The Medical Council of India (MCI) advocates that postgraduate training should be competency-based and essentially self-directed [8]. However, PBLI as a competency is not explicitly stated in this document. There is also lack of expertise in teaching and assessing PBLI in India. In teaching hospitals, the pressure of clinical work often takes priority over resident-training. While residents are expected to provide service, they must not be short-charged regarding the quality of teaching. The prevailing scenario can be improved by explicitly incorporating elements of PBLI in the residency training curriculum.

Practice based learning and improvement is best described as a cyclical continuous process (Fig. 1) [9]. In an attempt to link education to quality of patient care, the ACGME Outcome Project [10] defined eight constituent components under the core competency of PBLI, which are summarized in Box 1.

Fig.1 Cycle of practice-based learning and improvement.

In a competency-based education and training system, the unit of progression is ‘mastery’ of specific knowledge and skills [11]. The ACGME has defined the levels of proficiency expected at each learning level [12]. Milestones have been identified for each competency, which describe the performance level of skills, knowledge or behavior that a learner is expected to demonstrate at a certain level of professional development [13]. Breaking down these competencies into observable milestones is useful both to the learner and to the assessor as they help in determining an individual learner’s trajectory from a beginner to a proficient practitioner.

ACGME suggests writing five levels of milestones [14] based on the Dreyfus model of skill development [15], as discussed in an earlier paper [16]. Milestones have been defined specifically for different clinical specialties [11]. For Pediatrics, milestones under different components of PBLI have been defined in several ways [17-22]. Web Table I illustrates different milestones under each competency and provides practical examples of these.

Each of these PBLI competencies are discussed in detail below:

Learners may be able to identify their deficiencies and limits because they are either: Motivated by external threat of a negative consequence; e.g. punishment, morbidity, bad grades; or Motivated by external positive consequence; e.g. reward, good scores in examination, praise from superior; or Intrinsically motivated by reward: such as ease of work, comfort, satisfaction of learning; or Intrinsically motivated to excel and acquire expertise.

Identification of gaps serves as a stimulus to identify their strengths and limitations in performance, by working hard to master skills against required standards. Kolb [23] suggests that when learners perceive gaps in knowledge, skills and attitudes on reflecting on their experiences, they tend to engage in active experimentation like applying new strategies to learn further. Schon’s model [24] talks of the importance of reflection either before ("reflection for action") or during ("reflection in action") or after a particular action ("reflection on action"). This pushes learners to seek new knowledge in ambiguous situations and incorporate new knowledge into practice.

Self-directed learning is a process in which "individuals take initiative (with or without the help of others) to diagnose their own learning needs, formulate goals, identify human and material resources for learning, choose and implement appropriate learning strategies and evaluate learning outcomes" [25]. This task requires them to formulate both short-term and long-term learning and improvement goals. Triggers to discovering new learning needs can be: questions which arise during patient care, while reading, during conversations with other peers or while attending formal academic sessions. Self-directedness is influenced by factors such as motivation, self-regulation and self-efficacy [26].

Learners must be aware of their preferred learning styles [23] and must have sufficient understanding of what they need to learn (in terms of knowledge, skills, behavioral change). They also need to know what instructional methods most effectively and efficiently address their specific learning needs and where they can access these resources. This may require considerable discussion, consultation and trial-and-error before identification of strategies that work best for them.

Formative feedback intends to improve specific aspects of a learner’s performance by offering insight into their behavior, rather than offering a judgment on overall performance [27]. Learners must eventually learn not only to listen to feedback and incorporate it into their practice, but also be proactive in seeking feedback for improvement. In practice, a learner must be aware of his limitations and must know when a situation requires him to summon help from a superior without compromising the safety of a patient.

Residents are expected to be able to apply their knowledge of desired standards of patient care, standard protocols, evidence-based guidelines and principles of quality improvement in their day-to-day practice. They need to imbibe reflective practice and learn how to manage change. If individuals are not trained in reflective practice, they may turn defensive, when shown evidence for their need to improve. In early stages, their focus might be on individual patients. However, in the long run, clinicians will need to shift their focus to their teams and to the system [28]. This can be taught by integrating residents in the team which is involved in the hospital’s quality improvement programs [29]. For example, an effort to improve the care of low birth weight babies should also include attention to the system – like the process of recording weight, record keeping, training of nurses and other care providers, provision of nutritional advice and availability of educational material.

