Six-Step Approach to Curriculum Development (Kern et al., 2009).
Step 1: Problem Identification and General Needs Assessment; A meeting of Professors in Community Medicine of the state run medical colleges regarding the required reforms in PG curriculum revealed that; in the present format of postgraduate medical education in Community Medicine the information provided to the students is in disconnected pieces and mostly looks out of context, it encourages mostly a passive approach and pays little emphasis on solving practical problems. A lot of variation in teaching and learning the subject among colleges was also a cause of concern. They suggested that the identified problem could be overcome by designing and implementing a standard curriculum to bring uniformity, while respecting the right of each college to go beyond as per their own needs. Thereafter, a Technical Working Group made specific recommendations relating to curricular reforms which are incorporated in finalizing this document.
Step 2: Needs Assessment of the targeted postgraduate students & teachers; A needs assessment study using a Cross-sectional design was conducted through administration of an online questionnaire to identify the need of a common Post Graduate Curriculum (Misra, 2016). Before formulating the questionnaire, a Focus Group Discussion (FGD) with PG students of the College was conducted. There were ten PGs in the department and all of them were part of one FGD conducted using a semi-structured guideline, developed purposively for the discussion and this was conducted in English. At the beginning of the FGD, the participants were explained regarding the purpose, and confidentiality of the discussion and a verbal consent was taken. They were explained that they had the liberty to refuse to answer any question that they did not like. There were no disturbances and almost all could remain present throughout the discussion. Audiotape was not used as per the denial of the participants. The discussion lasted for one and half hours and the notes were expanded within 24 hrs of the discussion. Transcripts of FGD were prepared by two separate investigators, revised and analysed for content and key concepts as mentioned earlier. The moderator was the first author of this paper who is trained in qualitative research. Based on responses and emerging themes from FGD, the questionnaire was designed and pilot tested on ten PGs. The questionnaire was organized based on the current curriculum, for their opinions about the (1) general demographic information (2) qualities of the current curriculum/needs’ assessment (3) questions requesting classification of syllabus in Must to Know, Nice to Know and Desirable to Know. For questions about the qualities of the curriculum, a five-point agreement scale was used (1-strongly agree, 2-agree,3-neither agree nor disagree 4-disagree, 5-strongly disagree). In each section of the questionnaire, space was provided for additional comments.
The questionnaire was mailed to 100 PG students and 80 Teachers of Community Medicine from six Government and two private Medical Colleges of the state. Prior approval for the study was obtained from the Institutional Scientific and Ethics Committee. Important findings from needs assessment include;
- Majority of the respondents felt that there were no defined learning outcomes, teaching-learning methods and assessment methods.
- The curriculum lacks clarity, is not Competency-based and lacks linkages with professional development.
- All of them agreed that there is a need of introducing Formative assessment during PG course.
In a teacher’s own words to an open-ended question,” I wondered currently, ‘what a PG student of community medicine does for entire three years? There is a definite need of defining curriculum for three different years”. Another put it like this, “There is no formal formative assessment, except feedback given during presentation”. However, most of them agreed that the available curriculum helped students to utilize basic statistical analysis, material resources were available and students were being supported in independent learning. These findings reinforced a strong need of developing a curriculum for three separate years of course that could be followed by all Medical Colleges of the state. Important and relevant feedback from teachers and students has been incorporated in this document.
Step 3: Goal and Objectives; Once the needs of targeted learners were identified, goals and objectives for the curriculum were written, starting with broad or general goal and then moving towards specific and measurable objectives. Objectives included acquisition of competencies under the three domains of learning viz; Cognitive (knowledge), Affective (attitudinal) & Psychomotor (skill).
Programme Goal; The student shall acquire the understanding and the skill in Community Medicine and develop the quality of leadership so that s/he becomes an expert and function effectively as Community Physician, Public Health Specialist, Health Manager, Faculty and/or Researcher in the field of Community Medicine.
Some very basic Guidelines for Competency Based PG Training Programme for MD – Community Medicine by Medical Council of India, New Delhi were referred to by the faculty as a team. And first draft of the same was presented at a state level conference.
Entrustable professional activities (EPAs): To produce specialists of Community Medicine who upon successfully qualifying in the M.D examination shall have the following competencies/Skills;
(I) Public Health Specialist; can practice the Community Medicine specialty ethically and in step with the principles of health care.
(II) Epidemiology; has a spirit of scientific enquiry and is oriented to the principles of research methodology and epidemiology.
(III) Health Team Leadership; can function as an effective leader of a health team engaged in health care, research and training.
(IV) Teaching and Training: has the basic skill in training of the medical and paramedical professional.
(V) Research; can demonstrate competence in basic concepts of research methodology.
Entrustable professional activities were then specified in form of departmental objectives for example;
(II) Epidemiology, he/she should be able to;
- effectively use the tools of epidemiology for understanding disease causation and determinants of diseases.
