CBME

Competency-Based Medical Education
(CBME) in General Surgery for MBBS
Students in India
Understanding CBME: A Paradigm Shift in Medical
Education

The Competency-Based Medical Education (CBME) curriculum, introduced by the Medical
Council of India (now National Medical Commission – NMC), marks a significant shift from a
time-based, knowledge-centric approach to an outcome-based strategy. The core objective
of CBME is to produce an “Indian Medical Graduate” (IMG) who is not only knowledgeable
but also possesses the necessary skills, attitudes, values, and responsiveness to function
effectively as a physician of first contact in the community, while remaining globally
relevant.

Key Principles of CBME:
•
Learner-Centric: The focus is on what the student should be able to do at the end of
their training.
•
Patient-Centric: Training is geared towards providing preventive, promotive, curative,
palliative, and holistic care with compassion.
•
Outcome-Oriented: Clearly defined competencies are the foundation, with teaching
learning strategies and assessment methods designed to ensure these outcomes are
achieved.
•
Integrated Learning: Emphasis on horizontal and vertical integration of subjects to
break down traditional silos and foster a holistic understanding of medical problems,
often using a problem-based learning approach.
•
Early Clinical Exposure: Providing students with early exposure to clinical settings to
facilitate practical learning.
•
Skill Acquisition: A strong focus on developing practical skills, with certain essential
skills requiring certification for independent performance.
•
Attitude, Ethics & Communication (AETCOM): Dedicated curriculum time for
developing ethical values, responsiveness to patient needs, and effective
communication skills.
•
Formative and Internal Assessments: Streamlined assessment methods to align with
the curriculum’s objectives. 

Teaching and Learning Methods under CBME
CBME emphasizes diverse teaching and learning methods to ensure comprehensive skill
development. These include:
•
Lectures: Traditional and interactive lectures for foundational knowledge.
•
Small Group Discussions: Facilitating active learning, critical thinking, and
collaborative problem-solving.
•
Bedside Clinics: Direct patient interaction for history taking, physical examination, and
clinical reasoning.
•
DOAP Sessions (Demonstrate, Observe, Assist, Perform): A practical session format
where students observe demonstrations, assist performers, perform in simulated
environments, and eventually perform independently under supervision. This is crucial
for skill acquisition.
•
Skill Labs: Dedicated facilities for practicing and mastering procedural skills in a
simulated environment.
•
Role Play: For developing communication and ethical skills, particularly in sensitive
patient interactions.
•
Case-Based Discussions: Integrating knowledge from various disciplines to understand
and resolve clinical problems.
•
Self-Directed Learning: Encouraging students to take ownership of their learning
journey.

Assessment in CBME: Beyond Rote Learning
Assessment under CBME is designed to evaluate the attainment of competencies rather
than just rote memorization. It includes:
•
Written Examinations: Short notes, structured essays, and theory papers.
•
Viva Voce: Oral examinations to assess understanding and critical thinking.
•
Skill Assessment: Evaluating practical skills in clinics, skill labs, or skill stations. This
often involves Objective Structured Clinical Examinations (OSCE) or Objective
Structured Practical Examinations (OSPE).
•
Logbook Documentation: Tracking and certifying the performance of essential skills,
especially those requiring independent performance.
•
Clinical Assessment: Evaluating performance in real clinical settings.
Levels of Competency (Miller’s Pyramid):
CBME defines levels of competency based on Miller’s Pyramid:
•
Knows (K): Basic knowledge (e.g., enumerates or describes).
•
Knows How (KH): Higher level of knowledge (e.g., discusses or analyzes).
•
Shows How (SH): Skill attribute (e.g., identifies or demonstrates steps,
interprets/demonstrates complex procedures).
•
Performs (P): Mastery and independent performance (rarely required in pre-internship,
often done under supervision).

CBME in General Surgery: A Student’s Guide
General Surgery under the CBME curriculum focuses on developing a well-rounded surgeon
who can effectively manage common surgical conditions. The curriculum emphasizes both
theoretical knowledge and practical skills, alongside ethical considerations and effective
communication.

