Designing a curriculum for postgraduate training in family medicine in India.

CONTEXT: Family physicians, trained in handling primary care problems through the principles of family medicine (FM), were needed in India. The training required a comprehensive and detailed curriculum that could be implemented across the country. AIM: The aim was to create a document that includes rationale, goals, subject-based objectives, educational methods and assessment methods that align to the objectives. DESIGN AND METHODS: Kern's Six-Step-method was used to create a curriculum document. The six steps are (a) problem identification and general needs assessment, (b) targeted needs assessment, determining and prioritizing content, (c) writing goals and objectives, (d) selecting teaching/education strategies,(e) implementation of the curriculum and (f) evaluation and application of the lessons learnt. RESULTS AND
CONCLUSIONS: Based on the given steps, a team of faculty identified needs, requirements and barriers, wrote goals and objectives along with aligned educational and assessment methods. The curriculum document was created for FM resident training. The first set of residents have been trained based on this curriculum and an evaluation is being planned. Copyright:

Introduction

The policy makers of the National Health policy in 2002 (NHP-2002) noted that the quality of undergraduate medical education in most colleges was sub-standard and theoretical, and thus, unable to equip fresh graduates, licensed to practice as independent general practitioners, to meet the primary health care needs of the Indian population.[1] The NHP-2002 recommended postgraduate training in the discipline of Family Medicine (FM) and suggested that one-fourth of the postgraduate seats be set aside for FM. The Medical Council of India (MCI), the apex organization responsible for the accreditation of undergraduate and postgraduate medical training in India had recognized FM as a specialty in 2000.[2] Moreover, the World Health Organization, in a scientific working meeting in 2004, recommended that FM be considered as a separate specialty in the member countries of the Southeast Asian region.[3] We needed a curriculum for training these graduates in FM.

The National Board of Examination (NBE), another postgraduate accrediting body in India, had been running postgraduate training in FM since the late 1980s.[4] Even though they had generic objectives for the course, it lacked intended learning outcomes for resident posting in various departments that are essential for any training program. Additionally, they had not addressed the roles of a family physician other than the role of a clinical expert. There were a few distance educations courses in FM which did not have a formal curriculum and did not have residential clinical training. Following the NHP-2002, various State Medical Councils were recommended to start MD training in FM. Few states took up this training challenge in the face of stiff competition from other specialties. The State Medical Council of Kerala put up a syllabus (not a curriculum) for the postgraduate training of FM in 2014.[5] The syllabus had theoretical content of the rotations without specific learning objectives or teaching learning methods. This also necessitated a need for a curriculum in FM acceptable to the MCI. Additionally, the curriculum document also has to describe the residents’ learning environment as it is an essential determinant of the trainees’ education and achievement.[6]

India bears a large portion of global burden of communicable and non-communicable diseases. With a population of 1.4 billion in 2017, the top five causes of mortality were ischemic heart disease, chronic obstructive pulmonary disease, stroke, diarrheal disease and lower respiratory tract infection—all of which are preventable and treatable by efficient family physicians.[7] The survey by the National Health Accounts showed that 88% of household expenditure is for health, and of this, 48% is on primary curative care provided by the general practitioners who are not formally trained in FM or primary care.[8] A FM specialist would be able to manage these needs for primary curative care with the available resources and in the context of the patient.

Against this background, the postgraduate training of family practice in India poses many challenges. Bearing the mortality and morbidity profile of India in mind, the trained family physician should know how to manage common medical conditions that include communicable and non-communicable diseases. They need to respect the primacy of the person of the patient. They would have to be well versed in communication skills, patient-doctor relationship and applied professional, collaborative and managerial skills. They would bring this unique set of skills to a unique population setting and provide continuous and family-based care. The training of such a family physician would need a curriculum that would address all the needs, at the same time, keeping in mind the restrictions and regulations of the regulators.

Our institution is based in one of the southern states and is known for its high academic achievements and social engagement with the local communities. The institution consists of a tertiary medical hospital, three peripheral hospitals – two in rural sites and one in an urban site. These peripheral sites were potential clinical teaching sites for a broad-based, comprehensive discipline like FM. The administrative body of the institution and the alumni had willed for the initiation of the department of FM, one of the first of its kind in India and established in the year 2009. The faculty consisted of trained family physicians who were certified by the NBE. The department was gearing up to start postgraduate MD training in FM. The faculty realized that there was no definite curriculum for postgraduate training available in the MCI. The curriculum of NBE did not encompass the crucial principles of FM.

