Exploring Competency-Based Anatomy Education Through Direct Observation with Checklist as Teaching-Learning and Assessment Method: Lessons Learnt Through Student Feedback

Abstract

INTRODUCTION

The National Medical Commission's mandate to standardize medical education through implementing Competency-Based Medical Education (CBME) has necessitated the need for robust assessment strategies aligned with desired clinical competencies.

METHODOLOGY

In the context, the current study was conducted at Pramukhswami Medical College, Karamsad on 150 first-year MBBS students and investigates the efficacy of Direct Observation with Checklist as a teaching-learning and assessment method in anatomy education, specifically surface anatomy in the Abdomen and Pelvis regions of gross anatomy. The study employed qualitative and quantitative methods to evaluate student performance and perceptions.

RESULTS

Quantitative analysis revealed a significant difference in scores between Direct Observation with Checklist and traditional viva voce methods, underscoring its effectiveness. Qualitative findings from focus group discussions highlighted that this method enhanced understanding, retention, and confidence among students. It provided structured feedback, promoted reflective learning, and reduced assessor bias, thus supporting its role in assessing competencies at the “shows how” level of Miller's pyramid and aligning with CBME objectives.

CONCLUSION

The research underscores the transformative potential of Direct Observation with Checklist as a pedagogical tool in anatomy education, advocating for its wider adoption across medical disciplines as it evolves towards competency-based frameworks, such methods are crucial for ensuring that graduates are well-prepared for life-long clinical practice.

Keywords

Competency-based medical education surface anatomy focus groups checklists workplace-based assessment

Introduction

The National Medical Commission (NMC), erstwhile Medical Council of India (MCI), in their aim to standardize the output of graduate medical education in the form of an “Indian Medical Graduate” proposed curricular reforms through their document “Vision – 2015”. While the proposed changes emphasized on designing and implementing a curriculum that focused on desired and observable abilities in the form of competencies¹; Unfortunately, the alignment of assessment towards measuring these competencies was neither discussed in appropriate details nor included.² In 2018, MCI with the help of panel of experts drawn from across the country, laid the basic framework in the form of three volumes of curricular framework for the proposed Competency-based Medical Education (CBME).³ The thrust in the new regulations is to make medical education more learner and patient centric, outcome oriented with interactive teaching-learning methods and skill acquisition, but once again there is minimal guidance on assessment leaving it to the discretion of individual universities and institutions.⁴

This worldwide shift towards CBME ensures active participation of students in learning and clinical competence, but the restructured curriculum also mandates large-scale reforms in assessment approaches and methodologies.⁵ It warrants a robust and multi-faceted assessment system with enhanced attention to formative assessment that drives learning by setting clear expectations, providing opportunities to self-monitor and receiving feedback. Such competence can be better inferred from observable workplace performance using Workplace-based Assessment tools that assess at the “does” level of Miller's pyramid.⁶ On the other hand, poorly aligned assessments can mar the quality of learning.^7,8

In current pedagogical trends of anatomy, the function of living and surface anatomy has increased in medical curricula with it forming a bridge between clinical practice and gross anatomy. The surface anatomy provides ample opportunity to practice physical examination at very early stage in medical education preparing for life-long clinical practice. Also living and surface anatomy are better tested as a skill, assessed at “Shows How” level of Miller's pyramid.⁹ Hence the current study was designed to evaluate Direct Observation with Checklist as a teaching-learning and assessment method in anatomy.

Methodology

Setting and sample

The current observational interventional study was conducted at Pramukhswami Medical College, Bhaikaka University, Karamsad on undergraduate students of first MBBS (n = 150). The NMC Nodal center for Medical Education and technology runs a Competency-Based curriculum mandated by the National Medical Commission in 2019.

Design

The interventional study introduced Direct Observation with Checklist as a teaching-learning and assessment method for surface marking in anatomy and explored student's perceptions through focused group discussions.

Data collection

Identifying topics and defining Specific Learning Objectives: Anatomically and clinically relevant competencies of surface anatomy were identified for the Abdomen and Pelvis region of gross anatomy and were further analyzed into specific learning objectives.

