020, 20(Suppl 2):458
framework, such as Peyton’s four-step approach [7], is a
useful model to break the teaching of a skill into discrete
steps. The provision of feedback is essential in reducing
the gap between current and desired performance. Once
skills are acquired, deliberate practice is important in
maintaining and improving the performance of a skill.
Take home message
• Skills need to be broken down into smaller steps when teaching
others, and the use of frameworks, for example, Peyton’s four steps
provide useful approaches.
• Provision of constructive feedback, for example, using Pendleton’s
model is an integral part of the skills teaching process.
• Once skills are acquired, they must be maintained through deliberate
practice.
Abbreviations
MCQs: Multiple choice questions; OSCEs: Objective Structured Clinical
Examinations
Acknowledgements
The authors have no acknowledgements to declare.
About this supplement
This article has been published as part of BMC Medical Education Volume 20
Supplement 2, 2020: Peer Teacher Training in health professional education.
The full contents of the supplement are available online at URL. https://
bmcmedicaleducation.biomedcentral.com/articles/supplements/volume-20-
supplement-2.
Authors’ contributions
AB, CM and CVD contributed to the drafting, writing, and critical review of
the manuscript. CR contributed to the critical review of the manuscript. All
authors read and reviewed the final version of the manuscript.
Funding
No funding was received.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors have no competing interests to declare.
Author details
1
The University of Sydney, Faculty of Medicine and Health, Sydney Medical
School - Education Office, The University of Sydney, Edward Ford Building
A27, Sydney, NSW 2006, Australia. 2The University of Sydney, Faculty of
Medicine and Health, Sydney Health Professional Education Research
Network, The University of Sydney, Sydney, Australia. 3The University of
Sydney, Faculty of Medicine and Health, The University of Sydney, Sydney,
Australia. 4The University of Sydney, Faculty of Medicine and Health, Sydney
Medical School, Central Clinical School, The University of Sydney, Sydney,
Australia.
Page 6 of 6
Published: 3 December 2020
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9. Nicholls D, Sweet L, Muller A, Hyett J. Teaching psychomotor skills in the
twenty-first century: Revisiting and reviewing instructional approaches through
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skills to students in a dental college in India. J Dent Educ. 2011;75:1502–6.
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education theory-based method to teach a procedural skill. Arch Dermatol.
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approach for skill acquisition and retention: teaching manual defibrillation
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Auerbach M, Johnston L, Kessler D. Learn, see, practice, prove, do, maintain:
an evidence-based pedagogical framework for procedural skill training in
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 medical education in review
The long case and its modifications: a literature review
Gominda G Ponnamperuma,1 Indika M Karunathilake,2 Sean McAleer1 & Margery H Davis1
CONTEXT This review provides a summary of
the published literature on the suitability of the
long case and its modifications for high-stakes
assessment.
METHODS Databases related to medicine were
searched for articles published from 2000 to
2008, using the keywords ‘long case’, ‘clinical
examinations’ and ‘clinical assessment’. Refer-
ence lists of review articles were hand-searched.
Articles related to the objective structured
clinical examination were eliminated. Research-
based articles with hard data were given more
emphasis in this review than those based on
opinion.
RESULTS Eighteen articles were identified.
The main disadvantage of the long case is its
inability to sample the curriculum widely,
resulting in low reliability. The main advantage
of the long case is its ability to assess the
candidate’s overall (holistic) approach to the
Medical Education 2009: 43: 936–941
doi:10.1111/j.1365-2923.2009.03448.x
1
Centre for Medical Education, University of Dundee, Dundee, UK
2
Medical Education Development and Research Centre, Faculty of
Medicine, University of Colombo, Colombo, Sri Lanka
936 ª Blackwell Publishing Ltd 2009. MEDICAL EDUCATION 2009; 43: 936–941
patient. Modifications to the long case attempt
to: structure the format and the marking
scheme; increase the number of examiners;
observe the candidate’s behaviour, and increase
the number of cases.
CONCLUSIONS The long case is a traditional
clinical examination format for the assessment
of clinical competence and assessment at this
level is important. The starting point for the
majority of recent research on the long case has
been an acceptance of its low reliability and
modifications to the format have been pro-
posed. Further evidence of the efficacy of these
modifications is required, however, before they
can be recommended for summative assess-
ment. If further research is to be undertaken
on the long case, it should focus on finding
practicable ways of sampling the curriculum
widely to increase reliability while maintaining
the holistic approach towards the patient,
which represents the attraction of the long case.
Correspondence: Gominda G Ponnamperuma, 16 ⁄ 5 Quarry Road,
Mirihana, Nugegoda, Sri Lanka. Tel: 00 94 1128 27531;
Fax: 00 94 1126 91581; E-mail: gominda@googlemail.com

INTRODUCTION
The long case enjoys a unique place in many clinical
assessment systems and continues to be used in both
undergraduate and postgraduate medical education
in many parts of the world. The 2009 Australian
publication Mastering the Medical Long Case by Jaya-
singhe1 was recommended on the basis that ‘all
medical schools have recognised the ‘‘Long Case’’ as
an integral part of the learning and examination
process of the medical program’. Use of the long
case in high-stakes assessment continues, despite
concerns raised about its validity and reliability. The
continued popularity of the long case stimulated us
to review the literature to investigate its pros and
cons. This review also looks into possible alternatives
to the long case, as well as ways and means
of improving it.
The long case is a traditional clinical examination
that assesses candidate competence at the ‘shows
how’ level in Miller’s pyramid.2 The candidate
initially spends time (30–60 minutes) with a patient,
taking a history and carrying out physical examina-
tion, without examiner observation. Then the
candidate presents the findings to one or more
examiners and answers oral questions. In most
instances each candidate is given a unique patient
and a unique examination. Traditionally, the candi-
date is scored with unstructured marking criteria
that are based on neither standardised checklists nor
on rating scales with descriptors related to candidate
competence.
Prior to the turn of this century, two problems were
identified in relation to the long case. Firstly, Wilson
et al.3 found some substantial differences in scores
given to the same candidate by different examiners
in an undergraduate clinical examination in Glas-
gow, UK, resulting in low validity and reliability.
Secondly, van der Vleuten4 and Dugdale5 pointed
out that the long case attempted to generalise the
abilities of the candidate across a broad spectrum
of clinical scenarios with a single clinical case. This
problem has been confirmed by more recent
studies.6,7
Given the above two problems, the main research
questions investigated through this literature review
were: What modifications to the long case have
been attempted with a view to improving its
psychometric properties? What are the advantages
and disadvantages of the long case?
ª Blackwell Publishing Ltd 2009. MEDICAL EDUCATION 2009; 43: 936–941
The long case and its modifications
METHODS
MEDLINE, BIDS, Blackwell Synergy (for the journals
Medical Education and Internal Medicine), Ingenta,
PubMed, AskEric, TimeLit and Google Scholar were
searched for articles published from 2000 to 2008. The
keywords were ‘long case’, ‘clinical assessment’ and
‘clinical examinations’. The reference lists of review
articles were then hand-searched. This hand-search
identified articles published prior to 2000. Those that
directly dealt with the long case and related clinical
assessments were selected for this review.
RESULTS
Although it is much used, there is little published
research on the long case. Eighteen articles directly
related to the ‘traditional’ long case were found. The
findings of these articles and the pre-2000 papers
identified by the hand-search are discussed under
three headings: modifications to, advantages of, and
disadvantages of the long case.
MODIFICATIONS TO THE LONG CASE
The observed structured long case
Gleeson8,9 introduced the objective structured long
examination record (OSLER), a 10-item analytical
record of the traditional long case, with an examiner-
observed history-taking and physical examination
process, and a criterion-referenced marking scheme
to improve the reliability of the long case. No
reliability figures for the OSLER were reported. In
postgraduate clinical skills assessment, Gleeson8
reported the ability of the OSLER to identify the
curriculum content that needed more input by
the curriculum designers. Van der Vleuten4 noted that
the OSLER was strong in educational value in terms
of providing feedback. He pointed out, however, that
improvements in reliability were better achieved by
increasing the number of cases than by focusing on
observing the student during the long case.
In a study of doctor trainees with an observed long
case and a structured assessment form, Pavlakis and
Laurent10 found that the trainees did not pay
attention to physical examination skills as these skills
were not previously observed. The study upheld the
value of observation of the long case as it compelled
the candidates to master clinical skills. The authors
937
G G Ponnamperuma et al
were critical of the importance placed on the discus-
sion of patient management in the long case at the
expense of the assessment of clinical examination
technique.
The structured long case with multiple examiners
Olson et al.11 evaluated the usefulness of a structured
question grid for the long case, where two assessors
assessed the candidate on one long case. One
examiner marked with the aid of a structured
question grid and the other did not. Based on the
results of 391 students taking 1564 long cases in
internal medicine, paediatrics, reproductive
medicine or surgery, there was no significant differ-
ence ‘in the chance of students being assessed as
failing or on the likelihood of a discrepancy between
the ratings’. The student group that was assessed with
the structured question grid, however, perceived the
assessment as less representative of their ability.
The observed structured long case with multiple
examiners
Wass and Jolly6 experimented with the traditional
history-taking long case by using two pairs of examin-
ers and incorporating examiner observation into
the final MBBS examination at a London medical
school. A pair of examiners first observed the candi-
date taking the history (Part 1). Thereafter, the
candidate presented the case to another pair of
examiners (Part 2). Inter-rater reliability was higher
for the observation (checklist 0.72; global 0.71) than
the presentation (checklist 0.38; global 0.60) part. The
authors also found that observation of the long case
history taking constituted a distinct component of
clinical competence, which the usual long case
(i.e. only the presentation part) would fail to measure.
Norcini,12 however, argued that although experi-
ments similar to that conducted by Wass and Jolly6
improved reliability, these modifications did not raise
the long case to a level that supported its use in high-
stake situations. Three factors that contributed to
its unreliability were: case specificity; examiner
stringency, and the aspects of competence
evaluated.13 Norcini proposed that the modification
of these three factors, respectively, would bring
about substantial gains in reliability, as follows:
1 cases or encounters: by increasing the number of
cases or encounters;
2 examiners: by minimising differences among
examiners; by increasing the number of examiners,
and by training the examiners, and
938 ª Blackwell Publishing Ltd 2009. MEDICAL EDUCATION 2009; 43: 936–941
3 aspects of competence: by increasing the number
of aspects of competence assessed and providing
the examiners with lists of competencies; by
standardising across examiners through
examiner training, and by using examiner-
observed student–patient interactions.
Price and Byrne14 assessed clinical psychiatry skills,
where two examiners first directly observed the
candidate taking a history for 20 minutes and then
evaluated candidate competence on case-specific
tasks, such as partial mental state assessment, as
requested by the examiners. The key feature of this
method was that it allowed the examiner to adjust for
the degree of difficulty of the case. Although the
authors reported satisfactory inter-rater reliability
(kappa coefficient of 0.7), this study did not address
the low generalisability problem of the long case.
The study only partially addressed the problem of
lack of standardisation by allowing the examiners
to adjust the scoring according to the level of
difficulty of the case.
Increasing the number of cases: multiple observed
structured long cases with multiple examiners
Improvements to the observed long case include the
direct observation clinical encounter examination
(DOCEE)15 and the integrated direct observation
clinical encounter examination (IDOCEE).16 Both
examinations expose the candidate to multiple
patient interactions in which multiple examiners
from different specialties observe the candidate
carrying out history taking and physical examination.
In the DOCEE, each candidate was examined with
four patients and two pairs of examiners. Each pair of
examiners assessed the candidate in two patient
encounters. Every three consecutive candidates were
examined with the same set of patients and examin-
ers. The generalisability coefficient for four cases and
two examiners for each case was 0.84.15 The IDOCEE
was very similar in structure and conduct to the
DOCEE, except for the number of patients (four to
six) and examiners (two panels, each with two or
three examiners) encountered by each candidate.
Each panel of examiners assessed a candidate in two
or three patient encounters. The students and
examiners were ‘highly satisfied’ with the structure,
organisation and effectiveness of this examination.16
In a separate experiment with two observed long
cases and a pair of examiners, Newble17 demon-
strated the effectiveness, as measured by student and
staff feedback. Luiz et al.18 also found that when each
candidate took two structured, standardised,

observed long cases, each marked by a different
examiner, examiner agreement on candidate
achievement of clinical skills was 89%. Wass et al.19
experimented with two observed long cases, each
examined by two examiners. They found that if each
long case was observed by one unique examiner, at
least 10 observed history-taking long cases were
required to achieve 0.8 reliability. Each long case
lasted 21 minutes (a 14-minute patient encounter
followed by a 7-minute interview) and each candidate
encountered eight different examiners and patients.
It should be stressed, however, that this modification
applied to only the history-taking component of
the conventional long case.
ADVANTAGES OF THE LONG CASE
Authenticity
The long case provides an interaction between the
candidate and the patient6 that integrates history
taking, physical examination, investigation, diagnosis
and management. The candidate needs to obtain
relevant information, structure a problem, synthesise
the findings and formulate a management plan.13
Because ‘real’ patients are used, the long case is more
authentic (i.e. it represents a real-life experience)
than simulated patient scenarios can be4,6,13 and
hence has greater validity5,6,20 in that it provides a
real-time, actual patient problem, which must be
approached holistically. Furthermore, it offers direct
contact between the candidate and the examiner.4
Educational value
The long case is an educationally valuable test4,6
because it provides diagnostic feedback to both
students and teachers. The long case is a good
method of formative assessment.4,12 Teachers can use
the results of the long case to identify any neglected
areas or teaching deficiencies based on course
outcomes.10 The long case can also be used as a
screening device to identify weak students for reme-
diation.12,17 It has proven to be useful in evaluating
the effectiveness of educational programmes.8–10,12
DISADVANTAGES OF THE LONG CASE
Non-generalisability
A good result in one long case does not guarantee
a similarly high result in another long case. The result
ª Blackwell Publishing Ltd 2009. MEDICAL EDUCATION 2009; 43: 936–941
The long case and its modifications
of one long case is not a generalisable indicator of
the candidate’s ability across a range of other
cases and clinical situations.4–6 Van der Vleuten,4
summarising its inappropriateness, reiterated: ‘We
intuitively believe that when we have measured
someone’s competence with one patient we can
predict how competent that person will be with
another. Unfortunately, this prediction tends to be
poor, and it is this factor that leads to serious
unreliability.’ Dugdale5 then drove the point home,
saying: ‘…if a doctor failed to diagnose my (hypo-
thetical) prostatic carcinoma, it would be small
consolation to know that he had done brilliantly in
his clinical long case on multiple sclerosis.’ The
inability to assess candidate competence through a
single case has been termed ‘case specificity’. Many
authors4,6,16 have emphasised that one long case
does not offer a sufficiently representative sample
of cases to measure examinee competence.
Olson,21 however, observed that, except for border-
line students, a single long case in one discipline was
good enough to predict performance in internal
medicine, paediatrics, reproductive medicine or
surgery. He arrived at this conclusion by comparing
long case marks in four disciplines, obtained over
6 years. He also found that for borderline students,
two cases would be sufficient to predict the outcome
in the four disciplines. This is the only study we found
supporting the generalisability of a single long case.
This finding must be balanced against a large body
of evidence and opinions4–6 to the contrary.
Low in reliability
Van der Vleuten,4 Gleeson,9 Olson et al.,11 Norcin-
i,12,13 Abouna and Hamdy16 and Paul22 all identified
the poor reliability of the results of the long case.
A recent study23 in postgraduate assessment esti-
mated that at least five or six, 85-minute (a candidate
spends 60 minutes with the patient and 25 minutes
with the examiners) long cases were necessary to
achieve 0.8 dependability, which is a more conserva-
tive figure of reliability (i.e. dependability takes into
account the variance contributed to the measure-
ment error by factors or facets not directly associated
with the candidate, such as cases, examiners, and
interaction between cases and examiners). This
study also found that, with two such long cases, the
percentage variability (i.e. variance) explained by
the candidate’s ability and the interaction between
cases and candidates were similar. The latter find-
ing confirms that case specificity24 is a major
contributor to the (un)reliability of the long case.
‘Over the past 30 years,’ suggested Norcini,13 ‘it has
939
G G Ponnamperuma et al
become increasingly apparent that the long case
does not yield results that achieve reasonable levels
of reproducibility.’
Norman25 commented that the long case may have
slightly better reliability than the objective structured
clinical examination (OSCE) if it is conducted as
observed, multiple long cases. As Wass et al.19 found,
the reliability of the long case, when carried out
with two pairs of examiners, was not better or worse
than that of the OSCE. They estimated that a
reliability of 0.8 can be achieved with 10 long cases on
history taking with two examiners observing each
long case. However, the time, logistics and cost-
effectiveness issues related to running multiple long
cases with multiple examiners preclude their use in
standard examinations.
Low in validity
The low validity of the long case stems from its
inability to generalise from the results of a single
patient interaction, non-observation of the candidate
during the patient interaction, lack of structure, and
lack of patient standardisation.
Attempting to judge competence across a range of
clinical conditions on the basis of one unobserved
case9 is a major contributor to low content validity.
Although Olson’s21 findings suggested that this was
possible except for borderline candidates, this is a
highly important exception as it is the borderline
candidate who presents the greatest assessment
challenge.
As the traditional long case is not observed by the
examiner, it assesses history-taking ability, communi-
cation skills6,16,26 and physical examination skills only
poorly.10
The low validity of the traditional long case may also
be related to a lack of structure6 that leads to global
pass or fail decisions.26 As identified above, however,
there have been various moves to structure the
long case.
The lack of patient standardisation and heavy
dependence on the ‘luck of the draw’9,26 (different
candidates are assessed on different patients) may
contribute to the low validity of the long case. As
the long case did not allow examiners to adjust
according to the degree of difficulty posed by the
patient, Price and Byrne14 described a modification,
in which the examiners first marked patient difficulty
on a 10-point rating scale independently, and then
940 ª Blackwell Publishing Ltd 2009. MEDICAL EDUCATION 2009; 43: 936–941
marked the candidate performance on a 7-point
rating scale, initially independently, followed by
consensus. Unfortunately, the authors did not reveal
how the difficulty rating was used to modify the
candidates’ scores. The candidates found the exam-
ination stressful, but rated the method as appropriate
for clinical assessment.
Feasibility, efficiency and cost-effectiveness
Although it is a lengthy examination, Wass and Jolly6
indicated that the time taken to assess a candidate in
the long case may be an advantage. However, most
examination time is not spent on examining the
candidate, but represents unobserved time that the
candidate spends with the patient.13 The above
authors were doubtful whether this long time period
is put to good use in terms of assessment of outcomes
or agreed competencies. Abouna and Hamdy16
observed that their version of the long case, the
IDOCEE, was more cost-effective than the traditional
long case.
In summary, the modifications to, and the advantages
and disadvantages of the long case indicate that the
main impediment to improving the validity and
reliability of the long case concerns the overly long
time the examination takes, which poses challenges
to sampling the assessment content more broadly
(i.e. by introducing more cases).
CONCLUSIONS
Various modifications to increase the number of
examiners and cases and to standardise and structure
the long case have been attempted. More evidence of
the effectiveness of these modifications is required,
however, before they can be recommended for
summative assessment.
The advantages of the long case include its authen-
ticity in assessing candidate competence holistically,
and its educational use in providing feedback to the
candidate, teacher and institution about the curric-
ulum, teaching and candidate ability. Its disadvan-
tages include the inability to generalise from one
long case about the candidate’s ability in other cases,
poor reliability, low validity, and the long duration of
the examination. These disadvantages preclude its
use in high-stakes examinations unless and until a
more psychometrically and educationally desirable
format of the long case has been devised to accom-
modate multiple, observed patient interactions with
multiple examiners.

If sampling of more cases can be incorporated into
the long case format, then the main advantage of the
long case can be utilised (i.e. it is a realistic, holistic
and in-depth assessment of patient encounter).
Although the possibility of introducing more cases to
the long case format might be explored in future
research, the value of such studies is debatable when
set against the practicability of an examination
comprising multiple long cases.
Contributors: GGP performed the literature review, wrote
the first draft of the paper and made subsequent
amendments to the original manuscript. IMK contributed
to the literature search and commented critically on the
draft manuscript. SM and MHD contributed to the draft
manuscript, read and critically commented on the
subsequent manuscript, and recommended revisions. All
authors approved the final manuscript for publication.
Acknowledgements: none.
Funding: this study was internally funded.
Conflicts of interest: none.
Ethical approval: not required.
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2003;37 (7):587–8.
25 Norman G. Editorial: the long case versus objective
structured clinical examinations. BMJ 2002;324:748–9.
26 Sood R. Long case examination – can it be improved?
J Indian Acad Clin Med 2001;2 (4):251–5.
Received 23 December 2008; editorial comments to authors
25 February 2009; accepted for publication 5 June 2009
941
 Clinical review

ABC of learning and teaching in medicine

Learning and teaching in the clinical environment
John Spencer

Clinical teaching—that is, teaching and learning focused on, and

usually directly involving, patients and their problems—lies at
the heart of medical education. At undergraduate level, medical
schools strive to give students as much clinical exposure as
possible; they are also increasingly giving students contact with
patients earlier in the course. For postgraduates, “on the job”
clinical teaching is the core of their professional development.
How can a clinical teacher optimise the teaching and learning
opportunities that arise in daily practice?

Strengths, problems, and challenges

Learning in the clinical environment has many strengths. It is
focused on real problems in the context of professional
practice. Learners are motivated by its relevance and through
active participation. Professional thinking, behaviour, and
attitudes are “modelled” by teachers. It is the only setting in
which the skills of history taking, physical examination, clinical Clinical teaching in general practice
reasoning, decision making, empathy, and professionalism can
be taught and learnt as an integrated whole. Despite these
potential strengths, clinical teaching has been much criticised
for its variability, lack of intellectual challenge, and haphazard
nature. In other words, clinical teaching is an educationally Common problems with clinical teaching
sound approach, all too frequently undermined by problems of
x Lack of clear objectives and expectations
implementation. x Focus on factual recall rather than on development of problem
solving skills and attitudes
x Teaching pitched at the wrong level (usually too high)
Challenges of clinical teaching x Passive observation rather than active participation of learners
x Inadequate supervision and provision of feedback
x Time pressures x Little opportunity for reflection and discussion
x Competing demands—clinical (especially when needs of patients x “Teaching by humiliation”
and students conflict); administrative; research x Informed consent not sought from patients
x Often opportunistic—makes planning more difficult x Lack of respect for privacy and dignity of patients
x Increasing numbers of students x Lack of congruence or continuity with the rest of the curriculum
x Fewer patients (shorter hospital stays; patients too ill or frail; more
patients refusing consent)
x Often under-resourced
x Clinical environment not “teaching friendly” (for example, hospital
ward)
x Rewards and recognition for teachers poor

The importance of planning

Many principles of good teaching, however, can (and should) be
incorporated into clinical teaching. One of the most important
is the need for planning. Far from compromising spontaneity,
planning provides structure and context for both teacher and
students, as well as a framework for reflection and evaluation.
Preparation is recognised by students as evidence of a good
clinical teacher.