The amount of medical information is ever-increasing and clinicians must learn strategies to search for the evidence and apply it in their practice [30]. Confronted with uncertainty in a clinical case, the learner must be able to actively question the rationale of patient care. For example, ‘In this patient, what is the best antibiotic we should be using? What is the evidence we have for this decision?’

One cannot practice evidence-based medicine (EBM) without being able to set improvement goals for oneself or without being motivated to be a lifelong learner. The skills required to be learnt in order to practice have been detailed previously [17].

The milestones which characterize learners in various stages of development of this sub-competency are illustrated through examples in Web Table I. Learning EBM needs a steep learning curve and a methodical approach. Several authors suggest introducing EBM to undergraduates when time constraints are less. These skills can subsequently be strengthened through actual practice during residency training.

Information technology is now vital to the practice of medicine. The availability of the internet, the adoption of hospital information systems and electronic health records (EHR) and use of technology such as tablets and smartphones to provide access to information at the point of care have changed the way in which clinical medicine is practiced [31]. Medical colleges also have invested majorly in computers and internet access.

Acceptance of technology is affected by perceived ease of use and perceived usefulness. Of these, the perceived ease of use has a greater impact on behavior and early learners must overcome this hurdle to adopt technology [32,33]. While training new learners it is important to keep in mind the following factors which determine early perceptions of ease of use of a new system [34]:

Patient-education requires several skills and capabilities such as: knowledge about the disease process, counseling skills, and interpersonal and communication skills. Learners must be trained in carrying out interactive, two-way, patient-centered counseling sessions, while paying special attention to the behavioral, psychosocial and environmental attributes of health and disease [35,36]. They must be able to perform data gathering, educate the patient, negotiate and resolve issues, and demonstrate empathy [37].

Teaching the competency of PBLI may require different pedagogical strategies compared to those used to foster clinical-reasoning skills or patient-interaction skills. The basic principles of designing these strategies are to clearly define key learning outcomes, identify potential workplace settings which can be opportunistically used to impart PBLI competencies and select engaging and learning-rich experiences. The developmental milestones enumerated in Web Table I will be useful to identify the level of the learner and build on previous learning.

Learners must be encouraged to use both formal and informal approaches. Some of these approaches are: use of study groups with peers, problem solving exercises, formal clinical rotations, online modules (for knowledge); demonstrations, simulations, review of video recording of learner, deliberate practice (for skills); and sharing real life experiences in discussions, behavioral interventions, and appropriate role models (for behavior). Deliberate practice involves improving and extending the reach and range of skills which one already possesses. Deliberate practice entails consider-able, specific and sustained efforts to develop expertise in something which the learner cannot do well [38].

Literature has documented many teaching-learning strategies ranging from small-group learning [39], workshops [40] to project-based learning [41], which can help in fostering these behaviors in learners. Many curricula and models have also been developed and tested [42-44]. Some of the best documented instructional strategies for cultivating PBLI behaviors in learners have been documented in the ACGME project report [45] and are summarized in Fig.2. Some of these instructional strategies are elaborated below:

Fig.2 Teaching-learning strategies to cultivate practice-based learning and improvement behaviors in learners.

A case, problem or inquiry is used to stimulate discussion and impart learning. Based upon the level and nature of inquiry, residents’ discussion can be observed, analyzed, evaluated and critiqued as it reflects their level of knowledge, skills, and attitudes. Probing can divulge the existing status of knowledge as well as resident’s ability to recognize learning gaps. Some of the case based approaches are:

A morbidity and mortality audit is a specific audit that tends to review negative clinical outcomes. A bizarre audit finding can act as a lead and can direct further investigation into practice patterns [49]. The resident scrutinizes an morbidity and mortality case in terms of his or her own practice behaviors, reflects on it, and uses that to improve practice behavior [43,50]. The resident presents a description of the case, reflections on what went wrong, and a list of resources used to gain a better understanding of the case. Presenters are expected to challenge themselves with self-queries like what they would do differently and what they would have to learn in order to improve. Clinical teachers rate residents in areas of practice analysis, improvement opportunity, resources to support analysis, and action plan [50].

