Original Article

Perspectives of Teachers at Medical Colleges Across India regarding

the Competency based Medical Education Curriculum – A Qualitative,
Manual, Theoretical Thematic Content Analysis
Jeevithan Shanmugam1, Rashmi Ramanathan2, Mohan Kumar1, Sridhar M. Gopalakrishna3, Kalanithi T. Palanisamy4,
Seetharaman Narayanan1
Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
1

2
Department of Physiology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
3
Department of Biochemistry, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
4
Department of Internal Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India

Abstract

Background: Competency-based medical education (CBME) curriculum has been implemented in India since 2019 with a goal
to create an “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values, and responsiveness.
Objectives: To explore teachers’ perceptions across India at medical colleges on the newly implemented competency-based
medical education curriculum.
Methods: This was a qualitative cross‑sectional study conducted among teachers working at medical colleges across India,
between February and April 2022 (n=192). The data collection was done using Google forms online survey platform on teachers’
perception regarding CBME, its specific components, and perceived bottlenecks. We analyzed this qualitative data using manual,
theoretical thematic content analysis following the steps endorsed in Braun and Clarke’s six-phase framework.
Results: The majority of the teachers (64.1%) have positively responded to the CBME curriculum’s implementation. However, it
came with a caution that the curriculum should continuously evolve and adapt to regional demands. The foundation course, early
clinical exposure, and the family adoption program were the specific components of CBME curriculum over which the teachers
raised concerns. The need for additional teachers in each department (department-specific teacher or faculty per hundred students
ratio to be worked out) and the need for enabling faculty preparedness through adequate training was highlighted. Concerns were
also raised regarding implementing CBME with teachers without a medical background (especially in preclinical departments).
Conclusion: It is the need of the hour for the curriculum to incorporate a systematic feedback mechanism built into the system,
though which such critical appraisals can be meaning collated and acted upon, to ultimately evolve, thereby creating an “Indian
Medical Graduate” for the needs of todays’ society.
Keywords: Cross-Sectional Studies, Feedback; Goals, Search Engine, Curriculum, Faculty, Students, Attitude.

I ntroduction the kind of competencies learners should attain to address

those needs.[3] In India, the regulations on graduate medical
Over the past two decades, medical education has witnessed a
paradigm shift towards competency-based medical education
(CBME).[1] However, any medical education system focuses on Address for correspondence: Jeevithan Shanmugam,
training graduates to become effective healthcare providers.[2] Department of Community Medicine, KMCH Institute of Health Sciences and Research,
CBME is a concept where teaching, learning and assessment Coimbatore, Tamil Nadu, India
E‑mail: [email protected]
are driven by the population’s needs, which in turn direct

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How to cite this article: Shanmugam J, Ramanathan R, Kumar M,
Gopalakrishna SM, Palanisamy KT, Narayanan S. Perspectives of Teachers
at Medical Colleges Across India regarding the Competency based Medical
DOI: Education Curriculum – A Qualitative, Manual, Theoretical Thematic
10.47203/IJCH.2023.v35i01.007 Content Analysis. Indian J. of Com. Health. 2023;35(1):32-37.
Received: 21-11-2022, Accepted: 04-03-2023, Published: 31-03-2023
 Jeevithan Shanmugam, et al.: Competency based medical education curriculum and teachers perspectives

education (1997, Amendment notification dated 4th November Table 1: General perception towards CBME
2019) notified the introduction of CBME curriculum for Codes Participant responses (Verbatims)
MBBS courses starting from the academic year 2019-20 For CBME Verbatim 1.1.1: “Integration is the key to CBME. Very
onwards.[4] The national goals of the curriculum include (but good initiative”
not limited to) creating an “Indian Medical Graduate” (IMG)
with the ability to recognize “health for all” and health right Verbatim 1.1.2: “CBME is evolving, and it will continue
of all citizens, practice holistic medicine, develop scientific to do so”
temper; acquire educational experience for proficiency
Verbatim 1.1.3: “Uptake of competency-based training
in profession; and fulfilment of social and professional curriculum is much appreciated. However, it is being
obligation by observance of medical ethics.[5] The set of roles implemented in haste, Change is drastic”
expected from an IMG are being a clinician, life-long learner,
communicator, leader, and professional.[6-8] Some of the newer Against Verbatim 1.2.1: “Old curriculum with certain
CBME improvements would have been sufficient”
elements under the CBME curriculum include a foundation
course, early clinical exposure and integration, self-directed Verbatim 1.2.2: “The new curriculum is nothing
learning, electives, pandemic modules, family adoption new from the old one with regards to what
program, revamped examination, and assessment patterns in student ultimately learns. It is a consortium of new
addition to modules on attitude, ethics, and communication terminologies”
(AETCOM).[9]
Verbatim 1.2.3: “CBME is literally great stress and
As with any change in curriculum, teaching faculty are harassment to very young Indian medical students
supposed to play a catalyst role in moderating the transition; and their teachers”
understanding, adopting, and implementing frameworks of
CBME.[10] They also play a pivotal role in motivating the
stakeholders to be a competent physician.[11] The charge
of carrying the curriculum forward demands a distinctive
intellectual and scholarly cast of medical educators.[12] The
multidimensional roles of the teacher in medical colleges is
summarized in Figure 1.[13-15] Teachers at medical institutions
may not be able to provide adequate training for the students
without being formally trained because the concept of faculty
development as a whole is still evolving. A well-planned
faculty development strategy can address the deficiencies in
Figure 1: Roles of a teacher
training of health professionals and accelerate the possibility
of successful implementation of CBME towards improved
health outcomes.[16,17]
Against this background, the primary aim of this study
was to explore the perceptions of teachers at medical colleges
across India on the newly implemented competency-based
medical education curriculum.