Any medical discipline would have rapid and profound changes over time, and thus, the development of a current, active and contextual curriculum was the dire need. One of the FM faculty enrolled for a FAIMER (Foundation for Advance of International Medical Education) fellowship. The faculty chose to design the FM postgraduate curriculum as the project for the fellowship. This paper reports the process and a few key elements behind the designing of the FM postgraduate curriculum.

Development Process

The curriculum development process was based on the steps articulated by David Kern and Patricia Thomas.[9] The six steps are the following:

Problem identification and general needs assessment

Targeted needs assessment, determining and prioritizing content

Writing goals and objectives

Selecting teaching/education strategies

Implementation of the curriculum

Evaluation and application of lessons learnt.

Kern's Step 1-Problem identification and general needs assessment

We formed a core team of faculty from the institution who had been trained both in the currently available FM on NBE syllabus and in medical education. An advisory team consisting of the past and current FM residents, faculty from other institutions and the NBE was formed and provided additional review. An extensive literature review was done to identify the current health care needs and mortality and morbidity profile in the country. The various FM curriculum available in India were discussed in multiple face-to-face meetings. These were compared to the established competency-based curricula of Canada, United States and the United Kingdom. The meetings provided opportunities to discuss the current training that the faculty and the residents experienced and the gaps in learning were identified. Most of the faculty and residents had been through block rotational training. There were no specific leaning objectives in the various rotations or methods of assessment of learning. Moreover, there was no direction of teaching on incorporating the basic FM principles like patient centeredness, continuity of care, community-based care, etc., This was particularly because the rotational training was by subject-based specialists in the various rotations and not practicing family physicians.

Kern's Step 2-Targeted needs assessment

The targeted needs assessment included the following stakeholders: current faculty, recent graduates in the DNB training in FM and academic clinicians trained in medical education. The existing curricula of the National Board of Examination, Kerala Medical University and Dr. MGR Tamil Nadu Medical University were read through, analysed and discussed by the stakeholders. The methods used were informal discussion, strategic planning sessions with faculty and questionnaires with case scenarios applying FM principles. We also had informal interviews with residents. The residents were asked about their training experiences, perceived competence and perceived needs. Residents and training faculty noted that the experience included management of common illnesses in ambulatory and inpatient care areas. However, there was limited training in applying principles of FM to the many consultations they had in the training areas. There were gaps in knowledge and skills of behavioural sciences, community-oriented care, family-oriented care and managing “undifferentiated patients” (the hallmark of a family physician).

Specific barriers identified were the lack of established academic departments of FM in almost all of the medical colleges. The academic department of FM would need academic qualified teachers, its service providing area and a definite practice population. Suggestions were written in the curriculum document for overcoming these barriers. Any medical college which chose to train postgraduates in the specialty of FM must form a separate Department of Family Medicine run by trained family medicine faculty. In the absence of trained FM teachers, as in this case, it was proposed that departments be formed in a two-phased manner. The MCI regulations mandated that there be at least one professor, one associate professor and one assistant professor for the establishment of a department.

In phase 1, the FM department could consist of the following: A professor of FM (if available), Internal Medicine, Paediatrics, General Surgery or Obstetrics and Gynaecology. An associate professor may be from any of the following disciplines: FM, Internal Medicine, Obstetrics and Gynaecology, Paediatrics, and General Surgery. Assistant Professor may be assigned from any of the following disciplines: Medicine, Obstetrics and Gynaecology, Paediatrics, and General Surgery. Since this is a new specialty, all faculty of department of FM will have to attend a mandatory faculty orientation and development program. As far as possible, care should be taken to have a representation of all disciplines in a department. Hence, if the Professor is from Internal Medicine, then the associate professor should be either from Obstetrics & Gynecology, Pediatrics or Surgery. Similarly, the assistant professor post can be given to a person from a discipline which is not represented in the other two posts. Under no circumstances all the posts should be filled by the same discipline. As soon as FM graduates become available for teaching posts, they can be inducted into the departments. In phase 2, the head of department could be from Family Medicine or Internal Medicine. All other cadres should be from the discipline of FM.

The curriculum document also suggested that the FM department be based in the tertiary teaching hospital to ensure proximity to the other core disciplines. The administration of the medical college should ensure that the department runs a separate outpatient clinic and has at least a 30-bed inpatient facility. The outpatient should cater to all the problems, both gender, adult and paediatric and across all ages. It is ideal to have an outpatient treatment room for small procedures. In order to facilitate community-oriented care, we suggest that the resident has a rotation in the nearby community health centre/district or taluk hospital. The faculty of the teaching hospital should also conduct outpatient clinics in the same district or taluk hospital on some days of the week, along with the staff of the concerned hospital. This would enable supervision and teaching of the resident.