How doctors teach

Almost all doctors are involved in clinical teaching at some Questions to ask yourself when planning a clinical teaching session
point in their careers, and most undertake the job
conscientiously and enthusiastically.
However, few receive any formal training in teaching skills,
and in the past there has been an assumption that if a person
simply knows a lot about their subject, they will be able to teach

BMJ VOLUME 326 15 MARCH 2003 bmj.com 591

Clinical review
it. In reality, of course, although subject expertise is important, it
is not sufficient. Effective clinical teachers use several distinct, if
overlapping, forms of knowledge.
How students learn
Understanding the learning process will help clinical teachers
to be more effective. Several theories are relevant (see first
article in the series, 25 January). All start with the premise that
learning is an active process (and, by inference, that the
teacher’s role is to act as facilitator). Cognitive theories argue
that learning involves processing information through interplay
between existing knowledge and new knowledge. An important
influencing factor is what the learner knows already. The quality
of the resulting new knowledge depends not only on
“activating” this prior knowledge but also on the degree of
elaboration that takes place. The more elaborate the resulting
knowledge, the more easily it will be retrieved, particularly when
learning takes place in the context in which the knowledge will
be used.
Experiential learning
Experiential learning theory holds that learning is often most
effective when based on experience. Several models have been
described, the common feature being a cyclical process linking
concrete experience with abstract conceptualisation through
reflection and planning. Reflection is standing back and
thinking about experience (What did it mean? How does it
relate to previous experience? How did I feel?). Planning
involves anticipating the application of new theories and skills
(What will I do next time?). The experiential learning cycle,
which can be entered at any stage, provides a useful framework
for planning teaching sessions.
Experience Reflection
Planning Theory
Experiential learning cycle: the role of the teacher is to help students to
move round, and complete, the cycle
Questions
Questions may fulfil many purposes, such as to clarify
understanding, to promote curiosity, and to emphasise key
points. They can be classified as “closed,” “open,” and
“clarifying” (or “probing”) questions.
Closed questions invoke relatively low order thinking, often
simple recall. Indeed, a closed question may elicit no response
at all (for example, because the learner is worried about being
wrong), and the teacher may end up answering their own
question.
592
Knowledge about
Learning learning and
context teaching
Knowledge Case
Knowledge
about based
about the
the "teaching
subject
learners scripts"
Knowledge
about
the patient
Various domains of knowledge contribute to the idiosyncratic teaching
strategies (“teaching scripts”) that tutors use in clinical settings
How to use cognitive learning theory in clinical teaching
Help students to identify what they already know
x “Activate” prior knowledge through brainstorming and briefing
Help students elaborate their knowledge
x Provide a bridge between existing and new information—for
example, use of clinical examples, comparisons, analogies
x Debrief the students afterwards
x Promote discussion and reflection
x Provide relevant but variable contexts for the learning
Example of clinical teaching session based on experiential
learning cycle
Setting—Six third year medical students doing introductory clinical
skills course based in general practice
Topic—History taking and physical examination of patients with
musculoskeletal problems (with specific focus on rheumatoid
arthritis); three patients with good stories and signs recruited from
the community
The session
Planning—Brainstorm for relevant symptoms and signs: this activates
prior knowledge and orientates and provides framework and
structure for the task
Experience—Students interview patients in pairs and do focused
physical examination under supervision: this provides opportunities
to implement and practise skills
Reflection—Case presentations and discussion: feedback and discussion
provides opportunities for elaboration of knowledge
Theory—Didactic input from teacher (basic clinical information about
rheumatoid arthritis): this links practice with theory
Planning— “What have I learned?” and “How will I approach such a
patient next time?” Such questions prepare students for the next
encounter and enable evaluation of the session
Effective teaching depends crucially on the teacher’s
communication skills. Two important areas of
communication for effective teaching are questioning and
giving explanations. Both are underpinned by attentive
listening (including sensitivity to learners’ verbal and
non-verbal cues). It is important to allow learners to
articulate areas in which they are having difficulties or
which they wish to know more about
BMJ VOLUME 326 15 MARCH 2003 bmj.com
 Clinical review

In theory, open questions are more likely to promote

How to use questions
deeper thinking, but if they are too broad they may be equally
ineffective. The purpose of clarifying and probing questions is x Restrict use of closed questions to establishing facts or baseline
knowledge (What? When? How many?)
self evident.
x Use open or clarifying/probing questions in all other circumstances
(What are the options? What if?)
x Allow adequate time for students to give a response—don’t speak
Questions can be sequenced to draw out contributions or too soon
be built on to promote thinking at higher cognitive levels x Follow a poor answer with another question
and to develop new understanding x Resist the temptation to answer learners’ questions—use counter
questions instead
x Statements make good questions—for example, “students
sometimes find this difficult to understand” instead of “Do you
Explanation understand?” (which may be intimidating )
x Be non-confrontational—you don’t need to be threatening to be
Teaching usually involves a lot of explanation, ranging from the
challenging
(all too common) short lecture to “thinking aloud.” The latter is
a powerful way of “modelling” professional thinking, giving the
novice insight into experts’ clinical reasoning and decision
How to give effective explanations
making (not easily articulated in a didactic way). There are close
analogies between teacher-student and doctor-patient x Check understanding before you start, as you proceed, and at the
end—non-verbal cues may tell you all you need to know about
communication, and the principles for giving clear explanations
someone’s grasp of the topic
apply. If in doubt, pitch things at a low level and work upwards. x Give information in “bite size” chunks
As the late Sydney Jacobson, a journalist, said, “Never x Put things in a broader context when appropriate
underestimate the person’s intelligence, but don’t overestimate x Summarise periodically (“so far, we’ve covered . . .”) and at the end;
their knowledge.” Not only does a good teacher avoid answering asking learners to summarise is a powerful way of checking their
questions, but he or she also questions answers. understanding
x Reiterate the take home messages; again, asking students will give
you feedback on what has been learnt (but be prepared for some
surprises)
Exploiting teaching opportunities
Most clinical teaching takes place in the context of busy
practice, with time at a premium. Many studies have shown that
a disproportionate amount of time in teaching sessions may be
Patient Teach general
spent on regurgitation of facts, with relatively little on checking, encounter principles
probing, and developing understanding. Models for using time (history, ("When that
examination, etc) happens, do
more effectively and efficiently and integrating teaching into this..." )
day to day routines have been described. One such, the
“one-minute preceptor,” comprises a series of steps, each of
which involves an easily performed task, which when combined
form an integrated teaching strategy. Get a
commitment Help learner
("What do you identify and
think is give guidance
Teaching on the wards going on?" ) about omissions
and errors
Despite a long and worthy tradition, the hospital ward is not an ("Although your
suggestion
ideal teaching venue. None the less, with preparation and of Y was a
forethought, learning opportunities can be maximised with possibility,
Probe for in a situation
minimal disruption to staff, patients, and their relatives.
underlying like this, Z is
Approaches include teaching on ward rounds (either reasoning more likely,
dedicated teaching rounds or during “business” rounds); ("What led because..." )
you to that
students seeing patients on their own (or in pairs—students can conclusion?" )
learn a lot from each other) then reporting back, with or
without a follow up visit to the bedside for further discussion;
and shadowing, when learning will inevitably be more Reinforce what was done well
opportunistic. ("Your diagnosis of X was well
supported by the history..." )
Key issues are careful selection of patients; ensuring ward
staff know what’s happening; briefing patients as well as
students; using a side room (rather than the bedside) for
“One-minute preceptor” model
discussions about patients; and ensuring that all relevant
information (such as records and x ray films) is available.

Teaching in the clinic

Although teaching during consultations is organisationally
Teaching during consultations has been much criticised
appealing and minimally disruptive, it is limited in what it can for not actively involving learners
achieve if students remain passive observers.
With relatively little impact on the running of a clinic,
students can participate more actively. For example, they can be

BMJ VOLUME 326 15 MARCH 2003 bmj.com 593

Clinical review
asked to make specific observations, write down thoughts about
differential diagnosis or further tests, or note any questions—for
discussion between patients. A more active approach is “hot
seating.” Here, the student leads the consultation, or part of it.
His or her findings can be checked with the patient, and
discussion and feedback can take place during or after the
encounter. Students, although daunted, find this rewarding. A
third model is when a student sees a patient alone in a separate
room, and is then joined by the tutor. The student then presents
their findings, and discussion follows. A limitation is that the
teacher does not see the student in action. It also inevitably
slows the clinic down, although not as much as might be
expected. In an ideal world it would always be sensible to block
out time in a clinic to accommodate teaching.
The patient’s role
Sir William Osler’s dictum that “it is a safe rule to have no
teaching without a patient for a text, and the best teaching is
that taught by the patient himself” is well known. The
importance of learning from the patient has been repeatedly
emphasised. For example, generations of students have been
exhorted to “listen to the patient—he is telling you the
diagnosis.” Traditionally, however, a patient’s role has been
essentially passive, the patient acting as interesting teaching
material, often no more than a medium through which the
teacher teaches. As well as being potentially disrespectful, this is
a wasted opportunity. Not only can patients tell their stories and
show physical signs, but they can also give deeper and broader
insights into their problems. Finally, they can give feedback to
both learners and teacher. Through their interactions with
patients, clinical teachers—knowingly or unknowingly—have a
powerful influence on learners as role models.
Drs Gabrielle Greveson and Gail Young gave helpful feedback on early
drafts.
John Spencer is a general practitioner and professor of medical
education in primary health care at the University of Newcastle upon
Tyne.
The ABC of learning and teaching in medicine is edited by Peter
Cantillon, senior lecturer in medical informatics and medical
education, National University of Ireland, Galway, Republic of Ireland;
Linda Hutchinson, director of education and workforce development
and consultant paediatrician, University Hospital Lewisham; and
Diana F Wood, deputy dean for education and consultant
endocrinologist, Barts and the London, Queen Mary’s School of
Medicine and Dentistry, Queen Mary, University of London. The
series will be published as a book in late spring.
BMJ 2003;326:591–4
One hundred years ago
A “surgical marvel” at the London Hospital
That modest institution the London Hospital, which does so
much good by stealth and doubtless blushes to find it fame, and
which has been the scene of so many surgical triumphs, has, if the
Pall Mall Gazette is to be believed, almost beaten its own record. A
man was “stabbed through the heart” and afterwards “had the
puncture sewn up at the hospital.” The operation, says our
contemporary, was, though not unique, a very remarkable one.
Remarkable indeed it must have been beyond anything in the
annals of surgery if the description of it given by the Pall Mall
Gazette is correct. After being informed that “an operation on the
594
Patient
"Sitting in" as observer
Teacher
Student
Patient
Three way consultation
Teacher
Student
"Hot seating"
Patient
Student
Teacher
Seating arrangements for teaching in clinic or surgery
Working effectively and ethically with patients
x Think carefully about which parts of the teaching session require
direct patient contact—is it necessary to have a discussion at the
bedside?
x Always obtain consent from patients before the students arrive
x Ensure that students respect the confidentiality of all information
relating to the patient, verbal or written
x Brief the patient before the session—purpose of the teaching
session, level of students’ experience, how the patient is expected to
participate
x If appropriate, involve the patient in the teaching as much as
possible
x Ask the patient for feedback—about communication and clinical
skills, attitudes, and bedside manner
x Debrief the patient after the session—they may have questions, or
sensitive issues may have been raised
Suggested reading
x Cox K. Planning bedside teaching. (Parts 1 to 8.) Med J Australia
1993;158:280-2, 355-7, 417-8, 493-5, 571-2, 607-8, 789-90, and
159:64-5.
x Parsell G, Bligh J. Recent perspectives on clinical teaching. Med Educ
2001;35:409-14.
x Hargreaves DH, Southworth GW, Stanley P, Ward SJ. On-the-job
learning for physicians. London: Royal Society of Medicine, 1997.
heart is difficult, not only owing to the paramount importance of
the organ, but because of its deeply-imbedded position in the
body, and in order to do his work the surgeon had to temporarily
displace the breast, cartilage, ribs, and lungs,” we are further told
that “it was at first thought that the heart itself would have to be
removed.” Fortunately this formidable contingency was avoided,
for, “on washing away the blood clots and raising it a little the
puncture was found.” The man, we are glad to learn, continues to
improve, and we hope that he will live long in undisturbed
possession of the heart which he so nearly lost. (BMJ 1903;i:1332)
BMJ VOLUME 326 15 MARCH 2003 bmj.com
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/321271719

Preparation of Blueprint for Clinical Assessment of Undergraduate Medical

Students in Psychiatry

Article in Journal of Research in Medical Education & Ethics · January 2017

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 Journal of Research in Medical Education & Ethics DOI: 10.5958/2231-6728.2017.00034.8
Vol. 7, No. 3, November, 2017, pp-205-208

ORIGINAL RESEARCH

Preparation of Blueprint for Clinical Assessment of Undergraduate Medical

Students in Psychiatry
Sandeep Kumar Goyal1*, Naveen Kumar2, Dinesh Badyal3, Ankit Kainth4, Tejinder Singh5
*Corresponding author email id: goyaldrsandyy@gmail.com

ABSTRACT
Context: Assessment is an integral part of medical education. Traditional method of assessment has many pitfalls for
example subjectivity of the paper setter. Aims: 1. To plan blueprint for clinical assessment of undergraduate medical
students in psychiatry. 2. To collect feedback from faculty towards the blueprinting. Settings and design: This prospective
study was conducted in the Dept of Psychiatry of Christian Medical College & Hospital, Ludhiana. Methods and material:
A blueprint was prepared for practical examination in psychiatry, and students were assessed as per the blueprint. The
feedback questionnaire was administered to faculty. All faculties of the department provided their feedback. The feedback
questionnaires were analysed. Results: All the faculty members found that assessment was in alignment with learning
Downloaded From IP - 157.39.32.168 on dated 6-Dec-2017

objectives, proper weightage was given to topics, blueprinting acts as guidance to paper construction, it increases validity
of exams, and it should be integral part of assessment. 80% faculty agreed that in-depth knowledge of students was tested
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by new assessment method. Conclusions: Blueprint for clinical assessment of undergraduate students in psychiatry was
www.IndianJournals.com

prepared and implemented successfully.

Keywords: Blueprint, Psychiatry, Knowledge assessment, Undergraduate education, Medical education, Feedback

INTRODUCTION A blueprint specifies the content areas topic, the

domains of learning (knowledge, skills and attitudes)
Assessment is an integral part of medical education.
and the appropriate methods or tools of assessment.
Traditional method of assessment has many pitfalls
A comprehensive blueprint, therefore, serves as a
for example subjectivity of the paper setter. When we
reference framework for the question paper setter to
speak to undergraduate medical students after the
prepare questions according to accepted norms and
examinations, not infrequently, we hear them
guidelines. Blueprinting makes the assessment fair to
complaining in theory examinations that – too lengthy
the students as they can have a clear idea of what is
paper; all questions were from few topics only! They
being examined and can direct their learning efforts in
have not taught these, and in practical examinations,
that direction[2].
we hear them complaining that – I had never seen
this case before; Most of the theory questions, long We started this project to improve teaching of
case, short case and viva questions, all were from one/ undergraduate students by planning layout of
few systems only[1]. assessment.
These problems can be taken care by blueprinting of
AIM AND OBJECTIVES
assessment. Blueprinting is a technical component of
assessment; it is a document which demonstrates the Aim: To improve teaching of undergraduate students
link between learning outcomes and what is assessed. by planning layout of assessment so that they can

1
Professor and HOD, 2Assistant Professor, 4Senior Resident, Department of Psychiatry, Christian Medical College, Ludhiana, Punjab
3
Professor and HOD, Department of Pharmacology, Christian Medical College, Brown Road, Ludhiana, Punjab, India
5
Professor, Department of Paediatrics, Professor and HOD, Department of Medical Education, Christian Medical College, Brown
Road, Ludhiana, Punjab, India

IndianJournals.com 205
 Sandeep Kumar Goyal, Naveen Kumar, Dinesh Badyal et al.
deliver preventive, promotive, curative and
rehabilitative services for the care of patients and to
refer advance cases to specialist.
SPECIFIC OBJECTIVES
1. To plan blueprint for clinical assessment of
Undergraduate Medical Students in Psychiatry.
2. To collect feedback from faculty towards the
blueprinting.
SUBJECTS AND METHODS
This prospective study was conducted in the Dept of
Psychiatry of Christian Medical College & Hospital,
Ludhiana, from September 2015 to February 2016.
Downloaded From IP - 157.39.32.168 on dated 6-Dec-2017
Planning
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Approval from research committee and institutional
www.IndianJournals.com
ethics committee was taken.
Discussion with Faculty and Sensitisation
The faculty of Department of Psychiatry was sensitised
regarding the need of planning blueprint of assessment.
Planning of Blueprint of Assessment for
Psychiatry Practical Exam
A blueprint was prepared for practical examination in
psychiatry, and it was peer reviewed by all the faculty
members from the Department of Psychiatry, and
necessary changes were made as per their
suggestions. Topics to be covered were decided with
consensus of all the faculty members considering
undergraduate level.
STEPS IN PREPARATION OF BLUEPRINT[2,3]
(i) Deciding the Number of Items to be Included
in the Assessment
Considering the time of assessment (2 h) and number
of faculty available for assessment, assessment was
divided into three parts that is viva, short cases and
multiple choice questions MCQs ( Table 1).
206
Table 1: Skeleton of assessment tool*
Sections Pattern No. of questions Marks
A Viva 5 10
B Short cases 3 15
C MCQs 10 10
Total 18 35
*This is only a representative example. However assessment can
be planned for 50 or 100 marks as per requirement.
(ii) Deciding the Weightage to be Given to
Content Areas and Methods of Assessment
The weightage to a topic was decided on the basis of
two parameters
(a) perceived impact of a topic in terms of its impact
on health (I): (1) non-urgent, (2) serious but not
life threatening and (3) life threatening emergency.
(b) the frequency of occurrence of a particular disease
(F): (1) rarely seen, (2) relatively common and
(3) very common.
All the faculty members recorded their perception of
the impact of a topic in terms of its impact on health
(I) and the frequency of occurrence of diseases. I × F
was calculated for each topic and sum of I × F of all
topics was labelled as T. Weightage coefficient of each
topic was calculated as I × F/T. Number of questions
of each topic was calculated by multiplying weightage
coefficient with total number of items in assessment
and total marks of each topic were calculated by
multiplying the corresponding value of weightage (W)
by total marks the students were assessed as per the
blueprint.
FEEDBACK QUESTIONNAIRE
The feedback questionnaire for faculty regarding
blueprinting of assessment was also prepared. All the
feedback questionnaires were peer reviewed and
necessary changes were done as per their suggestions.
Feedback questionnaire was based on Likert 5-point
scale.
RESULTS
The proposed assessment plan developed as a result
of this exercise is shown in Tables 2 & 3. The
Vol. 7, No. 3, November, 2017
 Preparation of Blueprint for Clinical Assessment of Undergraduate Medical Students in Psychiatry

Table 2: Blueprint for psychiatry practical assessment

Topic Impact Frequency of I×F W= No. of questions Marks = W × 35
(I) occurrence (I × F)/T = W × 18
(F) Rounding Rounding
off off
Schizophrenia 2 2 4 0.129 2.32 3 4.5 4
M.D.D. 2 3 6 0.193 3.47 3 6.75 7
Bipolar disorder 2 2 4 0.129 2.32 3 4.5 5
Anxiety disorder 2 3 6 0.193 3.47 3 6.75 7
Substance abuse 2 3 6 0.193 3.47 3 6.75 7
Dementia 1 2 2 0.064 1.16 1 2.24 2
Mental retardation 1 2 2 0.064 1.16 1 2.24 2
ADHD 1 1 1 0.032 0.58 1 1.12 1
T = 31 0.997 18 35

Table 3: Final blueprint for psychiatry practical assessment feedback from all the five faculty member of the
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Content/System/Topic MCQ’s Short Viva Total Department of Psychiatry was collected (Table 4).
Case Marks
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Schizophrenia 2 1 4 DISCUSSION
www.IndianJournals.com

M.D.D. 2 1 7
Blueprinting reduces two major validity threats. The
Bipolar disorder 1 2 5 first is the under-sampling or biased sampling of the
Anxiety disorder 2 1 7 curriculum or course content e.g. too little weightage
Substance abuse 2 1 7 for a topic of national health importance. This is called
as construct under-representation. The second threat,
Dementia 1 2
construct-irrelevant variance, can occur as a result of
MR 1 2
flawed item formats, items that are too easy or too
ADHD 1 1 difficult questions, or examiner bias[2]. We prepared

Table 4: Feedback by faculty on blueprinting of assessment

Question Strongly Agree Neutral Disagree Strongly
Agree Agree
Assessment has distribution of questions across all important topics 5 0 0 0 0
Assessment plan is aligned with learning objectives 5 0 0 0 0
Assessment plan has questions distributed according to must know 1 4 0 0 0
and other categories
Assessment plan tests in-depth knowledge 2 2 1 0 0
Proper weightage is given to topics of public health importance 5 0 0 0 0
Blueprinting acts as a guidance to paper construction 4 1 0 0 0
Blueprinting increases the validity of exams 4 1 0 0 0
Blueprinting should be integral part of assessment 4 1 0 0 0
Blueprinting makes examination fair 4 1 0 0 0

