Developing a competency-based undergraduate logbook for pediatrics: Process and lessonsT Singh1, R Aulakh2, P Gupta3, J Chhatwal4, P Gupta5
1 Departments of Pediatrics and Medical Education, SGRD Institute of Medical Sciences and Research, Amritsar, Punjab, India
2 Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
3 Department of Pediatrics, ESIC Medical College and Hospital, Faridabad, Haryana, India
4 Department of Pediatrics, Kalpana Chawla Govt Medical College, Karnal, Haryana, India
5 Department of Pediatrics, University College of Medical Sciences, New Delhi, India
Keywords: Assessment, competency-based, logbook, pediatrics, reflections
We are in the midst of a paradigm shift in our current approach to medical education in India with the implementation of competency based medical education (CBME) across all medical colleges since 2019. This mandates a change in assessment methodology as well as greater emphasis on formative, on-going, criterion-based assessment with regular feedback to the learner which should not only be quantitative but also qualitative. While proposing a model for competency-based assessment of the Indian Medical Graduate (IMG), we have already highlighted the importance of record keeping for internal assessment in the form of a logbook or e-portfolio.
Logbook is defined as 'a verified record of the progression of the learner documenting the acquisition of the requisite knowledge, skills, attitude and/or competencies' in relation to the new curriculum. With certain additions (such as 'reflections'), logbooks can also provide 'evidence' of learning and can double up as e-portfolio. Contrary to the popular belief, logbooks are not simply a documentation tool but can also function as effective assessment tools, especially for competencies where there is no formal assessment.
The erstwhile Medical Council of India (MCI), [now National Medical Commission (NMC)] have provided guidelines for designing subject specific logbooks but left the final design and format to the institutions. To ensure uniformity in teaching and assessment of students in the subject of pediatrics, uniform learning objectives derived from specified competencies have been already designed. With the 2019 batch of MBBS students entering pediatric clinical posting soon, creation of a Pediatric logbook in consonance with the NMC UG Curriculum was felt to be need of the hour. No such document is yet available in the public domain.
While there is no accepted 'model' or 'technique' for developing a logbook, we were guided by the cardinal concept of utility of assessment in designing this logbook. Out of the five parameters of good assessment viz. 'validity', 'reliability', 'feasibility', 'acceptability', and 'educational impact', we picked up feasibility and educational impact as the most important ones. It would have been inappropriate to have a logbook so elaborate that the students (and teachers) would not find enough time to complete (and assess) it, nor so brief that it would not provide evidence of, or a direction to learning.
Our objective was to design a logbook that would provide a concise record of all activities requiring documentation as per NMC UG Curriculum. The complexity of the task was to simplify the logbook template as much as possible so that it could be useful to all the medical colleges across India, which differ significantly in their infrastructure, patient load, faculty strength and student intake. Furthermore, as the medical undergraduate would have to maintain logbook for many other departments at the time of their pediatric postings, emphasis was on not only making it compact but also designing an interesting thought-provoking activity resulting in enhanced depth of learning.
The logbook template was created after enormous brainstorming amongst authors to identify activities requiring documentation as per the NMC undergraduate curriculum. The NMC Pediatric UG Curriculum 2019, has 35 topics with 406 competencies covering various domains of learning i.e., knowledge, skill, attitude and communication. The competencies are further classified in terms of a (modified) Miller pyramid as: Knows (K), Knows How (KH), Shows (S), Shows How (SH) or Perform (P). The level 'Perform (P)' in the context of undergraduates indicates independent performance under supervision. While it would be tempting to include all the competencies in the logbook, it will make the implementation extremely difficult. The unique requirements of the logbook and their incorporation are shown in [Table 1].
[Figure 1] details the distribution of competencies for the subject of Pediatrics and the selection process for the logbook. Of the 406 competencies mentioned under Pediatrics, 230 are Know (K) or Knows How (KH) with suggested assessment by written/viva format in 228 competencies. These were removed from the purview of the logbook as record of their teaching and assessment would be maintained in the department. The remaining 176 competencies are at Shows (S), Shows How (SH) and Perform (P) level. Of these, 23 competencies are requiring certification, each with a pre-specified number of successful attempts by the student before being certified. These certifiable competencies have been included in the logbook with a monitoring and assessment template suggested in NMC guidelines. Each attempt at certifiable competency is to be verified by the teacher and feedback provided to the student. Extra rows for remedial attempts, if required, have been provided. Space has also been provided for the students to write their reflections. Should they reflect on each or select a few important ones (e.g., perform developmental assessment versus identify a BCG scar) is a decision which we have left to the individual departments and included space for five reflections. We have suggested Rolfe et al. (2001) model of reflection due to ease of use and strength of familiarity but individual departments can use others depending on their preference. We have also suggested that the page depicting summary of the certifiable competencies may be kept as a perforated sheet, which can be detached and put in student's file after completion. It may be noted that we have not critiqued the competencies, teaching methods or assessment as suggested in the curriculum and followed the suggested pattern to create the logbook.