A case under a resident’s care, which generated uncertainty either during evaluation or management or counseling and which definitely requires some action is chosen. The resident discusses the case with a facilitator. Then a Medline search is conducted by the resident for relevant literature review. Again a meeting with facilitator is conducted and a tutorial is prepared. The same is presented to the group in a structured-manner, giving questioning opportunities after every session [51]. By utilizing their own clinical cases, the residents appreciate the need to learn, identify learning-gaps, and improve by self-reflection on real life situations, thus improving PBLI skills.

Residents work with a facilitator to recognize an area of their practice that needs improvement, plan a project-intervention to improve upon that gap, execute the improvement, and establish its efficacy of the implementation during next year. By learning their own practice-gaps and improving upon by self-reflection, and implementation of improvement-project, the residents inculcate PBLI skills [52].

The focus of journal clubs can be one specific skill (such as how to use likelihood ratios, or how a search strategy is developed), and then specific articles can be chosen to teach that particular skill. Residents must eventually learn how to weigh the strength of the scientific evidence and regular sessions on critical appraisal of journal articles are most valuable for this purpose.

While PBLI needs to be explicitly included in the postgraduate training program, it can be introduced early in the undergraduate curriculum with Early clinical exposure (ECE); using student electives to reinforce the value of evidence-based medicine; and by allowing undergraduates to shadow patients in the clinics.

Assessment of PBLI as a whole is difficult as it spans different roles of a scholar, professional, manager, communicator, and lifelong learner. It is not possible to measure all competencies with a single assessment tool. Lack of validated and reliable tools to assess this competency compounds the problem. Dependable methods of assessment must be developed. By defining milestones for each competency, assessment criteria specify the level of achievement or mastery expected at each stage. During assessment, the rate of progress of the learner’s knowledge, skills and behavior on each competency must be documented.

Assessment of PBLI involves longitudinal observation of the learner demonstrating self-directed learning behaviors, during multiple encounters [17]. One option to demonstrate improvement is to use the same assessment tool at different points along the training, provided that the tool is able to consistently distinguish between the different levels of performance.

It is important to clarify what will be assessed, how and when the assessment will be conducted and who will be responsible for assessment. Assessment can both be formative as well as summative. Some of the approaches which have been used to assess PBLI are detailed below:

Portfolios: Residents in most institutes in India, use pre-formatted logbooks as a popular means to document learning experiences in patient care. These are seldom taken seriously and scarcely provide opportunities of reflective behavior, feedback and improvement in patient care. Portfolios are a compilation of one’s professional work and achievements over a period of time and can be used to assess progress. Self-reflection is the inherent characteristic of any portfolio-linked learning and professional development, and that’s where they differ from logbooks, which are merely a compilation of record of one’s work [53]. Reviewing and analyzing a portfolio along with a mentor is a good strategy for a resident to receive formative feedback [54]. Portfolios can also be maintained electronically to track learner progress. The flexibility, comprehensiveness and potential for integration offered by use of portfolios makes it a top choice for assessment of PBLI competencies [9].

Medical record review and Chart-stimulated recall: Patient records are reviewed during one-on-one sessions with faculty in formal or informal settings using standardized forms. The focus of the review can be resident’s decision making, medications given, tests ordered, impact of interventions and their comparisons with standard patient care guidelines.

Performance ratings using checklists or global rating forms: Global assessment of competencies using rubrics or observation checklists may be other methods of demonstrating progress of learners [2,13]. Rubrics must clearly show how the learner has moved to a higher level of performance on each competency. Checklists are useful when competencies can be broken down into specific behaviors or actions. Each clinical encounter requires enlisting of determined standards before assessment can be implemented. Both checklists and rubrics require trained raters to assess completeness and correctness of each outcome.

Procedure or case logs: Residents prepare summaries of patient care experiences or procedures, which include both clinical data as well as their reflections [2]. These logs are useful for documentation of experiences and deficiencies, and can form part of the portfolio. Review of these logs with a faculty can be used to assess PBLI competencies.

Evidence-based medicine skill test: Some residency programs use written or oral EBM skill tests to assess knowledge of critical appraisal. Different abilities–such as formulating well-structured clinical questions; performing advanced literature searches; and assessing validity of evidence in published studies can be tested. The EBM skill test can be conducted several times; once before exposure to EBM curriculum and after that to record improvement in learning. Sustainability of improved behavior can be also assessed with EBM skill tests [55].