Key Areas of Focus in General Surgery (based on the 2019 UG Curriculum Volume III):
Here’s a breakdown of the topics and competencies you, as an MBBS student, will
encounter in General Surgery:
Foundational Surgical Concepts:
•
Metabolic Response to Injury: Understanding the body’s response to trauma,
including metabolic changes and mediators. (K, KH)
•
Shock: Pathophysiology, types, principles of resuscitation, fluid replacement,
monitoring, clinical features, and appropriate treatment. Crucially, communicating and
counseling patients and families about shock with empathy. (K, KH, A/C – SH)
•
Blood and Blood Components: Indications, appropriate use, and complications of
blood transfusions. Observing transfusions and counseling patients/families for blood
donation. (K, KH, S – SH, A/C – SH)
•
Burns: History taking, physical examination, pathophysiology, diagnosis of type and
extent, treatment planning, and medicolegal aspects. Communicating and counseling
patients on outcomes and rehabilitation. (K, KH, A/C – SH)
•
Wound Healing and Wound Care: Normal healing, factors affecting it, history taking for
wounds, differentiating wound types, and management. Medicolegal aspects of
wounds. (K, KH, C – SH)
•
Surgical Infections: Etiology, pathogenesis, prophylactic and therapeutic antibiotics,
and appropriate management. (K, KH)
•
Surgical Audit and Research: Planning and conduct of surgical audit, principles of
clinical research in General Surgery. (K, KH)
•
Ethics in General Surgery: Principles of ethics, professionalism, and empathy towards
surgical patients. Discussing medicolegal issues in surgical practice. (K, KH, A/C – SH)
•
Investigation of Surgical Patient: Choosing and interpreting biochemical,
microbiological, pathological, and imaging investigations. Communicating results and
counseling patients. (C – KH, C – SH)
•
Pre, Intra, and Post-operative Management: Principles of perioperative management,
obtaining informed consent (simulated environment), observing and assisting in
surgical procedures, and performing basic surgical skills like suturing and minor
procedures in a simulated environment. (K, KH, S/A/C – SH, S – KH, S – P)
•
Anaesthesia and Pain Management: Principles of preoperative assessment, types of
anesthesia, airway maintenance (mannequin), day care surgery, and post-operative
pain relief. (K, KH, S – SH)
•
Nutrition and Fluid Therapy: Causes and consequences of malnutrition, estimation
and replacement of fluid/electrolyte requirements, and nutritional support for surgical
patients. (K, KH)
•
Transplantation: Immunological basis, immunosuppressive therapy, surgical
principles, and management. Legal and ethical issues of organ donation, and
counseling patients/relatives. (K, KH, S – SH)
•
Basic Surgical Skills: Aseptic techniques, sterilization, disinfection, surgical
approaches, incisions, wound closure materials, and demonstrating asepsis and
suturing in a simulated environment. (K, KH, S – SH)
•
Biohazard Disposal: Classification and appropriate methods of hospital waste disposal.
(K, KH)
•
Minimally Invasive General Surgery: Indications, advantages, and disadvantages. (K)
System-Specific Surgical Conditions:
•
Trauma: Principles of first aid, basic life support (BLS), management of mass casualties,
pathophysiology and management of head injuries, soft tissue injuries, and chest
injuries. Demonstrating airway maintenance and managing tension
pneumothorax/hemothorax in a simulated environment. (S – KH, S – SH, K, KH)
•
Skin and Subcutaneous Tissue: Pathogenesis, clinical features, and management of
infections and tumors. Clinical examination of surgical patients with swellings. (K, KH, S – SH)
•
Developmental Anomalies of Face, Mouth, and Jaws: Etiology, classification, and
principles of reconstruction for cleft lip and palate. (K, KH)
•
Oropharyngeal Cancer: Etiopathogenesis, symptoms, signs, investigations, and
treatment principles. (K, KH)
•
Disorders of Salivary Glands: Surgical anatomy, pathology, clinical presentation,
investigations, and treatment. (K, KH)
•
Endocrine General Surgery (Thyroid, Parathyroid, Adrenal): Applied anatomy,
physiology, etiopathogenesis of swellings, clinical examination, differential diagnosis,
management of cancers, hypo/hyperparathyroidism, and adrenal disorders/tumors. (K,
KH, S – SH)
•
Pancreas: Clinical features, investigations, prognosis, and management of pancreatitis
and pancreatic endocrine tumors. (K, KH)
•
Breast: Applied anatomy, investigations, etiopathogenesis, clinical features, and
management of benign and malignant breast diseases. Counseling patients and
obtaining informed consent for malignant conditions. Demonstrating breast palpation.
(K, KH, A/C – SH, S – SH)
•
Cardio-thoracic General Surgery (Heart and Lungs): Role of surgery in coronary heart
disease, valvular heart diseases, congenital heart diseases, mediastinal diseases, and
lung tumors. (K)
•
Vascular Diseases: Etiopathogenesis, clinical features, investigations, and treatment of
occlusive arterial disease, vasospastic disorders, gangrene, and principles of
amputation. Examination of vascular and lymphatic systems. (K, KH, S – SH)
•
Abdomen: Pathophysiology, clinical features, investigations, and management of
hernias, peritonitis, intra-abdominal abscesses, and retroperitoneal tumors. Applied
anatomy, physiology, and disorders of esophagus, stomach, liver, spleen, biliary system,
small/large intestine, appendix, rectum, and anal canal. Clinical examination of the
abdomen. (K, KH, S – SH)
•
Urinary System: Causes, investigations, and management of hematuria, congenital
anomalies, UTIs, hydronephrosis, renal calculi, renal tumors, urinary retention, bladder
cancer, and prostate disorders. Demonstrating digital rectal examination. (K, KH, S – SH)
•
Penis, Testis, and Scrotum: Clinical features, investigations, and management of
phimosis, paraphimosis, penile carcinoma, undescended testis, epididymo-orchitis,
varicocele, hydrocele, and testicular tumors. (K, KH)

