|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 4-10
Expected surgical competencies of an Indian medical graduate: A gap analysis using a cross-sectional survey
Arun Jamkar1, Payal Bansal2, Seema Patrikar3, Gaurang Baxi4
1 Vice Chancellor, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
2 Professor and Head, Institute of Medical Education Technology and Teachers' Training, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
3 Statistician, Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
4 Assistant Professor, Institute of Medical Education Technology and Teachers' Training, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
|Date of Web Publication||31-Jul-2015|
Maharashtra University of Health Sciences, Vani-Dindori Road, Nashik, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: In 2010, the Medical Council of India published the Vision 2015 document, which sought to create an 'Indian Medical Graduate' as a 'physician of first contact of the community while being globally relevant'. This vision for undergraduate medical education is proposed to be realised through a competency-based curriculum. We conducted a gap analysis using a cross-sectional survey to document surgeons' perceptions regarding competencies identified in surgery. Methods: Eight competencies specific to surgery are proposed, which formed the basis for the study. We defined sub-competencies for each of these and developed a questionnaire containing ratings of importance and ability for the sub-competencies from low to very high on a 4-point Likert scale. The questionnaire was administered to 450 surgeons attending a state-level annual conference in surgery asking them to provide the importance ratings and their own ability on those (sub) competencies when they graduated. The importance and ability ratings were ranked and a gap analysis was done. Results: The study response rate was 69.8%. While most competencies were perceived by the surgeons as being highly important, their self-ratings revealed a statistically significant gap between importance and ability when they graduated. They also rated themselves as being more competent on some than on others. Some competencies were high on importance as well as on ability, while others were high on importance but low on ability, revealing a gap. A low importance-high ability relationship was seen for a few competencies. Competencies related to emergency and trauma care and communication had the largest gaps. Discussion: The gaps identified in surgical competencies for graduating physicians are specific and have implications for the competency-based curriculum and implementation in terms of teaching, assessment and faculty development. It also has implications for seamless transition between undergraduate and postgraduate competencies, as all of these are prerequisites at the start of a surgical residency.
Keywords: Surgical competencies, Indian Medical Graduate, competencies, gap analysis
|How to cite this article:|
Jamkar A, Bansal P, Patrikar S, Baxi G. Expected surgical competencies of an Indian medical graduate: A gap analysis using a cross-sectional survey. Educ Health 2015;28:4-10
| Background|| |
The education of health professionals has been evolving almost continuously over the past century, most recently with the call for transformative reforms in health professions education.  Several curricula across the world, describe the "qualities and attributes" required of a "competent physician" and focus on "enabling competencies"  for the practicing physician.  Various competency-based frameworks such as the United States ACGME (Accreditation Council for Graduate Medical Education) competencies,  the Scottish Doctor,  Netherlands Undergraduate Framework  and Can MEDS  have been developed and implemented.
The Medical Council of India, in 2010, published Vision 2015.  The document describes the "Indian Medical Graduate" as a 'physician of first contact of the community while being globally relevant'. In addition to being a clinician, the role of physician as a leader, communicator and lifelong learner, who is ethical and committed to excellence, are emphasised and elaborated.  Towards achieving this, a competency-based approach with integration, early clinical exposure, skills training and new teaching-learning strategies has been recommended for discipline-specific competencies for the "Indian Medical Graduate".
We explored the surgical competencies defined in the above context to obtain clarity regarding implementation of the envisaged competency-based approach. This cross-sectional study on surgeons' views regarding ability and importance of various competencies would serve as a needs assessment to determine the importance-ability gap, prioritise competencies that needed more attention while teaching, identify areas for faculty development and inform institutional strategies.
| Methods|| |
Study type and population
This was a cross-sectional survey focused on a session the authors conducted on competency-based education in surgery in the state level conference of the Association of Surgeons of India (MASICON 2012) in Maharashtra, India. During the presentation, attendees of the session received information on the concept of competency-based education with special reference to surgery. This was followed by administration of a peer-validated questionnaire containing undergraduate competencies in surgery towards creating a competent "Indian Medical Graduate" [Table 1]. The attendees represented a range of roles from residents to practitioners to academicians and educators.
|Table 1: Competencies in surgery required of the Indian Medical Graduate before graduation|
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The authors listed the sub-competencies for the eight competencies that have been outlined for the Indian Medical Graduate  with reference to the appropriate literature.  Faculty from the Department of Surgery of a local medical school met and discussed the listed competencies and sub-competencies. Thirty-four sub-competencies [Table 2] for the eight competencies were agreed upon by the subject experts. A questionnaire was developed for which the importance and ability of each sub-competency task, using a 4-point Likert scale was rated as low, moderate, high or very high. For each of the sub-competencies, the respondents were asked to rank its importance and their own ability at graduation. [Figure 1] illustrates an example of one competency along with its sub-competencies. The questionnaire was finalised by peer consensus, with the survey administered to 450 surgeons attending the session on competency-based education.
