|Year : 2020 | Volume
| Issue : 2 | Page : 70-73
Coverage of antimicrobial resistance in the revised indian medical curriculum: Lip service only?
Vijayaprasad Gopichandran1, Bharath Kumar Tirupakuzhi Vijayaraghavan2
1 Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India
2 Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu; The George Institute for Global Health, New Delhi, India
|Date of Submission||28-Sep-2019|
|Date of Decision||03-Aug-2020|
|Date of Acceptance||18-Aug-2020|
|Date of Web Publication||08-Dec-2020|
Bharath Kumar Tirupakuzhi Vijayaraghavan
Department of Critical Care Medicine, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The undergraduate medical curriculum has undergone a major revision. This study was designed to systematically review the revised Indian medical school curriculum to assess the extent of coverage of antimicrobial resistance (AMR) and antibiotic stewardship-related competencies. Methods: We undertook a document review of the recently revised Indian medical curriculum to identify the extent of coverage of competencies related to AMR and antibiotic stewardship. With the use of a previously described search strategy, we queried the online freely accessible version of the curriculum in duplicate and independently. We describe by volume, by subject and by the tenets of Miller’s pyramid all references to AMR and stewardship. Results: Out of 2939 competencies that medical students are expected to complete over a 5.5-year period, 17 (0.57%) relate to AMR and antibiotic stewardship policies (ASP). There are no references to AMR or ASP in Pediatrics, Surgery, Obstetrics and Gynecology, Ear, Nose and Throat, Ophthalmology and Orthopedics. Community Medicine has few links through integrated teaching but has no direct AMR or ASP content. When categorized by Miller’s domains, two of the competencies, both in Pharmacology, deal with the “Does” category, which is the practical skill gained by the student. There are five competencies which belong to the “Shows How” category and the remaining 10 belong to the knowledge categories. Discussion: There is poor coverage of AMR and stewardship in the revised Indian medical curriculum, suggesting that there is very little appreciation of the enormous threat that AMR poses to public health. This is a huge missed opportunity that needs immediate corrective action.
Keywords: Antimicrobial resistance, curriculum, medical education
|How to cite this article:|
Gopichandran V, Tirupakuzhi Vijayaraghavan BK. Coverage of antimicrobial resistance in the revised indian medical curriculum: Lip service only?. Educ Health 2020;33:70-3
| Background|| |
Antimicrobial resistance (AMR) is a global public health crisis with nearly 10 million deaths expected to occur annually by 2050 attributable to the burden of AMR. Along with climate change, it poses one of the biggest threats to human existence. In recognition of this threat, the 68th World Health Assembly in 2015 endorsed a Global Action Plan to combat this major crisis. As with climate change, the highest impact of AMR is expected to be on the impoverished peoples of the Global South and the largest number of lives are predicted to be lost in low- and middle-income countries (LMICs).
There are several important reasons for this huge burden in India and other LMICs. In addition to weaker surveillance systems, these countries are typically resource deprived in taking on the challenge of AMR.
The Global Action Plan proposed by the World Health Organization identifies “improving awareness and understanding of AMR” as one of the key strategies for tackling the threat of AMR. Given that antibiotic prescription is indiscriminate in India and awareness among healthcare providers low, one of the key target groups for this objective would be physicians, specifically doctors-in-training. Recently, the Medical Council of India revised the curriculum for the Bachelor of Medicine/Bachelor of Surgery (MBBS) course, the principle training program for doctors in India, after a gap of 21 years. The current edition of the curriculum represents one of the most substantive revisions ever undertaken with “competency-based medical education” being the overarching approach and will impact nearly 70,000 doctors-in-training every year across India. Training MBBS students who represent the future prescribers on the principles and epidemiology of AMR and on the need for antibiotic stewardship and appropriate prescription practices is central to any meaningful effort to containing the spread of AMR.
In a query of the postgraduate training curricula in the United Kingdom, Rawson and colleagues found poor coverage of AMR and antibiotic stewardship policies (ASP) across specialities. In this study, out of 37 specialties assessed, only 0.3% of topics and 0.4% of learning points were focused on AMR/ASP. In their quality assessment, they found that the majority of learning points required only knowledge and not a demonstration of practice.
In a systematic review of antimicrobial stewardship training, Silverberg et al. identified 48 studies; 14 of these included only undergraduate trainees, 11 included both, and 20 only postgraduate trainees. Didactic teaching methods were the most commonly used and most studies in this review did not evaluate the impact of the intervention on prescribing behaviors and instead focused on Kirkpatrick levels 1 and 2 predominantly (reaction and learning).
We hence undertook an interrogation exercise of the revised medical curriculum with the specific objective of identifying the extent to which AMR is addressed in this edition of the revised curriculum.
| Methods|| |
We accessed the freely available online versions of the revised curriculum and applied search strategies. The curriculum is spread over three volumes and 890 pages. Students are expected to achieve 2939 competencies over 5.5 years of training. The new curriculum is based on the key tenets of the Miller’s pyramid and aspires for the physician to demonstrate competency in five major roles – as a Clinician, Leader, Communicator, Lifelong learner, and a Professional.
