Medical education in India has historically been organized around discipline-based teaching, prescribed hours, clinical postings, and university examinations. Although this structure provides curricular standardization, concerns have persisted regarding excessive emphasis on factual recall, variable clinical-skill acquisition, limited structured feedback, insufficient integration, and uncertainty regarding whether examination success consistently translates into readiness for practice. The national shift to competency-based undergraduate medical education sought to address these limitations by defining the Indian Medical Graduate in terms of observable professional capabilities. The framework emphasizes early clinical exposure, horizontal and vertical integration, skills training, Attitude, Ethics and Communication (AETCOM), self-directed learning, electives, formative assessment, and certification of specified competencies. The educational continuum, however, extends beyond MBBS. Competencies acquired during undergraduate training should be consolidated during compulsory rotating medical internship, where learners begin functioning with genuine clinical responsibility. Postgraduate training should then build on these capabilities through increasing independence, workplace-based assessment, supervision, mentoring, and entrustment. This continuum can be conceptualized as: MBBS competency acquisition -> supervised clinical application -> compulsory rotating internship -> postgraduate specialty competence -> independent professional practice. The principal implementation problem is therefore not simply whether competencies are listed in curricula, but whether they are continuously developed, demonstrated, assessed, transferred, and entrusted across successive stages of training. Indian studies have documented faculty shortages, inadequate faculty development, large learner groups, infrastructure limitations, timetable congestion, difficulties with integration, logbook burden, inconsistent assessment, and uneven implementation between institutions. Emerging work at postgraduate level has additionally highlighted the need for explicit entrustable professional activities and more authentic workplace-oriented assessment. The present systematic review was designed around the Indian Medical Graduate continuum rather than a simple undergraduate-versus-postgraduate comparison. Its purpose was to identify where the continuum breaks, why those breaks occur, and what system-level solutions could improve continuity. Review Objectives 1. Identify barriers to competency acquisition during undergraduate medical training. 2. Examine challenges in translating curricular competencies into workplace performance. 3. Evaluate gaps at the transition from final MBBS to compulsory rotating medical internship. 4. Identify challenges affecting competency-based postgraduate training and entrustment. 5. Quantify the most frequently reported implementation barriers across the Indian evidence base. 6. Develop an India-specific continuum framework linking MBBS, internship, and postgraduate training. 7. Propose measurable implementation solutions for medical colleges and regulators

Review Design A systematic review with structured thematic synthesis was undertaken using PRISMA 2020 reporting principles. The review was designed around the medical-training continuum and not merely around differences between undergraduate and postgraduate education. SPIDER Framework Component Operational definition Sample Indian medical students, interns, postgraduate residents, faculty, and educational administrators Phenomenon of interest Implementation of competency-based medical education Design Surveys, qualitative studies, mixed-method studies, implementation evaluations Evaluation Barriers, challenges, feasibility, workload, assessment, feedback, preparedness, continuity Research type Quantitative, qualitative, and mixed-method Information Sources and Search Period The review framework included PubMed/MEDLINE, Scopus, Web of Science, ERIC, and Embase. Studies published from January 2019 to March 2026 were considered, reflecting the national undergraduate CBME rollout period. Search Strategy Search terms combined: ("competency-based medical education" OR CBME OR "Indian Medical Graduate" OR "competency based curriculum") AND (India OR Indian) AND (undergraduate OR MBBS OR internship OR CRMI OR resident OR postgraduate) AND (barrier* OR challenge* OR implementation OR assessment OR faculty development OR feedback OR logbook OR AETCOM OR "early clinical exposure" OR integration OR "entrustable professional activities"). Eligibility Criteria • Conducted in India or specifically evaluated Indian medical education. • Examined CBME or an identifiable component of the Indian competency-based curriculum. • Included undergraduate students, interns, postgraduate trainees, faculty, or educational stakeholders. • Reported implementation challenges, perceptions, barriers, feasibility problems, or system-level constraints. • Used empirical quantitative, qualitative, mixed-method, or structured educational evaluation designs. Exclusion Criteria • Not related to Indian medical education. • Conceptual discussion without primary implementation evidence. • Non-medical health-professional education. • Isolated examination-performance studies without implementation outcomes. • Editorials, letters, or opinions without primary data. • Duplicate or overlapping cohorts. • Insufficient methodological or extractable implementation information. Study Selection and Data Synthesis Records underwent title/abstract screening followed by full-text eligibility assessment. Extracted variables included author, year, educational stage, intervention or curricular component, study design, participant group, implementation barrier, and proposed solution. Because the included studies used heterogeneous questionnaires, qualitative methods, and implementation outcomes, statistical meta-analysis was not appropriate; thematic synthesis and frequency coding were used.

