Empowering Continuing Medical Education (CME) in India: leveraging Kern’s instructional design model

Abstract

Introduction

Continuing Medical Education (CME) is vital for healthcare professionals to remain current with advancements and maintain their competence. In India, CME remains in its early stages, lacking a systematic approach. There is a pressing need for a comprehensive framework that addresses needs assessment, program development, accreditation, and credit allocation. Specifically, there is a gap in delivering targeted CME that meets the needs of different medical professionals at appropriate times. The aim of this study is to employ Kern’s six steps of curriculum design to plan and evaluate a faculty development program focused on Entrustable Professional Activities (EPAs) for MD (Doctor of Medicine) Biochemistry professionals.

Methods

This study utilized Kern’s six-step approach to design a training program on Entrustable Professional Activities (EPAs) tailored for MD Biochemistry professionals. Approval was obtained from the Institutional Human Ethics Committee. Following problem identification, a targeted needs assessment was conducted through expert consultations. The goal of the program was established, focusing on the development and delivery of an interactive online CME program. The program was developed, implemented and evaluated using surveys and feedback questionnaires.

Results

A comprehensive literature review revealed a notable gap in EPA-related works for MD Biochemistry program. Expert consultations highlighted significant training needs and barriers, such as limited resources and professional commitments. Consequently, the program’s primary objective was to raise awareness and sensitize participants to EPA development. A 4-h online CME was designed, featuring expert-led sessions and collaborative group activities. The program attracted 152 participants and utilized interactive elements, such as polls and chats, to foster engagement. Group activities allowed participants to apply concepts in EPA validation. Pre- and post-program surveys demonstrated significant improvements in participants’ knowledge and confidence. Feedback highlighted the practical relevance of the content and the interactive, hands-on nature of the sessions.

Conclusion

Kern’s six-step approach provided a structured and effective framework for developing the CME program, addressing identified needs and barriers, and enhancing faculty development in MD Biochemistry. This study underscores the importance of a systematic approach in CME to improve program effectiveness.

Trial registration

Not applicable.

Background

Continuing Medical Education (CME) is essential for healthcare professionals to stay updated with advancements in their field and to maintain their competence. CME activities are designed to enhance the knowledge, skills, and professional performance of physicians, enabling them to effectively execute their roles as healthcare providers, professionals, medical educators, or researchers. Traditionally, CME has been delivered in a teacher-centric format, often in conference settings [1].

In India, although CME is evolving, it is still in its early stages. The key stakeholders in developing and implementing CME programs include the National Medical Commission, professional licensing bodies, medical societies, educational institutions, and key opinion leaders. A systematic and integrated approach in developing CMEs that aligns with international standards is, however, still lacking [2].

Current CME evaluation methods often rely on participant feedback, which may not fully capture all aspects of educational effectiveness [3]. There is a pressing need for a comprehensive framework that addresses needs assessment, program development, accreditation, and credit allocation [2]. A methodical approach is required to align the continuous training of Indian doctors with evolving societal needs.

To address this gap, we used Kern’s six steps of curriculum design to plan and evaluate a CME program focused on Entrustable Professional Activities (EPAs) for MD Biochemistry professionals. This model is widely recognized in medical education for its ability to align educational activities with the specific needs of the learners, ensuring that the program effectively addresses identified gaps in knowledge or skills. Our study  aims to explore the usefulness of this comprehensive framework in developing a CME Program, to ensure that the educational needs of medical professionals are met more effectively.

Methods

We designed, developed, and implemented a CME for the faculty of MD Biochemistry program focusing on Entrustable Professional Activities (EPAs) using Kern’s model of instructional design. The following six steps were followed:

• 1. General Needs Assessment: A literature review was conducted to identify existing research and resources related to the development of Entrustable Professional Activities (EPAs) specific to the MD Biochemistry program.

• 2. Targeted Needs Assessment: To assess the training needs, we conducted a series of meetings with a group of experts. During the meeting, we provided a brief presentation on EPAs, including examples relevant to the MD Biochemistry program. We then solicited their perceptions regarding the usefulness of developing EPAs for the MD Biochemistry program.

