Electives in the MBBS curriculum: Designing and implementation

INTRODUCTION

Change is constant, and the medical field is ever evolving. Today’s medical students are expected to be scholars, researchers and scientists, with a focus on experience-based learning and lateral thinking.^[1]

To enhance global relevance, the National Medical Commission (NMC) added electives to the UG curriculum, allowing in-depth learning unlike the rigid traditional MBBS programme.^[1]

Another benefit is teamwork, helping students understand team roles and human behaviour dynamics.^[2] This aligns with the goals and roles of the competency-based medical education (CBME) and allows them to function effectively as a member of the healthcare team.

Electives help students develop time management skills, requiring optimal use of learning tools in a short duration.^[2] Electives at the level of community settings increase awareness of the community needs and system shortcomings.^[2]

The following are the reasons for the introduction of electives in the MBBS curriculum:

1. Students have the freedom to choose a part of their study course, which helps them become more receptive to the learning they receive

2. It allows students to work in an area of their passion. Students are able to enhance their clinical skills and soft skills

3. Moreover, it makes students think with reasoning.

The NMC elective module defines electives and their necessity, outlining two blocks: Pre/para clinical (Block 1) and clinical (Block 2). Institutions manage allocation and conduct, requiring a structured system, which we developed and describe in this article.

With this background, the following are the aims and objectives of the study:

1. To develop a system for conducting electives

2. To establish a mechanism for elective allocation and implementation.

MATERIALS AND METHODS

At the Himalayan Institute of Medical Sciences, we needed to design a system for the allocation and implementation of electives as a part of the MBBS curriculum in the timeline as defined by the NMC. The total number of students in the batch was 145, and the process of planning the conduct of electives and the allocation and implementation of electives was done after seeking verbal informed consent. The planning was done before the completion of the 3^rd professional MBBS – Part I of the target batch. The actual implementation of the elective rotations was scheduled soon after the 3^rd professional MBBS – Part I University Examination. This was an observational descriptive study design. However, further studies need to be conducted to analyse perceptions of faculty and students for electives.

The process of elective conduct consisted of six steps

Sensitisation sessions for the faculty

The initiative began with two face-to-face sensitisation sessions of faculty from pre/para and clinical disciplines: The first outlined the elective module’s objectives and NMC structured framework for electives, and the second, focused on students (n = 145) elective allocation for both blocks.

Additional topics discussed included the maintenance of academic records through logbooks for electives and the selection of assessment methodologies upon completion of elective courses. A comprehensive timeline outlining the sequence of events, commencing from the release of the elective options for student selection to the final allocation process, was presented to the faculty [Figure 1]. Each session concluded with an interactive question-and-answer segment.

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Figure 1:

Image showing timeline for the implementation of electives (Images of block 1 electives only shown. However, all processes for both blocks were carried out simultaneously).

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Sensitisation sessions for the students

Subsequent to the faculty sessions, briefing and sensitisation sessions were conducted for the students. These sessions were conducted in both online and offline formats. Students were comprehensively briefed on various aspects, including the timing, duration, allocation process and assessment methodologies pertaining to the elective courses. Each introductory session, whether online or offline, concluded with an interactive question-and-answer segment, allowing students to seek clarification on any pertinent issues.

Preparation of elective topics and flyers

The diverse departments within the institute, including both pre/para-clinical and clinical departments, were tasked with formulating electives along with clearly defined objectives, taking into account the available resources and logistic considerations, in accordance with the guidelines stipulated by the NMC.

Upon receiving the electives from the respective departments, they were categorised into two blocks in accordance with the guidelines provided by the NMC. Block 1 comprised electives from pre/para-clinical departments, whereas Block 2 encompassed electives from clinical departments. Subsequently, for each block, a structured document was meticulously prepared, detailing the electives along with their corresponding objectives.^[1]

The documents containing the list of electives along with their respective objectives for each block were disseminated to the students in the form of flyers through Google Classroom [Figure 1]. This distribution occurred subsequent to their initial formative assessments, strategically timed to provide students with a period of clear thinking devoid of academic stress [Table 1].

Table 1: Block-wise distribution of electives.