PRISMA Study Selection The search yielded 603 records. After removal of 154 duplicates, 449 records underwent title and abstract screening. Of these, 369 were excluded. Eighty reports were sought for retrieval; four could not be retrieved. Seventy-six full-text reports were assessed, of which 55 were excluded. Twenty-one studies were included in the qualitative synthesis. 4.2 Full-Text Exclusion Reasons Reason for exclusion n Did not specifically evaluate Indian CBME implementation 14 Conceptual/editorial/review without primary implementation data 11 No extractable barrier or implementation outcome 10 Intervention unrelated to broader competency implementation 8 Population outside medical training continuum 6 Duplicate/overlapping cohort 4 Insufficient methodological information 2 Total 55 4.3 Distribution of Included Studies Training stage Studies Percentage Predominantly undergraduate MBBS 14 66.7% Community/internship-transition relevant 2 9.5% Postgraduate medical training 5 23.8% Total 21 100.0% 4.4 Characteristics of Included Studies No. Authors, Year Stage Focus Principal implementation finding 1 Shrivastava SR, Shrivastava PS, 2019 PGME Community medicine CBME Stakeholder sensitization, planning and EPA assessment difficulties 2 Ramanathan et al., 2021 UME Nationwide faculty perspectives Faculty shortage, inadequate preparation, ECE/integration challenges 3 Mahajan et al., 2022 UME Multicentric faculty adoption Variable stages of concern and continuing faculty-support needs 4 Pawar et al., 2022 UME Foundation Course Variation in organization, scheduling, and institutional execution 5 Soundariya et al., 2022 UME Phase I CBME Difficulty implementing ECE, integration, AETCOM, SDL and skills modules 6 Gopalakrishnan et al., 2022 UME Faculty barriers High student-faculty ratio, infrastructure limitations, assessment difficulty 7 Ganguly et al., 2022 UME AETCOM/bioethics Teaching time, participation, pedagogy and assessment challenges 8 Ramanathan et al., 2022 UME Faculty implementation Workload, faculty numbers, assessment complexity and preparedness 9 Sil et al., 2023 PGME Dermatology training Service pressures and disrupted competency-oriented training environment 10 Ravishankar et al., 2023 PGME Mentoring and EPAs Need for structured mentoring, direct observation and entrustment 11 Kundapur et al., 2023 PGME Community medicine Theory-heavy curriculum and inadequate policy/program competence 12 Rajaragupathy et al., 2023 PGME MD Biochemistry EPAs Need for specialty-specific EPAs and defensible entrustment 13 Shanmugam et al., 2024 UME Student perspectives Uneven experience and implementation between institutions 14 Agrawal et al., 2024 UME Faculty implementation Faculty preparedness, ECE/AETCOM delivery, workload and assessment 15 Sulena et al., 2024 UME Multicentric stakeholders Trained-faculty deficit, timetable and infrastructure constraints 16 Sethuraman et al., 2024 UME Psychiatry clinical training Variation in clinical exposure and implementation quality 17 Baruah & Choudhari, 2024 UME/community Family Adoption Programme Community logistics and implementation burden 18 Ganganahalli et al., 2024 UME/community Family Adoption Programme Community engagement and operational constraints 19 Bannaravuri et al., 2025 UME Pharmacology Shortened teaching duration and curricular compression 20 Bhagat et al., 2025 UME Student perspectives Logbook burden, limited self-study time and burnout 21 Virani et al., 2026 UME Northern India CBME Faculty training, infrastructure, teaching methods and assessment challenges 4.5 Methodological Profile Design n % Cross-sectional questionnaire study 8 38.1 Mixed-method study 5 23.8 Qualitative interview/focus-group study 4 19.0 Prospective/program implementation evaluation 3 14.3 Grounded-theory study 1 4.8 Total 21 100.0 4.6 Frequency of Major Barriers Barrier Studies reporting barrier (n=21) % Inadequate faculty preparation/training 16 76.2 Assessment/logbook/documentation complexity 15 71.4 Timetable and curricular congestion 14 66.7 Inadequate infrastructure/skills resources 13 61.9 Faculty shortage 12 57.1 Difficulty with horizontal/vertical integration 12 57.1 Inconsistent feedback/logbook quality 11 52.4 Learner workload/stress 10 47.6 Variability between institutions/departments 9 42.9 Technology/digital-resource limitations 8 38.1 MBBS-to-workplace continuity problems 7 33.3 Community/logistical implementation problems 6 28.6 PG workplace assessment/entrustment difficulties 5 23.8 Continuum-Based Thematic Synthesis Continuum Break 1: Faculty Capability Gap CBME requires faculty to act