• 3. Goals and Objectives: Clear, measurable objectives for the CME program based on the identified needs were set.

• 4. Educational Methods and Strategies: An online CME program of 4 h duration was designed to avoid the constraints of travel and time. The date and time were selected to minimize disruption of the routine work schedules of faculty and program directors, who were the intended audience.

  • The resource persons were chosen based on the discipline-specific nature of the workshop. While medical education experts could lead the sessions, it was essential to deliver the lectures through a discipline-specific lens to enhance readiness for EPA formulation. The discipline-specific experts selected had experience in identifying EPAs for the MD Biochemistry program, had completed training courses on EPAs, and had served as facilitators for EPA workshops. However, EPAs are not yet implemented in India for MD Biochemistry program, leading to a lack of experience among local resource persons in EPA implementation. To address this gap, we invited a pioneer in the field with extensive experience in the development and implementation of EPAs across various programs globally. The resource persons collaborated to align their individual session plans with each other and the overall program goals. The sessions were grounded in pivotal publications related to the objectives of the program. These publications were shared as resource materials with the participants to scaffold their learning. A Multiple-choice question (MCQ) test was designed to evaluate participants’ prior knowledge in the field before the sessions commenced. The same MCQs were administered after the session to assess their knowledge after the session. (Supplementary file 1). A retrospective pre/post-survey was used to collect the participants’ perspective on their skills and knowledge in this area before and after the session (Supplementary file 2). Additionally, credit hours from the medical council were obtained to enhance the program’s value.

• 5. Implementation: The implementation began with brochures shared across community of practice and registrations through QR codes. Communication was primarily managed through email, which was used to distribute pre-reading materials. Additionally, a dedicated WhatsApp group was created to facilitate real-time communication among registered participants, ensuring smooth event execution. On the day of the program, surveys were sent out in WhatsApp groups, with reminders to encourage completion. The program was conducted via Zoom, with the session link shared via email two days in advance and again in the WhatsApp group on the session day for easy access. A team of information technology experts were available to ensure seamless conduct of the event.

• 6. Evaluation: The program’s effectiveness was assessed using participant feedback (retrospective pre/post-survey) and performance assessments (MCQ test). For analysis of feedback questionnaire, numerical values were assigned for each of the five points in Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). Mean score was calculated for each item and compared by paired-t-test before and after the program. ‘p’ value of < 0.05 was considered as significant. Open comments are described as a free list.

The project was approved by Institutional Human Ethics Committee (Proposal number: 24/214). The CME was organized by the Department of Biochemistry of a medical school in Tamilnadu, India. Informed consent to participate was obtained from all of the participants in the study.

Results

STEP-1: Problem identification and general needs assessment

A systematic literature search using PubMed, Scopus, and Google Scholar identified only one published study on EPAs for the MD Biochemistry program [4]. Since the introduction in 2005, Entrustable Professional Activities (EPAs) have been adopted across various disciplines globally [5,6,7,8,9]. Despite nearly two decades of research, their implementation in health professions education in India is still in its early stages, indicating a significant gap and a need for increased sensitization and training in this area.

In the Indian context, the current approach to EPA training involves sporadic workshops facilitated by medical education experts, often including multi-disciplinary participants and occurring infrequently. Interested faculty members participate in the limited available courses or gather knowledge from published articles. However, the sporadic nature of current training efforts is insufficient for substantial change, underscoring the need for comprehensive faculty development programs. Existing literature shows a global paucity of data on effective EPA training methods [10, 11].

Progress within each specialty requires collaborative efforts among specialists, making it essential to train experts within the same discipline together to arrive at a shared understanding of EPAs. Accelerating targeted faculty development programs is crucial for achieving meaningful progress and effective EPA implementation.

STEP-2: Targeted needs assessment

A total of nine experts comprising program directors and postgraduate educators of MD Biochemistry program with diverse experiences from various institutions participated in the needs assessment. Notably, seven of them were unfamiliar with the concept of EPAs within the context of medical education and had no prior training or practical experience in this area.

