Building the 8-star doctor: a modified Delphi study to define, teach, and assess health professions education for undergraduate medical students | BMC Medical Education

Efforts by the World Federation for Medical Education (WFME) have increasingly emphasized the need to transition from traditional, didactic curricula toward student-cantered, lifelong learning. Strategies such as case-based learning, bedside teaching, and interprofessional education are now central to modern medical education. Despite global progress in defining undergraduate learning objectives, considerable variability persists in how teaching content is implemented and prioritized across programs [24].

Although the importance of teaching as a professional competency is well established, it remains underrepresented in many undergraduate medical curricula. Often relegated to elective modules or student-selected components, teaching is not formally recognized as a core skill [25,26,27]. While international studies have identified relevant learning objectives for undergraduate Health Professions Education (HPE) [10], considerable heterogeneity persists in terms of content, delivery, assessment methods, and structural format [6, 24]. The integration of new subjects such as HPE into medical curricula poses challenges related to curricular overload, faculty readiness, institutional resources, and competing priorities [26].

This study reinforces the necessity of embedding HPE content especially teaching, leadership, and professionalism into the undergraduate curriculum. Through a multi-phase consensus process, 17 key topics were identified that bridge both clinical and non-clinical competencies. Topics such as bedside teaching, procedural skills, and communication are strongly aligned with global competency frameworks like CanMEDS, affirming their relevance in diverse educational contexts [2]. However, cognitive domains such as curriculum design and learning theories did not reach consensus. Experts noted that including such content might contribute to cognitive overload and may not yield immediate practical benefits in already content-heavy curricula [28, 29]. These observations highlight the need to balance conceptual knowledge with hands-on competencies.

The results further demonstrate that competency-based learning, combined with student-centred teaching strategies and structured assessments, supports the development of critical thinking, leadership, and professional identity. Unlike conventional curricula that focus primarily on biomedical knowledge, the proposed framework prioritizes non-clinical domains such as patient safety and professionalism, addressing existing gaps in competency-based medical education (CBME) models [8. 10].

Student resistance to curricular integration of cognitive topics has been previously reported and often stems from preference for traditional methods or perceived content burden [28, 29]. Our findings echo these concerns, underscoring the importance of integrating experiential learning with cognitive scaffolding to enhance engagement and knowledge retention.

Core learning content: competencies for the modern physician

Leadership, patient safety, and professionalism emerged as essential competencies for contemporary medical practice. Despite broad endorsement, their implementation in undergraduate programs remains inconsistent. However, the inclusion of these competencies is supported by a substantial body of literature. Passi and Johnson [30] emphasized that Student as Teacher (SaT) progra ms must include modules on communication, professionalism, and feedback to ensure students are equipped for formal educational roles. A scoping review by Burgess et al. [25] concluded that internationally developed SaT curricula frequently incorporate these components, citing them as standard practice for safe and effective student-led instruction. The CanMEDS Physician Competency Framework (2015) also identifies Communicator, Professional, and Leader as key roles applicable to both clinical and educational settings [31].

While clinical teaching components received widespread support, certain topics such as online assessments and spiral curricula did not achieve consensus. Contextual factors including limited technological infrastructure, faculty preparedness, and institutional constraints were cited as barriers. These results suggest that while core content can be standardized, implementation strategies must remain adaptable to local contexts.

Preferred teaching strategies: emphasis on active learning

Student-centred pedagogies were clearly favoured, with small group discussions (SGDs) identified as the most effective modality, particularly for clinical subjects requiring observation, feedback, and reflective engagement [13, 32]. SGDs promote deeper understanding, collaboration, and professional development, aligning with global best practices.

Large-group interactive sessions (LGIS), although less preferred, were recognized for their practicality in resource-constrained settings. These sessions facilitate broad content delivery and can support professional identity formation through exposure to the hidden curriculum. (33)

Participatory models such as case-based learning (CBL), problem-based learning (PBL), and interprofessional education (IPE) have been widely acknowledged for enhancing retention and application of knowledge [33]. Student presentations, peer teaching, and feedback-driven formats were also valued for fostering motivation, confidence, and deeper conceptual understanding.

Assessment strategies: shift toward competency-based evaluation

The study highlights a paradigm shift from traditional knowledge-based testing toward holistic, competency-based assessment. Objective Structured Teaching Exercises (OSTE) and reflective portfolios emerged as preferred tools. Reflective portfolios were endorsed as formative, mid-stakes tools that support self-directed learning, metacognition, and professional development. When combined with structured feedback and debriefing, they contribute meaningfully to longitudinal assessment.

Objective Structured Teaching Exercises (OSTEs) are structured, simulated teaching scenarios where students perform brief teaching tasks (e.g., delivering a mini-lecture or providing feedback) to standardized learners under observation [34]. OSTEs allow for objective assessment of observable teaching behaviours, such as clarity, professionalism, and instructional effectiveness, in a standardized, reproducible format with immediate feedback [35].

Reflective portfolios, by contrast, are longitudinal, learner-driven tools. Students collect teaching experiences, personal reflections, feedback, and self-assessments over time. This method fosters deep reflection, self-awareness, and professional identity development, supporting the integration of teaching and ethical competencies. A recent BMC Medical Education study recommends portfolios for their capacity to assess complex, nuanced skills and encourage ongoing reflective practice [36].

However, standardization of HPE assessment remains a global challenge. For instance, while over 90% of U.S. medical schools assess teaching competencies, only 36% of Australian schools report formal HPE evaluation frameworks. Addressing this disparity requires institutional investment, faculty development, and alignment with accreditation standards.

Despite advances, most HPE programs continue to be offered as optional or short courses, lacking sustainability and scalability. Our study is the first from the region to formally propose teaching as a core component of undergraduate medical education establishing the physician as not only a clinician but also an educator committed to lifelong learning [35].

Barriers to effective integration include curriculum saturation, faculty limitations, and resource constraints [13, 28]. Overcoming these challenges demands institutional flexibility and support for context-specific adaptation of HPE content.

Implications for curriculum design

1. 1.

   Core Competencies:

2. 2.

   Emphasizing leadership, patient safety, and professionalism equips students for dynamic roles in multidisciplinary healthcare settings.

3. 3.

   Innovative Teaching Strategies:

4. 4.

   Preference for small group discussions and case-based learning reflects the global shift toward active learning environments. Incorporation of simulation and skills labs further enhances experiential learning.

5. 5.

   Pragmatic Assessment:

6. 6.

   Endorsement of OSTE and reflective portfolios reflects a move toward competency-based evaluation beyond rote knowledge testing.

Implications for lower- and middle-income countries (LMICs)

These findings are especially relevant for LMICs, where formal teaching training in medical education is limited. A validated student-as-teacher curriculum can bridge this gap by fostering academic competencies early, preparing students for peer teaching roles, and promoting culturally relevant professionalism. Additionally, this model can serve as a cost-effective faculty development strategy, reducing dependence on external training programs and contributing to capacity-building within local institutions.

Strengths and limitations

Strengths of this study include its rigorous multi-phase design, high response rate (> 90%), and wide regional representation. The Delphi process ensured consensus through iterative refinement, while anonymity reduced response bias. Alignment with internationally recognized frameworks such as CanMEDS and CBME enhances the study’s relevance and applicability.

Limitations include the exclusion of student perspectives and the lack of feasibility testing at the institutional level. Further research is needed to explore these areas and refine implementation strategies.