not only as content experts but also as observers, coaches, assessors, feedback providers, curriculum integrators, and contributors to entrustment decisions. Indian studies repeatedly indicate that broad awareness of CBME does not automatically translate into implementation competence. Longitudinal faculty-development pathways are therefore essential. Continuum Break 2: Curriculum Expansion Without Decompression CBME has introduced valuable elements including Foundation Course, ECE, AETCOM, integration, skills certification, SDL, electives, community programmes, formative assessment, and portfolios. When these are added without sufficient pruning of older content, timetable density increases and learner-centered reform may paradoxically create more academic compression. Continuum Break 3: Competency Assessment Becoming Documentation Logbooks, competency checklists, journals, attendance requirements, and internal assessment records can become administrative endpoints rather than evidence of performance. A signed record is not equivalent to demonstrated competence. Assessment systems must prioritize authenticity, direct observation, and actionable feedback. Continuum Break 4: Difficulty Achieving Authentic Integration Horizontal and vertical integration require common objectives, coordinated scheduling, interdepartmental planning, agreed depth of content, and shared assessment. Without these structures, integration risks becoming a timetable exercise rather than clinically meaningful interdisciplinary learning. Continuum Break 5: Skills-Laboratory and Clinical Exposure Gap Competency-based education depends on repeated practice and observed performance. Inadequate simulation infrastructure, limited clinical supervisors, high learner numbers, variable patient exposure, and competition for clinical opportunities can result in formal competency lists without adequate opportunities for every learner to demonstrate them. Continuum Break 6: Feedback Deficit Feedback is the mechanism that converts assessment into learning. Generic comments, retrospective signatures, and non-specific ratings provide little developmental value. Learners require feedback that clearly identifies what was done well, what needs improvement, and what the next learning action should be. Continuum Break 7: Learner Workload and Well-Being Students must simultaneously manage university examinations, postings, competency certification, logbooks, reflective writing, AETCOM, SDL, electives, community activities, and internal assessment. Several Indian studies indicate that documentation load and reduced self-study time can contribute to stress and burnout. Continuum Break 8: MBBS-to-Internship Transfer Gap Undergraduate competencies are generally recorded during MBBS, but those records do not consistently follow learners into internship in a way that determines supervision intensity, procedural opportunities, remediation, or increasing responsibility. This represents a critical continuity failure. Continuum Break 9: Internship as Service Versus Competency Consolidation Internship should represent the stage where the IMG moves from 'shows how' to 'performs under supervision' and then to 'performs with decreasing supervision.' When service requirements dominate, structured competency consolidation and deliberate observation may become secondary. Continuum Break 10: Postgraduate Competence Without Explicit Entrustment Postgraduate training should progress beyond procedure counts toward explicit judgments of whether a resident can be trusted to perform a professional activity with a defined level of supervision. Indian specialty-level work on EPAs suggests a pathway toward more defensible workplace-based progression decisions. 6. Stage-Specific Barrier Matrix Domain MBBS Internship PG training Faculty availability +++ ++ ++ Faculty CBME training +++ ++ ++ Timetable congestion +++ + ++ Logbook burden +++ ++ ++ Direct observation ++ +++ +++ Structured feedback ++ +++ +++ Skills infrastructure +++ ++ ++ Workplace entrustment + +++ +++ Interdepartmental coordination +++ ++ ++ Service-learning conflict + +++ +++ Learner stress ++ ++ +++ Longitudinal competency tracking ++ +++ +++ +++ = major priority; ++ = moderate priority; + = emerging/less dominant

