Competency-Based Medical Education in Radiology in Indian Medical Schools: A Narrative Review

Abstract

Competency-based medical education (CBME) is the latest reform in undergraduate medical education. Education in medicine is extremely dynamic and ever-evolving, which makes it necessary to integrate new strategies to educate students. Strategies that make education more student and patient centric, helping students better themselves and improve the quality of patient care with emphasis on patient understanding, consent, and autonomy. When it comes to radiology and implementation of CBME curriculum, it has proven to be beneficial to students. It exposes students to the limited and essential knowledge that students can comprehend moving forward. Teaching complex topics like MRI types or CT scan interpretation in the second professional year may be premature and ineffective. Therefore, dividing the course according to the understanding and accessibility of the students leads to better results in overall student understanding and patient care.

Keywords

CBME - radiology - undergraduate - assessment

Introduction

Globally, medical education has transformed in the past few decades. The transformation has largely been mandated with the necessity of ensuring that, as medical educators, we fulfil our societal responsibility to produce safe and competent medical practitioners. Medical education in India has also undergone a shift with the introduction of competency-based medical education (CBME). CBME emphasizes professional training, particularly regarding skills, attitudes, and communication to improve the quality of care at both clinical practice and community level. The new CBME curriculum is being implemented across almost all the medical schools in India with students taking a keen interest in it.[1]

Competency-based learning stresses the skills necessary for excellent medical practice, in contrast to the previous curriculum, which was time based, based on systems and disciplines, and focused on knowledge. The old curriculum focused on summative assessment with the CBME curriculum providing due emphasis for formative assessment in addition to the summative assessment. Feedback is a crucial component of the curriculum, providing both a framework for assessment and guidance on acquiring essential clinical skills. The goal is to have a “physician of first contact” who will meet the needs of the community. A key feature of competency-based training is that it measures learning outcomes rather than time spent in the program. Self, objective, and multisource assessments are all possible with it. The method has been applied to training in a variety of medical fields.[2]

CBME focuses on making knowledge student centric, patient oriented, gender sensitive, and goal driven while integrating medical fields in alignment with sustainable development goals and global trends. The goal is to instill information, clinical experience, and patient exposure that lasts a lifetime. The attitude, ethics, and communication module (AETCOM) emphasizes patient-oriented treatment, patient autonomy, and a greater comprehension of patient requirements; it was a welcome addition. CBME seeks to enhance the inclusivity, integration, and efficiency of undergraduate medical education. It is crucial to continuously assess existing curricula and create new ones that make it easier to incorporate new ideas and theories. This will enable students to put their theoretical knowledge into practice, promoting cumulative science and holistic education.[2]

CBME in Radiology

Radiology is a medical specialty that aims to use imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) to diagnose and treat patients. Today, imaging plays a crucial role, as doctors no longer rely solely on clinical history and physical examinations. Radiology in many aspects has become the foundation of modern medicine with advanced screening techniques, facilities available, and interventions that are quick and effective. However, this also poses a challenge when we discuss such a vast and important specialty.

Didactic lectures (DL) are no longer be the primary mode of instruction and communication between teachers and students. There were many problems with this strategy. With a subject like radiology that has many technical components that must be mastered, the passive nature of DL may make students lose interest in teaching and learning outside of the classroom.[3]

Modern student-centered approaches are being introduced to shift learning responsibility to the student. The focus is on adopting active learning strategies.[3]

The CBME curriculum for radiology in Indian medical schools is structured into assessment-based divisions by the National Medical Commission (NMC) as shown in [Fig. 1].[4]

Fig. 1 Division of curriculum in radiology as suggested by the National Medical Council (NMC).[4]

This structured division of the curriculum allows for a systematic and holistic approach to teaching radiology, ensuring students not only learn the theoretical aspects but also gain practical skills and ethical understanding necessary for clinical practice.

[Table 1] defines the key terms, competency classifications, assessment methods, and certification requirements used in the CBME curriculum for radiology, as shown in [Fig. 1].