Designing Checklists: Corresponding markings for checkpoints were derived from surface anatomical landmarks by performing surface marking of individual structures on mummified cadavers by the Principal Investigator and individual checklists weighing 5 marks each were prepared using the guidelines provided by Degani A. et al, Hales B et al and Stufflebeam DL.^10–12 (Table 1: Sample Checklist)

Internal and External validation of Checklists: Review versions of the checklists were shared with subject experts and comments and suggestions were carefully integrated validating and finalizing the marking scheme of each checkpoint.

Distribution of Checklists & Teaching-learning: Students were taught surface marking in small groups of 16-17 students each, routinely distributed during dissection classes using checklists along with their marking schemes. Their performances were observed and relevant improvements were suggested.

Assessment: Students were assessed individually during their single performance of surface marking by Direct Observation with Checklist by one assessor while another assessor rated the same student during the same performance by traditional unstructured viva voce methods.

Focus Group Discussion (FGD): A total of three FGDs comprising nine participants each were conducted by the principal investigator. Participants were recruited through purposive sampling by the faculty of the department ensuring equal and adequate representation of the key subgroups (dissection tables among which students are distributed) to gauge a detailed, valuable, and in-depth data through different opinions and perceptions across the class. Rapport was established with the participants as part of the regular teaching schedule and the participants were aware of the interviewer being the principal investigator of the research. Owing to COVID-19 lockdown, participants were approached telephonically to participate online in the FGD from their homes, and the discussions were conducted and recorded online on ZOOM Meetings platform, each lasting an average run-time of 2 h 47 min. One participant dropped out from the third group owing to network connectivity issues during the discussion. The principal investigator used a pre-validated interview guide (Appendix 1) with key questions and prompts to facilitate the discussion as well as overcome repetition and data saturation during the discussion (See acknowledgements). Notes were prepared during the discussion as well as during transcription and analysis of the audio-tapes. Data saturation was reached at the end of the three FGDs. No repeat interviews were conducted, neither was the transcript shared with the participants.¹³

Table 1.

Sample checklist (Stomach).

SR. NO.	POINTS TO ASSESS	MARKS
1.	Correctly marks the median plane	0.25
2.	Correctly palpates the sternal angle	0.25
3.	Correctly counts the ribs and identifies seventh costal cartilage	1
4.	Marks two parallel lines (L1 & L2) approx. 2 cm apart, directed downwards and left, 2.5 cm left of median plane on seventh costal cartilage	0.5
5.	Correctly palpates suprasternal notch	0.25
6.	Correctly palpates pubic symphysis	0.25
7.	Marks & Identifies a horizontal line, midway between them as Transpyloric plane	0.5
8.	Marks two parallel lines (L3 & L4) approx. 2 cm apart, directed upwards and right, 1.2 cm right of median plane from Transpyloric plane	0.5
9.	Joins L1 and L3 by a “J” shaped curved line	0.5
10.	Marks a line L5, convex upwards from line L2 to the left fifth intercostal space	0.5
11.	Marks another curved line downwards, convex to the left from L5 to L4	0.5
Total = (___ / 5)

Data analysis

The two assessment scores were computed using descriptive and relational statistics (Z-test) for analyzing significance. Z-test is a widely used statistical method to determine whether there is a significant difference between two samples when the population data is normally distributed. As for the FGDs, content analysis was performed through an inductive approach towards the data by two authors, whereby the discussions were openly coded through a thematic step-by-step analyzing method. The discussions were screened in reference to the interview guide to generate codes and categories that lead to a central organizing concept or a theme, having a certain level of pattern or meaning in relation to the questions in the data. Collaborative insights were generated among the researchers, findings were summarized, and a clear, organized final report was generated.¹⁴ No software was used for analysis and the report was shared with the participants for their feedback on the findings.

The reporting of this study conforms to the consolidated criteria for reporting qualitative studies (COREQ)¹⁵ (Appendix 2)

Results

Quantitative analysis

We observed a significant difference in the scores obtained by the students through both the methods. Z test computation also revealed sufficient evidence that there exists a significant difference between the scores obtained through Direct Observation with checklist and traditional viva voce methods (Table 2).

Table 2.

Scores obtained by the students (n = 147).