Block 1: Pre/para clinical electives	Block 2: Clinical electives
Number of electives offered: 28	Number of electives offered: 46
Duration: 2 weeks	Duration: 2 weeks

Submission of students’ choices

Students were instructed to carefully review the objectives provided for each elective and make well-informed decisions regarding their preferences. To facilitate this process, two separate Google Forms were distributed through Google Classroom, one for each block. Each form listed the electives available for the respective block, prompting students to rank their preferences by filling out the forms accordingly. Students were required to list 10 choices in order of preference for each block.

A timeframe of 1 month was allocated for the submission of responses. In addition, students were provided with specific guidelines, including the requirement to provide email IDs that would remain consistent throughout their MBBS course. Moreover, students were urged to make their selections only after thoroughly reviewing the objectives of the electives, as once allotted, changes to elective choices would not be permitted.

Allocation of electives

Upon receipt of students’ responses, the allocation of electives commenced, conducted separately for each block. Random allocation of each elective choice was facilitated using MS Excel [Figure 1] to ensure an unbiased opportunity to each student. The allocation methodology proceeded as follows:

• For a given elective choice ‘A’, students who had designated ‘A’ as their first choice were assigned to that elective, contingent upon the available vacancies. This process was repeated for all electives. To ensure an optimal teacher-to-student ratio, a maximum of five students were accommodated for each elective.

• Subsequently, for elective choice ‘A’, students who had ranked ‘A’ as their second choice were assigned to that elective, subject to the remaining vacancies. This automated procedure was replicated for all electives.

• In cases where a student was unable to secure any of their initial 10 choices, personalised consultations with key stakeholders were conducted to enable selection from available electives with vacancies.

• Following the completion of elective allocation, the execution of elective rotations commenced.

Execution of elective rotations

Upon the completion of the allotment process, students were divided into two cohorts, each comprising approximately 75 students, resulting in a total of 145 students. These cohorts were designated as groups A and B.

The commencement of elective courses was scheduled subsequent to the conclusion of the final professional part 1 examinations. Each block was scheduled to last for a duration of 2 weeks. During the initial 2-week period, group A would be assigned to Block 1, while group B would be assigned to Block 2. This arrangement would be followed by a crossover, with group A transitioning to Block 2 for the subsequent 2 weeks, while group B would move to Block 1 [Figure 2]. On completion of the elective, certificates were awarded on satisfactory day-to-day performance, logbook completion, seminars and presentations.

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Figure 2:

Image showing crossover of the Block rotations of the electives.

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RESULTS

The Department of Surgery emerged as the most sought-after department, with all available vacancies across its elective topics being promptly filled [Tables 2-3].

Within each elective, a minimum enrolment of two students and a maximum of five students were accommodated. Despite our efforts, eight students were unable to secure one of their initial 10 choices but were offered to choose from the available electives. Nevertheless, the majority of students were successfully allocated their preferred electives as per their choices [Table 2].

We believe that our method of random allocation is preferable over a merit-based system, as the latter may inadvertently deprive students of their right to choice based on a single academic outcome, which can fluctuate due to various factors from year to year. While our allocation process is not flawless, we remain committed to refining it by conducting pre-post-tests, rubric-based evaluation and satisfaction surveys to determine the perceptions of faculty as well as students.

DISCUSSION

While the concept of electives in medical education has been present and executed in the Western world for a long time now, the implementation of the same in the context of Indian medical education needs modifications to suit the students, faculty and community.^[3]

A detailed analysis of the implementation of electives was done by the strengths, weaknesses, opportunities and threats method [Figure 3].^[4] When we applied this framework to our methodology of implementation, we found that our strengths lay in conducting workshops to sensitise our faculty and students about the design and implementation of electives at our institute. This bolstered their understanding of the standard operating procedures for elective implementation.

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Figure 3:

Image showing strengths, weaknesses, opportunities and threats analysis of the study.

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Next, coming to our weaknesses, we found that some of our students were unable to get the electives as per their choices, because of a lack of vacancies in those electives. To maintain a good teacher-to-student ratio, the maximum number of students in any elective was capped at 5. To rectify this, we can consider increasing the maximum number of students allocated to each elective. Additionally, providing a wider selection of electives for students to choose from may further help accommodate their preferences. Another weakness was that even with the existing teacher-to-student ratio, faculty members from some busier specialities, such as internal medicine and allied as well as surgical specialities, found it difficult to teach an extra batch of students, apart from teaching in the regular classroom lectures and clinical rotations. While electives have been introduced as part of the curriculum, the faculty-to-student ratio needed to achieve the goals of the electives is not adequate.