The evidence indicates that Indian CBME has moved from policy formulation to a large-scale implementation phase. The principal problems are therefore operational rather than conceptual. Faculty capacity emerged as the most frequently reported barrier. The issue is not lack of clinical knowledge, but the additional educational expertise required for direct observation, feedback, integration, assessment design, coaching, remediation, and entrustment. A second major concern is the risk that competency-based assessment becomes dominated by documentation. When logbook completion becomes the practical endpoint, the educational purpose of assessment is weakened. Competency must remain an observed performance construct rather than an administrative signature. Curriculum density is another recurring challenge. Valuable components such as ECE, AETCOM, SDL, electives, and community-based learning can become burdensome when introduced without corresponding reduction of redundant content. The strongest conceptual finding of this review is the continuity gap between MBBS, internship, and postgraduate training. These stages are regulated sequentially but do not always operate as a single developmental competency pathway. Internship should serve as the bridge between undergraduate demonstration and postgraduate entrustment. A longitudinal competency record would enable supervision and responsibility to be adjusted according to demonstrated ability rather than treating every learner as educationally identical at transition points. At postgraduate level, competency-based training should move beyond case numbers and procedural counts. Entrustment-oriented decisions offer a more clinically meaningful way to determine progression toward independent practice. Accordingly, the next phase of Indian CBME reform should prioritize continuity, simplification, assessment authenticity, and measurable implementation quality rather than expansion of documentation requirements. Implications for the Indian Medical Graduate A successful Indian CBME system should not be judged primarily by the number of competencies signed off, logbooks completed, or teaching activities conducted. The Indian Medical Graduate should be demonstrably able to recognize common clinical problems, initiate appropriate management, identify emergencies, perform basic procedures, communicate effectively, act ethically, work within teams, understand community health priorities, recognize personal limits, and seek appropriate assistance. Strengths • India-specific focus across the full medical education continuum. • Continuum-based rather than simple UME-versus-PGME structure. • Integration of broad implementation studies with studies of specific curricular components. • Explicit identification of the MBBS-internship-PG transition as a separate implementation problem. • Use of measurable barrier-to-solution indicators. Limitations • Indian evidence remains concentrated on undergraduate CBME, with fewer empirical studies on internship and PG progression. • Many included studies are cross-sectional perception surveys rather than longitudinal evaluations. • Institutions differ considerably in faculty strength, patient load, infrastructure, and educational resources. • Definitions of successful CBME implementation vary across studies.

Competency-based medical education has fundamentally changed the architecture of Indian medical training, but successful implementation cannot be achieved through curricular documents alone. The principal barriers identified were inadequate faculty preparation, assessment complexity, curricular congestion, infrastructure limitations, faculty shortage, integration difficulties, inconsistent feedback, learner workload, and variability in implementation. More importantly, the evidence reveals a structural discontinuity between undergraduate competency acquisition, internship performance, and postgraduate entrustment. The next phase of reform should therefore emphasize continuity: competencies learned during MBBS should be demonstrated before graduation, strengthened through supervisedresponsibility during internship, and progressively entrusted during postgraduate specialty training. The true success of Indian CBME will be evident when the Indian Medical Graduate is not merely certified as competent but can consistently demonstrate safe, ethical, and effective performance in real clinical environments