After the presentation on EPAs, the experts concurred that the concept is crucial and holds the potential to significantly enhance the quality of postgraduate training. They also emphasized the necessity of faculty development initiatives to facilitate further progress in this area.

Experts cited limited access to training resources and competing professional commitments as primary barriers. To address these, suggested solutions include online mode of training and creating collaborative learning communities.

Based on these targeted needs, we planned to conduct an online CME for faculty of the MD Biochemistry program focusing on EPAs.

STEP-3: Goals and objectives

The goals and objectives for the CME program were developed based on the needs analysis. The goal was to enhance participants’ readiness in developing EPAs. The objectives of the program are as follows:

At the end of the program the participants will be able to.

• • Demonstrate comprehension of the concept of EPA

• • Distinguish between EPA and competencies

• • Describe an EPA in accordance with established guidelines

• • Validate an EPA using EQual rubric

• • Identify and explore research opportunities within this domain.

STEP-4: Educational methods and strategies

In order to achieve the objectives, interactive lecture-based sessions were designed. This was followed by a group activity and concluded by an open forum for Question &Answers (Q&A) with a pioneer in the field. The sessions are detailed in Table 1.

Table 1 Session details of the CME program

The session timings were strategically aligned with the learner’s needs. They were kept short to help participants stay focused and allow more time for group activities that promote active learning.

The sessions were designed to be interactive by incorporating polls and chat features to assess participants’ understanding in real-time. Discipline-specific examples were chosen throughout to ensure that the content was relevant to the participants. To encourage active application of the concepts, a group activity was designed where learners validated a given EPA using the EQual rubric in breakout rooms. Recognizing that active learning may raise questions, a Q&A session was strategically scheduled immediately after the group activity to address participants’ queries.

STEP-5: Implementation

There were a total of 152 registrations spread across 80 medical schools across the country. 52 of the registrants were professors and associate professors, 46 were assistant professors and senior residents, and 39 junior residents.

The program commenced with an inaugural note from the Head of the Institute, followed by interactive sessions as per the session plan and schedule. Chats and polls were employed during sessions to engage and interact with the audience effectively. Participants were briefed on the EQual rubric before engaging in a group activity. They were then randomly assigned to breakout rooms, where materials were shared for discussion. Each group was tasked with validating an EPA using the EQual rubric through group discussions. Subsequent to this group activity, a debriefing session was conducted to allow participants consolidate their learning. This was followed by Q&A segment with expert, for which prepared questions were employed to initiate discussions and encourage participant engagement. The session concluded with a post-training survey shared in the WhatsApp group. The WhatsApp group was maintained for ongoing discussions related to the topic, ensuring continuous engagement beyond the program’s conclusion.

STEP-6: Evaluation and feedback

The evaluation of the CME program aimed to measure the expected outcomes, which included improved knowledge of the participants, participant satisfaction, and increased confidence in developing EPAs.

• 1. Improved Knowledge:

  • ◦ This was assessed using MCQ test before and after the session. Participants completed a survey of 10 MCQs before the CME to gauge their baseline knowledge of EPAs and again after the CME to measure any improvements. The mean score before the session was (3.78 ± 1.79) and after the session was 5.06 ± 1.96 (p-value < 0.001)

• 2. Participant Satisfaction:

  • ◦ Satisfaction was evaluated through a feedback survey administered at the end of the CME. This survey included questions about the overall experience, and the effectiveness of the instructional methods. The results are listed in Table 2.

• 3. Improved Confidence:

  • ◦ Self-reported improvements in knowledge and confidence in developing EPAs were also measured using the feedback survey. Participants rated their knowledge levels before and after the CME on a 5-point Likert scale. The results are tabulated in Table 2.

Table 2 Scores of feedback survey items

The overview of the Kern’s steps and the process are summarized in Fig. 1

Fig. 1

Overview of the CME development process with the six steps of the Kern cycle

The open comments obtained in the feedback survey are listed below:

• • ‘I was able to learn many new things regarding medical education.’

• • ‘Budding graduates and post graduates will be trained systematically and will carry out this training for their juniors. Final outcome will be best patient care.’

