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Problem–based learning, Anatomy, Curriculum, Medical education, Learning, Teaching, IntroductionThe undergraduate curriculum in India has seen a drastic shift in the last few academic years. The concept of competency-based medical education (CBME) was first put forth by Mc Ghahie in 1978 ( 1, ). The new CBME by National Medical Council of India aims to be more learner-centric, patient-centric, gender-sensitive, outcome-oriented, and environment- appropriate ( 2, ). It is an outcome-driven undergraduate curriculum that has elements which encourage life-long learning. It is competency-based and not time-based like the traditional curriculum. The focus has shifted from traditional didactic lectures to self-directed learning or a flipped classroom approach. The crux of the CBME involves active student participation and engagement and team-based learning (TBL). Early clinical exposure (ECE), addition of elective subjects, acquisition of certain skills, development of the right attitude, ethics, communication (AETCOM) skills, self-directed learning (SDL), and addition of co-curricular activities are all components of CBME. Its major emphasis is on alignment and integration of all possible subjects both horizontally and vertically, so that the students will be able to realise the importance of a topic in clinical practice. This contrasts with the traditional medical curriculum, where the stress is on knowledge acquisition and all subjects in a particular year are introduced simultaneously &,ndash preclinical subjects in the first professional course, paraclinical subjects alongside clinics in the second professional course, and purely clinical subjects in the subsequent years. This method has been replaced by the new CBME to provide personalised holistic care to all patients ( 3, ).Implementation of CBME offers challenges to the faculty and students as there is major restructuring of the traditional pedagogic approaches ( 4, ). In anatomy, the method has always been team-based learning (TBL) and learning by doing ( 5, ). Clinical anatomy where normal anatomy is applied to daily life and clinical practice is always introduced right in the first professional medical course. Anatomy is the first introduction to true or real medicine ( 6, ). Even in traditional method, lectures in anatomy are always followed by corresponding laboratory training in the dissection room or in the histology laboratory. Thus, the students who acquire the skills of Know and Know How during the lecture easily acquire skills to Show, Show How and Do during the practical session ( 7, ). The curricular changes are easier to implement in anatomy as it is the starting point of professional medical education when a senior secondary school student shifts to college education. A good knowledge of anatomy is necessary for the understanding and practice of clinical subjects ( 8, ). Hence, it is necessary to modify the teaching and evaluation methods in all subjects, especially anatomy.As a part of the new CBME curriculum by the Medical Council of India, we introduced necessary teaching and assessment modifications in anatomy. There are several reports comparing traditional method and CBME. However, there are only few studies on the actual implementation of CBME. The current study aimed to assess the perceived usefulness of the teaching, learning, and assessment methodology (TLAM) based on written feedback from students. The methods were also continued during the online anatomy teaching in the wake of COVID-19. Since CBME is only taking its baby steps in several countries, we expect that this study would give valuable ideas for future curricular modifications. We hope that this study would lay a roadmap to plan and prepare for curricular reforms in future.MethodsThe study was conducted after the exams to avoid information bias and infringement of autonomy. The aim was to explore the perceptions of students about various TLAMs. All the 147 first MBBS students of the batch who underwent the new teaching, learning methodology and appeared for the first professional MBBS examination answered a pre- designed pre- validated questionnaire where items were aligned with the research question. Kirkpatrick level I framework was used for evaluation. A self-administered feedback questionnaire was used for the study. The questionnaire was tested for face and content validity. Face validity was assessed by a subject expert. Content validity was assessed by five experts (3 from anatomy and 2 in medical education). The experts assessed the content for 1) relevance of each question, 2) clarity, 3) necessity/essentiality, and 4) suggestions to improve/add/remove questions. Based on the recommendations by the content experts, the questionnaire was revised three times and the 3rd version was taken as the final version for the study. There were 45 items in the questionnaire which contained questions regarding the usefulness of various TLAMs. Of the 45 items, 34 were marked as very relevant by the content experts. The study was an evaluation of the perception of all new TLAM performed during the academic year, and the study was conducted after the completion of university exams as per the mandate by the institute Ethics Committee. Thus, the same participant could answer the question only once. Hence, test-retest reliability was not assessed. The questions were on self-reported