Table 1 Definitions of key terms used in the CBME curriculum for radiology

Column	Description	Example
1. Competency	Lists specific skills and knowledge expected under each topic, uniquely numbered (e.g., RD1.1, RD2.1)	RD1.1: Understanding general principles of imaging modalities like X-ray, CT, and MRI
2. Predominant domain (K/S/A/C)	Specifies the primary learning domain: • K: Knowledge (theoretical understanding) • S: Skills (practical abilities) • A: Attitude (professionalism) • C: Communication (conveying radiological findings)	RD2.1: K, S → Requires both theoretical knowledge and practical ability to choose the correct imaging modality
3. Level (K/Kn/Os/P)	Defines the complexity of learning: • K: Knows (basic understanding) • Kn: Knows how (applies knowledge) • Os: Shows how (demonstrates in a clinical setting) • P: Performs (executes task independently)	RD5.3: Kn, Os → Students must know how to differentiate fractures and demonstrate the skill
4. Core (Y/N)	Indicates whether the competency is core or noncore: • Y: Core (essential for all students) • N: Noncore (supplementary, not mandatory)	RD2.2: Y → Core competency as selecting the right imaging modality is fundamental
5. Suggested teaching–learning methods	Lists recommended teaching methods: • LGT: Large group teaching (lectures) • SGT: Small group teaching (interactive sessions) • SDL: Self-directed learning (independent study) • Flipped classroom: Students study at home and discuss in the class	RD3.1: Flipped classroom → Used for radiation hazards to encourage active learning
6. Suggested assessment methods	Specifies how students will be assessed. • Written (theoretical examinations) • Viva (oral examinations) • OSCE (objective structured clinical examination) • Direct observation (faculty evaluation in real clinical settings)	RD1.1: Written, viva → Assessed through written examinations and oral questioning
7. Number of competencies that require certification	Indicates how many competencies must be certified before progression. “NIL” means certification is not mandatory	RD6 (patient preparation): 1 competency requires certification

Some of the contemporary active learning teaching strategies that are recommended for use in CBME are discussed in the following sections.

Case-Based Learning

Interactive case studies provide an invaluable opportunity for learners to engage in the practical application of the content studied, all while being supported by the teachers. This approach closely mirrors the training environment received during residency. It allows students to apply theoretical knowledge in real-world contexts. Case reviewing allows learners to analyze what they have learnt theoretically and will help reinforce their understanding before they transition out of the academic setting. This active participation reduces the risk of leaving their learning to chance, which could result in a lack of real-world application and understanding of the concepts. The traditional method of learning often comes at the expense of deeper understanding and real-life application. The case-based learning (CBL) model not only provides students with a solid understanding of theoretical concepts but also gives them hands-on experience they need for effective training in their future careers. By bridging the gap between theory and practice, interactive cases are a key component of a comprehensive educational framework that prepares learners for the complexity of real-world situations. It makes the learners think and helps them answer the whys, hows, and not just the whats. However, CBL entails considerable effort in the preparation and curation of case studies, necessitates the utilization of specialized tools such as Picture Archiving and Communication System (PACS) and Digital Imaging and Communications in Medicine (DICOM) viewers, and presents challenges in the management of substantial file sizes. Furthermore, educators may have limitations imposed by the necessity to conform to examination formats, thereby constraining the applicability of practical experiences, while learners may encounter difficulties when confronted with atypical or real-world case variations.[5]

Problem-Based Learning

Unlike CBL, which in general is a highly facilitated discussion involving prior preparation by the students, problem-based learning (PBL) is radically different. In this approach, not much guidance is given to the students; thus, an exploratory learning environment is encouraged in PBL. Encouraging students to take the initiative to determine critical issues to be covered and set their learning objectives according to their perceived gaps of knowledge is encouraged. Students also begin to take more responsibility for their learning. Critical and creative thinking is used in solving problems and reaching a solution. PBL focuses on the role of the learners, so they will be put in charge of their learning. This allows them to research independently on matters of personal interest and relevance. This approach also makes it easy to merge theory with the practical aspect, filling the gap between textbook knowledge and real skills. Moreover, PBL emphasizes a lot on the collaborative problem-solving process that includes teamwork and facilitation skills. This approach enhances retention by engaging students in an interactive and dynamic learning process. The hands-on character of the challenges posed by PBL makes learning enjoyable and can help facilitate retention over time. All in all, this methodology thus offers a holistic educational experience, arming the student with the requisite abilities and knowledge necessary to succeed both academically and professionally.[6] PBL, however, may lead to shallow student engagement and may lead to creating knowledge gaps. Limited guidance in student-directed learning can lead to mistakes. Facilitators might also not have the necessary skills for effective PBL, and poor coordination could overlap with traditional lectures. Finally, PBL demands considerable resources and time for infrastructure, training, and curriculum development.[7]