- conduct epidemiological investigation of communicable, non – communicable and other diseases of public health importance and suggest appropriate solution.
- demonstrate competence in basic concepts of research methodology and epidemiology and be able to critically analyze relevant published research literature.
Departmental Objectives and specific learning objectives (SLO) were written in relation to the above competencies for all three domains viz: knowledge, skills and attitude.
Step 4: Educational Strategies; Once objectives were specified; curriculum contents were chosen and educational methods were selected in alignment with the objectives.
Course Contents for Theory; Topic Prioritization Guide was prepared and followed as shown in Table 1. For guidance to the student and faculty, topics were categorized into three, i) Vital (Must to Know), ii) Essential (nice to Know) & iii) Desirable to know. It gave an idea to the students and faculty regarding, the priority to be given to a topic while teaching and learning.
Table 1: Topic Prioritization Guide for Health systems in India and the world – Historical Perspective as an example
MD PSM, course contents for theory; Based on Core Contents
|
Priority
|
Teaching Learning Method
|
Must To
Know
|
Nice To
Know
|
Desirable To
know
|
Interactive
PG lecture
|
Discussion
|
Self-Directed
|
1. Health systems in India and the world –Historical Perspective
|
√
|
|
|
|
|
|
1.1. History of Public Health in India
|
√
|
|
|
|
|
|
History of Health Services in India
|
√
|
|
|
|
√
|
√
|
Indigenous Systems of Medicine in India
|
√
|
|
|
|
√
|
√
|
Bhore Committee’s and other “Committee Reports on Health Services,
|
|
√
|
|
|
√
|
|
Health care and Health Professional Education in India.
|
√
|
|
|
|
|
√
|
National Health Policy
|
√
|
|
|
√
|
|
√
|
An update of achievements of the country vis-à-vis the Health for all Indicators
|
√
|
|
|
|
√
|
√
|
1.2. History of Public Health in the World
|
|
√
|
|
|
|
√
|
Postings for PG Study in Community Medicine; Graded and increasing responsibilities were given to the students during first, second and third year of the course as shown in Table 2.
Table 2: Postings in Community Medicine at the studied Department
Name of place of posting: External (outside of hospital setting)
|
Duration in Days/weeks
|
Level (Semester)*
|
1. Central Water analysis laboratory/Public Health Laboratory:
|
Visit for a day under supervision of a faculty
|
III
|
2. Infectious Disease Hospital:
|
Visit for a day under supervision of a faculty
|
IV
|
3. Municipal Corporation:
|
1 week
|
V
|
4. Community Health Centre (CHC):
(Extension of posting from RHTC)
|
2 weeks
|
V, VI
|
5. CDHO Office
|
2 week
|
V
|
6. Any other
|
Urban & Rural Health Centers throughout (one year at least during the 3-year period), in rotation with experiential learning.
|
Name of place of posting; Internal (in hospital setting)
|
Duration in Days
|
Level (Terms)
|
1. Medicine:
|
2 weeks
|
III
|
2. Pediatrics:
|
2 weeks
|
IV
|
3. Obstetrics and Gynecology
|
2 weeks
|
V
|
OTHERS AS AND WHEN FEASIBLE:
|
|
|
Foods & Nutrition Dept.
|
2 days
|
II
|
National Institute of Malaria Research
(NIMR)
NADIAD
|
A day’s visit with a guide as a teacher
|
VI
|
Any other
|
|
|
*As per local resources and context.
The training was competency based and students were directed to acquire well identified competencies for which a list of competencies was prepared.
Organization of Teaching and Training: Teaching and training methods were spread over 6 semesters in three years and mostly included; interactive and organized sessions, case studies, practical exercises, guided learning by doing and thesis. All the activities were to be recorded and graded in the Log book. These were summarized at the end of semester/year/course as shown in Table 3.
Table 3: List of activities with minimum numbers to be achieved
These were summarized at the end of semester/year/course as below:
Summary of the activities carried out by the PG during __________Semester/_____ year /MD Course
Sr.
|
Activities
|
Minimum
Standards/ Numbers held
|
Achieved
(No given or 50% of activities held) Insert T* or A*
|
1.
|
Clinical posting (with Microteaching)
|
|
15
|
2.
|
Field visits
|
|
5
|
3.
|
Research (Field investigator/assistant)
|
|
5
|
4.
|
Epidemiological investigation
|
|
1
|
5.
|
Paper presented (Oral/poster/national/state)
|
|
2 in all semesters
|
6.
|
Paper published
|
|
1 in all semesters
|
7.
|
PG Presentation (Attended, presented)
|
|
15
|
8.
|
Journal Club (Attended, presented)
|
|
10
|
9.
|
UG Classes (Taken/Attended)
|
|
30
|
10.