PARAMETERS	DIRECT OBSERVATION WITH CHECKLIST	TRADITIONAL VIVA VOCE METHODS
Mean	4.21	3.67
±	±	±
Standard deviation	0.79	0.74
Median	4.5	4
Mode	5	4
Standard error	0.12
Z Score	6.18
P-value	<0.05

Qualitative analysis

The thematic analysis of the FGDs revealed that surface marking with direct observation as a teaching-learning and assessment method enhanced the understanding, long-term retention, visualization as well as empathy through a structured approach and point-wise instructions. The participants also praised the method for efficient revision, instilling confidence through repetition of practice as well as catering to different learning styles. As a method of assessment for learning, the participants rated it as a valuable self-assessment tool that aids in error identification and reflective learning. An immediate structured feedback through the checklist often contributed to their accuracy and continuous growth. Moreover, the analysis also underscores the importance of checklist method in reducing assessor bias, increasing objectivity, and having a fair and uniform structured evaluation approach.

The participants also critically analyzed that while it may have led to an improvement in the overall scores there were valid concerns of deep conceptual learning and taking the point-wise instructions as a mere mechanical exercise without any additional effort for exploring the depths of the subject. While opinions varied on its clinical applicability, the method's benefit in aiding creating mental frameworks and improving precision were evidently helpful for further clinical studies. The participants strongly supported the continued use of checklist method for surface marking as well as its incorporation into other areas and subjects owing to its ability to address challenges and positive effects on performance but also suggest taking a hybrid approach through incorporating diagrams and reference texts for streamlining complex structures (Table 3).

Table 3.

Thematic analysis of the focus group discussions.

ADVANTAGES
SR. NO.	THEME	FREQUENCY OF OCCURRENCE	SAMPLE PARTICIPANTS NARRATIVES	FGD	PARTICIPANT
01.	Ease of Understanding and Memorization	27	“The texts in reference books are at times voluminous and difficult to comprehend whereas a checklist offers a more structured and organized approach”	2	3
01.	Ease of Understanding and Memorization	27	“A point-to-point approach of the checklist reduces any ambiguity and facilitates memorization as well as recall”	3	6
02.	Anxiety & Pressure Reduction	13	“I have a clear organization of thoughts even before the performance has begun, so I am less stressed”	3	5
			“It takes the pressure off from the examination because I am clear of the step-by-step expectations out of me”	1	8
			“It removes the pressure of communication, I know I am going to be judged solely on the basis of my performance, unlike viva-voce”	1	1
03.	Transparency & Clarity in Assessment	21	“If you are very clear on what is expected out of you it certainly helps improve your performance, isn’t it. Because your efforts are also focused accordingly”	2	7
			“A pre-marked checklist instills a notion of the importance of each step in the context of marks and also prioritize specific points that carry extra weightage”	3	8
			“The checklist allows the opportunity to score full marks which is very difficult with other form of examinations”	1	2
04.	Improvement in performance	20	“with the checklists with us, we had a lot of opportunity to practice and hence repeated performance helped to improve my performance”	3	9
05.	Efficiency in Time Management	13	“No lengthy texts, so no confusion and even saves on time”	2	7
05.	Efficiency in Time Management	13	“It's easier and quicker to revise from the checklist”	1	5
06.	Visualization and Clarity	16	“it is like a GPS, you know, provides a clear path, like a photographic memory”	2	5
07.	Empathy and Affective domain	11	“The last point in each checklist is about empathy, like handling the cadaver properly…wiping after use…including separate marks, it helps address the issue and promotes empathy”	2	6
08.	Uniformity and Objectivity	20	“Other factors apart from my performance don’t affect my scores, like some people can’t speak in English or are more confident in vernacular language”	3	5
08.	Uniformity and Objectivity	20	“It levels the playing ground for all…we all have an equal opportunity to score”	2	4
09.	Enhanced Clinical Relevance	09	“If a radial pulse has to be palpated, we need to know all the points, which in a way also clarifies its course, so this method actually helps in better clinical understanding of the neuro-vascular structures atleast”	1	1
09.	Enhanced Clinical Relevance	09	“There is better visualization of structures since all palpable points are mentioned for one structure”	1	4
10.	Immediate Feedback and Self-Assessment	23	“If we are provided with our assessed checklists we can clearly identify and introspect on our mistakes”	1	2
			“It is easier to know to my mistakes, which points I am likely to miss and correct on those points”	2	7
			“Specific mistakes made by individual student can be identified and addressed which can help to improve the overall performance”	3	5
11.	Customization	08	“There are going to be different body types who come to us, some are obese, some are lean, but a standardized checklist makes it simple to examine”	1	6
12.	Peer learning	15	“My friend has the same checklist, I can observe her performance and learn because I have to do the exact same steps”	3	7
12.	Peer learning	15	“We can also use the checklists with each other to learn and assess each other without the need for subjective expertise”	2	9
CHALLENGES
01.	Lack of Depth and Understanding, Creative Thinking Constraints	21	“Many a times students just take it as a mechanical exercise and memorize the steps without grasping concepts”	2	8
			“Higher scores might not necessarily reflect genuine learning or deep understanding of the matter”	1	4
			“A checklist often leads us to a sort of Tunnel vision where it may limit our broader understanding and exploration of the subject”	3	7
02.	Contextualization	18	“With checklists students don’t use reference textbooks and just focus on specific steps which limits any subjectivity”	2	5
03.	Teacher Involvement	14	“Discussions and demonstrations with a faculty is crucial and this is often neglected with this method”	1	4
SUGGESTIONS & IMPROVEMENTS
01.	Application Beyond Anatomy & Surface Marking	18	“Even in Physiology, clinical examinations I think checklist might be handy, or even in Biochemistry during practical examinations”	2	7
02.	Visual Aids and Diagrams	22	“Inclusion of diagrams along with the checklist can be really helpful because they give us a clear picture of where to mark and how”	1	5
03.	Hybrid Learning Approaches	22	“May be the checklists can come with a little reference material alongside that encourages students for deeper understanding and learning improvement”	2	3
03.	Hybrid Learning Approaches	22	“There can be quick explanation of higher-graded points to enhance student's understanding about the basic concepts”	3	7