Evidence-Based Medicine

Evidenced-based radiology (EBR) requires an excellent and profound understanding of the available literature related to this area, and also the ability to identify and be aware of gaps within the available knowledge. Such a background is essential as it forms a sound basis that can be better used to enhance the quality of patient care and management techniques. This process would involve imbibing in it the exact skills of radiologists, which would bring into play a very unique insight and expertise in the field. ALARA (as low as reasonably achievable) refers to the principle of reducing radiation exposure to a patient without compromising the diagnostic information the patient can receive. The desires and priorities of the patients and physicians concerning different diagnostic options are what fuel the whole decision-making process. In an attempt to bring together these four elements—those already studied (existing research), the professional radiologists, safety considerations, and the preferences and values of the patients and physicians—EBR endeavors to provide a practice model that would be more effective as well as more patient centered. Adding EBR to undergraduate training for radiology will enable students to become better clinicians and health care providers in the future. Challenges of EBR include time constraints, limited evidence outside academia, and discrepancies between guidelines and clinical practice.[8]

Peer-Assisted Learning

Peer-assisted learning (PAL) is the advanced pedagogy where students assist each other in attaining knowledge. This peer learning process bears similarities to other models of cooperative learning, but it recognizes that learners may be coming from the same college or department, although they are registered in different courses or are at different levels of study. The academic literature categorizes PAL into several distinct categories: (1) peer learners who perform the roles of both the teacher and the learner; (2) students at more advanced levels of learning, who act as teachers to their less experienced peers in the same institute, often referred to as near-peer teaching; and (3) inter-institute peer instruction that takes place between two different institute entities. Each of these methods fosters an interactive environment to facilitate knowledge sharing and mutual growth.[9] One of the key advantages of PAL is that interacting with colleagues fosters an environment of discovery built on confidence and trust. Since peer educators share a common foundational knowledge and training, they are well positioned to articulate their thoughts in a manner that resonates with their contemporaries. Additionally, collaborative learning environments with minimal supervision from educators encourage the development of essential qualities such as self-confidence, independence, and leadership skills, which are particularly valuable in fields like health care. Furthermore, PAL establishes a constructive discussion platform where students can freely exchange ideas without the apprehension of criticism. However, despite its benefits, PAL also has certain drawbacks. Since students rely on peer participation, it may inadvertently reduce their direct interaction with faculty members, potentially limiting opportunities to seek instructors' feedback. Additionally, peer educators may encounter challenges in discussions due to their relatively limited knowledge and experience compared to faculty members' expertise.

Flipped Classrooms

The flipped classroom pedagogy provides an opportunity to learn core concepts and knowledge outside the regular classroom using a combination of strategies: reading, online modules, and prerecorded lectures. Following this self-directed learning (SDL), students are supplemented with engaging, interactive experiences in the classroom where teachers more proactively engage students in exercises aimed at enhancing their ability to apply the core concepts.

An important defining attribute of this blended model was the redistribution of classroom time toward collaborative participation in the application of knowledge, as well as an ontological shift in the role of the teacher from mere transference of information to facilitating meaningful learning.

Unlike the traditional teaching approach, which usually consumes more class hours with lectures and supplementary readings or problem sets left to work outside class, the flipped classroom approach allows students to learn core content at their own pace before coming to the class. It maximizes critical time in the classroom while encouraging better interaction among students and the teacher, leading to better retention of ideas. Radiology being intrinsically visually based would be particularly favorable for including video additions, online educational modules, and recorded lectures as valuable instruments for the application of flipped learning. These tools make it possible to present student-facilitated self-directed study opportunities that offer significant benefits to the educator in optimizing their use of short classroom time. The drawbacks associated with flipped classrooms include the potential for students to feel lost if they do not complete preclass assignments, disparities in foundational knowledge among students that may impede the progression of interactive sessions, and the intimidation some students may encounter due to the necessity for active participation.[10]

Team-Based Learning (TBL)

Team-based learning (TBL) was initially conceived for business courses as a method of small group learning, designed to enhance students' motivation and encourage the practical application of knowledge to problem-solving.