Journal of Research in Medical Education & Ethics 207

 Sandeep Kumar Goyal, Naveen Kumar, Dinesh Badyal et al.
blueprint of assessment to make assessment fair and
to increase validity of the assessment.
In our study, all the faculty members (100%) agreed
that assessment had distribution of questions across
all important topics and was in alignment with learning
objectives; questions were distributed according to must
know and other categories, proper weightage was given
to topics of public health importance. 80% faculty
agreed that in-depth knowledge of students was tested
by new assessment method. All the faculty members
(100%) also agreed that blueprinting acts as guidance
to paper construction, increases validity of exams,
should be integral part of assessment and makes
examination fair.
Our results are comparable to a study by Patil et al.[4],
in which the students and faculty felt that there was
appropriate distribution of questions across topics
Downloaded From IP - 157.39.32.168 on dated 6-Dec-2017
(77% and 89%, respectively), appropriate weightage
Members Copy, Not for Commercial Sale
given to topics of public health importance (65% and
www.IndianJournals.com
100%), and examinations were fair (86% and 89%).
The entire faculty felt that blueprints aligns assessment
with objectives and helps as a guide and to paper
construction.
208
View publication stats
REFERENCES
[1] Patil SY, Hashilkar NK, Hungund BR. Blueprinting in
assessment: how much is imprinted in our practice?
Journal of Educational Research and Medical Teacher
2014;2(1):4–6.
[2] Adkoli BV, Deepak KK. Blue printing in assessment. In:
Singh T, Anshu, editors. Principles of assessment in
medical education. New Delhi: Jaypee Publishers; 2012.
pp. 205–13.
[3] Gujarathi A, Dhakne-Palwe S, Patil R, Borade-Gedam P,
Mahale M, Gosavi S, Vankudre A, Almale B, Pawar-
Bhalerao S. Preparation of Blue Prints for formative
Theory Assessment of Undergraduate Medical Students
in Community Medicine. MVP Journal Of Medical
Science 2015;2(2):100-3.
[4] Patil SY, Gosavi M, Bannur HB, Ratnakar A. Blueprinting
in assessment: a tool to increase the validity of
undergraduate written examinations in pathology.
International Journal of Applied and Basic Medical
Research 2015;5(Suppl 1):S76–9.
Received: 28.08.2017
Accepted: 06.10.2017
Vol. 7, No. 3, November, 2017
TEAL Center Fact Sheet No. 8: Effective Lesson Planning
Effective Lesson Planning
Planning ahead to identify a course of action that can
effectively help learners reach their goals and objec-
tives is an important first step in effective instruction.
Lesson planning communicates to learners what they
will learn and how their goals will be assessed, and it
helps instructors organize content, materials, time,
instructional strategies, and assistance in the class-
room.
About Effective Lesson Planning
Planning ahead to identify a course of action that can
effectively reach goals and objectives is an important
first step in any process, and education is no excep-
tion. In education, the planning tool is the lesson plan,
which is a detailed description of an instructor’s
course of instruction for an individual lesson intended
to help learners achieve a particular learning objec-
tive. Lesson plans communicate to learners what they
will learn and how they will be assessed, and they
help instructors organize content, materials, time, in-
structional strategies, and assistance in the class-
room. Lesson planning helps English as a second
language (ESL), adult basic education (ABE), adult
secondary education (ASE), and other instructors
create a smooth instructional flow and scaffold instruc-
tion for learners.
The Lesson Planning Process
Before the actual delivery of a lesson, instructors en-
gage in a planning process. During this process, they
determine the lesson topic (if states have imple-
mented content standards, the topic should derive
from them). From the topic derive the lesson objec-
tive or desired results–the concepts and ideas that
learners are expected to develop and the specific
knowledge and skills that learners are expected to
acquire and use at the end of the lesson. Objectives
are critical to effective instruction, because they help
instructors plan the instructional strategies and activi-
ties they will use, including the materials and re-
sources to support learning. It is essential that the ob-
jective be clear and describe the intended learning
2010
outcome. Objectives can communicate to learners
what is expected of them–but only if they are shared
with learners in an accessible manner. Instructional
objectives must be specific, outcome-based, and
measurable, and they must describe learner behavior.
Heinich et al. (2001) refer to the ABCD’s of writing
objectives:
• Audience – learners for whom the objective is
written (e.g., ESL, ABE, GED);
• Behavior – the verb that describes what the au-
dience will be able to do (e.g., describe, explain,
locate, synthesize, argue, communicate);
• Condition – the circumstances under which the
audience will perform the behavior (e.g., when a
learner obtains medicine from the pharmacy he or
she will be able to read the dosage); and
• Degree – acceptable performance of the behavior
(i.e., how well the learner performs the behavior).
Learner assessment follows from the objectives.
Based on the principles of backward design devel-
oped by Wiggins and McTighe (1998), instructors
identify the lesson objective or desired results and
then decide what they will accept as evidence of
learners’ knowledge and skills. The concept of back-
ward design holds that the instructor must begin with
the end in mind (i.e., what the student should be able
to know, understand, or do) and then map backward
from the desired result to the current time and the stu-
dents’ current ability/skill levels to determine the best
way to reach the performance goal.
The WIPPEA Model for Lesson Planning
The WIPPEA Model, an acronym that stands for
Warm-up, Introduction, Presentation, Practice, Evalu-
ation, Application, is a lesson plan model that
represents a continuous teaching cycle in which each
learning concept builds on the previous one, serving
as an instructional roadmap for instructors. The WIP-
PEA lesson plan model is adapted from the work of
Hunter (Mastery Teaching, 1982). This six-step cyclic-
al lesson planning approach has learners demonstrate
mastery of concepts and content at each step before
Page 1
TEAL Center Fact Sheet No. 8: Effective Lesson Planning 2010

the instructor proceeds to the next step. See TEAL ber may use at home to make certain they understand
Center suggestions in italics below for incorporating the meaning of the words on the label. Gather feed-
each of these elements. back from learners in follow-up classes and help them
assess what additional support, if any, they may re-
Warm-up – Assesses prior knowledge by reviewing quire.
previous materials relevant to the current lesson. In-
troduce an activity that reviews previously learned The following graphic integrates the WIPPEA process
content (e.g., for a vocabulary lesson, the warm-up with backward design in a lesson planning wheel. In
may be a quick matching exercise with words pre- this cyclical approach, teachers assess prior know-
viously learned and their definitions), and also include ledge, provide a broad overview of the con-
an activity that focuses on the topic to be taught. tent/concepts to be taught, introduce vocabulary,
teach content/concepts, check comprehension, com-
Introduction – Provides a broad overview of the con- bine the content and vocabulary through guided prac-
tent and concepts to be taught and focuses the learn- tice, evaluate student performance, and provide an
ers’ attention on the new lesson. Introduce the pur- application activity. Instructional strategies vary de-
pose of the lesson by stating and writing the objec- pending on the lesson content and skill areas, and the
tives for learners and discussing the lesson content needs of the learners.
and benefits by relating the objective to learners’ own
lives. Assess learners’ prior knowledge of the new Figure 1. Planning Wheel
material by asking questions and writing learners’ res-
ponses on a chalkboard or flip chart.
Presentation – Teaches the lesson content and con-
cepts. Create an activity to introduce the concept or
skill (e.g., introduce new vocabulary by asking learn-
ers to work in groups to identify words related to tak-
ing medications) and then introduce information
through a variety of modalities using visuals, realia,
description, explanation, and written text. Check for
learner understanding of the new material and make
changes in lesson procedures if necessary.
Practice – Models the skills and provides opportuni-
ties for guided practice. Introduce a variety of activities
that allow learners to work in groups, in pairs, or inde-
pendently to practice the skills, concepts, and informa-
tion presented. Integrate technology into activities as
available.
Evaluation – Assesses each learner’s attainment of
the objective. Include oral, aural, written, or applied
performance assessments. For example, ask students
to fill in the blanks on a cloze activity using the four
medicine warning labels that were discussed in class.
For lower level learners, provide a word bank at the
bottom of the worksheet. Omit the word bank for more Planning for differentiated instruction requires various
advanced students. learner profiles to inform the process; see the TEAL
Center fact sheet, No. 5. Students demonstrate mas-
Application – Provides activities that help learners tery of concepts/ content in each step before the
apply their learning to new situations or contexts teacher proceeds to the next step.
beyond the lesson and connect it to their own lives.
Choose activities that learners can relate to or have The relationship of the objective to the evaluation
expressed concern about. For example, have learners keeps the lesson focused and drives instruction. By
read the label of a medication they or a family mem- keeping the end in mind (backward design) and creat-

Page 2
 TEAL Center Fact Sheet No. 8: Effective Lesson Planning 2010

ing the evaluation activity at the beginning of the les-
son, the teacher has a clear destination for the lesson
and a roadmap to get there. Instructors can then se-
lect materials and activities that will best prepare stu-
dents to successfully complete the evaluation activity
in the lesson. The process is repeated for each learn-
ing objective. Lesson planning is an ongoing process
in which instruction flows from one objective to the
next. This cyclical process is repeated for each learn-
ing objective.
How Does Lesson Planning Benefit Learners and
Instructors?
Instructors and learners benefit from thoughtful lesson
planning. It provides a framework for instruction, and it
guides implementation of standards-based education.
Lesson planning establishes a road map for instruc-
tors of what has been taught and what needs to be
taught. It allows them to focus on one objective at a
time and communicate to learners what they will learn
in each lesson. Because lessons incorporate ongoing
assessments that determine how well learners under-
stand concepts and skills, instructors are able to make
mid-course changes in instructional procedures or
provide additional support to learners. Additionally, the
practice and application components of the lesson
help learners use the new skills and knowledge in
educational and other settings, thus promoting gene-
ralization and relevance.
References
Barroso, K., & Pon, S. (2005). Effective lesson planning, A
facilitator’s guide. California Adult Literacy Professional De-
velopment Project. American Institutes for Research, Sac-
ramento, CA.
Heinich, R., Molenda, M., Russell, J., & Smaldino, S. (2001).
Instructional media and technologies for learning. Engle
th
Cliffs (7 edition), NJ: Prentice Hall.
Hunter, Madeline. (1982). Mastery teaching. El Segundo,
CA: TIP Publications.
Wiggins, G., & McTighe, J. (1998). Understanding by de-
sign. Association for Supervision and Curriculum Develop-
ment, Alexandria, VA.

Authors: TEAL Center Staff.

Adapted from CALPRO Professional Development Module, Effective Lesson

Planning. by Barroso, K. & Pon, S. (2004). AIR: Sacramento, CA.

About the TEAL Center: The Teaching Excellence in Adult Literacy (TEAL) Cen-
ter is a project of the U.S. Department of Education, Office of Vocational and
Adult Education (OVAE), designed to improve the quality of teaching in adult
education in the content areas.

This publication was prepared with funding from the U.S. Department of Education, Office of Vocational and Adult Education,
under contract No.ED-VAE-09-O-0060. The opinions expressed herein do not necessarily reflect the opinions or policies of the
U.S. Department of Education. This document is in the public domain and may be reproduced without permission. Page 3
 Medical Education

Designing a Comprehensive Lesson Plan: A Crucial Aspect in

Improving the Teaching‑Learning Process
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Debkumar Pal, Manish Taywade, Gajjala Alekhya

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/18/2024

Abstract
Lesson plan is required for all medical educators as it would help in completing their teaching‑learning activity within specific periods for
completion of all learning goals. There are six steps and eight components in the formulation of a lesson plan. The lesson plan should include
the instructional design or learning objectives. The learning activity should start with a proper set induction, i.e., induce the interest regarding
the topic in the students. There should be a brief travel to the past lessons, and it should end with feedback from the students and one assessment
for assessing the learning understandings of the students.

Key words: Learning, lecture, lesson plan, medical educator, medical student, teaching

Address for correspondence: Dr. Manish Taywade, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Room
Number: 322, 3rd Floor, Academic Building, Bhubaneswar ‑ 751 019, Odisha, India.
E‑Mail: drmanishtaywade@gmail.com

Introduction
A lesson plan can be considered as a written guide that is utilized to achieve learning outcomes. It is an integral part of the
planned teaching and learning activity.[1] Lesson planning is an essential tool to direct and achieve the goal of teaching. Therefore,
a medical teacher makes himself or herself more organized to attain the highest level of learning outcomes. As per “Oxford
Languages,” a lesson plan means “a teacher’s plan for teaching an individual lesson.”[2] Before the beginning of any activity,
the plan should be kept in mind as it would help in the proper and smooth functioning of the activity. Similarly, for teaching
purposes, before starting any class, the teacher should keep the plan of teaching ready in his/her mind or a physical medium (i.e.,
in the diary, electronic media), preferably in a physical medium.
Instructional design for a lesson plan is the key element to the acquisition of knowledge and skills more effectively and
efficiently.[3,4]
Why lesson plan is important?
A lesson plan helps both teachers and students in multiple ways.[4]
1. It will help the teachers in meeting the educational goals, especially when obvious educational objectives are not clear
2. It helps in providing a historical record of educational activity for validation of inclusion topics in question. A lesson plan
can also help in formulating a new class on the same topic
3. It helps in communication among teachers of any topic so that in the absence of a predesignated teacher, any other teacher
can take the class.

Date of Submission: 11‑Oct‑2021 Date of Review: 29-Oct-2021

Date of Acceptance: 16‑Nov‑2021 Date of Web Publication: 04-Feb-2022
This is an open access journal, and articles are distributed under the terms of the Creative
Access this article online Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Quick Response Code: remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Website: is given and the new creations are licensed under the identical terms.
www.cmijournal.org For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: How to cite this article: Pal D, Taywade M, Alekhya G. Designing a

10.4103/cmi.cmi_83_21 comprehensive lesson plan: A crucial aspect in improving the teaching-
learning process. Curr Med Issues 2022;20:48-51.

48 © 2022 Current Medical Issues | Published by Wolters Kluwer - Medknow

 Pal, et al.: Comprehensive lesson plan in teaching and learning
Requirements for formulating a lesson plan
For making a lesson plan following things should be kept in
mind.[5,6]
Students
It is essential to know the baseline knowledge of students,
what they want to learn, and the extent of their actual interest
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in learning.
Strategies
For the teacher, there should be specific strategies predetermined
for teaching his or her students.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/18/2024
Grouping
Teachers should know the group behavior of the students so
the group behavior can be utilized properly for the facilitation
of learning.
Timing
It should be predetermined what would be the limit in time
within which the teaching would be finished. Furthermore, it
will be important to choose the perfect timing within 24 h of
the day for the teaching of the particular subject.
Materials
All the materials and methods that are going to be used should
be prepared and rehearsed well before the teaching activity.
Success
The success of learning must be evaluated through an
assessment‑based approach from students so that it can help
in the improvement of the teaching capability of the teacher.
Sequence
There should be a specific sequence of every event of any
teaching activity so that there will be a smooth transition of
knowledge with further improvement.
Rationale
Before starting making a lesson plan, it should be kept in
mind that why is that topic or subject is important, and this
importance should be told to students.
The main requirements of the lesson plan can be presented as
a triangle [Figure 1].
Components of the lesson plan
There are eight main components in the lesson plan.[7]
1. The predefined objective of learning activity fulfilling
SMART (Specific, Measurable, Attainable, Relevant,
and Time‑bound) criteria
2. One anticipatory set or set induction for attracting the
minds of students towards learning activity
3. Direct instruction for delivery of the content
4. Predetermined strategies for students for practicing what
they would learn
5. Properly closure the class with one brief discussion about
the topic in small groups
6. Independent practice of students at home in the form of
homework for practicing their learning
Current Medical Issues ¦ Volume 20 ¦ Issue 1 ¦ January‑March 2022
Figure 1: Requirements for making one effective lesson plan.
7. Proper materials and methods for content delivery
8. Formative or summative assessment for checking to if
learning objectives are met or not.
How to Prepare a Lesson Plan?
For developing any effective lesson plan, the following six
steps should be followed carefully[5,8]
1. Set Induction: The set induction is an essential element of
a lesson plan. The gaining of attention of students is one
of the most important steps in the educational session.
The attention of the students is needed to capture with a
stimulus, and the best way is to present a real‑life scenario
2. Formulating specific learning objectives: Specific learning
objectives will help in deciding at the end of class what the
student would be able to learn or perform. This should be
in concordance with the competency to be acquired. The
learning outcomes will help the students motivate them,
essentially, if they are eager to complete the lesson. For
that purpose, one teacher must know about the topic of the
lesson, what the teacher wants to impart in the minds of
the student during the class and what the teacher expects
the student to take home in their mind from the class after
understanding. These learning objectives should also be
prioritized. It is the pillar of any lesson plan. The domains
of learning can be divided into psychomotor, cognitive,
and affective domains.[9,10]
For any topic, the special learning objectives can be made by
a. “Do” ‑ The action verb
b. “What” ‑ The thing to be done
c. “How” ‑ The adverb for your action.
Example: For the topic of hypertension, the specific learning
objective can be: Measure (do) blood pressure of patients (what)
following guidelines (how). The specific learning objectives
should follow SMART criteria, i.e., Specific, Measurable,
Attainable, Relevant, and Time‑bound.[10]
3. Building an introduction: The introduction of the topic
should be attractive to the students so that they can get
49
 Pal, et al.: Comprehensive lesson plan in teaching and learning

Table 1: Lesson plan for modern contraceptives (practical session)

Template for steps in lesson or session planning for teaching modern contraceptives
Date Cohort: MBBS students Number of students: 50
Title of course: Modern contraceptives
Lesson aims: To enlighten students with knowledge of modern contraceptives
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Lesson objectives
To learn about the importance of contraception in family planning
Explain various methods of contraception
Gagne’s nine events of instruction model will be used for delivering the content of the lecture, i.e., attention gaining, informing the learners
regarding objectives, enhancing the recall of previous, providing stimulus, providing guidance to learners, eliciting performance, providing
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feedback, assessing performance and enhancing of retention and transfer of knowledge[12,13]

Duration of the lesson: 3 h Classroom
Time (min) Lesson content Teaching method Teaching aids
5 State and explain lesson topic and objectives VE PPT slide
15 Ascertain students existing knowledge on contraception and various Q and A
methods of contraception
60 Explaining the various contraceptive methods, explain the clinical skills VE PPT slides
regarding methods of issue of contraceptive, rationales for performing
them including recapitulation of anatomy and physiology
30 Teaching the skill of insertion of an intra‑uterine contraceptive device at VE PPT slides
a slow pace, ascertaining rationales for each step Video clips
15 Recapitulation and respond to any question VE and Q and A
15 Testing each student, evaluation of the session Test/evaluation MCQ/quiz sessions
15 Evaluation of session VE Time‑table slide
10 Take‑home message VE PPT slide
15 Feedback VE Feedback forms
VE: Verbal exposition, Q and A: Questions and answers, PPT: Powerpoint, MCQ: Multiple choice questions

interested in the topic. The introduction part should total period. The starting and closing of any teaching
be interactive, so students feel that learning is not session are the important part.
unidirectional. For introducing any subject, a teacher can
incorporate any personal experience with it to make the Conceptual Framework of the Lesson Plan
topic more relevant
Table 1 is depicting one example of formulating a framework
4. Plan to check if the students understand or not:
for lesson plan for topic of modern contraceptives[12,13-15]
Assessment or Evaluation of students’ understanding
of a given topic is of utmost importance. This has to be Conclusion
planned to ensure that the learning outcomes are met Student‑centered learning and behavior are positively
after the lesson. The teacher should plan the questions influenced by a lesson plan. The medical educator plays an
in the form of multiple‑choice questions, oral questions, immense role in enhancing the understanding of a particular
and quizzes or activity demonstrations regarding the topic.
understanding of the topic. There are various platforms,
Kahoot, Socrative, etc., that can be utilized for assessment Financial support and sponsorship
Nil.
5. Summary: There should be a summary of the whole
class at the end constituting the key points of the topic, Conflicts of interest
which will emphasize depending on their importance. There are no conflicts of interest.
This take‑home message should be brief and specific
so that it can create an impact in the memory lane of References
students 1. Batmanabane G. Linking lesson plan to teaching learning principles.
6. Timeline: There should be a one‑time constraint Ann SBV 2013;2:1‑2.
framework for all activities or specific learning objectives 2. LESSON PLAN | Definition of LESSON PLAN by Oxford Dictionary
on Lexico.com also Meaning of LESSON PLAN. Oxford. Available
during class as the attention span is not unlimited, which
from: https://www.lexico.com/definition/lesson_plan. [Last accessed on
in most cases is approximately 15 min.[11] All the teaching 2021 Jul 09].
activities should be divided equitably within the provided 3. Gagne, R.M., Wager, W.W., Golas, K.C., Keller, J.M. and Russell, J.D.

50 Current Medical Issues ¦ Volume 20 ¦ Issue 1 ¦ January‑March 2022

 Pal, et al.: Comprehensive lesson plan in teaching and learning
(2005), Principles of instructional design, 5th edition. Perf. Improv., 44:
44-46. https://doi.org/10.1002/pfi.4140440211.
4. Vaccari A, Farias GF, Porto DS. Implementation of a lesson plan model
in the nursing laboratory: Strengthening learning. Rev Gaucha Enferm
2020;41:e20190174.
5. Saunders RB. Constructing a lesson plan. J Nurses Staff Dev
2003;19:70‑8.
6. Milkova S. Strategies for effective lesson planning. Center for Research
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on learning and Teaching. 2012;1(1):1-29.
7. Fink LD. Integrated Course Design. IDEA PAPER [Internet]. 2003
[cited 2021 Sep 20];1–7. Available from: https://www.ideaedu.org/
idea_papers/integrated-course-design/.
8. Yonkaitis CF. Lesson plan basics: Teaching in the classroom with
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confidence. NASN Sch Nurse 2020;35:136‑9.
9. Singh T, Gupta P, Singh D. Principles of Medical Education. 4th ed.
Current Medical Issues ¦ Volume 20 ¦ Issue 1 ¦ January‑March 2022
Delhi: Jaypee; 2013. p. 27‑38.
10. Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med
Libr Assoc 2015;103:152‑3.
11. Chatterjee D, Corral J. How to write well‑defined learning objectives.
J Educ Perioper Med 2017;19:E610.
12. Bradbury NA. Attention span during lectures: 8 seconds, 10 minutes, or
more? Adv Physiol Educ 2016;40:509‑13.
13. Samuel S. How to design a comprehensive lesson plan. MedEdPublish
2014;3:1‑8.
14. Miner A, Mallow J, Theeke L, Barnes E. Using Gagne’s 9 events of
instruction to enhance student performance and course evaluations in
undergraduate nursing course. Nurse Educ 2015;40:152‑4.
15. Tambi R, Bayoumi R, Lansberg P, Banerjee Y. Blending Gagne’s
instructional model with Peyton’s approach to design an introductory
bioinformatics lesson plan for medical students: Proof‑of‑concept study.
JMIR Med Educ 2018;4:e11122.
51
 Samuel S MedEdPublish 2014, 3: 32
http://dx.doi.org/10.15694/mep.2014.003.0032

Article Open Access

How to design a comprehensive lesson plan

Sharmeen Samuel

Corresponding author: Sharmeen Samuel sharmeensamuel@hotmail.com

Department: The University of Dundee, Scotland.

Received: 07/08/2014
Accepted: 07/08/2014
Published: 25/08/2014

Abstract

Lesson planning is an indispensable element of constructive teaching-learning process providing the

instructor with a coherent framework of teaching and assisting with the smooth flow of the lesson. It
is essential for medical educators to be mindful of the characteristics of a sound lesson plan and be
well- informed of the pre- requisites of creating a good lesson plan. Robert Gagne a renowned
American psychologist has done a remarkable job in the field of instructional designing. He organized
the critical steps of lesson planning into nine events which he termed as events of instruction. By
adhering to these steps one can achieve the targets set for constructing a sound lesson plan. Gagne in
his theory focuses mainly on the outcomes and how following these steps can influence the student
learning behaviours. Instructional designing gives structure to the lesson and positively influences the
student learning.

Practice points
1. Why lesson planning is essential? It provides structure and organization to a lesson which
positively influences student learning behaviour.
2. What should a teacher know prior to formulating a lesson plan? Components of a lesson plan ,
capabilities of students and an in-depth knowledge about the subject matter .
3. What is an instructional design? Gagne used this term for a lesson plan. He organized the
critical steps of lesson planning into nine events.
4. Why follow the events of instruction? Following these steps lead to a systematic teaching-
learning process.

Keywords: Curriculum

Article

Introduction

A lesson plan is a written guide for trainers in order to achieve the intended learning outcomes. It
specifies the learning objectives, equipments, instructional media material, requirements, and conduct of
training (educational dictionaries). Lesson planning is essential for directing goal-directed teaching,

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http://dx.doi.org/10.15694/mep.2014.003.0032

providing an outline for a smooth flow of a teaching session, making the teacher more organized,
and helping him or her to achieve the set targets within the given frame of time.

What is meant by an Instructional design?

Robert Gagne has used the term Instructional design for a lesson plan and described it as a structure
which makes the acquisition of knowledge and skills more effective and efficient, is appealing to the
learner and is enduring, that is the information is stored in the long term memory and can be
recalled when required (Gagne et al. 1992). Another important characteristic of a good lesson plan is
that it is mutable; it guides rather than dictating a teacher (Linda Jensen 2001). What should a
teacher consider when writing a lesson plan? A teacher should be well informed of the abilities and
the learning preferences of students, their cultural backgrounds, the different learning styles, their
ability to engage in a discussion and their prior knowledge. He or she should have a grip over the
subject matter being discussed and know about the instructional material or equipment that will be
needed to make the whole process successful (Teachnology 2010).

Components of a lesson plan

It is important for a teacher to have knowledge about the components of a lesson plan, which is the
profile, the objectives, materials/equipment, the procedure and assessment. For example if one is
planning a lesson on anti-diabetic medication, he/she should be aware of the grade of class and its
strength, should specify the objectives first, and make a list of the materials/equipment needed, then
work on the activities one intends to include in the lesson, keeping in mind the objectives. In order
to evaluate if the objectives are achieved or not, assessment activities, such as quizzes should be
included (Table 1).

Events of instruction

Robert. M Gagne, a psychologist well known for his work on instructional design has sequenced the
appropriate steps into nine events which he has given the name of “events of instruction”.
Instructional design theories are greatly influenced by the theory of behaviourism and cognitivism
(Molenda 2002). Gagne’s events of instruction are also informed by these theories.

1) Gaining Attention

According to Gagne’s steps of instruction, before starting the lesson, gaining attention of the learners
is an important step. In order to capture the attention of the learners, a stimulus should be provided,
that arouses interest in them (Khadjooi 2011). This can be done by presenting a real life scenario or
a short video of a patient with diabetes.

2) Informing the learner of the objectives

The objectives are the driving force behind a lesson plan (Gagne et al. 1992). These are the
comprehensive set of statement exactly what will a student be able to achieve after a successful study
(Adams 2004). Learners will have a clear understanding of their goals and will develop an insight
towards the main content. Defining the learning outcome will motivate the learner to complete the
lesson (Khadjooi 2011). Every step in the instructional design will be decided by the objectives so it
can be considered as a pre-requisite for all the steps.

