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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 30-36

Attainment of Indian Medical Graduate (IMG) roles through the curriculum: The untold stakeholder perspective


1 Additional Professor, Department of Anatomy, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
2 Senior Resident, Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
3 Professor, Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
4 Professor, Department of Pediatrics, Jawaharlal Nehru Medical College, Sawangi, Maharashtra, India
5 Associate Professor, Department of Pediatrics, Government Medical College, Latur, Maharashtra, India

Date of Submission05-Jun-2021
Date of Decision08-Oct-2021
Date of Acceptance23-Nov-2021
Date of Web Publication01-Feb-2022

Correspondence Address:
T S Gugapriya
Department of Anatomy, All India Institute of Medical Sciences, Nagpur - 441 108, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_74_21

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  Abstract 


Background: Graduate Medical Education Regulations 1997 and “Vision 2015” documents were the steps toward training a skilled and competent Indian Medical Graduate (IMG). To implement the changes in the curriculum and to achieve the IMG goal, a nation-wide faculty development program was started by the Medical Council of India in 2009. Even before the introduction of Competency-Based Medical Education (CBME) in 2019, the Indian medical curriculum imbibed and trained the Graduates in competencies relevant for an IMG. This research was to attempt to understand the stakeholder perspective of the contribution of the curriculum in attaining the IMG roles prior to 2019. Methodology: The present multicentric study was carried out among 450 interns belonging to batch 2018 in the state of Maharashtra. A self-administrated, online, structured questionnaire containing 27 items based on IMG roles was used as the study instrument. Descriptive analysis was performed to arrive at the perception of stakeholders. Results: Analysis of self-rating of the competency for IMG roles showed a 30.7% for the “leader and as a team member role”. A detailed analysis noted that the majority of the participants lacked confidence in the role of the “medical expert.” Competency in the psychomotor domain gained maximum self-rating in comparison to the affective domain. The overall rating about their undergraduate training toward five IMG roles had an unsatisfactory score of 56.3% for the “lifelong learner” role. Conclusion: The study highlighted the stakeholder perspective about curriculum equipping them in developing “leader and a team member” while failing with “lifelong learner” IMG role. The study also emphasized that the attitudinal domain needs addressing by the CBME curriculum.

Keywords: Competency, curriculum, medical education


How to cite this article:
Gugapriya T S, Banarjee S, Girish M, Damke S, Bhattad S. Attainment of Indian Medical Graduate (IMG) roles through the curriculum: The untold stakeholder perspective. Natl J Clin Anat 2022;11:30-6

How to cite this URL:
Gugapriya T S, Banarjee S, Girish M, Damke S, Bhattad S. Attainment of Indian Medical Graduate (IMG) roles through the curriculum: The untold stakeholder perspective. Natl J Clin Anat [serial online] 2022 [cited 2022 May 22];11:30-6. Available from: http://www.njca.info/text.asp?2022/11/1/30/337045




  Introduction Top


The goal of MBBS training has always been to produce good medical professionals who will excel as clinicians, be updated throughout their professional career and provide yeoman service to the society as leaders and good communicators which in turn will help them to be good 'doctors of first contact' or primary care physicians.[1] However, there have been rising concerns, more so since the early 21st century about the quality of training. The need to address the long-suffering state of medical education in India was finally acknowledged officially in the 1997 Graduate Medical Education Regulations (GMER) which then took the shape of a “Vision 2015” document released in 2011.[2] All efforts were made to standardize the output of graduate medical education in the form of an “Indian Medical Graduate” (IMG); a skilled and motivated primary physician. Revision of medical curriculum with emphasis on competency-based curriculum was then proposed in the form of GMER 2012.[3]

Nationwide faculty training programs in basic medical education technology were made mandatory by the Medical Council of India (MCI) in 2009[4] to cover 100% of teachers in medical institutions across the country and train them in new teaching and assessment methods and thereby improve the quality of medical graduates in India. Thus, roles of the IMG namely, clinician, professional, communicator, leader, and lifelong learner have been an implicit goal of medical education much before the formal implementation of the Competency-Based Curriculum Competency-Based Medical Education (CBME) for undergraduate training in 2019. In contrast to the already existed curriculum, the CBME curriculum is outcome-based which expects the medical graduates to exhibit the competency attained during their training. The purpose of this research was to determine the contribution of the curriculum in attaining the IMG roles by stakeholders in a period before the formal implementation of the CBME curriculum. The self-rating of the competency levels attained by primary stakeholders was also an attempt to provide a baseline for future evaluation of the CBME curriculum in later years.


  Methods Top


Study design and setting

Three different types of tertiary care teaching hospitals were included in this study-a privately owned medical college and a government medical college, both affiliated to Maharashtra University of Health Sciences and a medical college under a deemed university, each with an intake of 150 students per year. At the time of the study, several novel teaching strategies like problem-based learning, case-based learning, integrated teaching, student seminars, training in communication skills, and student research activities were already incorporated in the undergraduate curriculum in these three institutions.