M ethods
This qualitative cross-sectional study was conducted among
teachers working at medical colleges across India between Figure 2: Overview of results
February and April 2022. We considered being Assistant
Professor as the minimum eligibility to participate in the identification details, perception regrading CBME and its
study. The study was approved by Institute Human Ethics specific components, and perceived bottlenecks. The link to
Committee (IHEC), KMCH Institute of Health Sciences and the questionnaire was circulated through existing social media
Research, Coimbatore, Tamil Nadu, India. The participant platforms and national level faculty groups (department wise
information sheet (PIS) in English was provided to the study WhatsApp and Telegram groups).
participants digitally and were enrolled in the study only after The qualitative data was analyzed using manual,
obtaining informed digital consent. theoretical thematic content analysis following the steps
The study questionnaire was designed to capture endorsed in Braun and Clarke’s six-phase framework.[18,19]
teachers perception on various facets of competency based The transcripts were read and re-read to ensure familiarity
undergraduate curriculum. The data collection was done with the data corpus. Also, the notes were made, and early
using Google forms online survey platform that included impressions jotted down. The data was then organized in a

33 Indian Journal of Community Health ¦ Volume 35 ¦ Issue 1 ¦ January-March 2023

 Jeevithan Shanmugam, et al.: Competency based medical education curriculum and teachers perspectives

Table 2: Perception towards specific components of CBME Table 3: Human resource requirements and training
Codes Participant responses (Verbatims) Codes Participant responses (Verbatims)
Foundation Verbatim 2.1.1: “Though I understand the rationale Need for Verbatim 3.1.1: “There is dire need for improving
course for having a foundation course (at the time of entry additional the faculty number as soon as possible”
into medical colleges), what I see is that students feel human
exhausted and create aversion towards the subject” resources Verbatim 3.1.2: “Faculty student ratio is not at
all adequate. Especially with more small group
Verbatim 2.1.2: “Foundation course can be split into activities increasing faculty strength should be
two parts - 15 days each, to deliver the prescribed prioritized”
content in the beginning and mid of the phase 1”
Training Verbatim 3.2.1: “Faculty preparedness is
Verbatim 2.1.3: “1 months foundation course is utter requirements inadequate”
nonsense”
Verbatim 3.2.2: “Faculty training is the need of
Verbatim 2.1.4: “Foundation course duration can hour”
be reduced to 10 days, with select topics. At present
its too long leaving both students and faculty Verbatim 3.2.3: “Most of our clinical departments
exhausted” are not aware of this CBME based new curriculum;
training is essential and should be done urgently”
Verbatim 2.1.5: “Foundation course should be
shortened to 2 weeks” Verbatim 3.2.4: “CBME can be implemented after
Early clinical Verbatim 2.2.1: “ECE from phase 1 is overwhelming training all the faculty for better results”
exposure for the teachers. It distracts the students – jumping
to conclusions (for example. signs and symptoms or Verbatim 3.2.5: “Quicker and more sessions of
diagnosis) and not actually understanding the basic faculty training on RBMET & CBME - CISP, are
science” needed first. Or else we won’t be able to achieve the
objectives of CBME”
Verbatim 2.2.2: “ECE could be implemented from
Faculty Verbatim 3.3.1: “In the vision of training an Indian
second half of phase 1, once they are adapted well to
competency Medical Graduate, non-medical faculty should be
new course”
eliminated from pre and para clinical departments”
Verbatim 2.2.3: “2 years are required to learn the
Verbatim 3.3.2: “Faculty with MSc qualification can
basics of medicine; too much of early clinical exposure
be used as tutors ONLY for teaching paramedics,
and integration will not help them in their initial
Not CBME”
semesters”

