The areas of performance expected from the medical graduates of the 21st century are defined in terms of outcomes of a medical graduate, which with minor variations in terminology across countries, require future doctors to be skillful practitioners, professional and ethical, manager and leaders, health advocate, scholar, communicator, collaborator, systems thinker, and life-long learner.^1,2 The current curricula of undergraduate medical education have been formulated on these principles worldwide and the same is the case in Pakistan. The graduates are expected to be knowledgeable, skillful, critical thinkers, professionals, scholars, role models, and community health promotors.³ The outcomes of the graduate can only be achieved through backward design where the curriculum is designed from the final year to the first year, so that we can track the progress of the students towards the set goals. This indeed is the essence of the Outcome Based Medical Education.

Pakistani Medical Universities in the last decade have seen a transition from traditional subject-based models to modular system-based curriculum models.⁴ To ensure that the outcomes of the Pakistani graduates are achieved, the focus has broadened from just a foundation in basic concepts, processes, and mechanisms of the disease resulting in graduates who are knowledgeable and have basic procedural skills, to also incorporate training that can equip medical graduates with required, research acumen, empathy and professionalism, communication, collaboration, and leadership skills to ensure a holistic professional.⁵

This has led to the inclusion of the modules of one or all of professionalism, ethics, research, and leadership skills (PERLs) which align with the previously published PERLs model by the author.⁶ In which for meaningful transfer of knowledge to practice, the acquisition of human skills is designed as a spiral vertical PERLs Module in the MBBS curriculum based on sound principles of andragogy. The vision is a “humanistic doctor who will have the knowledge, skills and attitudes to be able to generate practice-based evidence, advocate healthcare, counsel patients, collaborate within and outside the profession and lead healthcare teams and organizations to bring a sustainable change through continuous self and system improvement.”

The current writing is a further elaboration of the PERLs spiral of the proposed curriculum model where these four domains are envisioned to be divided into attributes that are deemed best suitable under each domain by the author and further explained by the competency statements of each (Table 1). These are derived from the available curricular frameworks^1,2,7 which have been modified according to the local context keeping in view that in Pakistan students start medical college immediately after 12 years of education and need training from the very basics in every domain.

Table 1. PERLs module domains, attributes, and related competencies.

Table 2. PERLs module competencies as related to content and type of portfolio entries.

Table 3. PERLs module year-wise distribution of portfolio entries.

To operationalize the achievement of each competency the taught content has to be identified and also the evidence for acquisition of each competency needs to be incorporated. Portfolios are the mainstay in developing the human skills required for a graduating physician as it has shown to be an effective tool in measuring student progress based on goals that are set by the training faculty and the trainees together.⁸ An outline of the contents along with the evidence that can be collected to be part of the student’s training portfolio for achievement of defined competencies is proposed in Table 2.

The next step in implementation will have to ensure that the module is actually a spiral which means that concepts are revisited and experiences accumulated every year. Table 3 highlights a plan for year-wise portfolio entries of the competencies with almost every attribute addressed every year again with an increased level of complexity. For example, the student will initially be expected to demonstrate communication with their peers and teachers, this will be translated to proper communication with the patients, leading to learning to communicate with members of other health professions along with the difficult patients and commencing in communication with patient families and the larger public. The reason to keep the module to four years is that the final year of the undergraduate degree program is rightly based on clerkships and all these skills learned in isolation need to be practiced in the final year of undergraduate academics as holistic competencies. This in turn is expected to ensure the graduation of a Seven Star Pakistani doctor.

The PERLs module is developed based on theoretical knowledge and thorough analysis of the available literature by the author only and needs to be tested and evaluated in the local context for turning it into an evidence-based document. The PERLs module domains, competencies, attributes, and contents along with the possible portfolio entries are proposed based on global standards contextualized to Pakistan. The framework is kept broader in terms of how the competencies are divided into complexity per year, the mode of delivery, and the type of portfolio entry chosen by the universities and institutions.

The philosophy of assessment of human skills that are involved with changing underlying attitudes is believed to be grounded in the processes implemented⁹. So whichever process is to be followed for training graduates to achieve the mentioned competencies should be decided by the college academic councils and must be followed in letter and spirit. Following the due process will result in proper tracking of student effort and progress that can later be assessed with skill-based stations or portfolio-related viva evaluation in the middle and at the end of the year both as part of formative and/or summative assessment.

Elaborating the framework further is proposed to be left to the medical colleges which on the basis of their available physical infrastructure and human and capital resources can decide when and how to teach and if to develop a paper based on an electronic portfolio. The finalization of the PERLs module curriculum should be done by in consultation with all stakeholders and modified as and when deemed necessary based on the evaluation received by the faculty, students, patients, and administrators along with the other healthcare professionals working with the doctors to ensure safe and quality patient care. The module can be used for guiding the training of other healthcare professionals in these domains as well.