The repercussions of this may be faced by the students. When students are unable to get the attention needed to learn a skill, they start feeling uninterested in the course. This could undermine the purpose of electives, as they are designed to foster a student’s interest and motivation to explore a specific topic of their choice.

While recruiting additional faculty may not always be feasible due to staffing constraints, fostering a spirit of teamwork and collaboration amongst the existing faculty can help ensure a balanced and manageable distribution of responsibilities. This can be achieved through strategic scheduling, rotating elective responsibilities across departments and streamlining the number of students per elective, as we did by capping each elective to five students. In the initial years, as the system of electives evolves, combined efforts of faculty, students and key stakeholders – through structured sensitisation sessions, clear timelines, mutual cooperation and support – will be essential for successful implementation. These sessions, already implemented at our institute, helped familiarise both faculty and students with the CBME framework, elective objectives and assessment protocols, thereby strengthening institutional preparedness.

A potential weakness in our system of implementation is the absence of a dedicated review committee for the elective courses. This was not constituted at the beginning due to time constraints and the urgent need to adhere to the NMC-mandated timelines for elective execution. However, moving forward, a review committee comprising representatives from each major department is essential. Such a committee would ensure periodic evaluation and relevance of electives, including updating objectives and suggesting removal or addition of topics as needed. The inclusion of such oversight will also facilitate the development of supplementary resources such as course booklets and curated reading material, as recommended under CBME for promoting self-directed learning.

When we discuss the opportunities that our system of elective implementation offers, several points stand out. First, the opportunity for students to get what they want: The allotment of electives was conducted through a randomised, preference-based system rather than a merit-based one. This ensured that the process remained equitable and reduced the undue academic pressure often associated with high-stakes selections. We chose this method deliberately to prevent students with slightly lower academic performance from being unfairly denied electives, they were genuinely passionate about. Unlike a merit-based system, which can fluctuate due to temporary academic setbacks, our method promotes fairness by respecting individual interest and choice – a key objective of the NMC’s CBME framework.

Second, students were offered a wide variety of electives (28 in Block 1 and 46 in Block 2) with well-defined objectives, allowing them to make informed decisions aligned with their interests and career goals [Table 2].

Third, the structure facilitated a meaningful, immersive experience. Since the number of students was capped at 5/elective, students had adequate access to faculty, equipment and departmental resources. The adequacy of resources was ensured during the preparation phase, where departments were instructed to submit electives only after assessing logistical feasibility and available infrastructure.

Fourth, assessment was built into the structure. All students maintained logbooks, which were checked regularly by faculty. In addition, departments employed various assessment tools such as seminars, reflections, group discussions and case presentations. While departments had the autonomy to choose their assessment modalities based on the nature of their electives, all assessments adhered to the broad framework of CBME, ensuring alignment with competencies and learning objectives. Standardisation was maintained through faculty sensitisation sessions, where assessment strategies were discussed and synchronised across departments to maintain fairness and consistency.

Finally, since most of the students got the opportunity to choose what they wished to learn, it enabled them to become self-directed learners.^[5]

There were a few threats posed by the implementation of electives: First, the threat of absenteeism lurks. When teachers are overoccupied, they may not be able to notice the absence of student(s) and this may be used by students as a loophole to escape the elective rotation. Such absenteeism is dangerous to the successful establishment of electives in our curriculum, since, without skills, there is no point in gaining a certification.^[6] Another threat is that certain electives, were allotted the same fixed duration as mandated uniformly across all electives, despite having objectives that could be adequately covered in less than the standard 2-week duration. This mismatch between content depth and allocated time was highlighted during informal feedback from both students and faculty. For example, electives focused primarily on literature review or introductory concepts may have required less than the allotted time. However, since time-on-ground quantification was not formally recorded, we suggest that future cycles include time-motion studies or structured feedback forms to more accurately gauge the optimal duration for each elective. Tailoring duration based on content intensity could help avoid unnecessary time loss, especially considering students are in the final stages of their undergraduate training.

With this analysis, we realised that the implementation of electives is a learning curve for both the faculty and the students and needs regular review and improvement.

CONCLUSION

The NMC aims for electives to diversify learning and encourage research. Implementing electives allowed students to achieve these goals. Despite some challenges, we plan to improve the process for future batches.