Verbatim 2.2.4: “Admitting MSc faculty in medical R esults

colleges for teaching CBME – we can’t expect them The results included perspectives of 192 teachers of cadre
to be useful in AETCOM, ECE, foundation course, Assistant Professor and above working in medical colleges
professional and clinical competencies” across India on the newly introduced CBME curriculum. Of
Integrated Verbatim 2.3.1: “Non-medical staff find teaching the 192 medical teachers, 108 (56.3%) were from government
classes clinical concepts very difficult” medical colleges and 84 (43.7%) were from private medical
Family Verbatim 2.4.1: “The norms regarding FAP are really colleges. More than one third, 67 (34.9%) were Assistant
adoption vague. The families enrolled should be outside field Professors, 96 (50.0%) were Associate Professors and 29
program practice areas, preferably unserved or underserved (15.1%) were Professors.
by existing public health system (rare in Tamil Nadu); Theme 1 - General perception towards CBME: The results
five for each student; and should be followed by the
of the present study show that majority (n = 123, 64.1%) of the
department after three years.
This means each year 750 new families are to be teachers have received the introduction of CBME curriculum
followed; and in five years 3750 families to be positively. However, it came with a rider that the curriculum
managed by the department” should continuously evolve and adapt to regional ground
level demands (Table 1). On the contrary, we found that a
systematic meaningful way by generating codes. Because
significant number (n = 69, 35.9%) of teachers considered
each open-ended question was thematically enquired about, CBME curriculum a stressor. Few verbatims read CBME to
the data was thematically sorted to start with. However, it be a “Consortium of new terminologies” and “Old wine in new
was ensured whether the themes make sense, data supports bottle” for the teaching methods already in practice. Teachers
these themes, trying to fit too much into a theme, overlaps, perceived that ‘too much’ is being implemented ‘too quickly’.
subthemes within predetermined themes, or other novel Theme 2 - Specific components of CBME (regarding): The
themes within the data. The results were presented according perspectives of medical teachers towards specific components
to themes (n = 3) (Figure 2). Under each theme, codes and of CBME are summarized in Table 2. Almost all the teachers
supportive manually chosen verbatims were provided. opined that the current duration and contents of foundation

© 2023 Indian Journal of Community Health 34

 Jeevithan Shanmugam, et al.: Competency based medical education curriculum and teachers perspectives