Clinical case presentations, competencies, and skill learning sessions
The logbook begins with a section on clinical case presentation with phase-wise division and record of cases presented or attended by the student. The latter delineation might motivate students to proactively present more cases, than be just an observer during bedside clinics. We have included the three competencies to be taught in the skill labs, but refrained from providing any checklist for the same. These need to be maintained in the departments and an entry made in the logbook when the student has completed all the requirements for each one of them.
Affective competencies and clinic/field visits
Of the remaining 153 competencies, 20 are included under 'A or A/C domain' and 5 included under 'S domain' but the latter too are related to the affective domain [to be integrated with AETCOM (Attitudes, Ethics and Communication) module, either horizontally or vertically]. Of these 25 competencies, 23 are specified to be documented in the logbook as per the assessment method in NMC curriculum. All of these have been included.
Of the remaining 128 competencies, 8 are related to field/clinic visits and these were included along with 1 from 'K level' of competency bringing it to a total of 9 competencies under clinic/field visits in order to encourage the student to spend time observing, recollecting and documenting the first experience as an observer in an ongoing clinic. We were finally left with 120 competencies, but to keep it manageable, we included only those 50 which were specified to be documented in the logbook as per the NMC Curriculum along with 1 competency from 'KH level' of competency requiring documentation and separated these 51 under 'competencies requiring documentation', but left it open for colleges to add more if required. We have deliberately not included attendance or assessment records in the logbook as they may be prone to manipulation and disputes. They are best maintained in the respective department.
Participation in department activities
To highlight, promote and reward participation by undergraduates in departmental activities, separate section to document these has been created to document participation in Information Education and Communication (IEC) activities during specific health promotion days, attendance in seminars/CMEs, participation in Indian Academy of Pediatrics (IAP) undergraduate quiz, pediatric specialty clinics, and other similar academic/clinical/social activities. Special emphasis on research during under graduation has also been made by providing opportunity to students to depict papers presented/submitted or published and participation in research projects like Short Term Studentship (STS) Research Projects under Indian Council of Medical Research (ICMR).
Self-directed and integrated learning
A special section on self-directed learning has been provided which would help the student assess his own learning process and understand the ways to improvise it under guidance of teacher-cum-mentor. A record of integrated teaching-learning which can be updated while the student progresses through various phases of MBBS curriculum has also been provided for a more holistic reflection by the student with augmentation in his understanding/comprehending skills. Additional pages for notes by students have been added to help inculcate kind of 'journal writing habit' by taking down important notes during clinical rotations which would further add uniqueness to their individual logbooks' records.
The draft template was sent to 8 reviewers from various medical colleges. The suggestions received were reviewed and incorporated to improve the utility.
The logbook template is available at https://www.researchgate.net/publication/352350197_Logbook_for_Pediatrics_Under-graduate_competency-based_curriculum_of_NMC
As the CBME based NMC Curriculum is in initial stages of implementation with paradigm changes in teaching-learning and assessment methods, both teachers and students would be required to adopt a new approach to adapt to the current medical education requirements. This Pediatric logbook template has been created to assist them in this endeavor. With the MBBS 2019 Batch now entering Phase II, a Pediatric logbook would be required so that complete record of the student is available as he progresses through various phases of MBBS curriculum. The institutions may use this logbook template to build their own institute-specific logbook based on the infrastructure, faculty strength, clinical patient load, student intake and preferred assessment method(s). Although the students may have learnt to write reflections by the time they come for pediatric posting, it may be worthwhile to re-iterate the technique for students. Teachers may also need orientation to assess reflections, provide feedback and help students for further learning. We believe that providing feedback on reflections and SDL should happen before teachers sign the relevant pages and therefore, signatures of the teachers on reflection pages would mean that feedback (oral/written) has been provided to the students. It would also be worthwhile to integrate this logbook with the internship logbook (and later the postgraduate one for students opting for post-graduation in pediatrics) to provide a longitudinal record of the trajectory of learning for each student. A completed well-maintained logbook can be an important component of a student's learning portfolio.
Like any other learning or assessment tool, the utility of logbook will also depend on the way it is used by the students, teachers, departments, institutions, and universities. It is crucial to have all stakeholders on board to maximize the learning potential. We hope that the process described will also help other clinical departments also to design a logbook for their own subject area.
We emphasize that this is not a prescriptive model and the way of recording, format (electronic/physical) etc., can be modified to suit the individual requirements and local conditions.
Dr Ajay Gaur, Dr Anju Kapoor, Dr Dheeraj Shah, Dr Harmesh Singh Bains, Dr Kuldeep Singh, Dr Manab Narayan Baruah, Dr Shahi Kant Dhir, and Dr Sujata Kanhere, for thoroughly reviewing the logbook in making and providing valuable suggestions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.