3) Stimulating recall of prerequisite knowledge

The subject matter structure refers to the various interrelationships among the components of the
subject matter. Learning pre-requisite relations must be identified before the new information is
provided. A Learning pre-requisite relation is the obligatory information learner must have, in order to
understand the new information that is intended to be provided (Merill et al. 1994). A teacher should
be aware of the other information, related to the topic intended to be taught and therefore encourage

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 Samuel S MedEdPublish 2014, 3: 32
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the students to review those in order to have a better understanding of the subject. This can be done
before starting the discussion of the main topic, stimulating the students by asking some questions
that will coerce them to recall their prior knowledge of insulin, its functions and the pathologies
involved in type 1 and 2 Diabetes and then allowing a small group discussion in which exchange of
ideas take place, helping every participant develop a more extensive and deep knowledge. This action
is based on the theory of social constructivism (Vygotsky 1978). The recalling of this knowledge
will make their mind a fertile ground for the plantation of the new seed (new information).

4) Presenting the stimulus material

The new content can be presented by various ways. The choice of the teaching technique can be
based upon many factors but anything promoting the process of conceptualization should be preferred.
Taking the topic into account, the lesson can be presented as a Power point presentation using the
projector, discussing with the students the different treatment regimens available for diabetes, the
detailed mechanism of action of drug, the benefits and the various adverse effects. Relevant questions
would be appropriate to ask especially at the point where the main topic relates to the reviewed
information so that the integration and bridging between information takes place, that helps develop
the process of conceptualization and maintaining the link of the new information with the prior
knowledge. It will also help the students to actively engage in the discussion, stimulating the thought
process in them as evidenced by the theory of constructivism. The Serialist learners will especially
be benefitted by such activities, who learn the content step by step, building a logical and structured
framework of knowledge (Pask 1976). Convergers will also derive benefit from this, who tend to
follow a line of argument, in a stepwise fashion and reaching on the right conclusion (Hudson 1996).
This step is allied with the previous step.

5) Providing learning guidance

Presenting the knowledge into real life scenarios is essential to build a clinical approach towards the
subject. The information of the main content is a pre-requisite for this area. A real life scenario of a
Diabetic patient, with a short question at the end that requires students to do some brainstorming,
answering the question keeping in mind the knowledge of the anti-diabetic medication and associating
it clinically will result in a better understanding and long term memory of the subject, evidenced by
the theory of cognitivism. Such activities will help the learners, making the stimulus as meaningful
as possible (Khadjooi 2011) and will be favourable for those students with an activist learning style
who are open minded and tackle problems by brainstorming (Honey and Mumford 1986) or those
who are divergers producing novel approaches to problems (Hudson 1966).

6&7) Eliciting the performance and providing feedback

Eliciting performance provides an opportunity for learners to confirm their correct understanding
(Khadjooi 2011). It is especially important when a skill is being taught. For the above lesson the
teacher can prepare some real life scenarios and the students will be encouraged to answer these with
the information they have just learned. Based upon the overall performance of the student, feedback
will be provided. Appreciating the students for their active participation will help reinforce such
behaviour (Positive reinforcement). One can ask the students for their feedback too, which will help
the teacher to plan lesson in the future.

8) Accessing the performance

Assessment is done to ensure that the learning outcomes are met. It should preferably be done by the
teacher so as to ensure completely that the students know what are taught and to know how far
he/she has been successful in attaining his/her targets. It can be done via a handout of mcqs, oral
questioning and quizzes. This step will be greatly influenced by the time of the lesson.

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9) Enhancing retention and transfer

The session can be closed by repeating the keys concepts of the subject, highlighting their importance
in practical medicine or asking students to repeat the key points. The repetition of the learned concept
is an effective means of enhancing retention (Khadjooi 2011). Gagne has placed such activities under
the event of “enhancing retention and transfer”.

Conclusion

Lesson plan is a vital component of systematic teaching-learning process, giving structure to the
objectives, resulting in a better understanding of the subject (Khadjooi 2011). As Gagne himself says,
“organization is the hallmark of effective instructional materials”. Instructors can follow the above
steps to give their lesson a systematic flow within the provided restraints of time. However
amendments to these steps can always be done according to the requirements of a particular lesson.
The interest of the instructor should lie in promoting student learning and changes to these steps
should be made preferably to enhance the process of conceptualization.

Glossary Items:

Theory of constructivism: It is based on constructing a new set of information on prior knowledge

and extracting a meaningful idea that demonstrates the ability of structuring and organizing knowledge
based on one’s own judgment ( Kaufman 2003 ).

Theory of social interaction: Interaction among participants results in the exchange of ideas and
experiences, helping in their cognitive development ( Vygotsky, 1978 ). Theory of social
constructivism can go hand in hand to the theory of constructvism to provide the best learning
outcomes.

Theory of behaviourism: It is based on the principle of stimulus-response ( Thorndike 1905).

Positive reinforcement ( rewarded on a desired behaviour ), Negative reinforcement ( removal of an
unpleasant stimulus, reinforces desired beahviour ), Punishment ( applying an unpleasant stimulus to
undermine an undesired response ) can assist in achieving the desired response in the learners (
Skinner 1953 ).

Theory of cognitivism: This theory is based on the thought process behind a behaviour. Changes in
behaviour are used as indicators, as to what is happening inside a learner’s mind ( Schuman 1996 ).

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Table 1

Components Inclusions of the components

Profile Title of lesson: Anti-diabetic medications.
(basic information about Subject: Pharmacology.
lesson and class) Level of class: Third year medical students
Strength of class: 100 students (Approx)

Objectives Students should know about

(What you the students
should know or be able to
do at the end of lesson)
 The different treatment regimens available for diabetes.
 Mechanism of action of drugs.
 Effects and side effects on body.
 Contra-indications and interactions with other drugs.
 Apply this knowledge in practice of medicine.

Materials/Equipment
 Multi-media
needed to conduct the
lesson.  Mike
 Pointer
 Checklist
 Hand-outs

Procedure Follow the Gagne’s nine events of instruction.

(What method you
follow to organise your (Other methods that can be used are Peyton’s steps, Hunter’s steps and 5E’s
lesson) model)

Assessment
 Oral questioning and answering
(Activities included to
ensure that learning  Hand-outs with multiple choice questions.
outcomes are achieved)

Table 2

Gagne’s Events of Instruction

Session title: Anti-diabetic medications

Student / trainee level: Third year medical students

Level Activity
1 Gaining Presenting the students with a real life scenario. A middle aged, obese man comes
attention to you, who recently was diagnosed with Diabetes Mellitus. He tells you that since
when he was informed about diabetes, he is exercising regularly and taking a
diabetic friendly diet but none of these has worked and his blood glucose levels are
still poorly controlled. He asks you about the various treatment regimens available
for Diabetes. He seems a bit concerned about the side effects of the various drugs.
What information would you provide him?
In addition to the scenario a picture of a middle aged obese man would add to the
effectiveness of the scenario.

2 Informing A slide shown to the learners informing them about the objectives.
learner of AT THE END OF THE SESSION YOU WILL KNOW ABOUT

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objectives
 Various treatment regimens available for different forms of diabetes.
 Mechanism of action of the anti-diabetic medication.
 Effects of the drugs on the body and the various side effects involved with
the use of these drugs.
 Contra-indications and interactions with other drugs.
 How to apply the knowledge of anti-diabetic drugs in real life medicine.

3 Stimulate recall A short question answer session and discussion about the prior knowledge of
of prior learning normal release of insulin in the body, factors responsible for insulin release,
functions of Insulin in the body, effects of insulin deficiency on the body and the
various pathologies involved in type 1 and type 2 Diabetes Mellitus.

4 Presenting Presenting the new material using a power point presentation. Detailed explanation
stimulus about the various regimens, their mechanism of action, their benefits and the
various side effects involved. Relating the new content with the prior knowledge.
For example when discussing the mechanism of action of the drugs of group
Sulfonylureas, relating it to the process of normal release of insulin. Emphasizing
on the keys points and giving time to the learners and yourself to do reflective
thinking.

5 Providing Presenting real life scenarios and discussing it with learners.

learning A 75 year old diabetic male, who come to you with complaints of renal dysfunction.
guidance Prior to giving any treatment to this patient, you ask about the medications which he
is currently taking and he tells you that he is taking Metformin for his diabetes.
What appropriate action would you take?
( More real life scenarios can be added in this event depending upon the limitation
of time, needs of the subject, level of understanding and preferences of students)

6 Eliciting Giving students the opportunity to formulate their action plan concerning the
performance scenario and discussing it with the fellow students. For the above scenario, the
student using the knowledge of the adverse effects of diabetes will indicate that
Metformin should be immediately withdrawn as it increases the risk of lactic
acidosis in patients with renal dysfunction.

7 Providing Giving students feedback about their participation during the session. Appreciating
feedback them if they have done well and encouraging them if they are too relaxed to learn
and actively participate.
Feedback from the learners about how this session has informed them of the various
treatment regimens of diabetes and their practical application in medicine. What are
the deficiencies they find in this interactive session and how these can be improved?

8 Assessing A handout can be given to all students that consist of a small number of multiple
performance choice questions that will inform them about the core knowledge of the anti-diabetic
drugs.

9 Enhancing Repeating the keys points or asking students to repeat the key points of the session.
retention and
transfer

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References:

Adam, S., 2004. Using Learning Outcomes: A consideration of the nature, role, application and
implications for European education of employing learning outcomes at the local, national and
international levels. Report on United Kingdom Bologna Seminar, July 2004, Herriot-Watt
University

Gagne, R. et al., 1992. Principles of Instructional Design. 4th Ed. Fort Worth, TX: HBJ College
Publishers

Honey, P and Mumford, A., 1986. Using Your Learning Styles. Maidenhead.

Hudson, L., 1966. Contrary Imaginations. Penguin.

Jensen, L., 2001. Planning Lessons. In M. Celce-Murcia (Ed.), Teaching English as a Second or
Foreign Language. 3rd Ed. pp. 403-413.

Kaufman, D.M., 2003. Applying educational theory in practice. ABC of learning and teaching in
medicine, 326(7382), pp. 213-216.

Khadjooi, K. et al., 2011. How to use Gagne's model of instructional design in teaching
psychomotor skill. Gastroenterology and Hepatology From Bed to Bench, 4(3), pp. 116-119.

Merill, M., 1994. Instuctional design theory. 1st Ed. New Jersey: Educational Technology
Publications.

Molenda, M., 2002. A New Framework for Teaching in the Cognitive Domain. ERIC Digest.
Academic Search Premier Database.

Pask, G., 1976. Styles and strategies of learning. British Journal of Educational Psychology, 46, pp.
128-148.
http://dx.doi.org/10.1111/j.2044-8279.1976.tb02305.x

Schuman, L., 1996. Perspectives on Instruction.

http://edweb.sdsu.edu/courses/edtec540/Perspectives/Perspectives.html

Skinner, B. F., 1953. Science and Human Behavior. New York : Simon and Schuster.

Teachnology, 2010. What to Consider When Writing a Lesson Plan http://www.teach-

nology.com/tutorials/teaching/lesson_plan/ (accessed on 05-20-14) .

Vygotsky, L. S., 1978. Mind in society: The development of higher psychological process (M.Cole,
Trans.). Cambridge: Harvard University Press.

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 Samuel S MedEdPublish 2014, 3: 32
http://dx.doi.org/10.15694/mep.2014.003.0032

Acknowledgments

Special thanks to

Dr Sharoon Qaiser, MD
Clinical fellow, Medical Education at University of Illinois, Chicago.

Dr Sean McAleer, BSc and DPhil

Course director in medical education at University of Dundee, Scotland.

Notes on contributors

Sharmeen Samuel, MD
Enrolled in program of Post Graduate certificate in Medical Education.

Declaration of interest

The author reports no declaration of interest.

Page | 8
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How to Design and Apply an Objective Structured Clinical Examination (OSCE)

in Medical Education?

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Review

How to Design and Apply an Objective Structured Clinical

Examination (OSCE) in Medical Education?
a,b,
Said Said Elshama *
a
Department of Forensic Medicine and Clinical Toxicology, College of Medicine, Suez Canal University, Ismailia City, Egypt
b
College of Medicine, Taif University, Taif, Saudi Arabia

ARTICLE INFO ABSTRACT

Article history: The Objective Structured Clinical Examination (OSCE) is considered a gold standard
Received 25 October 2020 summative and formative assessment method wherein it is a comprehensive and
Received in revised form 04 standardized tool assessing the clinical competencies including psychomotor domain,
November 2020 attitudes, and behaviors that will be manifested in the real work of the medical
Accepted 05 November 2020 graduates. Therefore, the implementation of OSCE depends on the design of a blueprint
that consists of two axes; the first axis is the tested competencies according to the
Keywords: learning objectives while the second axis represents a system or problem that is related
Objective structured clinical to these competencies. Thus, the blueprint of OSCE is a translation for the learning
examination objectives into clinical competences such as history taking, physical examination,
Educational assessment radiographic and laboratory data interpretation, technical skills, attitudinal behaviors,
Medical education and counseling skills. In addition, the utility index proved that OSCE has a good balance
Clinical competence for acceptability, reliability, validity, credibility, feasibility, cost, and educational impact.
However, the use of OSCE for the students' assessment is considered expensive and
exhausted because it requires many facilities, a great deal of the personnel besides the
needed consuming time for its application.

© 2021 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access article
under the CC BY license (http://creativecommons. org/licenses/by/4.0/).
HOW TO CITE THIS ARTICLE: Elshama SS. How to Design and Apply an Objective Structured Clinical Examination (OSCE) in
Medical Education? Iberoam J Med. 2021;3(1):51-55. doi: 10.5281/zenodo.4247763.

promote the learning because the learning within a relevant

1. INTRODUCTION
Practical clinical training and assessment of the medical
student should be closely matched. Therefore, the use of the
real environment or authentic situation for the learning and
the assessment of medical competence are essential to
context enables the medical students to store and retrieve
the knowledge in a better way [1].
It is known that Miller classified the medical competence
into four levels or categories such as knows, knows how,
shows how and does. So, it should be a necessity to
organize a comprehensive and standardized tool

* Corresponding author.
E-mail address: saidelshama@yahoo.com
ISSN: 2695-5075 / © 2021 The Authors. Published by Iberoamerican Journal of Medicine. This is an open access article under the CC BY license
(http://creativecommons. org/licenses/by/4.0/).
http://doi.org/10.5281/zenodo.4247763
52 IBEROAMERICAN JOURNAL OF MEDICINE 01 (2021) 51-55
(examination) to assess the medical student for the levels of
shows how and does assessing the clinical competencies in
the psychomotor domain, attitudes, and behaviors that will
be manifested in the real work of the medical graduates.
This tool or examination that was created in the last years is
called an objective structured clinical examination (OSCE)
that is considered as an alternative to the unstructured
clinical observations. So, it can assess content skills,
process skills, and clinical management wherein it evaluates
clinical competence of the student in history taking,
physical examination, and technical procedures [2].
Furthermore, OSCE is considered a gold standard
summative and formative assessment method of clinical
skills. It gives feedback to the student (formative) for the
learning and practices before the summative assessment
that is a suitable method to assess the performance of the
students via creating the clinical situations via using
simulation technology to decrease the variables and clarify
the objectives besides it limits the complexity [3].
Noteworthy, OSCE is designed for clinical and theoretical
knowledge application wherein the theoretical knowledge is
required with the standardized questions. Furthermore, it is
considered an objective exam because it is based on using
the same stations and the same assessment checklist in the
student evaluation to enable the student to get marks for
every performed step. In addition, it is also considered a
structured exam because it depends on providing the
designed specific tasks that cover all curriculums for all
students with specific instructions. So, the name of the
objective structured clinical examination (OSCE) is derived
from the composition of its elements [4].
Furthermore, the success of OSCE application in medical
education results from specific measurements such as
validity, reliability, feasibility, and credibility those were
essential factors in the evaluation of its performance. The
validity of OSCE includes content validity “a good
sampling of matching skills with the learning outcomes”,
predictive validity, and concurrent validity to measure what
it was designed to measure while the reliability measures
the consistency of OSCE. In addition, the evaluation of
OSCE performance includes also the item analysis to test
the difficulty of every station related to the overall exam.
Moreover, the grading of OSCE may also depend on a
criterion-referenced system, norm-referenced system, or
both [5].
Therefore, OSCE is considered a valid and reliable exam.
In more detail, OSCE can increase the reliability of
measurement because the student moves through many
stations to perform a task in each station wherein his
performance is scored by an examiner using a checklist or
rating scale. Noteworthy, the use of detailed checklists in
OSCE may decrease inter-rater unreliability and then
reinforces the reliability because the test results depend on
the direct observation and the repeated measurements that
help the examiner to assess many different qualitative
aspects such as efficiency and the student skill
performance. It is also considered valid test or exam
because it depends on multifactor such as the blueprinting,
the scoring system, and the standardized criteria besides
authenticity that is considered an essential and contributing
factor for the validity [6].
2. WHAT IS THE OSCE?
OSCE consists of multiple short stations containing a wide
sampling of clinical and communication skills with a large
number of the involved examiners and the standardized or
real patients within a limited time via using a structured
measurement method such as a specific checklist or global
rating scale. Therefore, OSCE includes a broad spectrum of
the clinical tests such as the standardized patient or the real
patient examination, review of radiographs, multiple-choice
written questions and the use of models or manikins for
testing the technical skills that are valued tests but it is
restricted to the thoughts of examiners [7].
It should like to mention here that the short stations in
OSCE enable the medical student to achieve a large number
of different stations in the available testing time. In
addition, the large number of examiners and patients who
involve in the different stations of OSCE may also limit the
bias to a large extent. However, there is another point of
view which says that the use of short stations in OSCE may
be destructive to the validity of the test because it does not
allow assessment other aspects of shows how level such as
the ability of students to deal with complicated situations
that need the integrated different skills such as decision
making, drawing the conclusions based on physical
examination and investigation, and management skills of
the case. Thus, the use of short stations should be limited to
technical skills only. On another hand, the use of long
stations as an alternative is also controversial because it
may affect the reliability of the testing according to the
opinions of some medical educators. On the opposite side,
some experts refuse this direction indicating that the station
length has a limited influence on the reliability. Therefore, I
think that the best is using a balanced content during
determining the assessment task apart from the
controversial views to ensure the authenticity and the
efficiency of measurement [8].
 IBEROAMERICAN JOURNAL OF MEDICINE 01 (2021) 51-55
3. HOW TO ORGANIZE AND APPLY THE
OSCE?
Initially, a structured and organized committee or
organization must be formed with specific responsibilities
for administering OSCE from the design to implementation.
This committee will be responsible for the determination of
content, reliability, validity, and the implementation of
OSCE with assigning an examination coordinator who will
coordinate between the different activities of OSCE during
the implementation [9].
Secondly, responsible teamwork should design a blueprint
of OSCE which should consist of two axes; the first axis is
the tested competencies according to the learning objectives
of the educational course or module while the second axis
represents a system or problem that is related to these
competencies. Thirdly, the blueprint should translate into
definite skills, behaviors, and attitudes that will be assessed
by the examiners based on the learning objectives through
clinical competence assessment in history taking, physical
examination, radiographic and laboratory data
interpretation, technical skills, attitudinal behaviors, and
counseling skills [10]. An illustrated example is shown in
Table 1.
Fourthly, the stations of OSCE and its number should be
determined according to the tested skills and behaviors
wherein the total number is 10-12 at least besides a design
and preparation of the questions of examination for the
critical thinking assessment based on the differential
diagnosis and management of the case. In addition, the time
of the station and the time in-between the stations and the
Table 1. OSCE Blueprint of the Respiratory Module
Tested
Competency History Physical
Diagnosis
Of Taking Exam
OSCE
System
Or
Program
Chest diseases Chest exam Chest X ray
Or
Health
Problem
OSCE: Objective Structured Clinical Examination
length of the examination should also be determined [11].
Furthermore, the profile or characters of every station
should be identified including the status of station whatever
dynamic or static, and the title or condition that is presented
in the station such as a case of ischemic heart disease which
should correspond with the domain and competence tested,
and the needed or the estimated time for performing the
task. Moreover, the station profile should also include the
53
specification of the most suitable tool for the demonstration
of the skill whatever the real or standardized patient,
mannequin, or virtual siting. In the related context, well-
prepared scenarios for all stations should be designed via
using the language of the patient without any medical terms
or redundant detail providing enough information to guide
the student to perform the required task [12].
Fifthly, the scoring criteria of the assessment should be
prepared for every station wherever all stations should have
one set of the total marks, let it be ten or twenty; it should
also be short, clear, and reliable including the helpful
instructions to the examiners. The most commonly used is
the checklist that divides the performance of required task
into practical, objective, and specific steps or procedures
wherein every step is scored by a mark. We would like to
mention that some steps which are related to ethics, general
consideration, attitude, and behavior, it should not be given
a high score as this will affect the overall score of the exam
[13]. Worthwhile, the rating in the checklist is useful for
unqualified or inexperienced examiners because the scoring
is not done or done. There is another scoring form may also
be used such as the rating scale that is like the checklist
wherein the examiner differentiate the performance based
on the quality and the level of mastery via a scale consisting
of satisfactory, borderline, weak, unsatisfactory (not done)
that are assigned by a mark for every level in the scale such
as 2, 1.5, 1, 0. The global rating is considered another type
that can be used with both the checklist and the rating scale.
It assesses the overall performance of the student to
differentiate the competent from incompetent. In this type
of rating, the examiner gives the student a global judgment
Communication Management
Procedures Skills and of Clinical
Counseling Cases
Health
Equipment
Education and
(Nebulizer,
Counseling For Cases of Chest
inhaler, Peak
the patient of diseases
Expiratory
infectious chest
Flow Meter)
diseases
such as pass, borderline, or fail. Moreover, the global rating
may also be used for the standard-setting in the borderline
group. In addition, we would like to mention the
construction of the marking scheme should be depending
on discrimination actions to distinguish between good and
poor performance [14].
Last but not least, some logistic procedures should be
achieved along with a preparation of the needed facilities
54 IBEROAMERICAN JOURNAL OF MEDICINE 01 (2021) 51-55
before the delivery of exam such as allocating the place of
examination, determination of the manikins and the
standardized patients that will be used in OSCE stations
with creating the instructions that are related to every
station, identification the examination stations circuit and
assigning of the examiners [15].
Noteworthy, the preparation of instructions is considered
essential for the examiner, patient and student wherein it
should outline the required task exactly at every station for
the student and outline the marking scheme instructions
about the action and performance of the student at every
station for the examiner and then it should outline the
dealing approach between the standardized or real patient
and the student. Moreover, it should remind that the
instructions of examiners should be simple and sharp
according to the scientific, logistic and legal rules of the
exam such as put the student at ease, observe the
performance of the student and interact with him without
chatting and do not give the student any feedback [16].
Furthermore, the instructions of the student should also be
clear, and placed inside and outside the station such as
switch off your mobile during the exam, read and follow
the instructions of every station carefully and do not discuss
with your colleagues during the changing of the stations.
Regard the standardized patient instructions, it should also
include some important points such as behave kindly with
the student, listen to the student carefully, present your
problem in a consistent and reliable manner, respond to the
student questions appropriately according to the given
designed scenario and respond to the unknown questions
that are out of the scenario by using no or I don’t know
[17].
In addition, the preparation of resources such as
examination rooms, manikins, and other facilities should be
done along with performing orientation sessions for
examiners, standardized patients, and volunteers. In the
related context, it should also evaluate the exam after
finishing it to detect mistakes and work to avoid them in the
future. Therefore and based on the above mentioned, it is
noticed that the use of OSCE for the students' assessment is
considered expensive and exhausted because of the need to
many facilities and the consuming time that is needed to
achieve it besides it requires also a great deal of the
personnel for its application [18].
Finally, we would like to mention that the feasibility of
OSCE stations should be investigated by verification of
some important points such as is the task authentic?
"Student can perform it", pilot the duration of the station” it
should be deciding the duration of the station before the
exam, is the duration of station suitable for performing the
intended task?” matching the clinical stations closely as
possible as and equipment checking [19].
4. ACTUALLY, IS OSCE CONSIDERED A
GOOD ASSESSMENT INSTRUMENT?
Briefly, to get an answer to the above-mentioned question,
it should mention the utility index of OSCE that depends
fundamentally on specific characters determining the extent
of the proficiency and success of any assessment
instrument. In more detail, we can say that OSCE has many
characters of good assessment instruments because of its
objectivity that minimizes the given chance to the
examiners to manipulate the questions, answers, responses,
performance, and judgment. Moreover, it has also validity
whatever face, content, construct or predictive besides the
reliability wherein it has repeatability and reproducibility or
consistency along with objectivity and validity that also
improve the reliability. There is also acceptability for this
exam because every student does the same task. In addition,
OSCE has also a high educational impact because it enables
students to learn more in-depth. Therefore and on based the
above-mentioned criteria, we can also confirm that all
components of the utility index come true for OSEC to be a
good assessment tool because it has a clear balance for
acceptability, reliability, validity, feasibility, educational
impact besides the cost [20].
5. CONCLUSIONS
The objective structured clinical examination (OSCE)
consists of a broad spectrum of clinical tests (stations) such
as the real or standardized patient examination, review of
radiographs, multiple-choice written questions or technical
skills by using manikins. OSCE has many characters of
good assessment instruments such as objectivity, validity
whatever face, content, construct or predictive besides the
reliability. It has also acceptability, credibility, feasibility,
and high educational impact leading to its proficiency and
success.
6. DECLARATION OF CONFLICTING
INTERESTS
The Author declares that there is no conflict of interest.
 IBEROAMERICAN JOURNAL OF MEDICINE 01 (2021) 51-55
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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/5476686