Other methods: Multiple choice questions, oral examination, use of standardized patients, objective structured clinical examination, work-place based assessment [56] like mini-clinical evaluation exercise (mini-CEX), 360° assessment and direct observation of procedural skills (DOPS), can be used for formative and summative assessment of PBLI. During 360° assessment or multisource feedback, residents receive structured feedback using standard forms from their peers, faculty, nurses, other staff and patients who observe their work on a day-to-day basis during patient care. Feedback maybe gathered on different aspects of their performance such as team work, professionalism, communication skills, management skills or decision making. These assessment forms could form part of the educational portfolio. In all these methods, direct observation of the learner in the workplace is followed by opportunities for reflection when constructive feedback is given by the faculty.

While we cannot emphasize the role of faculty in nurturing these skills enough, it must be said that strong institutional leadership and support are the keys to the effective implementation of these competencies. A rigid regulatory framework, shortage of faculty, unenthusiastic or overworked faculty, or lack of resources are all possible impediments to the successful functioning of this programme.

Faculty is required to guide and nurture learners to be self-directed [57]. Faculty or supervisors will be required to assist learners in envisioning long-term broader goals and then breaking them down into more achievable feasible short-term goals within a given time frame. It is important for faculty in each department to diagnose the stage of self-directedness that the learner lies in, so that they can facilitate their movement from a less advanced to a more advanced stage [58].

Faculty must be made aware of the importance of ensuring that students are trained and assessed for the competencies under PBLI. Faculty sensitization and training will be required to identify opportunities within the existing curriculum to incorporate PBLI training, provide constructive formative feedback, documentation of progress of milestones achieved by students in a longitudinal manner and assessment of competencies of PBLI. Ownership must be shared by several collaborators.

The development of expertise requires faculty who have the patience to observe students in their day-to-day work, and who have the capability of delivering constructive, and sometimes difficult feedback to the learner. Feedback which comes from a supervisor who has directly observed the learner is always more acceptable. To provide optimal feedback, faculty need to articulate it in a simple manner and provide clear messages, facilitate reflection and guide learners on how to translate learning goals into action [59]. Faculty must also have the ability to mentor, support and challenge learners in a manner that they are driven to achieve the next milestone. For skill acquisition, it is useful here to remember that there will be variations in how learners progress and acquire more advanced skills [15]. They must be given enough guidance, feedback, experience and practice to be comfortable with newer technologies.

Residents must be provided with ample opportunities to experience and practice their skills, in order to move towards acquiring expertise and acquire the competencies under practice based learning and improvement. It is important that they develop self-awareness of their abilities, are able to reflect on their proficiency and find avenues to pursue lifelong learning. Training and assessment of PBLI skills should be a mandatory part of the postgraduate curriculum and strategies to foster PBLI skills should be interwoven within all phases of training. Availability of milestones makes this process feasible enough to implement in practice.

Contributors: TS and Anshu: conceptualized the paper; RM and Anshu: wrote the manuscript; TS and PG: critically reviewed.

Funding: None; Competing interest: None stated.

1. Spencer J. Learning and teaching in the clinical environment. Br Med J. 2003;326:591-4.

2. Hayden SR, Dufel S, Shih R. Definitions and competencies for practice-based learning and improvement. Acad Emerg Med. 2002;9:1242-8.

3. Varkey P, Karlapudi S, Rose S, Nelson R, Warner M. A systems approach for implementing practice-based learning and improvement and systems-based practice in graduate medical education. Acad Med.2009; 84: 335-9.

4. Swing SR. Assessing the ACGME general competencies: General considerations and assessment methods. Acad Emerg Med. 2002;9:1278-88.

5. Paukert JL, Chumley-Jones HS, Littlefield JH. Do peer chart audits improve residents’ performance in providing preventive care. Acad Med. 2003; 78 (suppl 10):S39-41.

6. Sutherland JE, Hoehns JD, O’Donnell B, Wiblin RT. Diabetes management quality improvement in a family medicine residency program. J Am Board Fam Pract. 2001;14:243-51.