Its appeal lies in several key advantages: it accommodates a larger student-to-teacher ratio compared to traditional PBL, stimulates student interest in specific subjects, and fosters essential skills such as teamwork and critical thinking. Additionally, there are both advantages and disadvantages for the peer educator as they are supposed to lead and organize the class rather than just lecturing.

The original implementation of TBL consists of three independent phases. The original implementation of TBL consists of three distinct phases. Initially, students engage in SDL, guided by the instructions provided by their instructors. In the second phase, they complete an individual assurance test that assesses their understanding of key concepts and advanced knowledge drawn from the self-learning materials. In the second phase, they complete an individual assurance test that assesses their understanding of key concepts and advanced knowledge drawn from the self-learning materials. The test is then provided to the students in groups with a size of five to seven students. The third stage is immediate assessment by using feedback, which motivates the students to take collective action to find the right answers. In the process, it not only imparts preliminary knowledge to teams but also works very hard to undertake a real clinical challenge and gets instant feedback from fellows as well as instructors.

A systematic review and meta-analysis by Yan et al has demonstrated that the TBL approach in medical imaging courses has quite considerable advantages over the traditional lecture-based learning method, especially in terms of improvement in both theoretical and practical skill scores. However, it is worth noting that the improvement in skill scores among students in the higher-grade subgroup did not reach statistical significance. The disadvantages of TBL in radiology education include difficulties for some students to adapt to this method, with some preferring traditional approaches. Prior preparation for TBL can be time-consuming, and inadequate preparation may lead to reduced effectiveness. Discussions in the class may lack focus or depth due to excessive group size or limited time, preventing many students from actively participating. Unequal contributions among team members can lead to feelings of unfairness, and the success of teamwork can be heavily influenced by individual attitudes.[11]

E-Learning

The traditional methods of using texts, lectures, pictures, and books are well enhanced once incorporated with innovative e-learning strategies. Advanced technological tools have made electronic learning an essential tool in medical training, especially in radiology, with its intricate imaging demands. Radiology education is important not only for both radiographers and specialized radiologists but also for junior physicians and undergraduate medical students to not miss the significant findings in the process of interpretation. Furthermore, the adoption of electronic learning within medical facilities continues to advance, and studies indicate that e-learning occupies 70% of the training hours included in the curriculum of radiology education within European medical facilities. Nonetheless, a comprehensive review conducted by Zafar et al reveals a lack of compelling evidence supporting the efficacy of e-learning in undergraduate radiology education, particularly in its ability to enhance or elevate clinical practice performance. Challenges include sufficient interaction between students and educators, which is essential for the timely resolution of inquiries, as well as the possible inefficiency stemming from the considerable time students expend revisiting virtual lectures. Some of the students preferred the traditional live approach to learning rather than e-learning.[12]

Active student participation in small-group sessions enhances long-term knowledge retention and fosters SDL skills.[3]

This review proposes the following structured framework for embedding CBME principles into radiology education for MBBS students in Indian medical schools. By aligning radiology teaching with the CBME curriculum, this framework aims to foster early exposure, interdisciplinary collaboration, and skill-based learning, ultimately preparing students to utilize imaging effectively in patient care.

Vision and Objectives

Vision: To provide undergraduate medical students with the basic knowledge and skills in diagnostic and interventional radiology (IR) for effective clinical practice and decision-making.

Objectives

• Understand the role of diagnostic radiology and IR in patient care.

• Develop competence in basic image interpretation and selection of appropriate imaging modalities.

• Emphasize safety in imaging, including radiation protection.

• Promote collaboration between radiologists and clinicians.

Curriculum Integration across Phases

[Table 2] provides a structured approach to incorporating radiology education across different MBBS phases, including objectives, teaching methods, and key competencies.