usefulness of various TLAMs on a 3-point Likert scale (1 - Not useful 2 &,ndash Useful 3 &,ndash Extremely useful) the quantitative data are expressed as proportion. Qualitative data were collected by asking the students to write down their opinions and suggestions about the TLAMs that were used. They were also asked to write down suggestions to modify and/or improve them. Only open-ended questions were asked regarding various TLAMs. Qualitative data were analysed after thematic analysis. The recurring themes were assessed. The themes were generated by the first author and validated by the second one. In the analysis stage, the qualitative data were used to substantiate the quantitative data hence, it is an Embedded design mixed method study (Figure 1,).Figure 1. Embedded design mixed method study designThe TLAMs that were evaluated are, 1. Lecture classes - Conventional teaching, teaching using clinical case vignettes, videos, animations. 2. Integration &,ndash Horizontal integration with Departments of Physiology and Biochemistry, Vertical integration on clinically relevant anatomy topics by clinicians from relevant clinical departments (Surgery, Orthopedics, Otorhinolaryngiology). 3. Early clinical exposure (ECE). 4. Dissection &,ndash Self - dissection, prosecution, team-based learning (peer group discussion, peer teaching). 5. Active learning methods - Daily short seminars on topics covered on the previous day, region-wise seminars on a few large topics covered in that particular region and frequent weekly or fortnightly quizzes, small group discussion (SGD), team based learning (TBL) near-peer teaching, self-directed learning (SDL) 6. Preparation and priming methods - PowerPoint projection, short videos, clinical vignettes prior to dissection, histology practicals, small group discussion, self-directed learning. 7. Embryology and radiology - Embryology classes were taken using PowerPoint sessions using case vignettes and animated videos. The students would then be divided into small groups for peer group discussion and SDL. 8. Assessment - Formative assessments (FA) were conducted once weekly as objective or short answer tests after which a facilitator would provide feedback to the individual students at the end of the session. Summative assessments (SA) were conducted as traditional Theory and Practical examinations in the prescribed university pattern. 9. Attitude ethics and communication (AETCOM) - Apart from the orientation programme conducted by the institute, the anatomy faculty conducted a cadaver disrobing ceremony in the beginning of the academic year and robing ceremony at the end of the year to create awareness of the body donation programs and develop a feeling of the human donor as their first patient. This session included videos, audios and feedback by faculty and students about their perceptions on human donor and dissection. Sessions on professionalism, ethics and humanities in medicine were also conducted as part of the AETCOM module to teach them the importance of the medical career, and history of Modern Medicine and dissection. 10. Electronic media - The various electronic media used in learning include e-learning platforms like Moodle and WhatsApp groups where quizzes are posted, and the students can clear their doubts. Various methods of SDL, FA, SA, Integration, ECE, small group teaching were conducted using online platforms like Google Meet, even during online classes. Ethical Consideration The study was approved by the Institute research committee and Institute ethics committee (CDSCO- Reg No. ECR/400/Inst/Py/2013).ResultsOf the 147 first MBBS students who participated in this study, 92 (62.58%) were girls and 55 (37.41%) were boys. As it was program evaluation, the response rate was 100%. The usefulness of various TLAMs is given in Figure 2,. The suggestions and comments by students on various TLAM are given in Table 1,. The thematic analysis of students&,rsquo feedback regarding usefulness of various TLAM is given in Table 2,. The striking findings of our study is as follows,Figure 2. Usefulness of various Teaching Learning and Assessment methods as rated on Likert ScaleSl.no.Students&,rsquo comments1We need more clinical pictures and case videos in lecture.2We need more clinical case-based teaching.3We need more lectures integrating with clinical subjects especially when the patients are brought to the class, or we are taken to the wards. It is very much interesting and extremely interactive. We never forget what we see.4We need more seminars, quizzes, and group discussions. These were useful for last minute preparation for university examinations.5We need short weekly test / short spotters test after each topic apart from the routine monthly internal assessments.6We need videos at the start of every dissection class which gives us an overview of the region to be dissected.7Embryology is difficult to understand, especially general embryology. Apart from routine lecture class the teachers should first give an orientation during small group teaching followed by our peer group discussion.8We need more clinical case scenarios-based essays in internal assessment.9We need more formative assessments. Such short questions were useful for answering short notes during university examination.Table 1.General Comments/suggestions by students on various Teaching, Learning, and Assessment methodsMethodologyStudents&,rsquo commentsLECTURE CLASS |