course is creating dislike towards the core medical subjects competency based medical education curriculum, its specific
among medical students. In their perception, it may be components, and perceived bottlenecks.
attributed to the exhaustive nature of foundation course. The medical teachers have favored the introduction of
The teachers suggested that the contents and duration of competency based medical education curriculum. However,
foundation course should be revisited. The duration may they opined that it should be dynamic, with scope to evolve
range from ten days to two weeks as a one-time event or with considering the heterogeneity associated with India in
reinforcement after six months into the course. terms of geography, human resources, health systems and
Early clinical exposure aims at providing a context that disease burden. Literature evidence also supports such
will enhance basic science learning. However, many of a notion – any curriculum should incorporate a subject
the preclinical teachers opined that phase 1 is too early to centered approach, interest curriculum approach, structure-
introduce students to clinical scenarios. They added that early of-knowledge approach, and the humanistic approach with
clinical exposure may be implemented in the second half of sufficient flexibility for contextual variations.[20] The strength
phase 1, preferably from phase 2. Also, presence of teachers of competency based medical curriculum is that it focuses on
without medical backgrounds in basic science departments outcomes, be it at individual, departmental or institutional
adds to the burden of the department in relation to effective level.[21] It considers the fact that each learner is unique and
implementation of AETCOM, early clinical exposure, learns at his/her own pace. It understands that the art of
foundation course, and professional and clinical competencies. medicine can be attained not only through knowledge and
Concerns regarding the clarity of family adoption program skill but requires the right attitude and communication. It
choice of area, follow-up of families after documented promises greater accountability because the assessments
three years of student follow-up, requirement of additional are very close to what would actually be done in real life
human resources and logistics were raised by teachers from situations.[22] However, more than one third teachers in the
department of Community Medicine. present study considered CBME curriculum a stressor.
Theme 3 - Human resource requirements and training
This may be attributed to bringing about a paradigm shift,
Regarding human resource requirements, almost all
that is drastic and hasty, in regular teaching–learning
(n=190, 98.9%)expressed the need for additional teachers in
and assessment methods. Also, this may stem from the
each department. The common reasons specified were, CBME
inadequacy of competency-based curriculum to convince the
demanding increased individual student attention through
teachers in terms of student relationship, students’ academic
small group teaching; need for teachers’ feedback on many
performance, and job satisfaction.[23] In a recent review it
aspects of the curriculum including increasing assignments,
was documented that competency-based training in medical
logbooks, records, and reflections, and increased need for
education provides very little benefit for doctors in training;
multiple documentation with the introduction of CBME
and disapproved the emphasis on individual skills rather than
(Table 3).
overall learning experience.[24] Another study highlighted
Similarly, all the teachers included in the study indicated
the inadequacy of CBME to describe the higher order skills
the need for training teachers being a part of CBME
curriculum. A specific verbatim read “Faculty preparedness necessary for professional practice, suggesting the need to
is inadequate” highlighting the lack of orientation to newly emphasize workplace learning.[3, 25]
introduced competency based medical curriculum. Teachers The foundation course, early clinical exposure, and the
documented the necessity to conduct training of trainers (ToT) family adoption program were the specific components of
for faculty development programs, increase the number of CBME curriculum over which most of the concerns were
training centers, training sessions and number of participants raised by the teachers. The perceptions of teachers regarding
per session. foundation course revolved primarily around the contents
One other concern regarding the implementation of CBME and duration of the course. It was made clear that the current
was availability of teachers without a medical background (for duration of course should be cut down to about ten to fifteen
instance, M.Sc. in any preclinical subject). This is important days, and to go with it the contents of the course. Few opined
with CBME aiming at an effective outcome-based, student- that the course can be repeated (probably with updated
centered strategy for medical education – through introduction additional contents) after six months into the course for
of clinically correlated components including attitude, ethics, better uptake. The existing literature of longitudinal studies
and communication (AETCOM) modules, foundation course, highlight that the stress levels among medical students were
early clinical exposure and integration, self-directed learning, high during the initial months of joining the course and during
electives, family adoption program, revamped examination, examinations.[26,27] Stress during examinations is relatable,
and assessment patterns. however, stress during initial months of joining the course
needs further exploration. Though foundation course, aims at
D iscussion orienting the students to entire system of medical education
The present study qualitatively summarizes the perceptions and hospital functioning, ease students into medicine in the
of medical teachers across India on their perception regrading immediate months of joining the course, it is understood in

35 Indian Journal of Community Health ¦ Volume 35 ¦ Issue 1 ¦ January-March 2023

 Jeevithan Shanmugam, et al.: Competency based medical education curriculum and teachers perspectives

the present study that students feel overwhelmed. Teachers teachers of clinical departments. Secondly, we did not present
perceived that the students may feel apprehensive towards disaggregated analysis for government and private medical
the curriculum and environment, personal competence, and college teachers; regional analysis (that is, east, west, north,
endurance, with concerns regarding time outside medical and south); and departments. Thirdly, online data collection,
school or life outside medical school.[28] volunteer bias and COVID-19 related disruptions should be
Teachers opined that early clinical exposure should considered while interpreting the results of the study.
be built upon knowledge of basic sciences, not alongside
it and definitely not before it. They perceived that the C onclusion
students priority towards basic sciences takes a backseat The present study summarizes the perceptions of teachers at
with early clinical exposure. The teachers from non-medical medical colleges across India regarding competency-based
backgrounds have a limited role in implementing attitude, medical education curriculum. It is the need of the hour for
ethics and communication modules, early clinical exposure, the curriculum to incorporate systematic feedback mechanism
and other integrated sessions. Family adoption program is built into the system, though which such critical appraisals
one other initiative under the CBME curriculum. To provide can be meaning collated and acted upon, to ultimately
an experiential learning opportunity to Indian Medical evolve, thereby creating an “Indian Medical Graduate”
graduates towards community-based healthcare and thereby possessing requisite knowledge, skills, attitudes, values, and
enhance equity in health, the initiative mandates each student responsiveness, so that she or he may function appropriately
to longitudinally visit a minimum of five families from and effectively as a physician of first contact of the community
villages not covered under primary health centers adopted while being globally relevant.
by the medical college for three academic years.[29] By the
end of these three years, the department has to continue F inancial S upport and S ponsorship
with the follow-up for the subsequent years – by which time Nil.
the department will also have three parallel family adoption
programs running for the subsequent batches. This definitely C onflicts of interest
is laborious; however, the need for additional human resources There are no conflicts of interest.
in terms of teachers, social workers, or medical counselors
have not been considered in the family adoption program R eferences
guideline. To give a broader context, the department of 1. Ryan MS, Holmboe ES, Chandra S. Competency-Based
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37 Indian Journal of Community Health ¦ Volume 35 ¦ Issue 1 ¦ January-March 2023