7. Parenti CM, Lederle FA, Impola CL, Peterson LR. Reduction of unnecessary intravenous catheter use: Internal medicine house staffparticipate in a successful quality improvement project. Arch Intern Med. 1994;154:1829-32.

8. Medical Council of India. Post Graduate Medical Education Regulations 2000. Available from: http://www.mciindia.org/RulesandRegulations/PGMedical EducationRegulations2000.aspx. Accessed July 17, 2016.

9. Lynch DC, Swing SR, Horowitz SD, Holt K, Messer JV. Assessing practice-based learning and improvement. Teach Learn Med. 2004; 16: 85-92.

10. Swing SR. The ACGME outcome project: retrospective and prospective. Med Teacher. 2007;29:648-54.

11. Sullivan RL. The Competency-based Approach to Training. Strategy Paper No 1. JHPIEGO Corporation: Baltimore, Maryland; 1995. Available from: http://pdf.usaid.gov/pdf_docs/Pnacg569.pdf. Accessed July 17, 2016.

12. Nasca T. The next step in the outcomes-based accreditation project. ACGME Bull. 2008;2-4.

13. Swing SR,　Beeson MS,　Carraccio C,　Coburn M,　Lobst W,　Selden NR, et al. Educational milestone development in the first 7 specialties to enter the next accreditation system. J Grad Med Educ.　2013;5:98-106.

14. Holmboe ES, Edgar L, Hamstra S. ACGME: The Milestones Guidebook; Version 2016. Available from: https://www.acgme.org/Portals/0/MilestonesGuidebook. pdf. Accessed July 17, 2016.

15. Dreyfus HL, Dreyfus SE. Mind over Machine. New York, NY: Free Press; 1988.

16. Dhaliwal U, Gupta P, Singh T. Entrustable professional activities: Teaching and assessing clinical competence. Indian Pediatr. 2015; 52: 591-7.

17. Burke AE, Benson B, Englander R, Carraccio C, Hicks PJ. Domain of competence: Practice-based learning and improvement. Acad Pediatr. 2014; 14: S38-S54.

18. Hicks PJ, Schumacher DJ, Benson BJ, Burke AE, Englander R, Guralnick S, et al. The pediatrics milestones: conceptual framework, guiding principles, and approach to development. J Grad Med Educ. 2010; 2:410-8.

19. American Board of Pediatrics and Accreditation Council for Graduate Medical Education. The Pediatrics Milestone Project. Available from: https://www.abp. org/abpwebsite/publicat/milestones.pdf. Accessed July 17, 2016.

20. Englander R, Burke A, Guralnick S, Benson B, Hicks PJ, Ludwing S, et al. The pediatric milestones: a continuous quality improvement project is launched-now the hard work begins! Acad Pediatr. 2012;12:471-4.

21. Hicks PJ, Englander R, Schumacher DJ, Burke A, Benson BJ, Gurulnick S, et al. Pediatrics milestone project: next steps toward meaningful outcomes assessment. J Grad Med Educ. 2010;2:577-84.

22. Schumacher DJ, Lewis KO, Burke AE, Smith ML, Schumacher JB, Pitman MA, et al. The pediatrics milestones: initial evidence for their use as learning roadmaps for residents. Acad Pediatr. 2013;13:40-7.

23. Kolb D. Experiential Learning as the Science of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.

24. Schon D. Educating the Reûective Practitioner. San Francisco, Calif: Jossey-Bass Publishers; 1987.

25. Knowles MS. Self-Directed Learning. A Guide for Learners and Teachers. Englewood Cliffs: Prentice Hall/Cambridge; 1975.

26. Morris C, Blaney D. Work-Based Learning. In: Swanwick T, (editor). Understanding Medical Education: Evidence, Theory and Practice. Wiley-Blackwell: Oxford, UK; 2010.

27. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-81.

28. Moore LG, Wasson JH. Improving efficiency, quality and the doctor–patient relationship. Fam Pract Manag. 2007;14:20-4.

29. Ashton CM. "Invisible doctors": making a case for involving medical residents in hospital quality improvement programs. Acad Med. 1993;68:823-4.

30. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-2.

31. Duncan J, Evens R. Using information to optimize medical outcomes. JAMA. 2009;301:2383-5.

32. Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Q. 1989;13:319-39.