Curriculum (Supplementary documents available on link https://www.jfmpc.com/article.asp?issn=2249-4863;year=2021;volume=10;issue=9;spage=3453;epage=3458;aulast=Rajkumar).

The steps of writing goals and objectives and selecting teaching learning strategies are discussed in this section. The goal of the postgraduate degree course in FM in India is to produce family physicians who will have the competencies, and professional orientation, to function effectively in diverse health care settings, in district hospitals and community health centres in India providing care for a defined population in the context of the individual, family and the community.

Our curriculum defines the essential FM principles, namely, person-centred care, family-oriented care, community-based care, comprehensive care, continuous care, health promotion and disease prevention, collaborative, coordinated team-based care, resource management and health advocacy and lifelong self-learning. In addition, roles and competencies of the family physician is incorporated into the curriculum design in order to structure the necessary knowledge and skills the resident should demonstrate for competence. The roles being FM clinical expert, scholar, system-based practitioner, communicator, professional, collaborator and leader.

Kern's step 3: Writing goals and objectives

The objectives were written based on the core principles [Table 1] of FM decided upon by the faculty after multiple informal meetings which included discussion based on the Canadian Triple C Curriculum and seminal articles authored by Dr. Ian McWhinney.[1011] The team attempted a longitudinal curriculum methodology.

Table 1

Examples of an educational objective and assessment based on FM core principle

FM core principle	Educational objective	Learning methods	Setting	Assessment methods
Person-centeredness	Utilize personal and subjective aspects in clinical care	Eliciting ideas, concerns and feelings of patients	All clinical encounters in all rotations	Medical record documentations, clinical case discussion
Family-focussed care	Collects factors in the patient’s family which affect disease and utilizes them in the clinical management, connects with patient and manages conflict	Family study proforma, family Apgar, three-stage assessment	Field area rotation, families from these areas	Comprehensive home visit record
Community-based care and community orientation	Collaborates with other practitioners and allied health team, improves health care systems	Management of ambulatory care of patients with chronic illness, health screening activities in the community	Field area rotation	Field note, workplace-based assessment
Comprehensive care	Manage preventive, diagnostic, therapeutic, rehabilitative, health maintenance, psychological and social aspects of care of a patient	Problem based diagnosis, clinical case discussion	All rotations	Problem-oriented medical record
Resource Manager	Partners with patient to use resources efficiently and cost-effectively	Experiential learning while managing patients in inpatient and ambulatory care	All rotations	Field note, 360-degree assessment
Promotive and preventive care	Health promotion and preventive care of the individual	Clinical case discussion	All clinical encounters in all the rotations	Medical records, case discussion

Curricular topics

The curricular overview shows foundation course, peripheral rotations, main department rotation and electives [Figure 1]. The foundation course would be in the department of FM. The peripheral rotations were planned in core subject departments in the tertiary care teaching hospital and included Internal Medicine, paediatrics, Obstetrics and Gynaecology, General Surgery, Orthopaedics, Dermatology, Psychiatry, Accident and Emergency and Ophthalmology and Otolaryngology.

Figure 1

Curriculum rotation overview - Total duration 3 years and 36 months

The purpose of the peripheral rotations is to enable exposure to a high clinical load of relatively advanced stage of disease. It also assisted in the initiation of collaborative relationship with the faculty and peers in these departments. Thus, valuable insights into referral policies, system-based contexts and continuity of care were appropriated.

The residents were planned to come back to the FM department once a week during the peripheral rotations. This was to establish and maintain the longitudinal continuity of care in the curriculum. On this day the residents had academic sessions, followed up patients in the continuity clinics and completed scholarly work like audits and thesis.

Kern's Step 4: Selecting teaching/education strategy

Teaching and learning strategies

The curriculum recommended student directed, analytical and active teaching learning strategies. The teaching-learning activities should be organized primarily around the clinical cases seen by the residents on a day-to-day basis. Examples of these methods include case-based discussion and bedside clinics. Didactic teaching was recommended for basic science concepts. Self-learning and reflection were encouraged in the form of assignments, journal club presentation and clinico-social discussion. The residents had to engage in original research dissertation as part of their course completion. This process enabled learning of research methodology. Maintaining a log book was compulsory and contributed towards documentation of procedural learning and reflection.