How CBME Affects Your Learning in Surgery and How to Be
Ready for It
CBME demands a proactive and integrated approach to learning. Here’s how it affects you
and what you can do:
1. Shift from Rote Learning to Application: You’ll need to move beyond memorizing
facts to understanding how to apply that knowledge in clinical scenarios. Focus on
problem-solving and critical thinking.
2. Emphasis on Skills: Practical skills are paramount. Actively participate in DOAP
sessions, skill labs, and bedside clinics. Practice procedures on mannequins and
simulated patients until you achieve proficiency. Maintain your logbook diligently.
3. Integrated Understanding: Don’t study subjects in isolation. Understand how
anatomy, physiology, pathology, pharmacology, and other basic sciences integrate with
surgical conditions. This will help you grasp the ‘why’ behind surgical interventions.
4. Communication is Key: AETCOM is not just a separate module; it’s woven into every
aspect of patient care. Practice communicating effectively and empathetically with
patients, their families, and your colleagues. This is vital for obtaining informed
consent, explaining diagnoses, and counseling.
5. Early Clinical Exposure: Make the most of early clinical postings. Observe, ask
questions, and try to connect theoretical knowledge with real-world cases.
6. Self-Directed Learning: The curriculum provides a framework, but you are responsible
for your learning. Utilize resources, read widely, and identify your learning gaps.
7. Focus on Competencies: Understand the specific competencies expected for each
topic. These are your learning goals. Use them to guide your study and practice.
8. Prepare for OSCE/OSPE: These practical assessments will test your ability to perform
skills and apply knowledge in a simulated clinical setting. Regular practice and mock
tests will be beneficial.
9. Professionalism and Ethics: Develop a strong sense of professionalism, integrity, and
ethical conduct. These are core to being a good doctor.
10. Utilize Faculty and Mentors: Your teachers are there to guide you. Don’t hesitate to
seek clarification, discuss cases, and ask for feedback on your performance.
By embracing these aspects of CBME, you will not only excel in your examinations but also
develop into a competent, compassionate, and well-prepared Indian Medical Graduate
ready to face the challenges of modern surgical practice.