Networking in medical education: Creating and connecting

Article in Indian Journal of Medical Sciences · April 2008

DOI: 10.4103/0019-5359.39616 · Source: PubMed

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LETTER TO EDITOR
PUBLIC-PRIVATE PARTNERSHIP
IN IMMUNIZATION SERVICE
PROVISION IN SRI LANKA
Sir,
Public-private partnership and intergraded
services would be the future strategies for
maintaining equitable and accessible health
services in most of the countries. As the
present public-health care delivery system in
Sri Lanka is catering to all children despite
the usage of private sector by parents, Public
Health Midwives (PHM) are supposed to issue
Child Health Development Records (CHDR),
record the immunization data, carry out the
home visit, and educate the mothers regarding
immunization among private sector users.
As we had reported earlier, the private sector
contribution to childhood immunization in Sri
Lanka is 33.59%.[1] We further analyzed the
available data to evaluate public services,
private services, and their partnership, and
made a comparison between public and private
sectors in order to gain more understanding of
the prevailing situation. Methodology of the study
can be found in the previously published article.
Out of the 553 households studied, 99 [17.9%]
received shared care from private and public
sectors. The main reasons given for using
private sector by these mixed users were
availability of non-EPI vaccines [11.7%],
combined vaccines [6.1%] and efficiency of
services [10.7%]. Public sector users were
more satisfied with competency of vaccinator
[78.9%] and quality of vaccines received
[68.4%], compared to private sector users [50%
117
and 44.2% respectively]. Fifty-seven [54.82%]
private sector users, compared to 320 [91.4%]
public sector users, received PHM services.
These services include providing awareness
about vaccines, home visits for detecting
vaccine side effects, reminding of the time of
next vaccine, and follow-up of children who
developed reactions after immunization. Private
sector providers have shared the government-
issued CHDR for recording immunization data
among majority [64.6%] of the mixed users.
According to these results, in a setting where the
private sector contribution is high for childhood
immunization, the partnership and shared care
is not up to satisfactory level. People who use
private sector for immunization services are
deprived of some of the other essential services
provided by PHM. These parents use private
sector because of lack of non-EPI vaccines and
combined vaccines in public clinics, not because
they refused all the services from public sector
health care providers. This understanding is
essential to improve the quality not only of
immunization service but also of other public
health services.
S. B. AGAMPODI, D. A. C. L. AMARASINGHE1
Post Graduate Institute of Medicine, University of
Colombo, 1Epidemiology Unit, Sri Lanka
Correspondence:
Dr. S. B. Agampodi, Post Graduate Institute of Medicine,
University of Colombo, Sri Lanka.
E-mail: sunethagampodi@yahoo.com
REFERENCES
1. Agampodi SB, Amarasinghe DACL. Private sector
contribution to childhood immunization: Sri Lankan
experience. Indian J Med Sci 2007;61:192-200.
Indian J Med Sci, Vol. 62, No. 3, March 2008
118
PRACTITIONERS’ SECTION
NETWORKING IN MEDICAL EDUCATION:
CREATING AND CONNECTING
AVINASH N. SUPE
ABSTRACT
Social networking is being increasingly used as a tool of choice for communications
and collaborations in business and higher education. Learning and practice become
inseparable when professionals work in communities of practice that create interpersonal
bonds and promote collective learning. Individual learning that arises from the critical
reconstruction of practice, in the presence of peers and other health professionals,
enhances a physician’s capability of clinical judgment and evidence-based practice. As
such, it would be wise for medical schools, whose responsibility it is to prepare students
to make a transition to adult life with the skills they need to succeed in both arenas, to
reckon with it.
Key words: Education, interprofessional relations or interdisciplinary communication
or cooperative behavior or communication or social networking, knowledge sharing or
diffusion of innovation
The word “network” (plural, “networks”) has and other devices connected together to
different meanings in different contexts. share information (e.g., the copy machine is
Commonly, network means any interconnected connected to the network so that it can now
group or system (e.g., a network of roads serve as a printer).
crisscrossing the country). However, it is also
used as a directory of people maintained NETWORKING IN EDUCATION -
for personal advancement (e.g., to get a job BUILDING COMMUNITIES AND SHARING
in today’s economy, it is important to have KNOWLEDGE
a strong network). Over the last decade,
there is a new meaning assigned to the word Networking refers to the art of creating
“network” - a system of multiple computers interdependent or interconnected groups or
systems for the mutual benefit of all members
of the system. In medical education, it would
Director, GSMC-FAIMER Regional Institute, and
Professor and Head, Department of Surgical mean “the conscious creation of interconnected
Gastroenterology, Seth G. S. Medical College and relationships among various students, teachers,
K. E. M. Hospital, Mumbai, India
and other stakeholders with similar interests,
Correspondence: either directly or through intermediaries, for
Dr. Avinash N. Supe, Sangeeta Towers, 6th Floor, Chembur,
Mumbai - 400 071, India. E-mail: avisupe@gmail.com the purpose of achieving common or individual
Indian J Med Sci, Vol. 62, No. 3, March 2008
 INDIAN JOURNAL OF MEDICAL SCIENCES
goals, sharing resources, as well as social
communications.”
“Networking Is First About Building
Relationships... Approached With Respect And
Honesty (Young).”[1]
YOUR NETWORKS EVOLVE WITH YOUR
PROFESSIONAL NEEDS
Networking means different things at different
stages in your career development. As your
priorities change, so do your professional
priorities and the means by which you choose
to find new associates. In schools and colleges,
you have network amongst co-students and
sometimes among teachers. In later life, you
have network at the place of work or practice,
developing along with your social and family
networks.
It has been my observation that medical
professionals in the beginning of their medical
practice tend to view their job as an extension
of their education. Going to work is like going
to school; and just as in college, where you
made friends of your classmates, the tendency
at work is to make friends of your co-workers.
The line between your professional life and
your social life is blurred; so the tools you use
to connect with your friends tend to cross those
boundaries as well.
As your career develops and you mature,
the tools you adopt to develop and maintain
your professional contacts evolve as well.
At some point, you start separating your
professional and personal life. You start
looking for fulfillment in different places,
which means you start compartmentalizing
your home life, family, hobbies, and work. In
119
the same way, you start compartmentalizing
the tools you use to maintain those different
relationships. At workplace we use tools such
as meetings, lunches, as well as group work,
to foster networks. At the professional level,
one uses conferences, workshops, as well
as task forces, to create such networks. In
India, family get togethers, festivals, as well
as marriages and other functions, offer an
environment conducive for building social
networks.
Online social networks are, in essence, the
same as traditional social networks, i.e., a
group of people who are affiliated to one
another through either personal connections
(friends, family, work colleagues) or areas of
common interest (football fans, favorite bands,
travel interests). What differentiates online
social networks from any other traditional
network is the ease with which members can
interact with one another and enhance their
offline relationships through the functionality of
online social networking sites.
On the internet, you start using tools such as
LinkedIn, Jigsaw, and NETSHARE to maintain
your professional connections. These types
of services are more geared to professional
networking and provide information in a context
where you are clearly indicating that you are
looking for professionals who can assist you,
not online friends. Common popular networks
used all over the world by students are
“Myspace”, “Facebook” and “Orkut”. Though
controversial at times, these are best social
networking tools for the net-savvy Indian
younger generation. The age group of 18 to
25 years accounts for the majority of the traffic
at these sites and will certainly testify that
interaction here has long since overtaken plain
Indian J Med Sci, Vol. 62, No. 3, March 2008
120 NETWORKING IN MEDICAL EDUCATION
old conversations. But can social networking
sites work beyond dating and friendship
to emerge as platforms for careers and
educational resources?
These professional networking sites could
broaden their offerings to make themselves
more effective. Being able to share photos is
useful, and basic personal information such
as whether a contact likes golf or collects
wine can be useful in a business context.
But all in all, these professional sites are
designed to help you connect with like-minded
professionals in a way that promotes dialog.
In medical education also, there are now
many strong networks, both offline and online.
Faimer[2,3] is a good example of an effective
medical education network. It connects more
than 300 education leaders from more than 40
countries to share views, ideas, and resources,
as well as to work together for various tasks,
publications, and programs.
Of course, as you advance up the educational
ladder - as you reach the principal or dean
level - the challenges of professional networking
become more complex. Since we all have
limited time and resources, we should take a
hard look at the tools we are using today to
manage our professional relationships. Are you
able to give them enough time and attention
and are the relationships connecting you with
the right people in the right way? Is there
something about associations or conferences
that you still find valuable or are you getting
more educational leads from FAIMER or
other networks or do you need both? As
with everything, you get as much out of your
networking tools as you invest; so allocate your
time and resources wisely.
Indian J Med Sci, Vol. 62, No. 3, March 2008
SOCIAL NETWORKING AND
EDUCATION[4,5]
Social networking sites are, by definition,
places on the internet where people converge
around shared interests or causes. One can
specify one’s education, university, occupation,
industry, company, title, career skills, and career
interests. It thus becomes a mini résumé itself.
There are also a large number of communities
dedicated to education. These cover a variety
of issues such as online tutorials, institute
listings, academic resources, etc. In India as
well, there are now sites such as “MedRec” or
“Smartteach” that have student’s communities
and provide rich educational resources. Many
medical schools in India now have wireless
networks and provide web resources for
students. These are welcome changes and
allow students to study at their own pace and
convenient time. One can also find information
on a specific educational topic from the
global community that would clear away any
confusion one might have on issues concerning
a particular field or the latest developments.
Communities share their own experiences and
help others in decision making. Nonmedical
coaching institutes too have an online presence.
These institutions (e.g., Mahesh Tutorials in
Mumbai) offer coaching for class 10 and 12
board exams and have communities for each of
its branches. Students discuss with professors,
listen to lectures, clear difficulties, and arrange
meets. One of the discussion threads in this
community is regarding placement of previous
batch students.
NGOs are also walking up to the potential of
social networking sites. ‘Asha for Education’ is
 INDIAN JOURNAL OF MEDICAL SCIENCES
goals, sharing resources, as well as social
communications.”
“Networking Is First About Building
Relationships... Approached With Respect And
Honesty (Young).”[1]
YOUR NETWORKS EVOLVE WITH YOUR
PROFESSIONAL NEEDS
Networking means different things at different
stages in your career development. As your
priorities change, so do your professional
priorities and the means by which you choose
to find new associates. In schools and colleges,
you have network amongst co-students and
sometimes among teachers. In later life, you
have network at the place of work or practice,
developing along with your social and family
networks.
It has been my observation that medical
professionals in the beginning of their medical
practice tend to view their job as an extension
of their education. Going to work is like going
to school; and just as in college, where you
made friends of your classmates, the tendency
at work is to make friends of your co-workers.
The line between your professional life and
your social life is blurred; so the tools you use
to connect with your friends tend to cross those
boundaries as well.
As your career develops and you mature,
the tools you adopt to develop and maintain
your professional contacts evolve as well.
At some point, you start separating your
professional and personal life. You start
looking for fulfillment in different places,
which means you start compartmentalizing
your home life, family, hobbies, and work. In
119
the same way, you start compartmentalizing
the tools you use to maintain those different
relationships. At workplace we use tools such
as meetings, lunches, as well as group work,
to foster networks. At the professional level,
one uses conferences, workshops, as well
as task forces, to create such networks. In
India, family get togethers, festivals, as well
as marriages and other functions, offer an
environment conducive for building social
networks.
Online social networks are, in essence, the
same as traditional social networks, i.e., a
group of people who are affiliated to one
another through either personal connections
(friends, family, work colleagues) or areas of
common interest (football fans, favorite bands,
travel interests). What differentiates online
social networks from any other traditional
network is the ease with which members can
interact with one another and enhance their
offline relationships through the functionality of
online social networking sites.
On the internet, you start using tools such as
LinkedIn, Jigsaw, and NETSHARE to maintain
your professional connections. These types
of services are more geared to professional
networking and provide information in a context
where you are clearly indicating that you are
looking for professionals who can assist you,
not online friends. Common popular networks
used all over the world by students are
“Myspace”, “Facebook” and “Orkut”. Though
controversial at times, these are best social
networking tools for the net-savvy Indian
younger generation. The age group of 18 to
25 years accounts for the majority of the traffic
at these sites and will certainly testify that
interaction here has long since overtaken plain
Indian J Med Sci, Vol. 62, No. 3, March 2008
120 NETWORKING IN MEDICAL EDUCATION
old conversations. But can social networking
sites work beyond dating and friendship
to emerge as platforms for careers and
educational resources?
These professional networking sites could
broaden their offerings to make themselves
more effective. Being able to share photos is
useful, and basic personal information such
as whether a contact likes golf or collects
wine can be useful in a business context.
But all in all, these professional sites are
designed to help you connect with like-minded
professionals in a way that promotes dialog.
In medical education also, there are now
many strong networks, both offline and online.
Faimer[2,3] is a good example of an effective
medical education network. It connects more
than 300 education leaders from more than 40
countries to share views, ideas, and resources,
as well as to work together for various tasks,
publications, and programs.
Of course, as you advance up the educational
ladder - as you reach the principal or dean
level - the challenges of professional networking
become more complex. Since we all have
limited time and resources, we should take a
hard look at the tools we are using today to
manage our professional relationships. Are you
able to give them enough time and attention
and are the relationships connecting you with
the right people in the right way? Is there
something about associations or conferences
that you still find valuable or are you getting
more educational leads from FAIMER or
other networks or do you need both? As
with everything, you get as much out of your
networking tools as you invest; so allocate your
time and resources wisely.
Indian J Med Sci, Vol. 62, No. 3, March 2008
SOCIAL NETWORKING AND
EDUCATION[4,5]
Social networking sites are, by definition,
places on the internet where people converge
around shared interests or causes. One can
specify one’s education, university, occupation,
industry, company, title, career skills, and career
interests. It thus becomes a mini résumé itself.
There are also a large number of communities
dedicated to education. These cover a variety
of issues such as online tutorials, institute
listings, academic resources, etc. In India as
well, there are now sites such as “MedRec” or
“Smartteach” that have student’s communities
and provide rich educational resources. Many
medical schools in India now have wireless
networks and provide web resources for
students. These are welcome changes and
allow students to study at their own pace and
convenient time. One can also find information
on a specific educational topic from the
global community that would clear away any
confusion one might have on issues concerning
a particular field or the latest developments.
Communities share their own experiences and
help others in decision making. Nonmedical
coaching institutes too have an online presence.
These institutions (e.g., Mahesh Tutorials in
Mumbai) offer coaching for class 10 and 12
board exams and have communities for each of
its branches. Students discuss with professors,
listen to lectures, clear difficulties, and arrange
meets. One of the discussion threads in this
community is regarding placement of previous
batch students.
NGOs are also walking up to the potential of
social networking sites. ‘Asha for Education’ is
 INDIAN JOURNAL OF MEDICAL SCIENCES
one such community. Asha, a nonprofit initiative
dedicated to educating underprivileged children
in India, aims to discuss fund-raising, new
initiatives, and current events through these
communities.
TYPES OF SOCIAL NETWORKS
Social networks can be of various types:
1. Based on the strength, the network can be
close, moderate, or distant.
2. Based on type of relationship.
• Trust-based: on mutual interest; emotional
connection; competence
• Conveyance: of meaning; information;
solutions; favors; friendship
3. The networks can be small or large.
Depending upon the density and ties
amongst the network participants, they can
be sparse or dense.
4. Networks can be diverse and can have
different hierarchy levels, as well as involve
various organizational units. Network like
INclen can cross geographic boundaries.
Putting all together, the patterns of network
can be:
• High affiliation: These are dense but small
networks with similar interests. They have
strong ties and are of nondiverse nature.
They share the same information, same
world perspective, same support; have the
same motivation; and are cohesive.
• High efficiency: These are sparse but
large networks. These are diverse and
have weaker ties compared to affiliation
networks. There are many contacts that do
not know each other but are a great source
of power.
• Best: The best network one can have is
121
a blend of both - high affiliation and high
efficiency.
BENEFITS OF SOCIAL NETWORKS
If you have a rich network, what do you do
with it? In my experience, there are three key
aspects to social networking that sustain user
interest. These are quite basic and comprise
1) a sense of community, 2) the development of
friendships, 3) ease with which they can interact
with other users and ultimately learn from them.
Networks can be solutions looking for a problem
to solve or an opportunity to exploit. If there is
one rule of networking, it is that in an optimized
personal network - less is more - you leverage a
minimal number of contacts in order to maximize
your work efficiency and effectiveness. Other
nonessential contacts may provide benefits,
like a sense of belonging, friendship, or juicy
gossip. From a narrowly utilitarian perspective,
however, the time invested in maintaining these
network contacts does not provide sufficient
work-related returns.
LIMITATIONS OF NETWORKS
The major limitation of community resources
is authenticity. The accuracy of answers
to queries is open to debate. As with all
resources online, social networking sites too
face the problem of quacks and incorrect
information. Spamming and obscenity are
common phenomena as well.
One of the other claimed limitations is that
connections made on social networks are
superficial and short-lived as the amount of
effort required to make connections is minimal.
However, if any such community has short
Indian J Med Sci, Vol. 62, No. 3, March 2008
122 NETWORKING IN MEDICAL EDUCATION
contact sessions or events, these connections
become more deep and useful. FAIMER
network is a classic example of this.
THE IMPORTANCE OF NETWORKING
Sometimes the expression “it’s who you know”
is true when it comes to your work. By meeting
people involved in medical education, you can
gain valuable insights into a profession and get
your name noticed. This will help you build a
network of contacts. Network is also very useful
for sharing educational resources.
Communities of practice (CoPs)
Physicians interact with peers and mentors
to frame issues, brainstorm, validate and
share information, make decisions, and
create management protocols, all of which
contribute to learning in practice. CoPs offer
great potential for enhancing workplace
learning among physicians. It is likely that
working together in this way creates the
best environment for learning that enhances
professional practice and professional
judgment.
Parboosingh[6] makes a case for interactive
learning with peers and mentors in the
workplace as an effective and efficient way to
offer continuing medical education. He claims
that learning through reflective practice is an
effective way to improve a physician’s practice
and judgment because 1) people learn most
naturally when faced with a problem-solving
experience and 2) learning that is constructed
by the individual results in action. Parboosingh
underlines the need for skilful reflection in this
learner-centered approach and advocates the
critical reconstruction of practice to facilitate
Indian J Med Sci, Vol. 62, No. 3, March 2008
effective reflection. According to community
of practice (CoP) theorist Etienne Wenger,[7]
learning and practice become inseparable
when professionals work in CoPs, groups
that share an interest in a domain of human
endeavor and who engage in collective
learning that creates bonds among them.
Physicians working in care delivery units
naturally form CoPs and give priority to the
activities the CoP generates rather than the
needs of individuals.
IMPORTANT NETWORKING TIPS
• Get organized - prepare a summary of your
skills and the kind of position you want.
• Set realistic goals - create a plan for yourself
that’s easy to execute, such as obtaining
three or four new contacts a week.
• Be prepared - effectively communicate your
strengths and career goals.
• Be organized - keep a record of all persons
you’ve spoken to, including their full name,
phone number, and/or e-mail, plus notes
from your conversation.
• Follow up - make sure to thank all contacts
for their time and stay in touch on a regular
basis.
SUMMARY
Social networking is being increasingly used as
a tool for communications and collaborations, a
tool of choice in business and higher education.
Learning and practice become inseparable
when professionals work in communities of
practice that create interpersonal bonds and
promote collective learning. Individual learning
that arises from the critical reconstruction of
practice, in the presence of peers and other
 INDIAN JOURNAL OF MEDICAL SCIENCES
one such community. Asha, a nonprofit initiative
dedicated to educating underprivileged children
in India, aims to discuss fund-raising, new
initiatives, and current events through these
communities.
TYPES OF SOCIAL NETWORKS
Social networks can be of various types:
1. Based on the strength, the network can be
close, moderate, or distant.
2. Based on type of relationship.
• Trust-based: on mutual interest; emotional
connection; competence
• Conveyance: of meaning; information;
solutions; favors; friendship
3. The networks can be small or large.
Depending upon the density and ties
amongst the network participants, they can
be sparse or dense.
4. Networks can be diverse and can have
different hierarchy levels, as well as involve
various organizational units. Network like
INclen can cross geographic boundaries.
Putting all together, the patterns of network
can be:
• High affiliation: These are dense but small
networks with similar interests. They have
strong ties and are of nondiverse nature.
They share the same information, same
world perspective, same support; have the
same motivation; and are cohesive.
• High efficiency: These are sparse but
large networks. These are diverse and
have weaker ties compared to affiliation
networks. There are many contacts that do
not know each other but are a great source
of power.
• Best: The best network one can have is
121
a blend of both - high affiliation and high
efficiency.
BENEFITS OF SOCIAL NETWORKS
If you have a rich network, what do you do
with it? In my experience, there are three key
aspects to social networking that sustain user
interest. These are quite basic and comprise
1) a sense of community, 2) the development of
friendships, 3) ease with which they can interact
with other users and ultimately learn from them.
Networks can be solutions looking for a problem
to solve or an opportunity to exploit. If there is
one rule of networking, it is that in an optimized
personal network - less is more - you leverage a
minimal number of contacts in order to maximize
your work efficiency and effectiveness. Other
nonessential contacts may provide benefits,
like a sense of belonging, friendship, or juicy
gossip. From a narrowly utilitarian perspective,
however, the time invested in maintaining these
network contacts does not provide sufficient
work-related returns.
LIMITATIONS OF NETWORKS
The major limitation of community resources
is authenticity. The accuracy of answers
to queries is open to debate. As with all
resources online, social networking sites too
face the problem of quacks and incorrect
information. Spamming and obscenity are
common phenomena as well.
One of the other claimed limitations is that
connections made on social networks are
superficial and short-lived as the amount of
effort required to make connections is minimal.
However, if any such community has short
Indian J Med Sci, Vol. 62, No. 3, March 2008
122 NETWORKING IN MEDICAL EDUCATION
contact sessions or events, these connections
become more deep and useful. FAIMER
network is a classic example of this.
THE IMPORTANCE OF NETWORKING
Sometimes the expression “it’s who you know”
is true when it comes to your work. By meeting
people involved in medical education, you can
gain valuable insights into a profession and get
your name noticed. This will help you build a
network of contacts. Network is also very useful
for sharing educational resources.
Communities of practice (CoPs)
Physicians interact with peers and mentors
to frame issues, brainstorm, validate and
share information, make decisions, and
create management protocols, all of which
contribute to learning in practice. CoPs offer
great potential for enhancing workplace
learning among physicians. It is likely that
working together in this way creates the
best environment for learning that enhances
professional practice and professional
judgment.
Parboosingh[6] makes a case for interactive
learning with peers and mentors in the
workplace as an effective and efficient way to
offer continuing medical education. He claims
that learning through reflective practice is an
effective way to improve a physician’s practice
and judgment because 1) people learn most
naturally when faced with a problem-solving
experience and 2) learning that is constructed
by the individual results in action. Parboosingh
underlines the need for skilful reflection in this
learner-centered approach and advocates the
critical reconstruction of practice to facilitate
Indian J Med Sci, Vol. 62, No. 3, March 2008
effective reflection. According to community
of practice (CoP) theorist Etienne Wenger,[7]
learning and practice become inseparable
when professionals work in CoPs, groups
that share an interest in a domain of human
endeavor and who engage in collective
learning that creates bonds among them.
Physicians working in care delivery units
naturally form CoPs and give priority to the
activities the CoP generates rather than the
needs of individuals.
IMPORTANT NETWORKING TIPS
• Get organized - prepare a summary of your
skills and the kind of position you want.
• Set realistic goals - create a plan for yourself
that’s easy to execute, such as obtaining
three or four new contacts a week.
• Be prepared - effectively communicate your
strengths and career goals.
• Be organized - keep a record of all persons
you’ve spoken to, including their full name,
phone number, and/or e-mail, plus notes
from your conversation.
• Follow up - make sure to thank all contacts
for their time and stay in touch on a regular
basis.
SUMMARY
Social networking is being increasingly used as
a tool for communications and collaborations, a
tool of choice in business and higher education.
Learning and practice become inseparable
when professionals work in communities of
practice that create interpersonal bonds and
promote collective learning. Individual learning
that arises from the critical reconstruction of
practice, in the presence of peers and other
 INDIAN JOURNAL OF MEDICAL SCIENCES
health professionals, enhances a physician’s
capability of clinical judgment and evidence-
based practice. As such, it would be wise for
medical schools, whose responsibility it is to
prepare students to make a transition to adult
life with the skills they need to succeed in both
arenas, to reckon with it.
ACKNOWLEDGMENT
The author thanks Dr. John Norcini, Dr. William
Burdick and Dr. Page Morehan, FAIMER,
ECFMG, USA, as well as Dr Rita Sood,
Professor of Medicine, AIIMS, India, for their
suggestions while preparing this manuscript.
REFERENCES
1. Young KK. Networking 101: Some basics for
colleague contact. Scientist 2000;14:32.
2. Norcini J, Burdick W, Morahan P. The FAIMER
Institute: Creating international networks
123
of medical educators. Med Teach 2005;27:
214-8.
3. Pemba SK, Kangethe S. Innovative medical
education: Sustainability through partnership
with health programs. Educ Health (Abingdon)
2007;20:1-5.
4. Creating and Connecting - Research and
Guidelines on Online Social and Educational
Networking. NATIONAL SCHOOL BOARDS
ASSOCIATION report released in September
2007. [cited on 2008 Mar 8]. Available from:
http://www.nsba.org.
5. Harden RM. Change - building windmills not walls.
Medl Teach 1998;20:189-91.
6. Parboosingh JT. Physician communities of practice:
where learning and practice are inseparable. J
Contin Educ Health Prof 2002;22:230-6.
7. [Communities of Practice. Available from: http://
www.chsrf.ca/knowledge_transfer/pdf/digest_
20060817_e.pdf. [cited on 2008 Mar 8].
Source of Support: Nil, Conflict of Interest: None declared.
Indian J Med Sci, Vol. 62, No. 3, March 2008
124
NEWS
POOR SANITATION THREATENS
PUBLIC HEALTH
Sixty-two per cent of Africans do not have
access to an improved sanitation facility - a
proper toilet - which separates human waste
from human contact, according to the WHO/
UNICEF Joint Monitoring Programme for Water
Supply and Sanitation. A global report will be
published later this year, however, preliminary
data on the situation in Africa was released as
part of World Water Day 2008. The Day, built
around the theme that “Sanitation matters,”
seeks to draw attention to the plight of some
2.6 billion people around the world who live
without access to a toilet at home and thus are
vulnerable to a range of health risks.
“Sanitation is a cornerstone of public health,”
said WHO Director-General Dr. Margaret Chan.
“Improved sanitation contributes enormously to
human health and well-being, especially for girls
and women. We know that simple, achievable
interventions can reduce the risk of contracting
diarrhoeal disease by a third.”
Although WHO and UNICEF estimate that
1.2 billion people worldwide gained access to
improved sanitation between 1990 and 2004,
an estimated 2.6 billion people - including 980
million children – had no toilets at home. If
current trends continue, there will still be 2.4
billion people without basic sanitation in 2015,
and the children among them will continue to
pay the price in lost lives, missed schooling, in
disease, malnutrition and poverty.
“Nearly 40% of the world’s population lacks
Indian J Med Sci, Vol. 62, No. 3, March 2008
access to toilets, and the dignity and safety
that they provide,” said Ann M. Veneman,
UNICEF Executive Director. “The absence of
adequate sanitation has a serious impact on
health and social development, especially for
children. Investments in improving sanitation
will accelerate progress towards the Millennium
Development Goals and save lives.”
Using proper toilets and hand washing -
preferably with soap - prevents the transfer of
bacteria, viruses and parasites found in human
excreta which otherwise contaminate water
resources, soil and food. This contamination is
a major cause of diarrhoea, the second biggest
killer of children in developing countries, and
leads to other major diseases such as cholera,
schistosomiasis, and trachoma.
Improving access to sanitation is a critical step
towards reducing the impact of these diseases.
It also helps create physical environments that
enhance safety, dignity and self-esteem. Safety
issues are particularly important for women and
children, who otherwise risk sexual harassment
and assault when defecating at night and in
secluded areas.
Also, improving sanitation facilities and
promoting hygiene in schools benefits both
learning and the health of children. Child-
friendly schools that offer private and separate
toilets for boys and girls, as well as facilities for
hand washing with soap, are better equipped
to attract and retain students, especially girls.
Where such facilities are not available, girls are
often withdrawn from school when they reach
puberty.
View publication stats
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Competency based undergraduate curriculum for the Indian Medical