|
Family Study (Carried out/presented)
|
|
5
|
11.
|
Case study (Clinico-Epidemiolgical /Health System Case study/Hospital /others) Prepared/Presented.
|
|
5
|
12.
|
UHTC Posting
|
1 month
|
1 month
|
13.
|
RHTC Posting
|
1 month
|
1 month
|
14.
|
CHC Posting
|
1 week
|
1 week
|
15.
|
Health System Office Posting (Meetings attended)
|
2
|
2
|
16. |
Health Program Supervision/Monitoring visits |
2 |
2 |
17. |
Epidemiology / Public Health / Biostatistics Exercise
|
5
|
5
|
T*= Taken, A*= Attended
Step 5: Implementation; Activities undertaken during;
First Year: An Orientation Programme of one week was undertaken so that the students could get acquainted with the department / subject. During first year they got opportunity to review undergraduate (UG) level of learning as all PGs were not at the same level of learning at intake. They were posted at urban and rural health centres to develop competence in performing duties of a basic doctor (MBBS) at the affiliated health centres including referrals. Undertaking basic research methodology workshop, training in Software like EPI Info and SPSS, communicating sympathetically and effectively with patients, relatives and families were important part of training starting right from the first year.
Second Year: Application of public health principles of the subject i.e. epidemiology, prevention, environmental sanitation, nutritional counseling etc. were undertaken. Thesis related proposal writing, field work in form of State Routine Immunization Monitoring (SRIM), epidemic investigations, health department convergence posting, Clinical Posting at other related department like Obstetrics, Pediatrics and Medicine were arranged and conducted. Enhancement of their teaching skill through microteaching sessions was an important aspect of the curriculum. During the second and third year they were required to deliver health care to defined communities in rural and urban settings. They also participated in national health programs and training programs of medical officers and primary health care workers. Data collection for dissertation was completed by second year and the first draft of dissertation was required to be completed before end of 2nd year of residency.
Third Year: Activities included acquisition of competence in major skills of the subject viz; writing research proposals and reports, critical appraisal of research papers, participation in national health programs (NHP), health finance/economics, presentation skills, attending meetings conducted by Chief District Health Officer and others. During the third year, emphasis was given to acquisition of skills relating to independent evaluation exercises, organization of surveys and investigation of disease outbreaks and teaching Sessions.
Teaching Learning Methods; Formal interactive teaching, Problem based learning, Role Play, Panel discussions, Seminar presentations, Microteaching sessions, Observation through visits, Self-Directed Learning through Reflective practice and attending workshops/conferences, Project based learning, Assignments, Demonstrations, Exercises, Videos, Discussion with UGs during Clinical postings and RHTC (UG students and Interns), Teacher and Peer feedback and few others were methods of active learning.
Teaching Schedule; The departmental teaching schedule included each of the following activity once in every week. 1) Journal club/Seminar alternate week. 2) Family / Medico-Social Case Presentation. 3) Epidemiology / Public Health / Biostatistics Exercise. 4) Thesis work discussion / Extra Mural Posting. 5) Field Visit/Microteaching.
A list of Topics for Modular Teaching/Learning was prepared and two of them viz; Integrated Management of Neonatal & Childhood Illness (IMNCI) and Revised National Tuberculosis Control Program (RNTCP) were undertaken as Self-directed learning to start with. List of activities with minimum numbers to be achieved that could be summarized at the end of semester/year/course was also prepared.
Assessment & Scheme of Examination;
1. Self-Evaluation – Through daily Work Diary and feedback from faculty. 2. Faculty Evaluation – Through scrutiny of Diary (concept maps) and Log Book by Guide and Head of Department. 3. Technique of skills in Pedagogy – Through Microteaching Sessions, lesson plans and supervised taking of clinical posting/tutorial for undergraduates (30 tutorials). 4. Skill Evaluation – Through demonstration, practical and field reports supported by a checklist. 5. Knowledge Evaluation –Through journal clubs, seminars and tests.
Types of assessment for the proposed curriculum; Formative Assessment: Formative assessment did not affect result at the end of the program, but provided feedback to the candidate. A formative assessment three months before the University examination was administered which was as similar as possible to the Summative / university examination. The performance of the Postgraduate student during the training period was monitored throughout the course and was duly recorded in the log books as evidence of the ability and daily work of the student. Annexure /Checklists for Evaluation of various activities were developed.
Marks out of 100 were allotted as below in Table 4.