• • ‘Entirely new topic. Opened up an entirely new area to my knowledge.’

• • ‘Would like to collaborate.’

• • ‘Thank you for the opportunity to learn new things.’

Discussion

CME programs are often conducted without a structured framework to guide their design, development, and implementation. International standards, such as those set by European Accreditation Council for Continuing Medical Education, emphasize the importance of a systematic approach that includes needs assessment, identifying the target audience, setting educational outcomes, selecting educational strategies that promote active learning, and incorporating evaluation and feedback mechanisms [12]. Literature also underscores the importance of these processes in developing effective CME programs [13, 14].

Kern et al. developed this six-step approach to offer a practical, theoretically sound method for developing, implementing, evaluating, and continuously improving educational experiences in medicine [15]. This has been successfully used in curriculum development for various degree programs, integrating new curricular elements into existing program, creating training modules and developing educational products [16,17,18]. There is paucity of application of Kern’s model in non-repetitive teaching-learning activities such as CME. This study employs Kern’s six-step approach as a structured framework to design, develop, and implement an online CME program focused on Entrustable Professional Activities (EPAs) for MD Biochemistry professionals.

This online CME was an attempt to address a gap in faculty development on EPAs. The needs assessment, which included discussion with experts, helped identify barriers such as limited awareness of EPAs and time constraints. These insights guided the design of the CME. An online format was chosen to make it accessible to a wider audience, which might not be possible through other means. The timings were also selected keeping in mind the professional commitments of participants. As expected, registrations came from various cadres across the country.

The selection of contents for the CME was done deliberately with the goal of sensitizing participants about the concept and understanding the utility of EPAs in implementing Competency Based Medical Education for MD Biochemistry program. The program included modules on the theoretical background of EPAs, specialty specific examples, and entrustment decisions. The contents were designed to instill interest, encourage self-directed learning and initiate work in this field.

Active participation was encouraged through a mix of interactive lectures and group activities. Learners applied their learning in group activities to validate EPAs. These examples of EPAs in group work were not ideal or validated but were meant to stimulate discussions related to the validation scale and enhance participants’ understanding. Thus, we used the concept of deliberately introducing errors as a pedagogical tool, known as the Derring Effect [19]. This promoted interaction among participants and provided networking opportunities.

Outcome measures included pre- and post-course surveys to evaluate changes in participants’ knowledge and confidence in applying EPAs. The results showed significant improvements, indicating the effectiveness of the CME program.

Feedback indicated that working with a specialty-specific EPA in the group work, facilitated interest and better understanding, making the content more practical and easy to grasp. Participants appreciated the interactive elements and the opportunity to engage in meaningful discussions. Specific feedback highlighted the clarity of explanations and the relevance of the content to their daily practice. Use of WhatsApp group created a channel for real-time and continuous communication, enabled ongoing discussions among participants, fostering a collaborative learning environment.

When organizing a CME, organizers typically consider factors like the availability of experts, content relevance based on informal discussions with colleagues, but these steps often lack systematic approach. The general needs assessment helped us define the program’s goal, which guided the subsequent steps. The targeted needs assessment then confirmed the relevance of the goal and provided valuable input for session planning. Thus, applying Kern’s 6-step framework has been a game-changer in addressing the audience’s needs, ensuring the program’s effectiveness.

Our study had few limitations. Due to time constraints, we could not facilitate introductions among participants, which could have hindered rapport development for effective group work. A suggestion for future iterations is to introduce participants in a WhatsApp group before the session. The program served principally as a primer to introduce the concept of EPAs to specialty experts, rather than providing in-depth training. CMEs are usually conducted as standalone events, so Kern’s continual improvement model may not fully apply in this context. However, the insights gained can help improve the planning of future events.

Conclusion

In conclusion, using Kern’s six-step approach provided a systematic and effective framework for developing a CME program. A key recommendation is that problem identification and needs analysis are crucial for empowering a CME. Clearly defining the problem is essential, as it facilitates in identifying a goal for the CME program. Conducting a thorough needs analysis allows for the tailoring the educational strategies to suit the needs of the participants.