Learner assessment strategies

The curriculum suggests both formative and summative assessment strategies. Formative methods were planned for the various competencies described in the curriculum [Table 2]. For example, the suggested method of assessment for the competency of professionalism was 360-degree assessment and the evaluators would be peers and faculty teachers. Similarly, summative evaluation was also planned based on the competencies to be achieved. It was also aligned with the recommendation of the MCI, the accrediting body for postgraduate education in India.

Table 2

Examples of learner assessment strategies for various competencies

Competency	Assessment strategy	Assessor
Family medicine clinical expert	Theory exams, OSCE, MCQ, ward case presentations, chart audits	Clinical faculty
Scholar	Journal club presentation, critique of articles, seminars, observation of teaching assignments	Faculty and student feedback
System-based practitioner	Workplace-based assessment techniques like Mini-CEX, DOPS, field notes	Faculty, peers, team members in the family medicine unit like nurses, health care workers, social workers
Communicator	Video of consultation, consultation observation tool, field notes	As above
Professionalism	360-degree assessment	Peers, faculty, all staff members, patients
Collaborator/coordinator	WBPA, Role play, case discussions	As above
Leader	WBPA, case discussions, 360-degree assessment	Faculty, peers, staff members

The Foundation course unit of the curriculum – an example

The foundation course is described in this section in detail which was one of the units of the curriculum. The foundation course was planned as a crucial unit of the FM curriculum and at the start of the residency program. The rationale behind the curriculum was to sensitize the newly joined residents to their identity as FM specialists. Moreover, the MBBS training in India as noted earlier is not uniform across all colleges. As a result, residents would be at different levels in their clinical acumen and knowledge. The foundation course provided the opportunity for the faculty to assess the residents’ medical knowledge, clinical skills, communication styles and professionalism at entry.

The goal of the foundation course was to introduce the resident to FM core principles, revise basic medical history and physical examination skills and communication skills in the context of the broad-based discipline of FM.

Some important objectives planned for the students to achieve at the end of the course were that the resident should be able to conduct a patient-centred interview and physical examination of a broad group of patients (medical, paediatric, obstetric, gynaecological, etc.) presenting to the family practice care unit. The resident should be able to list the core principles of FM and apply them in day-to-day patient care situations. The resident would actively participate in formative assessment methods in FM such as mentoring, preceptorship, field notes, Mini-CEX, log book and reflective writing.

Some of the teaching learning methods employed were seminars, case-based discussion, bedside clinical presentation and one-minute preceptorship. The content of the foundation course consists of orientation to the FM curriculum, syllabus, purpose of peripheral rotations, evidence-based learning and practice and self-awareness exercises like Myers-Briggs type Indicator assessment.[12] A review of the clinical examination of all the basic systems like cardiovascular, respiratory, paediatric, new-born examination, etc., was planned. Moreover, the core principles of FM were introduced utilizing specific definitions and illustrative case scenarios. These were repeated and reinforced in every clinical consultation. Another important content introduced was family assessment techniques.

Step-5 Implementation

The target learners were our MD FM residents. Prior to them joining the institution, the curriculum was discussed in several meetings with the administrative and senior academic clinical staff of the institution. After their approval, it was presented and discussed with academicians in the State Medical Council and MCI, the postgraduate accrediting bodies of the country. Their suggestions and recommendations were incorporated into the curriculum.[13] Once approval was granted, the curriculum was implemented in 2017 with the first batch of MD FM residents.

The first batch of FM residents have completed the course. Three batches are currently in training. The learners had ongoing formative assessment of their learning during the course. The plan for evaluation of the curriculum is in process.

Step-6 Concepts for the evaluation of the effectiveness of the curriculum

We are currently planning a qualitative study of the learning experience of the MD residents, thus evaluating the effectiveness of the curriculum. This would be the first step in the Kirkpatrick's Levels of Evaluation.[14]

Conclusion

By utilizing a systematic approach of Kern's six steps for curriculum development, we were able to design the first curriculum for postgraduate training in the discipline of FM in India. As mentioned earlier, the practice of FM has become increasingly relevant in the nation's current health care scenario. Additionally, the current paucity of standard curriculum and training in the basic core principles of FM critically necessitates the designing and implementation of the FM curriculum. We hope ultimately to demonstrate the reproducibility of this curriculum thus leading to a wide-scale growth in standard postgraduate training in the speciality of FM both by the National Board and the MCI.

Key Messages

Indian FM residency needed a curriculum for training family physicians after completion of undergraduation in medicine. Kerns’ Six-Step method was followed to create a curriculum document. The curriculum takes into account the existing Indian contexts, the universal principles of FM and the generic competencies needed of a resident.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.