This cross-sectional, prospective interventional study was conducted after obtaining permission from the ethics committee of the institution- (Ref. no: IEC/NKPSIMS/1/2018 dated July 26, 2018). Anonymity was ensured and written informed consent was obtained from all participants. The study tool, a self-administered validated questionnaire in the English language was distributed to the participants during their internship after they completed their rural posting.

Sample size

All interns in the year 2018 in the three participating institutions were included. Thus, the sample size was 450.

Study instrument

The study instrument was a self-administered, online, structured questionnaire containing questions that were derived from the description of each IMG role given by MCI.[5] Content validation was done by expert trainers in advanced medical education technology from these three institutions. The study instrument had 27 items distributed over six sections [Table 1] and [Table 2]. The first section of the study instrument “demography” contained two multiple choice single response question items. The next two sections “clinician” and “leader and team member” had 4 items of 5-point Likert scale and 1 item of multiple-choice single response question type each. The subsequent three sections namely “medical professional,” “lifelong learner,” “communicator” had three items of 5-point Likert scale and 2 items of multiple-choice single response questions type each [Table 1] and [Table 2]. This mixed item type in the study instrument design was an attempt to minimize response biases while using the Likert scale and also to have concrete responses for key items. A set of five items in the study instrument focused on eliciting the overall rating of the participants for the training provided to them in their undergraduate curriculum towards specific roles [Table 2].
Table 1: Items of the study instrument eliciting individual self-rating of participant's competency in five roles of Indian Medical Graduate

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Table 2: Overall rating by participants about their undergraduate training in five Indian Medical Graduate roles

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Statistical analysis

Descriptive analysis of the obtained data was carried out, where categorical and continuous data were reported in number (percentage) and median interquartile range (IQR), respectively. Participants' self-rating of competency in five roles of IMG was calculated and total attained scores were reported in median (IQR). Total scores were converted to percentage scores (percentage of total attainable score obtained) to make them comparable as the number of items in the questionnaire tool varied between IMG roles [Table 1] and [Table 3]. The distribution of scores of different domains was presented using histogram, and average percentage scores of different IMG roles were reported using spider diagram. The percentage score was further divided into four quartiles and the number of participants having a percentage score in the upper quartile (75%–100%) was compared between different domains. Items of different domains were re-categorized into cognitive, affective and psychomotor domains and the average domain scores (percentage of total attainable score) were presented using a spider diagram.
Table 3: Indian Medical Graduate role wise total and percentage scores

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  Results Top


Out of 450 undergraduates, 409 participated in the study (91% participation rate). After removing incompletely answered questionnaires, a total of 352 questionnaires were deemed fit for analysis.

The collected data were analyzed as follows:

  1. Analysis of self-rating for competency in each of the five IMG roles
  2. Analysis of response from multiple option questions
  3. Comparative analysis of the participants' self-rating in the cognitive, psychomotor and affective domains
  4. Analysis of the overall rating about their undergraduate training from the perspective of the five IMG roles.


Analysis of self-rating of the competency for five roles of indian medical graduate

The self-rating scores were not normally distributed, with negative skewing for the role of the “clinician” and “leader and team member,” respectively [Figure 1]a and [Figure 1]b. Meanwhile, roles of “medical professional,” “lifelong learner” and “communicator” were approximately normally distributed with a sudden dip [Figure 1]c, [Figure 1]d, [Figure 1]e. The distribution of percentage score across domains showed that role of “leader and as a team member” and “communicator” have a high number (%) of participants in the 75%–100% range, in comparison to other IMG roles studied [Table 4].
Figure 1: Showing distribution of (a) Clinician, (b) Leadership, (c) Professional, (d) Lifelong learner, and (e) Communicator role scores among study participants (n = 352)

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Table 4: Distribution of participants according to percentage of total attainable score obtained in different Indian Medical Graduate roles (n=352)

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The self-rating analysis revealed that most of the participants have high self-rating for the role of the “leader and team member” whereas participants had high self-rating for the roles of “lifelong learner, medical professional, and communicator” [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e and [Table 4].

The median percentage score for the “leader and as team member” role was found to be higher (68.75), whereas that of “clinician” and “professional” roles was lower (43.75) [Figure 2].
Figure 2: Comparison of average percentage scores between different Indian Medical Graduate roles (n = 352)

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Analysis of multiple option items for three Indian medical graduate roles

The item numbers 16, 21, 24 were given as multiple choice (single response) questions [Table 1]. The authors wanted to have in-depth understanding of the response for these three pertinent questions in the IMG role of the medical professional, lifelong learner and communicator-being an expert, being a change agent and an expert communicator. Almost 75% of study participants expressed hesitancy and lack of confidence about their role as expert medical professionals [Figure 3]a. Only <20% of participants expressed their ability to be a change agent [Figure 3]b, the majority of them expressed confidence to be an expert communicator [Figure 3]c. These observations align with the previous finding of percentage scores obtained for the respective roles.
Figure 3: Distribution of response obtained for IMG roles a) Expert medical professional b) Change agent c) Expert communicator

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Comparison of self-rating of the participants as per domain