Graduate, the new MCI curricular document: Positives and areas of concern

Article in SBV Journal of Basic Clinical and Applied Health Science · December 2018
DOI: 10.5005/jp-journals-10082-01149

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 Medical Education

Competency based undergraduate curriculum for the Indian

Medical Graduate, the new MCI curricular document: Positives and
areas of concern
Ananthakrishnan N

Sri Balaji Vidyapeeth, Abstract

(Deemed to be University), The list of required competencies for the Indian Medical Graduate (IMG) along
Pillaiyarkuppam, with suggested teaching / learning methods and topics for integration have been
Puducherry-607402. notified by Medical Council of India. Also, the desired level of proficiency for various
competencies has been defined with emphasis on the need to certify some of them.
The corresponding Graduate Medical Education Regulations with details of curricular
time assignment for various disciplines, scheduling and details of the evaluation
process are still to be released and is expected shortly. With implementation fixed
for the academic year 2019-20, it is necessary for all faculty to be apprised of the
details of the changes being sought to be brought about. This paper will focus
on details of the new curriculum, its merits compared to the previous version and
some areas of concern which may require attention and rectification later on. One
possible strategy for preparing and implementing the curriculum by August, 2019
will be suggested.
Keywords:
Curriculum, competency based education, Indian medical graduate

For Correspondence
Introduction
*Dr. Ananthakrishnan N, In 2011-12, during the tenure of the
Email: n.ananthk@gmail.com first set of Board of Governors for
Date of the Medical Council of India, a new
Submisssion: 05-11-2018 vision document was prepared by a
Acceptance: 20-11-2018 distinguished committee of senior
teachers working for over one year. This
was labeled the Vision 2012 document
of the MCI on UG medical education.
With minor modifications it was
released as the Vision 2015 document
but still remained unimplemented.1 A
modified and detailed version of the
original document called “Competency
Based Undergraduate Curriculum for
the Indian Medical Graduate” has been
released by the MCI recently during
the tenure of the third set of governors.
It is proposed to be implemented as
Access this article online
the new curriculum with effect from
the 2019-20 batch of MBBS students.2
Quick Response Code The released document largely pertains
to the required competencies and
the appropriate teaching-learning
activities. Scheduling, subject-wise
curricular time and details of proposed
evaluation are still to be released.
Simultaneously the Attitude, Ethics
and Communication (AETCOM)
module of the MCI which is intended to
be run as a core curriculum throughout
the course with a clear definition of
what constitutes an “Indian Medical
Graduate – IMG” has also been placed
in the public domain.3
The time is, therefore, optimum to
review this document and highlight its
significant positive recommendations
and also focus on some residual
deficiencies which may need to be
corrected before implementation in the
next academic year.
Integration in the new
curriculum
A welcome part of the new curriculum
is the statement on the principles
of integration. There is a lot of
misconception in the minds of teachers
and administrators of what constitutes

https://www.jbcahs.org How to Cite: Ananthakrishnan N, Competency based undergraduate curriculum for the Indian Medical
Graduate, the new MCI curricular document: Positives and areas of concern. J Basic Clin
E-ISSN: 2581-6039 Appl Health Sci. 2018;1:34-42

34 SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate
integration. From the pedagogic point of view,
integration is a means to an end, viz. better learning.
It should, therefore, be promoted only when it leads
to a better comprehension of the subject, a greater
understanding of the relevance of the topic in the
context of future practice and enables better problem
solving. Forced integration when the above conditions
are not met is likely to lead to poor outcome as far
as results of the summative examinations go. Also,
integration beyond a certain level without altering the
evaluation pattern becomes meaningless as there is a
mismatch between the teaching learning content and
the valuation pattern.
These principles have been recognized in the
new curriculum. It is suggested that integration
should not exceed 20% of the total curriculum
at recommended levels. A method of achieving
this is case based discussions giving primacy to
achievement-based objectives. Harden’s Ladder of
Integration has been chosen as the model. 4 The steps
of the Harden ladder are shown in Figure 1 along
with an explanation of the integration process in each
step. The two pointed arrow on the left indicates
the levels of integration recommended by the MCI.
Nesting is possible for most lessons. In point of fact
Nesting consistently happens in clinical subjects
where the knowledge of basic sciences is reviewed
and revised as part of clinical teaching either in
the classroom or in the wards. To a large extent
temporal coordination is feasible, if the curricular
time for same or allied topics in the same phase of
the course are equal. There are, however, subjects
like limb anatomy in the subject of Anatomy which
has no counter part in Physiology or Biochemistry
making temporal coordination impossible in this
circumstance. Central Nervous system constitutes a
significant portion of curricular hours in Anatomy
and Physiology but has no real equivalent topic
in Biochemistry. Hence enforced integration in
the form of Temporal Coordination is likely to
adversely affect teaching of certain disciplines
which have a smaller role to play in the coordinated
portion. As per guidelines in the new curriculum,
most of the integration should focus on “Sharing
and Correlation.” Sharing involves only one or two
allied disciplines. In correlation some curricular time
can be found for topics which run across disciplines
like Tuberculosis, Lymphoma, Filariasis, Parasitic
infections etc. which can be included in the form of
multi-disciplinary modules during curricular hours
beyond 6 semester. This will save syllabus time since
repetition of the same subject in multiple disciplines
SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
would be avoided and a holistic picture of the disease
presented to students with the additional advantage
of including problem-based exercises. Up to the level
of correlation, integration can be carried out without
major alternations in the current evaluation pattern.
Higher levels of integration in the Harden’s Ladder
such as complementary teaching or Multi-disciplinary,
Inter-disciplinary and Trans-disciplinary approach
are not feasible in the Indian scenario. As per current
information, no major changes are being planned in
the new curriculum as regards the evaluation process
which will still remain discipline based. For these
levels an integrated, non-discipline based evaluation is
necessary. In a multi-disciplinary approach a number
of subject areas are brought together as a single course
with themes, problems, issues as the focus of students’
learning.4 Clinical problems and scenarios for example,
ethical issues etc can serve as an ideal trigger for multi-
disciplinary teaching. The topic chosen should have
no discipline specific boundaries. This progresses to
a higher level in inter-disciplinary integration where
discipline boundaries get gradually effaced but still exist
leading further to the highest level of Trans-disciplinary
integration where there is only a topic or a course or
a subject matter for discussion with no individual
disciplinary silos at all. Individual disciplines are not
mentioned or identified in the curriculum at the Trans-
disciplinary level. The new curriculum discourages these
higher levels of integration.
AETCOM module and its implications
An important recent development in the medical
education field is the release of the AETCOM module
by the MCI. Although not a part of the main document,
it is frequently referred to in the curricular document
released by the MCI. The AETCOM module is a
progressive step forward in recognizing the importance
of soft skills like professionalism, communication and
ethical behavior which in the previous curriculum
were under-emphasized. The AETCOM module is a
standalone document meant for faculty development.
The T/L methods desirably involve case scenarios.
A major deficiency, however, in this module is the
mismatch between the skills desired to be imparted
and the method of evaluation recommended for their
certification in students. Some of the mismatch is
highlighted below:
1. Competency – Awareness of what it means to
be a patient – Evaluation recommended -Short
Answer Questions
35
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate

Figure. 1: Harden’s Integration Ladder as applicable to the new curriculum

Trans-disciplinary
Inter-disciplinary
Multi-disciplinary
Higher levels of integration where Teaching and learning are not subject
based. Simultaneously evaluation has also to change with an integrated
evaluation and not-discipline based evaluation.

Simultaneous integrated parallel modules in addition to subject based

teaching which forms a smaller part of the curriculum. Evaluation may have
Complementary
to be dual – a larger component of integrated evaluation and a smaller
discipline based part.

Simultaneous integrated parallel modules in addition to subject based

Correlation
teaching which still continues to be a major part of the curriculum.

Two or more disciplines may jointly plan a combined Teaching / Learning

Sharing
exercise.

The curricular timetable is so drawn that common topics in different

Temporal coordination
disciplines of the same phase run parallel with each other at the same time.

Contents drawn from other subjects are embedded by a teacher in a limited

Nesting
way in their own class.

Teachers, usually in the same phase, have informal consultations with each
Harmonization
other which may influence their own class.

Teachers are aware of what is being taught in other disciplines at the same
Awareness
time, without actually making any attempt at integration.

Isolation Stand alone, isolated, silo based disciplinary teaching.

2. Bioethical issues – Recommended Evaluation Positive recommendations in the new

Short Answer Questions
3. Death and Dying, conveying bad news -
Recommended evaluation -Short notes
4. Professionalism – Recommended Evaluation -
MCQs
This is, perhaps, due to the fact that the logistics of
having to deal with large numbers of MBBS students
of up to 250 per batch, may make a “one is to one”
assessment program (which is what is required here)
difficult but not non-feasible with methods being
available for same.
curriculum
The new curriculum has several welcome and positive
recommendations. Departmental competencies
are stated in the form of Specific Instructional
Objectives for all departments in all phases. For each
competency there is a classification into knowledge,
skill, attitude or communication depending on the
competency. For definition of the acceptable level of
performance of the outgoing graduate, Miller’s pyramid
has been used.5 (Figure 2) Objectives are classified in
to those requiring only knowledge alone or ability
to understand and explain a concept, demonstrate or
perform independently. The competency list has been
drawn up by subject specialists.

36 SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate

Table 1. Department-wise objectives (competencies) with suggestions for integration

Ser. No. Department Total list of objectives Horizontal integration Vertical integration
1 Anatomy 381 41 192
2 Physiology 127 27 41
3 Biochemistry 69 15 77
4 Pharmacology 85 9 42
5 Pathology 172 21 142
6 Microbiology 54 25 39
7 Forensic Medicine 162 Nil 59 (31 with AETCOM)
8 Community Medicine 107 12 46
9 ENT 76 1 8
10 Ophthalmology 60 1 9
11 General Medicine 506 292
12 Respiratory Medicine 47 26
13 Pediatrics 416 197
14 Psychiatry 117 47
15 DVL 66 44
16 Physical Medicine 43 41
17 General Surgery 133 55
18 Obstetrics Gynecology 126 31
19 Orthopedics 39 30
20 Anesthesiology 46 31
21 Radio diagnosis 13 1
22 Radio therapy 16 7
23 Dentistry 23 8
Total number of competencies 2884 H=152, V=655, T=1617

AETCOM – Attitude, Ethics and Communication module

H – Horizontal integration, V – Vertical integration, T= Total suggestions for integration across all disciplines

Figure 2: Miller’s Pyramid For skills, DOAP (Demonstration, Observation,

Assistance and Performance) is recommended. This is
a new feature of the curriculum. For skills, the highest
level of acceptability, viz. “Does”, requires independent
DOES
ability to perform under supervision a pre-specified
number of times which will result in certification of
capacity. This again is novel. No attempt is being made
SHOWS HOW in this paper to comment on the appropriateness or the
necessity of individual competencies in the list since
KNOWS HOW this is largely a task for departmental subject experts.

The knowledge and the skills prescribed should be

KNOWS
The new manual prescribes methods of instruction
for both knowledge and skills – for knowledge the
common method advised is Lecture for larger groups
and small group discussion for smaller groups.
matched against the definition of the Indian Medical
Graduate (IMG) in the curriculum.2 The major required
competencies of the IMG are as follows:
1. Clinician, who understands and provides
preventive, promotive, curative, palliative and
holistic care with compassion

SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018 37
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate

Table 2. Procedures requiring certification

No. to be
Ser. No. Department Description of skills
certified
i. Microscopy of Epithelium 2
1 Anatomy
ii. Diagram of respiratory tree 2
i. Blood pressure measurement 3
ii. Pulse assessment 3
iii. RS examination 1
2 Physiology iv. CNS Examination 1 (Each part
v. Visual acuity, color vision, field mapping, taste and smell of CNS) –
assessment Total 5
1 (each task)
– Total 4
i. Detection of normal and abnormal constituents of urine 1
ii. Estimation of serum creatinine / calculation of creatinine 1
clearance
3 Biochemistry iii. Estimation of serum proteins, Albumin, Globulin, Albumin / 1
Globulin ratio
1 each –
iv. Estimation of glucose, urea in serum Total 5
1+1 = 2
i. Prescription writing 5
4 Pharmacology ii. Audit of prescriptions 3
iii. Critical evaluation of drug promotion literature 3
5 Pathology i. CSF examination 1
i. Gram’s stain 11
6 Microbiology ii. Hand hygiene 3
iii. Personal protection 3
7 Forensic Medicine Nil

8 Community Medicine Nil

i. Order, perform, interpret ECG 6
9 General Medicine ii. Capillary blood glucose 2
iii. Urine ketone bodies by dipstick 2
i. AFB stain 1
10 Respiratory Medicine ii. PFT, doing and interpreting 3
iii. Use of inhalers – counseling 3
i. Anthropometry 3
ii. Development assessment 3
iii. Breast feeding, observation and counseling 3
iv. BMI calculation 3
v. Prescription of Immunizations schedule 5
vi. Naso-gastric tube passage in manikin 2
vii. IV line in manikin 2
viii. Interosseous insertion in manikin 2
ix. Airway management 3
x. Oxygen administration 3
11 Pediatrics xi. Bag ventilation 3
xii. Monitoring of shock 3
xiii. IV access 3
xiv. Calculation of fluid requirements 3
xv. Monitoring of unconscious 3
xvi. Dehydration assessment 3
xvii. BLS in manikin 3
xviii. Urine dipstick 3
xix. Identification of BCG scar 3
xx. Interpret Mantoux test 3
xxi. AFB staining

38 SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate

No. to be
Ser. No. Department Description of skills
certified
12 Psychiatry Nil

13 DVL Nil

14 Physical Medicine Nil

15 General Surgery Nil

5
i. Testing for extra ocular movements
16 Ophthalmology 1
ii. Visual acuity, color chart, field mapping
3
17 ENT i. Interpretation of skiagrams of PNS, chest etc. 3
18 Ob. Gynecology i. Conduction of normal labor 10
19 Orthopedics Nil -
20 Radio diagnosis Nil -
21 Radiotherapy Nil
Total
number of
procedures 48 153
requiring
certification

2. Leader and member of the health care team and
system
3. Communicator with patients, families, colleagues
and community
4. Lifelong learner committed to continuous
improvement of skills and knowledge
training and skills are assessed in terms of Miller’s
pyramid which is easier to observe and certify. This
choice, however, may be open to criticism by educational
experts who may consider grading of skill levels as being
equally important for the undergraduate who is being
licensed to independently practice medicine as it is for
postgraduates. This difference in pedagogic perspective
may only be a matter of semantics.