|Figure 1: An example of a competency with sub-competencies in the administered questionnaire to define the perceived importance-ability gap reported by study participants|
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|Table 2: Perceptions of expected competencies and sub-competencies for surgery undergraduates: Mean importance, ability and gap scores, gap rankings and statistical significance|
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Ratings of low, moderate, high and very high were given a score of 1, 2, 3 and 4 respectively. Both importance and ability means were calculated for each sub-competency and the scores were ranked. The importance-ability gap was calculated and also ranked. Additionally, weighted averages were obtained for each competency. A t-test was used to calculate statistical significance, which was at the <0.001 level.
| Results|| |
Of the 450 questionnaires administered to surgeons, 314 completed questionnaires were returned, a response rate of 69.8%. Cronbach's alpha was 0.82 implying good reliability of the questionnaire. The descriptive statistics in terms of mean and standard deviation (SD) of the perceived importance and ability as well as the importance-ability gap scores for the competencies and sub-competencies along with the analysis are summarised in [Table 2].
Importance scores and rankings
Importance scores ranged from 2.82 (SD 0.93) to 3.63 (SD 0.62). Thirty-two of 34 sub-competencies scored >3.0, reflecting the agreement of the surgeons with the defined competencies and tasks. The top three tasks that scored a mean >3.5 were:
- Be a life-long learner by developing self-directed learning skills (3.63, SD 0.62)
- Maintain honesty, empathy and an inquiring mind (3.56, SD 0.69)
- Maintain confidentiality, compassion and respect for life (3.5, SD 0.71).
All of these were from the "Commitment to Advancement of Quality and Patient Safety in Surgical Practice" cluster. These findings reflect that in the respondents' view, "values" still remain the top attributes for being a good doctor. The three least important attributes were: Understanding and application of tumour node metastasis (TNM) classification to tumours (3.02, SD 0.86); knowledge of etiopathogenesis of common cancers in India (2.98, SD 0.8); and understanding the basic principles of tumour biology and carcinogenesis (2.82, SD 0.87).
Ability scores and rankings
The ability scores ranged from 1.91 (SD 0.83) to 3.02 (SD 0.89), reflecting a considerably lower score compared to importance. The top three scores for ability were:
- Removal of sutures and staples (3.02, SD 0.89)
- Being a lifelong learner and developing self-directed learning skills (2.98, SD 0.93)
- Maintaining honesty, empathy and an enquiring mind (2.92, SD 0.96).
The lowest three rankings were: Ability to understand basic principles of tumour biology and carcinogenesis (1.91 SD 0.83); ability to understand and apply the TNM classification for tumours (2.1 SD 0.87); and knowledge of etiopathogenesis of common cancers in India (2.13 SD 0.77). Thus, the malignancy cluster was considered least important as well as lowest on ability.
This was also reflected in the weighted averages for the eight competency clusters [Table 3].
|Table 3: Competency-specific weighted averages for importance, ability and importance-ability gap of surgical competencies expected of medical undergraduates|
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Commitment to advancement of quality and patient safety in surgical practice was the most heavily weighted cluster, while knowledge, prevention, early detection and treatment of common malignancies in India had the lowest weighted average score.
[Table 3] also presents the importance-ability gap-ranking for competencies. All sub-competencies reflected statistically significant performance gaps, which were clearly more pronounced for certain competencies. The competencies with lesser gaps were consistent with activities that are routinely taught in the undergraduate programme, indicating an adequacy of training. They are also relatively easy to learn by observation. In a typical teaching hospital, there are sufficient numbers of patients in a regular ward that provide the opportunity to observe, learn and develop skills.
The sub-competency with maximum ability-importance difference was "ability to maintain a legally correct medical record". The competency "ability to recognise, resuscitate, stabilise and provide advanced life support to patients following trauma" showed the highest performance gap. Of the top five sub-competencies with performance gaps, four belonged to this cluster [Table 4].
|Table 4: Highest and lowest importance-ability gap rankings by sub-competency for expected surgical competencies in medical undergraduates|
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In response to the question 'Would you like to mention any further competency which should be expected of MBBS graduates when they join a Surgical Residency Programme?' the following additional competencies were identified by respondents as being important.
- General managerial skills; finance and hospital management; how to run a clinic or nursing home (15 responses)
- Knowledge regarding legal aspects of practice and various government laws (6 responses)
- Having computer and internet skills (2 responses)
- Knowing medicines by generic names (1 response)
- Taking and interpreting an electrocardiogram (1 response).
| Discussion|| |
Our findings reflect the frequently echoed sentiment regarding diminishing "skills" and ability to "perform" among graduates in recent years. Concerns regarding this inadequacy have been widely expressed in the literature. ,, The situation in India has primarily arisen because of the postgraduate admission test conducted at the end of internship,  which is a written exam. The internship period, which is primarily meant for skill development, is spent in preparation for a high-stakes entrance exam. Various strategies to make the internship period more meaningful have been suggested. ,
The gaps revealed by our study include very critical areas - emergency and trauma care, taking informed consent and patient counselling. Overall, the performance gap was the maximum for the activities related to emergency and trauma care, a situation where the attending doctor seldom has the time to teach. Most of the learning is by observation, usually without much prior preparation or guidance. It is not common for interns to get an opportunity to practice these in a live situation. Simulated training is the exception rather the rule in low resource settings. These are complex tasks, and therefore difficult to learn by mere observation, and must be learned and practiced systematically before the real-patient encounter during internship. Informed consent and counselling, commitment to advancement of quality and patient safety in surgical practice were the other cluster scores that showed lesser skill development. The commonality across these is the lack of a formal or structured way of teaching in the curriculum.