33. Davis FD, Bagozzi RP, Warshaw PR. User acceptance of computer technology: a comparison of two theoretical models. Manage Sci. 1989;35:982-1002.

34. Venkatesh V. Determinants of perceived ease of use: integrating control,intrinsic motivation, and emotion into the technology acceptance model. Inf Syst Res. 2000;11:342-65.

35. Bird J, Cohen-Cole SA. The three function model of the medical interview. An educational device. Adv Psychosom Med. 1990;20:65-88.

36. Lazare A, Putnam SM, Lipkin M. Jr. Three functions of the medical interview. In:　Lipkin M Jr., Putnam SM, Lazare A, editors. The Medical Interview: Clinical Care, Education, and Research.　 New York, NY: Springer-Verlag; 1995. pp. 3-19.

37. Modi JN, Anshu, Chhatwal J, Gupta P, Singh T. Teaching and assessing communication skills in medical undergraduate training. Indian Pediatr. 2016;53: 497-504.

38. Ericsson KA, Prietula MJ, Cokely ET. The making of an expert. Harv Bus Rev. 2007;85:114-21.

39. Canal DF, Torbeck L, Djuricich AM. Practice-based learning and improvement: a curriculum in continuous quality improvement for surgery residents. Arch Surg. 2007;142:479-83.

40. Morrison LJ, Headrick LA. Teaching residents about practice-based learning and improvement. Jt Comm J Qual Patient Saf. 2008;34:453-9.

41. Ogrinc G, Headrick LA, Morrison LJ, Foster T. Teaching and assessing resident competence in practice-based learning and improvement. J Gen Intern Med. 2004;19 496-500.

42. Peters AS, Kimura J, Ladden JD, March E, Moore GT. A self-instructional model to teach systems-based practice and practice-based learning and improvement. J Gen Intern Med. 2008;23:931-6.

43. Ziegelstein RC, Fiebach NH. The mirror and the village: A new method for teaching practice-based learning and improvement and systems-based practice. Acad Med. 2004;79:83-8.

44. Tomolo AM, Lawrence RH, Watts B, Augustine S, Aron DC, Singh MK. Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills. J Grad Med Educ. 2011;3:49-58.

45. ACGME Outcome Project. Enhancing residency education through outcomes assessment - Advancing education in practice-based learning and improvement. Available from: https://www.usahealthsystem.com/workfiles/com_docs/gme/2011%20Links/Practice%20Based%20Learning. ACGME.pdf. Accessed July 17, 2016.

46. King A. Designing the instructional process to enhance critical thinking across the curriculum. Teach Psychol. 1995;22:13-7.

47. Whelan CT, Podrazik PM, Johnson JK. A case based approach to teaching practice-based learning and improvement on the wards. Semin Med Pract. 2005; 8: 64-74.

48. Arseneau R. Exit rounds: A reflection exercise. Acad Med. 1995;70: 684-7.

49. Yaffe MJ, Gupta G, Still S, Boillat M, Russillio B, Schiff B, et al. Morbidity and mortality audits. Can Fam Physician. 2005;51:234-9.

50. Rosenfeld JC. Using the morbidity and mortality conference to teach and assess the ACGME general competencies. Curr Surg. 2005;62:664-9.

51. Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med. 1997;12:742-50.

52. Lough JRM, Murray TS. Audit and summative assessment: a completed audit cycle. Med Educ. 2001;35:357-63.

53. Joshi M, Gupta P, Singh T. Portfolio-based learning and assessment. Indian Pediatr. 2015;52:231-5.

54. Salzman DH, Franzen DS, Leone KA, Kessler CS. Assessing practice-based learning and improvement. Acad Emerg Med. 2012;19:1403-10.

55. Smith CA, Ganschow PS, Reilly BM. Teaching residents evidence-based medicine skills: a controlled trial of effectiveness and assessment of durability. J Gen Intern Med. 2000;15:710-5.

56. Singh T, Modi JN. Workplace-based assessment: A step to promote competency based postgraduate training. Indian Pediatr. 2013;50:553-9.

57. Schmidt H. Assumptions underlying self-directed learning may be false. Med Educ. 2000;34:243-5.

58. Grow GO. Teaching learners to be self-directed. Adult Educ Q. 1991;41:125-49.