Abbreviations: FGD, focus group discussion.

Discussion

The results revealed a significant difference in the performance and scores of the students as well as a favorable reception for Direct Observation with Checklist as a teaching-learning and assessment method for surface marking in anatomy. The method aligns with the objectives to assess surface marking at “shows how” level with a constructive feedback mechanism as well as an effective self-assessment. It also promotes deep understanding of the subject by providing ample opportunities for reflective as well as collaborative learning and caters to diverse learning styles.

Abu Bakar et¹⁶ al in their scoping review of effective teaching strategies in surface anatomy suggested multimodal approaches with teaching-learning methods that encompass an active learning environment and interactive feedback to contextualize the learning as well as provide ample opportunities for experiential learning through hands-on-activity and by reflecting on the learned subject. This is in concordance with Direct Observation with Checklist as a teaching-learning method that uses a structured and instructive communication with the students to perform, reflect, and conceptualize specific tasks as checkpoints on a mummified cadavers / mannequin through guided hands-on-activity and provides adequate opportunities for reciprocal and reflective learning by engaging into a self-assessment and feedback as well as peer-to-peer interaction. Such strategies have often lead to improved understanding of anatomy^17–19 could probably have led to an improved understanding of anatomy and performance of the students.

Conventionally, for formative purposes, such as feedback and improvement, more weightage is given to educational impact acceptability and cost as weighting criteria for conceptualizing an assessment tool.²⁰ The results underline the impact and appropriateness of Direct Observation with Checklist as an assessment method. Moreover, direct observation of student performance has been a reliable approach for evaluating proficiency in demonstrating a range of clinical skills and performing physical examinations²¹ and a checklist in such context can be useful in assessing competence by breaking them down into specific actions done or not done.²²

While, anatomy education has often been viewed as dull, intensive and pertaining to rote-memorization students often recognize pedagogical frameworks to enhance their understanding of anatomy and its clinical relevance as well as bridge the integration gap with clinical practice.^23,24 We believe, teaching and assessment methods such as Direct Observation with checklist that empower students to actively engage in learning and foster their participation can be of significant value addition during this paradigm shift in medical education in India to address the critical challenges of paucity of trained faculty members as well as standard assessment strategies^25,26 and the need to deliver a substantial amount of anatomy content within limited time constraints, while also appealing to high-achieving academic candidates.²⁷

