Challenges in implementation of Competency Based Medical Education – A Cross Sectional survey among medical faculty in India

Background. In India, Competency Based Medical Education (CBME) is gaining foothold to transform the medical student into a doctor fullling community and societal needs. With that end in view the teaching faculty are getting sensitized and trained by the National Faculty Development Program (FDP). Objectives. To assess the awareness about FDP among teaching faculty in medical colleges. To study the attitude & perceived barriers to implementation of CBME. Methods. This questionnaire based multicentric cross sectional study was conducted among teaching faculties in Indian medical institutes. Electronic media [Google forms] was used to disseminate the questionaire. Attitudinal and perceptional differences were internally compared among the faculties. Results.


Introduction
Medical curriculum worldwide is experiencing a paradigm shift towards Competency-Based Medical Education (CBME), an outcome-based structure that needs the integration of information, skills, values, and attitudes into observable and measurable competencies. In our country there have been decisive steps in that direction as well [1,2] . The need for betterment in medical education is based upon landmark recommendations of the Accreditation Council of Graduate Medical Education of America which mandates the acquisition of six domains of competencies namely, patient care, knowledge, practicebased learning, communication skills, professionalism, and systems-based practice [3][4][5][6] . CBME emphasizes a shift from teacher-centered to learner-centered educative methods and a systematic interdisciplinary integrated learning rather than piecemeal information in each department. Another noteworthy alteration is problem-based learning which triggers the scholar to arm himself with knowledge crucial to encounter and solve real-life problems within the hospital or community. Entrustable Professional Activities (EPA) are observable and measurable outcomes in CBME which bridges the gap between the idea and practice of technical skills thereby integrating multiple competencies in a holistic nature [7,8] . CBME is conducive to the Dreyfus model which emphasizes the medical graduate to travel past ve milestones-a novice, advanced beginner, competent, pro cient, and expert as a graded transition [9] . ( Figure.1 ) The goal of CBME is to produce an Indian Medical Graduate (IMG) who is envisaged as a doctor ful lling the roles of clinician, leader, communicator, professional and lifelong learner [10,18] (Table 1). The new regulations on Graduate Medical Education (Amendment), 2019 is more learner-centric, patient-oriented, gender-sensitive, and environment-appropriate leading to an outcome-driven curriculum, in conformity with global trends. To initiate the process of transformation from traditional curriculum into CBME, the teaching faculty of medical institutions need to be sensitized and molded into the modern day medical education facilitators. The National Faculty Development Program (FDP) initiative of the Medical Council of India (MCI) is a step forward in the direction, which aimed to enable and empower faculty of every medical institution across the country by a structured and perpetuating process (Fig. 2).
There has been a steep rise in the number of medical colleges in India from 297 in 2009 (146 within the Government sector and 151 within the private sector) to a total of 554 medical colleges in 2019 (285 within the Government sector and 269 within the private sector) [10][11][12] . In the last 10 years FDP of MCI had trained 44,932 faculties in Basic Course in Medical Education Technology through 1697 workshops conducted by regional centers and nodal centers. The Curriculum Implementation Support Program (CISP-Phase 1) had been implemented through 557 programs which trained 15,509 faculty in a record time of 7 months [13] .
Though FDP's have been in vogue since 2009 till date very little research has gone into assessing the faculty's knowledge and mental preparedness to embrace CBME. Neither has it been evaluated whether the training process has percolated to the grass roots. In this research we aimed to study the existent level of awareness, attitude and perceived barriers towards implementation of CBME among teaching faculty of medical institutes countrywide.