The competency gaps in "Counselling, consent taking and addressing patient concerns" emphasises the need for a formal communication skills programme that will enhance their understanding of a doctor-patient relationship, what is expected, and give opportunities for students to practice their skills. This too can be learned in a simulated environment with the help of standardised patients. Both the modalities exist in the formal curriculum of developed countries. However, there is a misplaced misconception in the Indian scenario that due to patient numbers, there is ample opportunity to "practice" and learn hands-on skills. This is also true for the competency cluster for which the gap is third highest, i.e., commitment to advanced quality and patient safety in surgical practice. Simulated learning facilities can provide a mechanism for the needed preparedness. Considering that India has over 300 medical schools and many Indian doctors migrate globally, the issue assumes significance within and beyond geographical boundaries.
Of more relevance would be the implications of the gap analysis on curriculum organisation. If learners are to be prepared to be "ready for job" and competent in primary care, these competencies must be acquired. Rather than having skill acquisition occurring at the final stage of learning, a longitudinal progressive development of competencies is the better option.
The curriculum must explicitly describe the competencies, allot the necessary teaching time resources and facilities, like skills laboratory for training and practice, and clarify that the competencies will be assessed. Many tasks can be taught early on, starting with basic skills and then progressing to the advanced or more complex skills in the later years, as a longitudinal integrated skills programme. In fact, if the 34 identified sub-competencies are taught and assessed for progressive attainment, one could fairly say, with confidence, that this gap will be bridged.
Communication skills to deal with patients' concerns, medico-legal aspects, effective counselling, etc. are critical to patient satisfaction and need to be a part of formal teaching using active engagement strategies such as role plays, standardised patients for teaching, and assessing and giving feedback. The lower importance ratings on some competencies indicate that surgeons may not appreciate the importance of all competencies. Significantly lower scores on ability across all competencies reflect lower self-efficacy of recent graduates in general.
Undergraduate medical education, postgraduate training and medical practice should be a continuum, with a seamless transition from one into the other. , However, a steep learning curve and the lack of preparation can make it very stressful and intimidating for the resident, and can make assigning independent, unsupervised duties risky and may even present a threat to patient safety. In the Indian setting, the amount of time spent in a residency programme is short and supervision is constrained because of patient overload and faculty shortage. A gap in skills of entry-level postgraduates has been acknowledged.  In the undergraduate years it is perceived that the skills will be learned during residency, and therefore not taught. When the student joins the residency programme, the faculty wonders why the required skills were not already learned in undergraduate medical school.
In addition to guiding the implementation strategy for the new undergraduate curriculum, this study attempts to define the specific competencies for new residents that will prepare them well for the beginning of residency. The importance-ability gap analysis can be done for other content areas using the opinion of content experts with a broad range of experience that are important and relevant to a primary care physician.
A limitation of our study was using a cross-sectional survey of a continuing education programme audience largely consisting of postgraduates, faculty and practitioners. We did not include undergraduate students or interns. Additionally, the questionnaire was not piloted or pre-validated. Nevertheless, our findings reiterate the frequently expressed concerns regarding the skills of graduates. ,,,, We identify gaps in important areas that need to be addressed in the curriculum. Interventions can range from modifying the teaching-learning methods, the programme calendar or schedule, introducing new topics or faculty development and support for implementation. However, it would be fair to say that the competencies are the minimum expected as well as globally relevant.
The Vision 2015 document of the Medical Council of India  was the outcome of an effort to refine the undergraduate and postgraduate curricula for better alignment with societal needs as well as comparability with global trends and education standards. The best of curriculum documents require careful planning and preparation for successful implementation. Clarifying what needs to be done with particular reference to the context in an objective and specific manner is an important first step. A needs assessment such as this can help to determine areas of strength and concern, including what is being done well, areas that need strengthening and areas that need active curriculum development. This can be a useful guide for implementation and has implications for future assessment and faculty development.
| Author Contribution|| |
AJ participated in the conception of the study, questionnaire development, data collection, literature review, analysis and finalised the manuscript. PB participated in the conception and study design, questionnaire design, literature review, analysis and interpretation of data, drafted and revised the manuscript. SP assisted with study design, statistical analysis and interpretation of data. GB participated in conducting the survey, data analysis and helped to edit the manuscript. All authors read and approved the final manuscript.
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[Table 1], [Table 2], [Table 3], [Table 4]