5. Professional who is committed to excellence, is
ethical, responsive and accountable to patients,
community and the profession.
The 35 sub-competencies defined for these five
competencies makes the attributes of the IMG clear
and unambiguous.
For postgraduate education, in which mastery
of skills is the primary aim, it is better to state
competencies in the form of Entrustable Professional
Activities. and assess acceptable levels of performance
as per the guidelines of Dreyfus.6,7 However, for an
undergraduate course like the MBBS, acquisition of
baseline knowledge and comprehension is as important
as acquisition of skills. The skill list has necessarily to be
less complex. Hence competencies are stated in the form
of specific instructional objectives which would be clear
to all teachers irrespective of background pedagogic
A major feature of the new curriculum is its clear
definition of levels of integration which are optimal,
the departments which will contribute to acquiring of
a certain competency and the scope of horizontal and
vertical integration. Table 1 shows the departmental
list of competencies as regards total number and the
suggestions for horizontal and vertical integration
pertinent to that department’s objectives. A total
of 2884 competencies have been prescribed for
the MBBS course, out of which a total of 1617 has
been mentioned as possibilities for either vertical or
horizontal integration or both.
In the clinical phases beyond the third semester, all
the subject courses run more or simultaneously and the
students have finished their exposure to the preclinical
sciences and are undergoing the teaching / learning
programs in the paraclinical sciences. Hence the terms
vertical or horizontal no more remains relevant and

SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018 39
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate
accordingly there has been no attempt to separate
integration in to horizontal or vertical in this paper as
has been done in the new curricular manual.
The paucity of suggestions for integration in respect
of some departments such as ENT, Ophthalmology etc.
is an acceptance of the fact that forced integration for
the sake of integration is likely to be counterproductive
in many instances. Also, the fewer suggestions for
horizontal integration in subjects such as Anatomy,
Physiology, Biochemistry, Forensic Medicine etc. is a
recognition of the fact that these subjects are standalone
subjects at present where the scope of horizontal
integration or even temporal coordination, is extremely
difficult without compromising the teaching of the
subject and the preparation of the students to appear
in the summative evaluation which again is standalone.
Misguided efforts should, therefore, be avoided in
pushing for greater integration in all circumstances.
The curricular requirement of skills for each
department which need to be certified is shown in
Table 2. A total of 48 procedures (skills) are required
to be certified although the manner of certification
whether in formative or in summative evaluation is
not made clear. On the face of it, the logic of this
list remains obscure. For instance, the only two skills
mentioned in Anatomy or microscopy of the epithelium
and diagram of the respiratory tract. These would
probably not be the most important requirement of the
outgoing graduate after qualification. The Physiology
list looks appropriate but the Biochemistry list is full
of procedures which may not be required of an MBBS
graduate like estimation of serum creatinine etc. It
is surprising that Forensic Medicine, Community
Medicine, General Surgery, Orthopedics etc. have no
skills required to be certified. One would have thought
that skills such as bandaging, suture of simple skin
lacerations, splinting and immobilization of fractures,
issue of medico-legal certificates etc. would have been
considered mandatory. On the whole the skill list is
skewed with no rationale for many of the listed skills
and others which would be considered mandatory for
the MBBS candidate missing. The whole list requires
to be relooked before implementation. Many of the
skills can be practiced on mannikins and certified
on manikins. Skills labs are mandatory as per MCI
requirement in medical colleges and would facilitate
this process.. Also, as per the manual, a number of
repetitions are required from the candidate before
the ability to perform independently can be certified.
However, the list of skills mentions only one each for
many of the skills such as CSF examination, testing
40 SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
for ocular movements, AFB stain etc. which may be
considered inadequate to ensure proficiency.
Some areas of concern for future
revision
Many of the concerns have been mentioned earlier in
this paper. This section is only to emphasize the earlier
statements. The mismatch between the intended
competency and recommended method of assessment
for ensuring attainment of desired level in the AETCOM
module has already been mentioned. This needs attention
to ensure that the intention of the MCI as regards soft skills
is realized. It is also a matter of concern that there is neither
a mention of summative evaluation pattern with the new
curriculum nor the weightage for formative assessment
with its implementation. Summative evaluation cannot
remain an area of “no-touch” with no changes being
permitted or contemplated in view of departmental
objections. As and when more and more integration is
required to be practiced, there is a simultaneous need
for changes in the summative evaluation to fall in line
with needs for integrated evaluation to form part of the
process. It cannot remain forever subject based.
If competencies are the goal and necessary levels are
mandatory before qualification, it becomes obvious that
many of these cannot be certified only in the summative
process due to logistic reasons. Hence weightage for
formative evaluation has to considerably increase to
perhaps 50% to meet these requirements. Besides, many
of these competencies require workplace based assessment.
This has to be formalized in the recommendations on
formative evaluation as and when it is released. Also,
in view of increasing numbers of students with large
numbers of admissions of up to 250 per batch, along
with the difficulty of getting external examiners for a
prolonged final examination, the summative process
should drastically change from the current format to one
which permits greater use of measures such as OSPEs /
OSCEs, more objective written methods of evaluation
and a skill based final examination.
The competencies list on the face of it looks slightly
irrational as the number of competencies per subject
and the curricular time available for that subject are not
matching. For example, Medicine and Surgery have more
or less the same number of curricular weeks; however,
506 mandatory competencies are listed for medicine
and only 133 for surgery. Likewise, 416 competencies
are listed for Pediatrics and only 39 for Orthopedics
which have the same curricular time. There are many
other such examples. Gross mismatch between number
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate
of competencies to be attained and available curricular
time would apply pressure on some departments to fulfill
the requirement of training in these competencies. It
appears, therefore, that the subject committees did not sit
together to plan the list and competencies submitted by
individual subject specialists have been merely compiled.
One possible measure is to realize that many of the
subjects in the current curriculum have disproportionate
amount of curricular time largely as a matter of tradition.
For example, General Surgery is not truly a major
undergraduate discipline deserving of equal time with
General Medicine. The requirements of outgoing MBBS
graduate to practice what they have learnt in the huge
General Surgery curriculum are minimal. Realization
of the fact should logically lead to reduction of time
for General Surgery and allotting the curricular time
thus freed to those subjects which are more important
for an MBBS graduate to practice, such as General
Medicine, Pediatrics, Psychiatry, Dermatology etc. Or,
as an alternate measure, fresh courses can be introduced
on subjects such as Rational diagnosis and Therapy or
Palliative Medicine or the Care of the aged which may
be more relevant in the newly released curricular time.
This, however, calls for a transformational change, which
is likely to be forcefully opposed.
The skill list has to be rationalized based on the
job requirement of the IMG after graduation instead
of being left to individual subject experts. Also, those
finalizing the skills required to be certified should
have a relook to consider issues mentioned earlier
regarding some departments not having any skills to
be certified although they occupy a significant part of
the curricular time. The whole process should again
be based on the work expectation of the IMG. The
approved list of certifiable skills should be based on
recommendations of a multi-disciplinary committee
and not on individual subject committees.
Suggested strategy for implementation
The primary aim of the preparatory strategy should
be Faculty Development Programs so that all faculty
participate in this new endeavor as willing collaborators
and not as reluctant dragons. The first step is to apprise
all the faculty and not just the heads of departments
and the curricular committee members of the new
curriculum, the changes in it with reference to the
1997 document, the changes visualized in the teaching
/ learning programs, suggestions regarding integration
and what it implies and the skill list with mandatory
certification.
SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
Integration is a sensitive issue and needs to be
covered in workshop mode explaining the Harden’s
ladder and its steps and why one should not go above a
certain level of integration with the current subject or
discipline based evaluation. It should be emphasized
that the aim of integration is to facilitate learning
and explain relevance of a topic to future practice
and not a forced bringing together of departments.
Soft copies of the MCI document should be sent to
all faculty so that they may come prepared for the
workshop.
The next step is special faculty development
programs for the teachers of the first phase, who
have to implement the new curriculum with effect
from August, 2019. In this activity, the focus should
be on clarifying doubts and reviewing the existing
curriculum and the new document to identify where
the differences lie. The task in this workshop is to
prepare a new curricular plan for phase I by March,
2019. The focus should be on
a. Review of the competency list for the three pre-
clinical subjects by all faculty (not only HoD or the
curriculum coordinators.
b. Listing of the competencies and sub-competencies
list by grouping in to Teaching / Learning Units (i.e.
topics which can be grouped together for a single or
a few continuous classes).
c. These teaching / learning units pertaining to “Know
and Know how” as per the curriculum can be divided
in to those requiring large group teaching and those
requiring small group activities. Department faculty
has to make a decision on this jointly.
d. Identifying topics where more than one department
can useful participate as a sharing exercise as per
Harden’s ladder.
e. Those that require skill training (Show how /
independent performance to be classified in to
those which require practical / clinical / skill lab /
standardized patient exposure.
f. Discuss and establish a method of internally certifying
those skills which are require to be certified in the
MCI document.
g. Skill training time table can be embedded in the
schedule as and when the schedule is prepared.
41
 Ananthakrishnan: Competency based undergraduate curriculum for the Indian Medical Graduate
Training of all faculty, not only Heads of
Departments, in the AETCOM module which will
run as a core through the curriculum is the next
mandatory step. The responsibility for this will
lie on MEUs which should organize workshops for
groups of faculty (not more than 30 at a time). The
workshop can run for two days each and will intend
to train all faculty by end of February, 2019. Time
tabling and scheduling can wait till MCI notifies the
new Graduate Medical Regulations. All preparatory
work for phase 1 is to be completed before end of
March, 2019 and jointly approved by both colleges.
Initiation of work for phases 2 and 3 ( para-clinical
and final year part I), can begin simultaneously
after training of those concerned faculty, so that the
documents with respect to those phases are ready by
end of 2019. The finalization of the curriculum for
the Final year (Phase IV) can be undertaken in the
next Academic year.
As per the MCI document, integrations should not
exceed 20% and should not go beyond “correlation”
as per Harden’s ladder. It is suggested that integration
in first year is restricted to temporal coordination to the
extent possible (without disturbing the subject schedules
and depending on the length of the teaching / learning
activity required for each of those units). Sharing can
be encouraged between subject like Pathology and
Microbiology in phase II where ever appropriate. Every
pre-clinical class should have “nested’ the corresponding
clinical relevance of the topic. The nested part can be
covered either by the teachers of the subject or where
required by clinical faculty. After semester 5, one can
progress to the level of ‘correlation’. Modules can be
arranged in the afternoon of working days or Saturday
morning which are based on common topics running
across departments such as Tuberculosis, Lymphoma etc.
This modular list must be prepared by all curriculum
committees sitting together based on overall requirement
and relevance. In semesters 6,7 the modules can run
once a week and in semesters 8 and 9 twice a week.
Students should be made to actively participate in these
modules by encouraging problems solving exercises. The
42 SBV Journal of Basic, Clinical and Applied Health Science - Volume 1 | Issue 1 | October - December 2018
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strategies, of course, will vary slightly from institute to
institute depending on facilities.
Conclusion
The new curriculum has several advantages and is a
glaring improvement on the previous version of 1997. It
defines an IMG, mentions departmental competencies
and sub-competencies, methods of appropriate teaching
and evaluation for these and provides a list of skills with
level of proficiency required. It also suggests areas of
fruitful integration and the method of integration as
per Harden’s ladder.
However, there are notable deficiencies in the
departmental list of competencies which require
relook and revision. The certification process of skills
also requires clarification. There is no mention of any
forthcoming change in the evaluation system to meet
the requirements of the new curriculum. All these
need to be addressed before the next academic year and
before release of the new Graduate Medical Regulations
booklet.
References
1. Reforms in undergraduate and postgraduate medical education,
Vision 2015. Medical Council of India,2011. Available at www.
tnmgrmu.ac.in/images/medical-council-of-india/MCI_book.pdf,
(accessed on 22 October 2018)
2. Competency based undergraduate curriculum for the Indian Medical
Graduate. Medical Council of India, 2018. Medical Council of India,
Available at www.mciindia.org/CMS/information-desk/for-colleges/
ug-curriculum, (accessed on 22 October 2018)
3. Medical Council of India, Attitude and Communication
Competencies for the Indian Medical Graduate, Prepared for the
Academic Committee of Medical Council of India by Reconciliation
Board, Medical Council of India, New Delhi, 2015.
4. Harden RM, The integration ladder – a tool for curriculum planning
and evaluation. Med Edu. 2000; 34: 551-7.
5. Miller’s pyramid of assessment, Available at https://tomec.lmunet.
edu/files/ assessment_and_feedback_for_residents_and_students.
pdf, (accessed on 22 October 2018)
6. Cate OT, Nuts and bolts of entrustable professional activities, J Grad
Med Educ 2013; 5: 157-8.
7. Dreyfus SE, The five-stage model of skill acquisition, Bulletin Sci
Tech Soc, 2004; 24: 177-81. Available at http://bst.sagepub.com/
content/24/3/177 (accessed on 22 October 2018)
Mentoring
Seven Roles and Some Specifics
Martin J. Tobin
Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine and Hines Veterans Affairs Hospital,
Hines, Illinois
In Homer’s legend, when Ulysses, the king of Ithaca, went away
to make war on the Trojans, he left his infant son, Telemachus,
in the hands of Mentor (1). Ulysses was gone for twenty years,
and Mentor guided Telemachus in practical skills, such as archery
and wrestling, and also provided advice on moral matters. Giving
advice, however, is naive and presumptuous (2). Naive, because
experience cannot be transmitted; instead, each generation has
to acquire it for itself. Presumptuous, because no one has a
monopoly on wisdom; and those imagining themselves well en-
dowed are the least wise (3).
Books containing advice for young professionals come in two
forms: compendia of tedious pieties, and amoral manuals of
dodges and shady practices for getting on in the world (4). An
attempt to provide a noncynical description of the good mentor
inevitably falls into the former category and exposes an author
to accusations of moralizing oversimplification. Yet fear of being
labeled a self-righteous moralizer is insufficient defense for shy-
ing away from the challenge.
A mentor can be defined as an older academician who takes
a special interest in a younger person—a fellow or a junior
member of faculty (1). The older person is called the mentor,
but there is no good term for the younger person (5). The lack
of a self-evident term to describe the object of the mentor’s
interest bespeaks of much confusion on the subject. I focus solely
on the mentoring of a fellow who wants to become a physician-
researcher. I make liberal use of quotations, not simply for calling
on authority to buttress my case but for the illumination they
provide.
SEVEN ROLES
The physician-researcher as mentor has at least seven roles to
fill: teacher, sponsor, advisor, agent, role model, coach, and con-
fidante (1, 6, 7). The mentor needs to customize each role to
match the characteristics of the fellow. The following description
is an ideal after which mentors strive. It is also an ideal that
perhaps no mentor can fully attain.
Teacher
The mentor and laboratory assistants teach the fellow the techni-
cal skills unique to their field of research. The mentor guides
the fellow in how to read in an efficient manner and how to
reason from first principles. The fellow learns to write scientific
manuscripts by getting back drafts covered in red ink. The men-
Supported by a Merit Review grant from the Veterans Affairs Research Service
Correspondence and requests for reprints should be addressed to Martin J. Tobin,
M.D., Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs
Hospital, Route 111N Hines, IL 60141. E-mail: mtobin2@lumc.edu
This article has an online supplement, which is accessible from this issue’s table
of contents online at www.atsjournals.org.
Am J Respir Crit Care Med Vol 170. pp 114–117, 2004
DOI: 10.1164/rccm.2405004
Internet address: www.atsjournals.org
tor teaches the fellow how to apply for grants, and how to review
manuscripts (8). The mentor knows that education is not just
the imparting of facts—after all, these can be obtained in a book
(9). Instead, the ultimate goal of education is the formation of
character (the aggregate of qualities that constitute the moral
backbone of an individual) (10, 11). Henry Adams encapsulated
the legacy of teaching: “A teacher affects eternity; he can never
tell where his influence stops.”
Sponsor
As sponsor, the mentor introduces the fellow to a new social
world (6). Up to now, the fellow’s world has been parochial. To
succeed in research, the fellow needs to learn who’s who among
the cast of characters in a subdiscipline. When the fellow first
presents a research poster, the mentor lists researchers who have
a reputation for helping young people. When these individuals
come by the poster, the mentor tells the fellow to be very open
in discussing limitations of the study because they will help fix
them. The mentor also names another set of individuals who
get pleasure out of belittling a fellow, warning the fellow to be
on guard when interacting with them. Over time, the mentor
instills in the fellow the values and customs that make up the
norms of science.
Advisor
The mentor serves as advisor and counselor (1, 7). The fellow
needs a sounding board and reality check to help refine ideas
and gain clarity of thought. Being older, the mentor supplies the
missing experience—been there, done that. The fellow doesn’t
need someone to pave the road, but needs help in becoming a
better navigator. The mentor doesn’t try to personally solve the
fellow’s problems, but helps the fellow craft his or her own
solution—to become self-reliant. The mentor is not a nursemaid
or escort, but a catalyst for growth (5). A good mentor is an
amateur psychoanalyst, understanding what makes people tick.
The mentor’s greatest contribution may be in listening, saying
little. As Rousseau told us, people who know a lot tend to say
very little, whereas people who know little speak a lot. A good
mentor understands that it is best to give advice only when it is
requested (12).
Mentoring should not be confused with being a faculty advisor
(7, 13). With the latter, the exchange is relatively formal, largely
unidirectional, with little if any personal bonding. The exchange
may occur only once, whereas mentoring involves years of re-
peated back and forth, eyeball to eyeball. A student may not
view the faculty advisor as a role model, whereas a mentor is
always seen as a role model.
Agent
The mentor acts as an agent (7). The fellow knows the mentor
will go to bat for him or her. The mentor removes obstacles,
but only after the fellow has made a convincing attempt. And
the mentor is careful to avoid spoonfeeeding, which stunts the
development of independence.
Occasional Essays
Role Model
The fellow views the mentor as a role model and wants to
emulate his or her approach to academic life (14). Young people
do not assimilate values by listing attributes they wish to develop
(truth, caring, judgment) and looking up their definitions (15).
Instead, they identify with people who appear to have these
attributes, and emulate their behavior. Fellows do not learn
values from having them preached at them, but from seeing
values enacted in the routine of daily life. Values are best trans-
mitted through deeds, not words—a how, not a what. And that
is why role models are so important in medicine.
The fellow observes the mentor’s professional priorities. The
time devoted to helping colleagues, such as volunteer work in
reviewing manuscripts that goes uncredited by promotion com-
mittees (16). The mentor’s intellectual and scholarship style: it
must be unmistakable that he or she enjoys learning. The ap-
proach to thoroughness and truth telling. The mentor’s ability
to make work appear more fun than fun, and make drudgery
appear worthwhile. Success in research can lead to arrogance,
although Claude Bernard believed true scientific prowess leads
to a proportional decrease in pride (17). The fellow sees how
the mentor interacts with peers: the exercise of restraint, and
the instinct for maneuvering between behavior that might be
uncomfortably allowed and behavior that is impermissible. The
fellow sees the moral element in the mentor’s identity: how
the mentor defines what lines will not be crossed, and why (18).
The bulk of the fellow-mentor interaction is in the research
setting, but the mentor’s behavior as a clinician—irrespective of
whether his or her research is basic or patient oriented—will
determine how well the mentor transmits the values of academic
medicine. It must be crystal clear that the patient is always first
priority. The core values articulated by the mentor must be
evident in actions: he or she must walk the talk. When a mentor
fails to practice what is being preached, the hypocrisy mutes the
effectiveness of the advice (19).
Role models and mentors are often confused (5). Most people
who serve as role models do not act as mentors. Michael Jordan
is a role model for thousands. If he is to become a mentor, it
will only be for a handful of people. Likewise, William Osler
was a role model for thousands of physicians, but mentored only
a few. Many role models are like bright shining stars: as you get
closer, they seem too hot to touch (5). Most physician trainees
never have a true mentor—there are not enough to go around
(5, 6, 13). They have role models and faculty advisors. Having
a real mentor will always be a privilege of only a few.
Coach
A good coach motivates the players to win. Knowing when to
offer encouragement. When to push. And when to pause and
take a break. A mentor has to push for action while tolerating
inaction—a cause of considerable tension in the mentor (12). A
basketball coach is judged by the success of the players, not by
his or her own skill at shooting baskets. Likewise, a mentor
recognizes that it is far easier to give a lecture than to guide a
fellow in how to do it.
Motivating is the fulcrum around which coaching revolves.
The mentor conveys the sense of awe about the workings of the
body: the excitement in helping to unravel its complexity. He
or she imbues the fellow with the power of science, the best
hope for achieving progress (20). Science doesn’t prevent any of
us from making mistakes. But through the criticism of colleagues,
errors are gradually corrected and we approach truth. The men-
tor communicates the thrill of discovery—no drug is more ad-
dictive (21). The mentor relates to the fellow the comfort derived
115
from knowing that the research of today is connected to a much
greater process: contributing to the increase in scientific knowl-
edge and improved care of patients—work of everlasting value.
This thought helps one realize how trivial are the slings and
arrows of everyday life. But comfort of mind must not spill
over into complacency. Jacques Monod, one of the founders
of molecular biology, warned, “Personal self-satisfaction is the
death of the scientist. Collective self-satisfaction is the death of
research. It is restlessness, anxiety, dissatisfaction, agony of mind
that nourish science” (22). Proper balancing of anxiety and com-
fort of mind achieves equanimity.
The most creative individuals are driven by curiosity, getting
their reward directly from their work (causing colleagues to
think them odd) (18). The best people in an organization want
to work for reasons beyond salary or title, as if volunteers (23).
The mentor relates the sense of fulfillment from working in
public service (adding that thanks is rarely vocalized, and is
communicated least when the responsibility is greatest). Ad-
dressing young people, Albert Schweitzer said, “I don’t know
what your destiny will be, but one thing I know: the only ones
among you who will be really happy are those who will have
sought and found how to serve.” There is no smaller package
than an individual wrapped up in him or herself.
The mentor raises the bar and sets high standards. The fellow
is encouraged to achieve full potential: to reach for, and achieve,
more than he or she thought possible (24). People are not moti-
vated by small challenges. “Make no little plans. They have no
magic to stir men’s blood,” mused Daniel Burnham, the Chicago
architect. The mentor helps the fellow to take risks, to move
outside a zone of comfort. Expectations are lofty, yet realistic
(7). The idea is to distend, but not perforate.
Confidante
The mentor serves as a confidante: someone the fellow can
talk to, knowing the discussions are kept in strict confidence.
Mentoring is more an affair of the heart than of the head (7, 25).
It is a two-way relationship based on trust—the glue that prevents
the units of daily living from falling asunder. The mentor wins
and sustains the fellow’s trust through constancy (staying the
course), reliability (being there when it counts), integrity (hon-
oring commitments and promises), and congruity (walking the
talk) (26).
For the fellow’s development, the mentor’s most critical func-
tion is to help the fellow live out a dream (1, 6). A young person’s
dream is a personal myth, an imagined drama in which he or
she is the central character—a role widely portrayed in literature.
The mentor helps the fellow realize this dream through affirma-
tion and by helping the fellow emerge in a new world. Mentoring
involves an elemental form of the parental impulse, yet is quite
different (6). Unlike a parent, the mentor must also be part peer.
Excessive paternalism in a mentor will interfere with the primary
function as a transitional figure. The mentor’s task is to liberate
the fellow, and not be overly protective. An actual parent can
provide some of the functions of a mentor. But he or she cannot
be the primary mentor figure because a parent is too closely
connected to the offspring’s pre-adult development (in both their
minds) (6).
Objectivity must be maintained: the relationship must not be
seen as favoritism. The mentor not only conveys compliments,
but also points out weaknesses (6, 7). When criticizing, the men-
tor focuses on behavior, not the person. Specificity is especially
important: not much can be learned from vague criticism (or
vague praise) (25). A hundred-year-old letter from William
Osler, mentor to Harvey Cushing, can be seen in the online
supplement (1). Osler points out that specific aspects of Cush-
116 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 170 2004
ing’s behavior will be fatal to his success. Osler specifies why
this behavior is a problem, and ends by saying he knows that
Cushing will not mind the criticism because he understands that
Osler has his interest at heart. There is no fellow that does not
need to have aspects of behavior criticized. But the task requires
considerable tact: inept criticism surpasses mistrust, personality
struggles, pay disputes, and power struggles as a source of conflict
on the job (25). By holding up a mirror, the mentor enables the
fellow to see how his or her character is developing (5).
The fellow has feelings of respect, admiration, and apprecia-
tion for the mentor, but also feelings of inferiority, intimidation,
envy, and resentment (6). The fellow oscillates between beliefs
of being an inept novice, fraudulent imposter, and a rising star
that will outshine the mentor. Starting out in a subservient posi-
tion, the fellow matures to become an equal over time and
the relationship evolves into a meaningful friendship. But the
relationship can also dissolve into bitterness (6). This may occur
because the mentor is bad. Or because of arrogant ingratitude
on the part of the fellow. Tacitus grumbled that man is more
willing to repay an injury than repay a benefit, because gratitude
is a burden whereas revenge is a pleasure.
AND SOME SPECIFICS
Handling Failure
Because it is disheartening, we think of failure as all negative.
But it’s not (15, 27). Failure tells the size of the challenge taken
on. A research project that appears a totally safe investment has
a much smaller chance of making a substantial advance than a
project carrying a distinct chance of failure. Fear of failure is
the death of progress. A fellow can learn more from failure than
from success, because one has to ask oneself why one failed.
With success, a fellow may get rewarded for the wrong reasons,
which encourages bad habits. Major achievers are rarely satisfied
by success, and are instead spurred on—rather than de-
terred—by setbacks (11). “I regard every defeat as an opportu-
nity,” affirmed Jean Monnet, founding father of the European
Community (19). But failure is bruising, and the fellow has to
learn not to show it. When the fellow encounters failure, the
mentor is there to provide reassurance and to caution that dwell-
ing too much on the past can rob one of the future.
Steps to Success
Along the way, the mentor shows the fellow what is needed for
success. Success is not achieved by short cuts and gimmickry,
but by hard work and persistence (5). “Nothing in the world
can take the place of persistence. Talent will not; nothing is
more common than unsuccessful men with talent. Genius will
not; unrewarded genius is almost a proverb. Education will not;
the world is full of educated derelicts. Persistence, determination
alone are omnipotent,” counseled Calvin Coolidge (28). Persis-
tence is the hard work you do after you get tired of doing the
hard work you have already done (14). The fellow needs to
think of a task as beyond the whole. When running a 100-yard
dash, serious runners aim for 110 yards, so no one will beat them
in the last few yards. If they run fast for only 95 yards, the lack
of those final 5 yards makes the first 95 pointless (23).
The second requirement is focus, the principle most often
violated. Focus needs mental discipline, which is unpopular.
Without focus, the fellow ends up with numerous unfinished
projects.
Time management is third. Time is the most scarce resource
in academic life. Yet it’s treated as having no value. Time is
inelastic. “Work expands so as to fill the time available for
its completion,” says Parkinson’s Law (17). Academicians who
complain the most about being extremely busy are often the
lowest achievers. The mentor teaches the fellow to document
for him or herself where the time goes, to spot time wasters
and be ruthless in eliminating them. And the fellow learns that
wasting time that leads to innovation is good, and dumping bad
work is efficient.
The fourth requirement for success is learning how to handle
the natural desire for credit (29). Originality, and its corollary
priority, are major driving forces in science—aggravated by the
tendency for discoveries to be made simultaneously in more
than one laboratory. Attaining priority requires ambition, a word
with many meanings and wide variation in moral implications
(30). Ambition is healthy when it connotes persistence, resolu-
tion, and discipline. But vaulting ambition that includes corner
cutting and self-promotion is a disfigurement. The best way to
get research done, and succeed in academia, is not to mind who
gets credit for it (29). Lots of praise early in a career—even when
deserved—can make it more difficult to cope with subsequent
setbacks (29). This thought is communicated in the saying, “I
have been told of so many coming men. But where do they all
go”? And in, “Whom the gods wish to destroy they first call
promising.”
Picking a Mentor
When scouting for a mentor, what should the fellow look for?
Fellows in their late twenties should seek mentors in their late
thirties or forties—a half-generation older (6). Forty-year-old
faculty members have usually shed some of their earlier envies,
animosities, and petty vanities, enabling them to be more under-
standing mentors. Enthusiasm is the most important quality: the
mentor believes his or her research area is the most exciting in
the world. Time: the good mentor makes time to see the fellow,
even though he or she may be the busiest person on campus.
Leadership always comes down to a question of character: an
inner set of values directing a person to what is virtuous or right
(18, 31). The world loves talent but pays off on character (27).
Next come commitment, common sense, competence, responsi-
bility, and conscience (the inner voice that says somebody may
be looking). Because the fellow will need advice about future
career, he or she needs a mentor who has good judgment. The
good and bad are never neatly separated and most of life is
spent making discriminate judgments at the margins (30). In
truth, the challenge is more complicated: the choice is rarely
between straight bad and good, but in picking the best trade-
off among several good options (32). Judgment is the ability to
combine hard data, questionable data, and intuitive guesses to
arrive at a conclusion that events prove to be correct (33). And
lastly the fellow looks for maturity, self-confidence, vision, and
a mentor with awareness of what’s happening in the academic
world outside his or her own institution.
A bad mentor sounds like a contradiction in terms, but some
fellows get stuck with a faculty supervisor who lacks mentoring
skills (6). The bad mentor is selfish with time. (Time given by
a good mentor is immeasurable—and the part least recognized
by people who are not mentors.) A bad mentor wants all the
glory—it’s not enough to see the fellow shine—and may even
envy the attention the fellow attracts. Instead of nurturing aca-
demic development, the mentor exploits the fellow as a techni-
cian. A mentor may also act like Professor Higgins in My Fair
Lady and try to make the fellow into an image of his or her
own choosing, rather than fostering individuality and indepen-
dence. An overprotective mentor, though meaning well, is also
bad for the fellow’s development.
Mentoring at a Distance
When fellows find no faculty member to serve as a mentor, they
must take responsibility for aspects of their own education. Some
Occasional Essays
giants in history—Shakespeare and Beethoven—had no per-
sonal mentors (34). Einstein received his mentoring at a distance
through reading Mach, Poincairé, and Maxwell (34). Churchill
never attended university, and educated himself by studying the
works of Gibbon, Macaulay, and others (35); the permanent
effect of the former two is evident in Churchill’s oratory and
writing. The total aggregate of Lincoln’s schooling amounted to
less than a year (30). But he was a bookworm, and over time
Lincoln’s intellectual self-confidence surpassed that of graduates
of the best universities. Books enable a person in isolated circum-
stances to communicate across years and oceans with the greatest
of minds (30). Many leaders have found their principal mentors
and models entirely in books (26). For example, Nelson Mandela
was hugely inspired by General Kutuzov in Tolstoy’s War and
Peace (36). Researchers of any age can benefit from the insights
and maxims contained in the books of Peter Medawar, Michael
Polanyi, Richard Feynman, and John Ziman.
Not Pure Altruism
Mentoring is a two-way street, with mentors needing fellows as
much as the latter need a mentor (6). As with all teaching, mentors
learn more from pupils than they teach them. A researcher gets
more done by involving bright young people on projects than
working as a lone wolf. The mentor benefits from the reflected
glory of the fellow who does well. But the major benefit is the
fun of interacting with young people. The interchange liberates
forces of youthful energy within the mentor, and he or she gets
rejuvenated (6). Osler warned that the physician “who wraps
himself in the cloak of his researches, and lives apart from the
bright spirits of the coming generation, is very apt to find his
garment the shirt of Nessus”—and he will also miss out on “the
greatest zest in life” (37). By communicating the most important
values of medicine, the mentor satisfies the Hippocratic obliga-
tion of passing knowledge to the next generation and at the
same time satisfying the desire to pay back (1). “I hold every
man a debtor to his profession,” intoned Francis Bacon.
CONCLUSION
In guiding Telemachus, Mentor was assisted by Athena, the
Greek goddess who embodied good counsel, prudent restraint,
and practical insight (1). Mentors in academic medicine are mere
mortals, and do not get help from Greek goddesses. The virtues
I list for the ideal mentor are intimidating. A wise reader may
wonder whether through writing this essay, I am succumbing to
the counsel of my fellow Irishman, Oscar Wilde: “I always pass
on good advice. It is the only thing to do with it. It is never of
any use to oneself.”
Conflict of Interest Statement : M.J.T. is editor of AJRCCM. He receives a fixed
stipend from the American Thoracic Society. He does not receive financial support
for research from pharmaceutical, biotechnology, or medical device companies.
He does not serve as a consultant to or on the advisory board of any company.
He receives royalties for two books on critical care published by McGraw Hill, Inc.
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Twelve tips for developing effective mentors