The items were grouped into cognitive (item no: 4, 8, 10, 19 and 20), psychomotor (item no: 3, 24, 25) and affective domains (item no: 6, 5, 9, 11, 13, 14, 15, 18, 23) [Table 1]. The distribution of self-rating in cognitive, psychomotor, and affective domains showed especially abrupt decline in slope beyond 80% for the affective domain [Figure 4]a, [Figure 4]b, [Figure 4]c. The maximum total attainable score in the three domains was deduced [Table 3]. The comparison of percentage score of self-rating of the participants in three domains showed psychomotor domain to have maximum mean percentage scoring and affective domain the least percentage scoring [Figure 5].
Figure 4: Distribution of (a) Cognitive, (b) Psychomotor and (c) Affective domain scores among study participants (n = 352)

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Figure 5: Comparison of average percentage scores between cognitive, affective and psychomotor domains (n = 352)

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Analysis of the overall rating about their undergraduate training towards five Indian medical graduate roles

The analysis of items given in [Table 2], showed the role of lifelong learners having maximum unsatisfactory scoring [Table 5]. This observation reinforced the percentage score obtained in self-rating of competency as a lifelong learner [Table 4], [Table 6] and [Figure 2], [Figure 3]b.
Table 5: Distribution of overall self-rating among study participant's for their undergraduate training of Indian Medical Graduate roles (n=352)

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Table 6: Domain-wise total attainable and percentage scores (n=352)

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  Discussion Top


Indian medical education is undergoing a paradigm shift from being a structure and process-based medical education to a CBME.[5] This has brought in a lot of discussions, challenges, and limitations among the stakeholders.[6] There is limited scope for the prime stakeholders, the IMGs to voice out their opinions and experiences. This study was an attempt to capture the perceptions of IMGs who have experienced CBME based teaching and learning activities and to provide a basis on which the impact of the subsequent change in curriculum to CBME pattern can be compared.

Except for the “clinician” role, which stands upon the knowledge base, the other four IMG roles need a firm attitudinal base to flourish. Analysis of the participants' perception on competencies toward executing these roles showed a definitive need to address competencies in the roles of the “medical professional,” “communicator” and “lifelong learner” [Figure 2], [Figure 3]b, [Figure 3]c and [Figure 5].

Working effectively as a member or leader of a healthcare team is an important role of an IMG.[7],[8],[9] Study participants have given a high self-rating [Figure 1]b, [Figure 2] and [Table 4] and [Table 6] on this role which brings to the forefront the debate on the influence of the hidden curriculum. “Hidden curriculum” is a set of influences acting upon students as an outcome of their presence within a specific environment.[10],[11] The merits and demerits of this hidden curriculum are much debated but a lack of formal leadership programs has been pointed out as a major drawback of the pre-CBME curriculum.[12],[13] Observations in this study point toward a positive influence of hidden curriculum in honing the skills of an IMG as a leader and team member.[10],[11],[12],[13],[14],[15]

Lifelong learning has been defined as “all learning activity undertaken throughout the life, with the aim of improving knowledge, skills, and competences within a personal, civic, social and/or employment-related perspective.”[16] Among the IMG roles studied, the lifelong learner role training was perceived by the pre-CBME era learners as highly unsatisfactory [Table 5]. Fostering lifelong learning competency in IMG depends upon developing the traits of self-directed learning, metacognition, self-monitoring, and reflection. By fulfilling the role of life long learner, the IMG can always be abreast with current knowledge and skills and as a result, deliver optimum medical care.[17] Only a lifelong learner can lead and guide change to occur in any system.[18] By making the IMG competent in the role of lifelong learner, we can develop change agents capable enough to rise to any challenges in the perpetually updating health-care system of the country.

With the current focus on assessments rather than feedback, the IMG tends to concentrate more on knowledge acquisition rather than attitudinal change leading to an imbalance in knowledge and clinical application. This imbalance has led to an IMG who has a fountain of knowledge but incapable of being acclaimed in clinical practice.[19],[20] Recent observations of an increase in the incidence of violence against health professionals have often been linked to the lack of adequate training in the affective domain.[21],[22],[23],[24],[25] Despite being introduced to many aspects of the currently recommended CBME curriculum, analyses of student's perceptions in this study endorses the often-repeated phrase in criticism of the traditional curriculum-rule of the head (knowledge domain) supported by hand (Psychomotor domain) and neglected care of heart (affective domain) [Figure 5]. It is hoped that the introduction of the Attitude and Communication (AETCOM) module for the prospective IMGs will redress the imbalance in competencies in the domains of the 'head' and the 'heart.'[26] The effectiveness of the strategy to assess AETCOM components formatively in the CBME curriculum needs to be evaluated in future.

Limitations

The study tool design could be improved for qualitative data acquisition. The sampling frame could be expanded to get a pan-India consensus.


  Conclusion Top


The present study highlighted the positives of the pre-CBME curriculum as perceived by the stakeholders in developing IMG as a leader and team member and also failure in inculcating the attributes of a lifelong learner despite the introduction of several competency-based activities. The attitudinal domain remained the most vulnerable and it is hoped that the subsequent implementation of AETCOM in the CBME curriculum will go a long way in addressing this issue. The results of this study will be useful when comparing the outcome of a similar study in the post-CBME future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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