We acknowledge that the FGDs were conducted by the principal investigator and participants were selected by purposive sampling, which though necessary to capture a wide range of outcomes through a fruitful FGD^13,14 may have affected the discussions and the notable as well as positive qualitative data analyzed may be interpreted in the context of motivated participants as well as the potential bias (such as confirmation bias, moderator bias) of the principal investigator, despite the intended approach to remain open to the student's experiences. We mitigated the selection bias by ensuring selection of participants for discussion by other faculty of the department and framing bias was avoided by a pre-validated interview guide, also analysis and interpretation was done by co-authors other than PI to avoid any over/under-interpretation of data. While sample size/power analysis was not performed, all students were included for quantitative assessment and adequate representation was ensured for qualitative analysis. And while the results may not be automatically generalizable to different educational settings, the critical question is whether if directly observing a student performance with a pre-rated checklist does simulate a workplace-based assessment? If yes, to what extent?

Conclusion

Direct Observation with Checklist is a an affective teaching-learning and assessment method for psychomotor domain of anatomy education that can not only help in a significantly improving student performance by fostering deeper understanding and promoting active engagement among learners but also be implemented across medical education disciplines as it evolves towards a competency-based framework. It aligns with the competency-based educational framework advocated by the National Medical Commission, in the context of being student-centric, outcome-based, with ample opportunities of feedback and competency assessment, empowering students for a life-long clinical practice. There is a need to explore the method, especially during teaching-learning and formative assessment of psychomotor skills through checklists, even if in hybrid mode for optimum benefits not only in other areas of anatomy but other disciplines as well.

Supplemental Material

sj-docx-1-mde-10.1177_23821205251321807 - Supplemental material for Exploring Competency-Based Anatomy Education Through Direct Observation with Checklist as Teaching-Learning and Assessment Method: Lessons Learnt Through Student Feedback

Supplemental material, sj-docx-1-mde-10.1177_23821205251321807 for Exploring Competency-Based Anatomy Education Through Direct Observation with Checklist as Teaching-Learning and Assessment Method: Lessons Learnt Through Student Feedback by Jaikumar B Contractor, Sanat Rathod and Praveen Singh in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-2-mde-10.1177_23821205251321807 - Supplemental material for Exploring Competency-Based Anatomy Education Through Direct Observation with Checklist as Teaching-Learning and Assessment Method: Lessons Learnt Through Student Feedback

Supplemental material, sj-docx-2-mde-10.1177_23821205251321807 for Exploring Competency-Based Anatomy Education Through Direct Observation with Checklist as Teaching-Learning and Assessment Method: Lessons Learnt Through Student Feedback by Jaikumar B Contractor, Sanat Rathod and Praveen Singh in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgements

Dr Dinesh Kumar, Professor, Department of Community Medicine, Pramukhswami Medical College, Bhaikaka University, Karamsad

Author contributions

PS devised and supervised the entire project. JC and PS were involved in data collection while JC and SR processed and statistically analyzed the data. JC and SR were the major contributors in writing and editing of the manuscript. All authors read and critically reviewed the final manuscript.

Data availability

Raw data can be made available upon reasonable request to the correspondence author.

DECLARATION OF CONFLICTING INTERESTS

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval and consent to participate:

The research study has been approved by Institutional Ethics Committee – 2, Pramukhswami Medical College, Bhaikaka University on 14/09/2019 under reference no.: IEC/HMPCMCE/2019/Ex.12/167/19; and the permission to conduct online focus group discussions was approved under IEC/HMPCMCE/2019/Ex.12/142/20. The Institutional Ethics Committee – 2 has been registered with the National Ethics Committee Registry for Biomedical and Health Research, Department of Health Research, Ministry of Health & Family Welfare, Government of India (File No.: EC/NEW/INST/2021/592). As part of the approved protocol, the informed consent requirement by the IEC-2 was waived for quantitative data collection. A verbal informed consent from the subjects prior to online FGD (qualitative data collection) was approved and recorded on ZOOM Meetings.

FUNDING

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The article processing charge for this article was funded by Bhaikaka University, Karamsad.

ORCID iD

Jaikumar B Contractor

Sanat Rathod

Praveen Singh

Supplemental material

Supplemental material for this article is available online.

Appendix – 1

Interview guide

Appendix – 2

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

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