1. National Medical Commission. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. New Delhi: NMC. 2. National Medical Commission. Competency Based Medical Education Curriculum Guidelines 2024. New Delhi: Undergraduate Medical Education Board; 2024. 3. National Medical Commission. Compulsory Rotating Medical Internship Regulations, 2021. New Delhi: NMC. 4. National Medical Commission. Post-Graduate Medical Education Regulations, 2023. New Delhi: NMC. 5. Shrivastava SR, Shrivastava PS. Qualitative study to identify the perception and challenges faced by faculty of community medicine in implementation of competency-based medical education for postgraduate students. Fam Med Community Health. 2019;7:e000043. 6. Ramanathan R, Shanmugam J, Sridhar MG, Palanisamy KT, Narayanan S. Exploring faculty perspectives on competency-based medical education: a report from India. J Educ Health Promot. 2021;10:109. 7. Mahajan R, Virk A, Saiyad S, Kapoor A, Ciraj AM, Srivastava T, et al. Stages of concern of medical faculty toward adoption of competency-based medical education in India: a multicentric survey. Int J Appl Basic Med Res. 2022;12(2):87-94. 8. Pawar R, Vagha S, Pande V, et al. Challenges in implementation of the Foundation Course of newly launched competency-based medical education curriculum among Indian medical colleges. Asian J Med Sci. 2022;13(8):116-121. 9. Soundariya K, Kalaiselvan G, Rajalakshmi M, Sindhuri R. Implementation and evaluation of competency-based medical education in Phase I of undergraduate medical curriculum. J Adv Med Educ Prof. 2022;10(4):228-234. 10. Gopalakrishnan S, Catherine AP, Kandasamy S, Ganesan H. Challenges and opportunities in the implementation of competency-based medical education: a cross-sectional survey among medical faculty in India. J Educ Health Promot. 2022. 11. Ganguly B, D'Souza R, Nunes R. Challenges in the teaching-learning process of the newly implemented module on bioethics in the undergraduate medical curriculum in India. Asian Bioeth Rev. 2023;15(2):155-168. 12. Ramanathan R, Shanmugam J, Gopalakrishnan SM, Palanisamy KT, Narayanan S. Challenges in the implementation of competency-based medical curriculum: perspectives of prospective academicians. Cureus. 2022;14(12):e32838. 13. Sil A, et al. Impact of the COVID-19 pandemic on dermatology teaching and competency-based postgraduate training in India. 2023. 14. Ravishankar M, et al. Competency-based postgraduate training: mentoring and monitoring using entrustable professional activities. Natl Med J India. 2023;36(3):176-181. 15. Kundapur R, Rashmi A, Mishra KG, Panda M, Ravikoti S, Agarwal N. Understanding the need for developing a structured competency-based curriculum for health policy and programs among community medicine postgraduates: a grounded theory approach. Indian J Public Health. 2023;67(3):408-414. 16. Rajaragupathy S, et al. Identifying entrustable professional activities for MD Biochemistry postgraduate training in India. 2023. 17. Shanmugam J, et al. Perspectives of Indian medical students regarding the competency-based medical education curriculum: a qualitative thematic content analysis. 2024. 18. Agrawal A, et al. Challenges faced by medical faculty in implementation of competency-based medical education. 2024. 19. Sulena S, Kulkarni A, Mathur M, Jyoti N, Sidhu TK, Badyal D, et al. Challenges in implementing competency-based medical education in India - stakeholders' perspective: a mixed-method analysis. Int J Appl Basic Med Res. 2024;14(3):141-148. 20. Sethuraman B, Chari U, Perugu S, Salazar LJ, Sreedaran P. Students' perspectives of competency-based medical education in undergraduate psychiatry clinical training: a qualitative evaluation. Indian J Psychol Med. 2024;46(5):400-407. 21. Baruah A, Choudhari SG. Perceptions of stakeholders and the way forward to implementing the Family Adoption Programme in medical education: a study from Assam, India. Cureus. 2024;16(7):e63586. 22. Ganganahalli P, et al. Perception and impact of the Family Adoption Program among undergraduate medical students. 2024. 23. Bannaravuri R, Xavier AS, Kathiah R, Anandhalakshmi S. Challenges in implementing the competency-based medical education curriculum in pharmacology: impact of shortened duration and reduced teaching hours. Cureus. 2025;17(2):e78660. 24. Bhagat S, et al. Competency-based medical education: perspectives from medical students in India. 2025. 25. Virani S, Rewri P, Gupta P, Badyal D. Challenges and opportunities in the implementation of competency-based medical education for undergraduates in Northern India. International Medical Education. 2026;5(1):23. 26. Frank JR, Snell LS, Ten Cate O, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645. 27. Modi JN, Gupta P, Singh T. Competency-based medical education, entrustment and assessment. Indian Pediatr. 2015;52:413-420. 28. Sharma R, Bakshi H, Kumar P. Competency-based undergraduate curriculum: a critical view. Indian J Community Med. 2019;44:77-80. 29. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. 30. Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160.