Table 2 Curriculum integration of radiology across different phases of MBBS training

Phase	Emphasis	Teaching methods	Competencies
Phase 1 (foundation year—1st year MBBS)	• Fundamentals of imaging technology and its role in clinical diagnosis • Correlation of gross anatomy with radiographic anatomy • Principles of radiation safety and physics (ALARA principle, basic X-ray production) • Overview of the basics of interventional radiology (IR)	• Video demonstrations and didactic lectures on imaging modalities • Small group teachings for anatomy–radiographic correlation (e.g., gross bone anatomy with normal radiographs)	• Recognize important anatomical landmarks on radiographs • Describe the fundamental ideas of IR
Phase 2 (preclinical years—2nd year MBBS)	• Understanding normal vs. abnormal imaging • Correlation of imaging findings with pathological processes • Overview of basic IR procedures (aspirations, image-guided biopsies)	• Integrated teaching sessions with pathology and microbiology • Virtual demonstrations of simple IR procedures	• Identify common imaging abnormalities on chest and abdominal radiographs • Explain the role of radiology in disease diagnosis and staging • Identify and describe clinical situations requiring IR
Phase 3 (paraclinical years—3rd year MBBS)	• Application of diagnostic radiology in trauma, infection, and malignancy • Introduction to IR in emergencies (embolization, catheter placements) • Role of imaging in screening programs (mammography, lung cancer screening)	• Case-based discussions linking imaging with clinical outcomes • Observational learning in radiology and IR departments • Recognizing high-risk cases for pathology screening	• Interpret basic imaging findings for clinical decision-making • Understand indications and processes of IR interventions • Recognize the significance of screening high-risk individuals
Phase 4 (final year MBBS)	• Advanced diagnostic imaging techniques (MRI, Doppler imaging, nuclear imaging) • Comprehensive understanding of advanced IR procedures (TIPS, angioplasty)	• Multidisciplinary clinical discussions integrating diagnostic and IR • Practical exposure to IR procedures in clinical settings	• Correlate imaging findings with clinical management • Identify and explain the role of IR in patient care
Internship phase	• Practical application of diagnostic radiology and IR in patient care	• Structured rotation in the radiology department • Recognizing critical imaging findings (hemorrhage, pneumothorax) • Communicating findings to other clinical departments • Participation in basic nonvascular IR procedures (USG-guided abscess drainage, biopsies, FNACs) • Managing referrals in emergency IR procedures and postprocedural care	• Select appropriate imaging and IR interventions for clinical scenarios • Recognize critical findings and propose IR-based management plans

Abbreviations: ALARA, as low as reasonably achievable; FNAC, fine needle aspiration cytology; MRI, magnetic resonance imaging; TIPS, transjugular intrahepatic portosystemic shunt; USG, ultrasonography.

Assessment

Summative testing will include questions on both diagnostic and IR in the theory examinations. Formative testing will consist of objective structured clinical examinations for imaging interpretation and IR-based clinical scenarios, quizzes covering various imaging findings and procedural steps, and spotter assessments. Additionally, internship evaluation will focus on assessing decision-making skills in radiology and IR contexts.

Faculty Development

Regular workshops will be conducted for faculty members to enhance their understanding of CBME principles, mentorship, and assessment methods. Faculty partnerships with clinical departments will be encouraged to design integrated sessions, ensuring a multidisciplinary approach to radiology education.

Feedback Mechanism

Student feedback will be gathered through regular surveys to assess the effectiveness of teaching methods, clinical postings, and observational sessions. Faculty feedback will be collected to identify challenges in delivering integrated radiology teaching. The insights from both students and faculty will be used to refine teaching methodologies and improve the overall learning experience.

Although the suggested framework provides a methodical and competency-based strategy for incorporating radiology and IR into undergraduate medical education, few other tactics can improve its implementation and enrich the learning experience.