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 Medical Teacher, Vol. 28, No. 5, 2006, pp. 404–408
TWELVE TIPS
Twelve tips for developing effective mentors
SUBHA RAMANI1, LARRY GRUPPEN2 & ELIZABETH KRAJIC KACHUR3
1
Boston University School of Medicine, USA; 2University of Michigan Medical School, USA;
3
New York, USA
ABSTRACT Mentoring is often identified as a crucial step in
achieving career success. However, not all medical trainees or
educators recognize the value of a mentoring relationship. Since
Med Teach Downloaded from informahealthcare.com by Michigan State University on 11/05/10
medical educators rarely receive training on the mentoring process,
they are often ill equipped to face challenges when taking on
major mentoring responsibilities. This article is based on half-day
workshops presented at the 11th Ottawa International Conference
on Medical Education in Barcelona on 5 July 2004 and the
annual meeting of the Association of American Medical Colleges
in Boston on 10 November 2004 as well as a review of literature.
Thirteen medical faculty participated in the former and 30 in
the latter. Most participants held leadership positions at their
institutions and mentored trainees as well as supervised
For personal use only.
mentoring programs. The workshops reviewed skills of mentoring
and strategies for designing effective mentoring programs.
Participants engaged in brainstorming and interactive discussions
to: (a) review different types of mentoring programs; (b) discuss
measures of success and failure of mentoring relationships and
programs; and (c) examine the influence of gender and cultural
differences on mentoring. Participants were also asked to develop
an implementation plan for a mentoring program for medical
students and faculty. They had to identify student and faculty
mentoring needs, and describe methods to recruit mentors as
well as institutional reward systems to encourage and support
mentoring.
Introduction
Many professionals identify a mentoring relationship as an
essential step for achieving success in politics, business and
academia (Roche, 1979). Indeed, most successful people in
different areas of human endeavor can point to a mentor
who was crucial to their career growth and success. The
importance of mentoring throughout one’s career has been
emphasized, especially during professional transitions (Bligh,
1999; Freeman, 2000; Grainger, 2002; Levy et al., 2004).
Studies have shown that faculty members who identified
a mentor felt more confident, were more likely to have
a productive research career and reported greater career
satisfaction (Palepu et al., 1998; Ramanan et al., 2002; Levy
et al., 2004). Other reported benefits for mentees include:
socialization into the profession; help with choice and
fulfillment of career path; meaningful involvement in
academic activities; and the development of close collabora-
tive relationships (Morzinski et al., 1996; Pololi et al., 2002).
Self-reported benefits for mentors include pride in develop-
ing the next generation, building a network of professional
404 ISSN 0142–159X print/ISSN 1466–187X online/06/050404–5 ! 2006 Informa UK Ltd.
collaborators within an institution and being able to
disseminate their expertise and skills to a group of mentees.
From a mentoring program perspective faculty retention
has been reported as a positive outcome (Benson et al.,
2002). Despite these benefits, many early career clinicians
and investigators have difficulty in finding appropriate
mentors. Women and clinician-educator faculty in particular
are at risk of inadequate mentoring relationships (Chew et al.,
2003).
The mentoring relationship usually develops between
an older professional, the ‘mentor,’ and a younger colleague,
the ‘mentee’ (Grainger, 2002). In the Odyssey, Mentor was
a trusted friend of Odysseus, who entrusted Mentor with the
care of his house and the education of his son, Telemachus,
when he set out for the Trojan War. From this epic arose the
use of the word mentor as a wise and faithful counselor.
Today, a mentor is someone who is a counselor and a teacher
and instructs, admonishes and assists a junior trainee or
colleague in attaining success.
The 12 tips described below are a summary of participant
discussions at the Ottawa conference and AAMC annual
meeting workshops from a slightly different angle, namely the
needs of mentors themselves (Table 1).
Tip 1: Mentors need clear expectations of their roles
and enhanced listening and feedback skills
Mentors are not born but developed
Research reports have listed some valuable characteristics of
effective mentors (Bhagia & Tinsley, 2000; Grainger, 2002,
Hesketh et al., 2003; Jackson et al., 2003; Levy et al., 2004).
These include being knowledgeable and respected in their
field, being responsive and available to their mentees, interest
in the mentoring relationship, being knowledgeable of the
mentee’s capabilities and potential, motivating mentees to
appropriately challenge themselves and acting as advocates
for their mentees. Some key skills required when mentoring
others include listening and the ability to give positive as well
as negative feedback.
Many educators are not born with these skills and would
benefit from institutional staff development programs on
mentoring skills. Such programs could highlight the key
Correspondence: Subha Ramani, MD MPH DipMedEd, Department of
Medicine, Section of General Internal Medicine, Boston University School
of Medicine, 715 Albany Street, EB33A, Boston, MA 02118, USA.
Tel: 617-638-7985; email: sramani@bu.edu
DOI: 10.1080/01421590600825326

Table 1. Tips to promote effective mentors: three domains.
Developing mentors Rewarding mentors
Mentor staff development Academic recognition
Heighten awareness of gender Protected time
and culture issues
Education on professional boundaries Financial and non-financial rewards
responsibilities of a mentor, skills required for an effective
mentoring relationship and strategies to recognize problems
in a relationship (Benson et al., 2002). These workshops
would be most effective if they used a combination of
educational strategies that allowed prospective mentors to
engage in practical exercises such as watching videotaped
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scenarios and role-plays (Connor et al., 2000). One such
program at the University of Leeds used simulated GPs
(general practitioners) with roles based on real mentoring
experiences as a learning tool for improving mentoring skills
(Sloan & McMillan, 2003). There were opportunities for the
GP mentors to practice their skills on three different
simulated mentees followed by an in-depth discussion and
feedback. This proved to be an invaluable developmental
process for the GP mentors. It is to be emphasized, however,
that the actual outcomes of such staff development programs
should be measured in real mentoring settings. Examples of
For personal use only.
outcomes might include trainee satisfaction, observation or
videotaping of staff during their mentoring sessions with peer
feedback or evaluation of staff in an objective structured
teaching evaluation (OSTE) format.
Tip 2: Mentors need awareness of culture and
gender issues
Mentor and mentee matching by gender and culture should not
be mandatory, but available for those who desire it
Although differences in gender and culture have been
considered relative barriers to an effective relationship,
literature reports have documented that these have not been
viewed by most mentees as real barriers ( Jackson et al.,
2003). In fact, our workshop participants thought that
mentors can support mentees of different cultures and
gender by having zero tolerance for discrimination. Gender
and cultural differences can foster greater mutual growth
of the mentor and mentee as they gain knowledge of
each other’s cultures. It has been recommended that mentors
be aware of their own gender and culture biases as this
knowledge could possibly help people overcome innate
prejudices. It is also thought that faculty development
workshops can help all mentors become comfortable and
competent in working with students from different back-
grounds (Parker, 2002).
Two issues were raised at the workshops in relation to
cross-gender mentoring. The first was that of personal
boundaries and the second, lack of understanding of the
other gender’s domestic responsibilities. Despite these
concerns, most mentees did not feel the need for having
a same gender mentor. The opinions of our participants
reflected those reported in the literature. They felt that
Twelve tips for developing effective mentors
Supporting mentors
A peer-support group
Mentors for mentors
Referral panel: study skills
counsellors, psychologists etc.
No support Support
Challenge
Regression Growth
Stasis Validation
No challenge
Figure 1. Support vs. challenge.
Source: Figure adapted from Daloz (1986).
relationships across cultures and gender would promote
more acceptance of differences and lowering of biases. They
stated that institutions should not actively try to pair mentors
and mentees based on gender and culture and mentors
should be equipped with the skills required to understand
issues related to their mentees’ gender and ethnicity.
However, if individual trainees report discrimination or
significant barriers to meaningful mentoring based on these
characteristics/variables, the institution should find them
mentors who can put them more at ease and better fulfill their
mentoring needs.
Tip 3: Mentors need to support their mentees,
but challenge them too
Balance support and challenge
Daloz (1986) states that effective mentor–protégé(e) relation-
ships should balance three elements: support, challenge and
a vision of the protégé(e)’s future. If mentors are overly
supportive without challenging mentees, the mentees do not
grow professionally; on the other hand, challenging without
supporting causes mentees to regress in their professional
development (Figure 1). Effective mentors balance support
with challenge by providing opportunities and setting positive
expectations (Bower et al., 1998).
Tip 4: Mentors need a forum to express
their uncertainties and problems
Mentors have problems too
It is often assumed that once faculty become mentors, they
become all-knowing and do not need any further attention
from the program. However, many mentors expressed the
need to have a mechanism by which they could discuss
problems in their mentoring relationships and get advice.
Given that mentors often have more than one mentee and
each interpersonal relationship is likely to be different, skills
that are effective in one may be ineffective in the other. If they
can interact with mentoring colleagues, they might discover
solutions to each other’s challenges. While discussing
405
 S. Ramani et al.
challenges in their mentoring relationships and seeking
solutions, it must be remembered that details regarding
specific individuals must remain confidential (Freeman,
1997). Institutions can schedule periodic mentor meetings
led by senior educators along with external consultants who
are knowledgeable about methods for troubleshooting
problems in mentoring relationships. Such meetings could
provide a forum for mentors to report their successes and
failures, and to receive feedback from their peers and the
experts. These discussions should include only essential
details of the mentoring issues and mentee names and other
details must remain confidential.
Tip 5: Mentors need to be aware
of professional boundaries
Mentors should stick to mentoring
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There are several types of boundaries that need to be
considered in a mentoring relationship where the personal
contact between mentors and mentees is much closer than
in other professional relationships such as a student with
a teacher, advisor or role model. Moreover, personal issues
and problems may be discussed by a mentee, which could
lead to one or both of them harboring inappropriately
intimate emotions towards the other (Palepu et al., 1996;
Jackson et al., 2003). Mentees could become excessively
dependent on their mentors for personal and professional
For personal use only.
support, which may become a drain on the mentor’s energy.
As one of our participants stated: ‘‘I had a mentee who
expected me to mother him throughout his training period
and that was emotionally exhausting.’’ Mentor training
should include knowledge of professional boundaries, and
recognition of psychosocial problems that need referral to
professionals such as psychologists or counselors.
Tip 6: Mentors also need mentoring
Mentors for mentors
There were some senior faculty among the workshop
participants with vast experience in teaching and mentoring
different levels of trainees. All of them felt abandoned by the
system once they assumed leadership positions within their
institutions. Educational institutions often do not provide
mentors for senior teachers. Our participants felt that even
the most senior educators need to be mentored as they may
wish to change their career focus or professional path while
they already hold high positions within their organizations.
Tip 7: Mentors need recognition
Raise the value of mentoring
At most educational institutions around the world, mentors
usually perform their mentoring duties not because they are
reimbursed for it but because they consider it a rewarding
aspect of their profession. However, they usually carry out
their mentoring privately and neither their peers nor their
superiors are even aware of the mentoring load they carry, let
alone laud their efforts. To convince the entire institution
that mentoring is one of the most important duties at medical
schools, institutional leaders should publicly recognize their
406
group of mentors as an ‘elite’ group of faculty who are highly
valued and appreciated for their work (Palepu et al., 1998).
They can be given special honors within the institution and
their names announced at major university events and openly
appreciated.
Tip 8: Mentors need to be rewarded
Mentors can be rewarded in different ways
Educational institutions can reward their core group of
mentors in several innovative ways. Mentor retreats or
dinners can be held periodically. At retreats or even just
occasional dinners mentors can interact with their colleagues,
share their experiences and techniques, both effective and
ineffective. Another method to reward special mentors would
be to give them extra conference funding. These rewards can
easily be given by institutions even in times of economic
shortfalls. Additionally mentoring can become a criterion for
promotion (Benson et al., 2002).
Tip 9: Mentoring needs protected time
Mentoring cannot be done ‘on the fly’
Institutions should recognize that mentoring is one of the key
activities of faculty at any educational institution. Faculty
who mentor several trainees should be allocated some degree
of protected time to perform this important duty effectively.
Just adding this important duty to the existing workload is
a recipe for poor mentoring relationships.
Tip 10: Mentors need support
Mentors should not be expected to tackle personal or
psychological problems
Some mentees’ problems may overstep the boundaries of the
usual mentor–mentee relationships and discussions. Mentees
may be clinically depressed, have personality problems, have
substance abuse problems or just academic problems.
Mentors should be able to recognize when they feel unable
to resolve such problems and should be supported by
a network of specialists such as study counselors and
psychologists to whom they can refer their mentee. The
mentors should not be forced to take on roles in which they
do not have expert skills. Once again, the matter of
professional boundaries arises.
Tip 11: Encourage peer mentoring
A pyramidal model of mentoring
Medical educators who have studied peer (or near-peer)
mentoring suggest that it is a feasible and perhaps more
desirable alternative to traditional dyadic mentoring
approaches (Woessner et al., 1998; Pololi et al., 2002).
Participants identified their peers as ‘collaborators’ or
‘colleagues’ (implying a non-hierarchical relationship),
while seeking shared insights, experiences, ideas, guidance,
problem-solving and support from them. Their reference to
peer collaborators reflects a non-hierarchical mentoring
process, in contrast to senior–junior mentoring relationships

where characteristics such as power, dominance, dependency
and transference have been noted (Pololi et al., 2002).
Pressures on faculty time could be alleviated to a certain
extent by creating a pyramidal system of mentoring. Such
a model would entail a group of mentees at the bottom of
the pyramid who can seek advice from a small group of peers
a little higher in the pyramid with the more experienced,
senior mentors overseeing and guiding all of them at the top
of the pyramid. This pyramidal system would minimize
the threat of the power relationship, yet offer the benefit of
the valuable experience that senior faculty at the top of the
pyramid possess. The advantages of peer mentoring include
easier availability, greater understanding of day-to-day
problems related to workload stress or conflicts with teachers,
and early recognition of serious abuse or emotional problems.
Mentees may be more open to sharing their problems with
peers than with faculty. The same advantages would apply
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for faculty mentoring programs as well. It has been shown
that faculty may be more willing to share their difficult
problems with peer mentors than with senior mentors (Pololi
et al., 2002).
Tip 12: Continuously evaluate the effectiveness
of the mentoring programs
Mentoring is a work in progress
For mentoring programs to succeed, institutions need to have
For personal use only.
the mentees and mentors evaluate the program periodically,
report the current problems and suggest new approaches
to mentoring or changes to the existing program. Evaluation
of mentoring should look at process, content and outcomes
as noted below (Grainger, 2002):
. Process
! Clear objectives
! Regular, purposeful meetings
. Content
! Feedback
! Mentee could raise issues and challenge mentor
. Outcome
! Progress and career development
! Networking
All mentees and mentors at a given institution should be
asked to evaluate their mentoring relationships at least 3–4
times a year. The following items are examples of areas in
a mentoring relationship that could be evaluated:
. congruence on professional goals;
. availability of mentor(s);
. mentor giving mentee responsibilities and opportunities;
. mentor involving mentee on committees and other
professional activities;
. mentor facilitating networking with internal and external
faculty;
. mentor helping mentee integrate work and personal life;
. mentor showing respect for the mentee as a person;
. personal benefits from mentoring.
Institutional leaders could also consult outside experts,
particularly at national and international educational
Twelve tips for developing effective mentors
meetings, where they could discuss the mentoring challenges
at their home sites and take back ideas to overcome
those challenges. They could have a committee within their
institution that would be responsible for receiving feedback
from its mentors and mentees to modify their mentoring
system as needed.
Conclusions
Mentoring is a vital cog in the machinery of medical
education. Faculty who serve as mentors frequently are not
trained in effective mentoring skills or designing mentoring
programs. They are most often very busy with their core
clinical, research, administrative or educational responsibil-
ities and are expected to squeeze mentoring onto an already
full plate. Once they take on mentoring duties, they usually
are left to their own devices and have few avenues to discuss
problems and challenges in their mentoring programs or
relationships. It is evident from the foregoing discussion that
faculty need training to be mentors and to benefit from peer
mentoring themselves, and must be rewarded for a job well
done. Institutions should change their culture to overtly value
and reward mentoring so that mentoring does not remain
an invisible and only implicitly valuable aspect of their
educational programs.
Notes on contributors
SUBHA RAMANI, MD MPH MMedEd, is a general internist and medical
educator at the Boston University School of Medicine and its affiliated
Boston Medical Center. She is currently an Assistant Professor of
Medicine and Director of Faculty Development in Clinical Teaching for
the Department of Medicine. She also directs a clinical skills curriculum
for Internal Medicine residents. Her chief areas of interest in medical
education are staff development in teaching and clinical skills education.
LARRY GRUPPEN, PhD, is Professor and Chair of the Department
of Medical Education at the University of Michigan Medical School.
He is a cognitive psychologist whose areas of research interest include the
fundamental aspects of clinical reasoning, the evolution and assessment of
medical expertise, performance assessment, and educational leadership
development.
ELIZABETH KRAJIC KACHUR, PhD, is a medical education consultant with
22 years of experience throughout the continuum of medical education.
She is located in New York City but also works nationally and
internationally. Her experience with mentoring schemes ranges from
program and mentor development to project evaluation.
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