Table 4: Distribution of Marks for Formative Assessment (out of 100)
Sr. No.
|
Items
|
Marks
|
Marks obtained
|
1
|
Personal attributes: Behavior and Emotional (Qualitative)
|
25
|
|
2
|
Theory, Practical Work and Viva (formative assessment in semesters)
|
30
|
|
3
|
Academic activities
|
25
|
|
4
|
End of term theory examination (after 2 years and 9 months)
|
10
|
|
5
|
End of term practical examination (after 2 years and 9 months)
|
10
|
|
Students’ assessment criteria: A qualitative criteria was well defined for assessment of PG student for Personal Attributes viz: Behaviour and Emotional (for example diligence, regularity, sincerity, teaching skills, interpersonal skills, leadership and motivation and research aptitude) during different academic activities was prepared and was graded in form of a Likert scale of 1-5 (Very poor to Very good) as shown in Table 5.
Table 5: Criteria for Assessment of PG Student for Personal attributes: Behavior and Emotional and during different academic activities (Qualitative)
Assessment Criteria (Max 5)
|
Score *
|
Remarks
|
Availability including Punctuality & Regularity
|
|
|
Interpersonal Skills and Leadership Quality
|
|
|
Motivation and Initiative
|
|
|
Diligence including Stability
|
|
|
Honesty and Integrity
|
|
|
* Very Good – 5, Good – 4, Average – 3, Poor – 2, Very Poor – 1.
A score of four (institutes can set such standards) in all items be set as an acceptable standard in order to get a final certification for appearing for M.D. University Exam. Marks for personal attributes and academic activity were given annually by all the consultants under whom the resident was posted during the year. Average of the three years to be put as the final marks except end of term exam.
Summative/University examination: Was in the form of dissertation/thesis, written papers (Theory), Practical/Clinical and Viva Voce. As per university requirement a PG student is allowed to appear in the university examination only after the acceptance of the thesis by two of the three examiners appointed by the university. A Sample of practical examination is depicted in Table 6. It is planned to redistribute topics in the 4 theory papers and this shall be put up in the forthcoming Board of studies meeting of the University. Attempt was made to frame Modified Essay type (MET) and Patient Vignette type questions as this helps to cover wide contents of the curriculum and is likely to improve the validity of the testing method.
Table 6: A Sample of MD (Community Medicine) University Practical Examination at the studied Department
Particular
|
Number
|
Marks
|
Time Duration
|
Long family case from the community
|
1
|
150
|
45 minutes
|
Short Case
|
2 (One of them includes Inspection of Public Health Practices of public health importance and other from a communicable disease)
|
150 (75 each)
|
30 minutes each
|
Public Health Spots
|
5-10
|
50
|
5 minutes each
|
Epidemiological + Statistical problem-solving exercises
|
3 Epidemiological and 2 statistical
|
50 (25 each)
|
45-60 minutes
|
Viva with or without Pedagogy Exercise
|
|
200
|
|
TOTAL
|
|
600
|
|
Step 6: Feedback and Evaluation: Reflections of students in the form of feedback were obtained to improve upon the course, which is now being implemented regularly for other enrolled PG students. The first batch of PGs trained through this structured curriculum have now been absorbed as Lecturers in medical college (n=2), Medical Officers (with administrative roles in urban corporation and rural area, n=2) and as Public Health experts (UNICEF and Taluka Health Office of a city, n=2).
One of the students who underwent the course reflected as "A Needs Assessment in form of Focus Group Discussion for the PGs regarding their perceptions about the curriculum and expectations from the teaching staff was carried out; based on which, topics to be taken as part of teaching were decided. Cadre-wise faculty was assigned to undertake various topics for PG teaching". Emphasis was given on Healthcare Administration and Qualitative Research.
Another one mentioned that "The PGs were given teaching sessions for the MBBS students (Clinical Postings) after ‘Microteaching' sessions to improve their teaching skills. Peer based learning and case-based learning session were held for Health Management topics. Case based learning approach was also used for Community based E-learning. The innovative aspect was structuring rural training and planning of skits/ plays at Rural Health Training Centre (RHTC) which helped us to improve interactive and communication skills".
Program evaluation: Informal observations / discussions with students & faculty to provide ongoing feedback were undertaken. The purpose was to bring improvement in the curriculum and the learners. Also, to gain support and resources for the curriculum, in research situations to answer questions about the effectiveness of the curriculum and relative merits of the different educational approaches, Figure 2.
Figure 2: Informal discussion with postgraduate students regarding the Curriculum

Majority of the teachers and students mentioned that the curriculum was in alignment with the learning outcomes, teaching- learning methods and assessments. Most of them felt that the teaching and learning methods were relevant to the content and learning outcomes.
The curriculum did help students to apply knowledge to clinical/field situations and initiated critical thinking and problem-solving skills in them was mentioned by most of them. Majority of them agreed that resources were available to ensure effective teaching and learning for the curriculum content. The faculty made efforts to observe and certify core competencies.
All of the students and faculty strongly agreed that there is a need of introducing formative assessment during PG course. And that formative assessment would be helpful in motivating students and the same should have weight-age in final exams. Evaluation through a semi-structured questionnaire is planned with faculty and students of the forthcoming batch.