We used previously described key terms “anti*,” “resist*,” “infect*,” “drug,” “antibiotic,” “antimicrobial,” “multi,” and “stewardship” to search the curriculum and identify the prescribed competencies that relate to AMR and antimicrobial stewardship policies (ASP). The search was conducted in duplicate by both the authors and competencies identified. Disagreements and differences, if any, were resolved by consensus. Apart from this we also reviewed the curriculum of Pharmacology, Microbiology, Pathology, Community Medicine, General Medicine, General Surgery, Pediatrics, Orthopedics, Obstetrics and Gynecology in detail to specifically look for references to antibiotic use and AMR. We describe by volume, by subject and by the tenets of Miller’s pyramid all references to AMR and ASP with the related competencies.
Based on the study design, no ethics clearance was deemed necessary.
| Results|| |
We identified a total of 17 references to AMR/ASP-related competencies among all the medical school subjects put together. Of these, 7 are from Pharmacology, 3 from Microbiology, 5 from Internal Medicine, and 2 from Respiratory Medicine/Chest Medicine. There are no references to AMR or ASP in Pediatrics, Surgery, Obstetrics and Gynecology, Ear, Nose and Throat, Ophthalmology and Orthopedics. Community Medicine has few links to AMR topics through integrated teaching but has no direct AMR or ASP content. Anesthesiology, which includes competencies related to Critical Care Medicine, also has no references to AMR or ASP. [Table 1] presents the competencies identified along with the Miller domains from the streams of Pharmacology, Microbiology, Internal Medicine, and Respiratory Medicine.
|Table 1: Competencies related to antimicrobial resistance/antibiotic stewardship policies as identified by our systematic search strategy in the revised Indian medical curriculum|
Click here to view
When categorized by Miller’s domains, two of the competencies, both in Pharmacology, deal with the “Does” category, which denotes the practical skill to be gained by the student. There are 5 competencies which belong to the “Shows How” category and the remaining 10 belong to the knowledge categories of “Knows” and “Knows How.”
| Discussion|| |
Our review of the revised curriculum demonstrates low coverage of the key topics of AMR and ASP. Less than 0.6% of the total competencies relate to this enormous public health crisis. In the subject of Community Medicine, there is no direct inclusion of AMR/ASP. Given the scope of the problem and the fact that community abuse of antimicrobials and lack of community awareness plays a key role in the emergence of resistance, a more detailed coverage of this topic in Community Medicine is essential. Similarly, Anesthesiology and Critical Care Medicine which are uniquely placed in terms of being both at the receiving end of problems related to AMR and being a crucial source of antibiotic selection pressures and emergence of resistance, have no direct AMR or ASP content. Another major area of concern is the potential inappropriate use of antibiotics by surgical specialties. It is noteworthy that there is no mention of rational antibiotic use in surgery or the problem of AMR and ASP in these settings. The curriculum seems to suggest that antibiotics is a subject matter that only concerns medical specialties, thus displacing the responsibility of rational antibiotic use away from the surgical specialists.
Analysis of the Miller’s pyramid category of the competencies reveals that only two of the competencies, both in Pharmacology, deal with the “Does” category, which is the practical skill gained by the student. There are five competencies which belong to the “Shows How” category and the remaining 10 belong to the knowledge categories of “Knows” and “Knows How.” If the medical curriculum is to make an impact on the students to prevent indiscriminate and irrational use of antibiotics, there is a need for higher order competencies that create a sustainable change in prescription.
Whilst there are several admirable features of the revised Indian curriculum such as the focus on competency based education, the inclusion of the Miller’s pyramid as the paradigm model and the introduction of integrated teaching (to overcome the problem of a silo-based approach), it falls short of expectations in addressing an important threat to human health. Given that medical school education provides the building blocks and that the students represent future prescribers and policy-makers, this is disheartening. We see this as a huge missed opportunity.
The strengths of our study include a systematic document review of the revised curriculum. We searched the curriculum in duplicate and with previously described search strategies to ensure that key competencies are not missed. In addition, we have identified the key competency, the subject under which it is covered, whether it factors in integrated teaching and the Miller’s domain to which it belongs. To the best of our knowledge, our study represents the first such effort in identifying AMR and ASP coverage in the new curriculum.
There are a few limitations to our approach. We only identify the competencies included in the curriculum. The impact that the revision will have on the medical students in terms of AMR and ASP awareness, knowledge and behavior change will depend on the way these competencies are delivered across medical colleges in India and on how student assessments are undertaken. Ultimately, the real test of a curriculum lies in the changes it brings about in physician behavior and patient outcomes. Further quantitative and qualitative research will be needed to identify these changes.
In conclusion, our study highlights the major limitations of the revised medical school curriculum in delivering content related to AMR and ASP. We hope that the Ministry of Health, Government of India, the National Medical Commission, and other policy-makers will take note and address the concerns arising from our findings in future iterations of the curriculum.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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