Teaching and Assessing Communication Skills in Medical Undergraduate Training.

Good communication skills are essential for an optimal doctor-patient relationship, and also contribute to improved health outcomes. Although the need for training in communication skills is stated as a requirement in the 1997 Graduate Medical Education Regulations of the Medical Council of India, formal training in these skills has been fragmentary and non-uniform in most Indian curricula. The "Vision 2015" document of the Medical Council of India reaffirms the need to include training in communication skills in the MBBS curriculum. Training in communication skills needs approaches which are different from that of teaching other clinical subjects. It is also a challenge to ensure that students not only imbibe the nuances of communication and interpersonal skills, but adhere to them throughout their careers. This article addresses the possible ways of standardizing teaching and assessment of communication skills and integrating them into the existing curriculum.

Teaching and Assessing Clinical Reasoning Skills.

Clinical reasoning is a core competency expected to be acquired by all clinicians. It is the ability to integrate and apply different types of knowledge, weigh evidence critically and reflect upon the process used to arrive at a diagnosis. Problems with clinical reasoning often occur because of inadequate knowledge, flaws in data gathering and improper approach to information processing. Some of the educational strategies which can be used to encourage acquisition of clinical reasoning skills are: exposure to a wide variety of clinical cases, activation of previous knowledge, development of illness scripts, sharing expert strategies to arrive at a diagnosis, forcing students to prioritize differential diagnoses; and encouraging reflection, metacognition, deliberate practice and availability of formative feedback. Assessment of clinical reasoning abilities should be done throughout the training course in diverse settings. Use of scenario based multiple choice questions, key feature test and script concordance test are some ways of theoretically assessing clinical reasoning ability. In the clinical setting, these skills can be tested in most forms of workplace based assessment. We recommend that clinical reasoning must be taught at all levels of medical training as it improves clinician performance and reduces cognitive errors.

Competency-based Medical Education, Entrustment and Assessment.

The realization that medical graduates are failing to serve the health needs of the society has compelled the medical educationists and regulatory authorities worldwide to review the medical training. A medical curriculum oriented towards developing the key competencies that enable a fresh graduate to be delivering socially responsive health care is seen as a promising step towards alleviating this problem. This calls for a departure from the traditional approach of organizing the curricular components around educational objectives, to a competency-based approach for planning the curriculum. The present article discusses the concept of competency-based medical education in Indian context, the steps in planning and implementing such a curriculum, and the key aspects of assessment for its effective implementation.

Teaching and Assessing Professionalism in the Indian Context.

Developing professional values and behaviour is an indispensable part of training of medicine. Societal values have changed and there are increasing reports of unprofessional behaviour by physicians. It is now agreed that professionalism must also be 'taught' besides being 'caught'. Most regulatory documents in India mention professionalism in a cursory manner, and do not specify details of how it should be taught and assessed in the curriculum. Teaching-learning methods, assessment and the training schedule for professionalism need to be specified in the undergraduate and postgraduate curriculum for it to be taken seriously. This article discusses the concept of professionalism, its definitions and the various teaching and assessment methods that can be applied in the Indian context.

Workplace-Based Assessment: A Step to Promote Competency Based Postgraduate Training.

There has been an increasing emphasis on defining outcomes of medical education in terms of ‘performance’ of trainees. This is a step beyond the description of outcomes in terms of ‘competence’ that encompasses mostly ‘potential abilities’ rather than the ‘actual performance’. The contextual adaptations and behavior judgments of the trainees are best assessed by a program of in-training assessment. Workplace based assessment (WPBA) is one of the modalities, which assesses the trainee in authentic settings. Though Postgraduate (PG) medical training in India is said to be competency-based, most institutions do not have any formative or in-training assessment program for the same. The two cardinal elements of WPBA are ‘direct observation’ and ‘conducted in work place’ in addition to provision of ‘feedback’ to the trainee. The WPBA conforms to the highest (Level 4: ‘Does’) of Miller’s pyramid and also has the potential to assess at all four levels. Some of the tools used for WPBA are: Logbooks, Clinical Encounter Cards (CEC), mini-Clinical Evaluation Exercise (mini-CEX), Case based discussions, Direct Observation of Procedural Skills (DOPS), Multisource feedback (peers, co-workers, seniors, patients) etc. These can be documented in the form of a portfolio that provides a longitudinal view of experiences and progress of the trainee. The WPBA scores high on validity and educational impact by virtue of being based on direct observation in real situation and contextual feedback. The feasibility and acceptability is enhanced by making appropriate choices of tools, advance planning, building of mutual trust, and training of assessors. Given the established benefits of WPBA in shaping clinical learning, there is an imminent need for including this mode of assessment in our clinical training programs especially PG training.

The Quarter Model: A Proposed Approach for In-training Assessment of Undergraduate Students in Indian Medical Schools.

In-training Assessment (ITA) has the potential to test a wide range of competencies which are not testable by the yearend examination. However, despite high validity, educational impact and feasibility; its implementation is flawed. This paper proposes a “quarter model of in-training assessment” for implementation in the undergraduate medical curriculum in India. The model proposes that assessments be carried out at least quarterly; no teacher should contribute more than 25% of the marks for any student; no single assessment tool should contribute more than 25% marks; and no assessment should contribute to more than 25% of the total marks. We believe that structuring the implementation using multiple tests on multiple content areas by multiple examiners using multiple tools in multiple settings in the proposed quarter model will not only improve the reliability and validity of internal assessment, but also its acceptability.