Materials & Methods
This multicentric cross sectional study was conducted among teaching faculty from medical colleges of India. A validated questionnaire was propagated using an online platform [Google forms]. The validation process was done by external expertise. There were 3 sections in the questionnaire-Section A dealt with informed consent of the participants and their socio-demographic data. Those who consented to the study could access the Section B which addressed the awareness of the faculty and Section C investigated attitude and perceived barriers to implementation of CBME in our health system. Only fully completed forms could be successfully submitted. Study period was August 2020 to February 2021. Assuming that 50% of participants were aware of CBME, minimum sample size needed at 95% con dence interval and 5% precision was calcualted using formula n = z 2 pq/E 2 . Based on this formula sample size required was 178. Probability sampling method using Strati ed Sampling Technique was employed to ensure equitable representation from all segments of medical education like pre, para and clinical departments. All teaching faculty presently serving in Indian Medical Schools were eligible to participate. However only those with a minimum of 2 years of teaching experience were included. Faculty presently on leave for > 6 months or on psychotropic support or medications were excluded. The study was conducted by the Medical Education Unit members of Government Sivagangai Medical College and Government Villupuram Medical College. The study team regularly scrutinized data collection process and met periodically to review the study conduct and computing of data. At the end of study period, the coded and consolidated data were analyzed using IBM SPSS version 22.
The Section A containing socio-demographic data was analysed using descriptive methods of frequency such as percentage. Internal comparison between faculty of government sector and private sector in awareness about FDP (Section B) and attitude and perceived barriers on CBME (Section C) was done by cross tabulation and comparison of percentages. Chi square test was used to test statistical signi cance [p value < 0.05]. Descriptive analysis was carried out for assessing the closed response questions about perceived barriers to CBME. The questionnaires are as per Internal comparison between government and private medical college faculty revealed a signi cant increase in FDP attendance by the latter (p = 0.008). Furthermore, the groups differed in their ways to overcome barriers of CBME (p = 0.017). However, there was no difference in terms of teaching skills, MEU functions, and awareness [ Table 2]. 95.2% agreed that FDP was conducive towards implementing CBME.  • Mentorship program needs to implemented.
• National wide universities coordination for assessments Discussion Indian medical education system, one of the largest in the world is under the process of transforming itself into a structured and globally relevant principle (14) . Some of the hallmark alterations in the present curriculum include incorporation of androgogical teaching methods like Self Directed Learning [SDL], cooperative learning, small group teaching, community practices, special emphasis on formative assessment and wholesome acquisition of skills to function as part of the health care team. Such landmark reforms in education system is possible only if the medical educator understands and embraces the concept of CBME. This sets into motion the chain of events nally culminating in an education system on par with international standards. Faculty Development Programs are crucial rst steps fueling the evolution of modern day medical education facilitators.
In our study pre, para, and clinical faculties participated in adequate numbers to be representative of their respective elds. The majority were of the cadre of Assistant Professor, Associate Professor and Professor. In our study the government faculty outnumbered those from private institutes probably because the authors were from government sector and better identi ed among the same population.
Previous research by Rustagi SM et al. identi ed that 44.8% faculties had undergone RBCW and 39.7% attended CISP [15] . Appreciably we documented 64.5% RBCW trained and 74.9% trained in CISP which is encouraging and a signi cant improvement over the former record. The remaining faculty quote lack of opportunity as reason behind the lapse presumably due to heavy work burden. Nevertheless 93.6% are still aware that RBCW has been made mandatory for consideration for promotion in ranks. This leaves a large lacuna to be lled and is at the behest of the administrative heads to create opportunities for all.
The Medical Education Units of medical schools play a pivotal role in organizing FDP for all faculties. In this regard, it was reassuring to nd that 84.1% of participants were well aware of the structure and functions of MEU [ Reforms in the educational eld are fraught with challenges and impediments. Truthfully so, research ndings by Kulkarni et al in 2020 found that student to faculty ratio, poor infrastructure, time constraints, lack of commitment and human inertia to be the main hurdles in the way of CBME [16,18] . Our ndings mirrored similar re ections among the faculty as depicted in Table 4. To highlight a few, demotivation, fatigue among faculties, lack of administrative support and non uniformity in assessment methods were perceived as signi cant barriers to implement the new curriculum [17] . The mindset & attitude of teachers accustomed to the traditional curriculum has to change if CBME aims to spread roots into the system. Hearteningly we found that majority of our participants (95.2%) housed a positive attitude and were willing to walk the tight rope to enforce reforms.
The authors stand to understand that though there are quite a few impediments en route to full operationalization of CBME, the stakeholders are conducive and the transformation has long begun. However we recommend that politically committed administrative support and feedback evaluation from faculty and students be given due weightage to ease out the wrinkles of the system.

Limitation
The major limitation of this study was its sample size. We conducted the study during the peak phase of COVID 19 pandemic which probably evoked a less optimal response from the participants. Though the minimum appropriate sample size as per statistical formula was achieved a larger sample would de nitely have been more informative. Another drawback was a thin representation from the private sector institutes. The authors being from government run institutions couldn't evoke a more energetic response from their counterparts in the other sector.

Conclusion
There is an existing favorable environment for change from traditional curriculum to CBME. shows rollout plan for the implementation of CBME in India.

Figure 3
Pictogram showing number of participants undergone Faculty Development Programme (N=251)