Simulation-Based Learning

Simulators offer an exceptional opportunity for students to cultivate essential skills across various facets of radiology. By practicing ultrasound scanning techniques in a controlled setting, students can acquire invaluable hands-on experience before engaging with real patients. Furthermore, simulation-based learning serves as an effective method for imparting crucial knowledge about radiation protection practices, equipping students with a comprehensive understanding of how to minimize exposure while preserving image quality. Moreover, students can master fundamental interventional procedures, such as vascular access, through the use of simulators, fostering both confidence and proficiency in executing these techniques safely and effectively.

Incorporating Artificial Intelligence

Introducing students to the basics of artificial intelligence (AI) and its implementation in radiology can help them understand the evolving role of technology in medical imaging. AI-assisted software can be used to demonstrate pattern recognition in diagnostic radiology, allowing students to appreciate how machine learning algorithms can aid in detecting abnormalities. Exposure to AI applications in radiology will prepare students to integrate these technologies into their future practice and enhance diagnostic accuracy.

Rural Health Care Exposure

Postings in rural settings can provide students with valuable experience in understanding the challenges of radiology access in resource-limited environments. These experiences can help students learn to optimize the use of available resources and develop problem-solving skills when faced with limitations in imaging facilities. Exposure to rural health care can also foster an appreciation for the disparities in medical imaging accessibility and encourage students to contribute to improving health care in underserved areas.

Ethical and Socioeconomic Considerations

Students can be introduced to the ethical implications of imaging, such as the overuse of CT scans leading to excessive radiation exposure. Special emphasis will be placed on imaging in pregnancies, ensuring that students understand the risks and benefits involved. Additionally, they will be taught how to balance clinical utility with cost-effectiveness, particularly in resource-limited settings, to promote responsible and judicious use of imaging modalities.

Incorporating Research

Students can be divided into small groups and engaged in research projects focusing on novel diagnostic and IR topics. This hands-on approach will encourage critical thinking and innovation. Furthermore, access to webinars and conferences can be provided, allowing students to stay updated with the latest advancements in radiology and interventional techniques.

The CBME curriculum as a whole offers several advantages over the traditional system of education and also comes with certain challenges[13] ([Table 3]).

Table 3 Pros and cons of the competency-based medical education (CBME) curriculum

Pros	Cons
• Expands learning beyond theoretical knowledge by integrating practical experience, reflection, and application	• Requires extensive faculty training for understanding CBME concepts, competencies, assessment techniques, and learning processes
• Enhances student comprehension and skill development through small group teaching, self-assessment, and diverse assessment methods	• Requires curriculum restructuring and modifications to existing assessment and accreditation systems, which can be complex
• Incorporates varied assessment methods such as direct observation, workplace-based assessments, and formative feedback, ensuring a holistic evaluation of learners	• Demands additional resources, including faculty time, educational infrastructure, and technical support, increasing the burden on institutions
• Provides timely, targeted feedback, helping students identify their strengths and areas for improvement	• More frequent assessments and customized learning plans increase the workload for educators
• Encourages students to take responsibility for self-directed learning and career development	• The distinction between competencies and outcomes must be clarified to avoid confusion and ensure that subcompetencies are correctly classified

In the past two decades, many top-ranking doctors in India have chosen radiology as their first specialty for postgraduation. It has become the most sought-after career choice mainly because the current practice of evidence-based medicine has made diagnostics an essential component of the workup for the majority of patients. More significantly, the need for imaging has expanded due to rapid improvements in the field.[14] CBME plays a very important role in providing early exposure to students on the subject of radiology and helps them make a well-thought decision of whether they want to pursue radiology as a career or not.

Conclusion

Implementing CBME in a vast subject such as radiology is nothing but a welcome move. CBME fosters holistic student learning alongside patient care. The advantages of CBME evidently outweigh its limitations, and hence educational institutions must make a conscious effort to implement it effectively creating a positive learning experience for students and encouraging them to think independently, integrate, and practically apply the knowledge they have gained.

Conflict of Interest

None declared.

Authors' Contributions

S.R. contributed to the concepts, design, definition of intellectual content, literature search, manuscript preparation, manuscript editing, and manuscript review, and is the guarantor. A.T. and R.G. contributed to the concepts, design, definition of intellectual content, literature search, manuscript preparation, manuscript editing, and manuscript review. A.R. contributed to manuscript editing and manuscript review.

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Publication History

Article published online:
04 June 2025