Developments in Medical Education

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					The Dutch Case
Developments in Medical Education in the Netherlands

prof dr Herman JM van Rossum
Free University of Amsterdam

Porto
February 24th 2007

Groningen

Amsterdam VU Leyden

Amsterdam AMC
Utrecht

Rotterdam

Nijmegen

Maastricht

Developments in Medical Education in the Netherlands
Medical education in the Netherlands: a continuum, many stakeholders

Undergraduate medical education
content process structure Blueprint (8/8), competency based (5/8) the Bologna process: restructuring the program (5/8) Integration of medical faculties and hospitals (8/8)

Postgraduate education
content process structure Revising all programs; competencies, Teach the Teachers shorter programs? new professions? pilot study other umbrella: together with all health professions

Conclusions

Medical education: a continuum
4
Primary 12 Secundary 18-19 Undergrad 27 GP 30-33 65

Independent Learning
Selection

Pub
Specialist

Medical Practice

Quality Assurance

Competencies
Bologna

Competencies Accountability Efficiency

Medical education: a continuum
4
Primary 12 Secundary 18-19 Undergrad 27 GP 30-33 65

Independent Learning
Selection

Pub
Specialist

Medical Practice

Quality Assurance

Competencies
Bologna

Competencies Accountability Efficiency

Medical education and Health Care
“Market”
4
Primary 12 Secundary 18-19 Undergrad 27 GP 30-33 65

Pub
Specialist

Medical Practice

Education

Health Care

1. Two Ministries are financing: Education and Health Care. 2. Health Care: from individual doctor-patient health relation to Care „market‟ • Providers Hospitals, homes, clinics • Brokers Insurance companies • Employees Doctors and other personnel

Developments in Medical Education in the Netherlands
Medical education in the Netherlands: a continuum, many stakeholders

Undergraduate
content process structure

medical education
Blueprint (8/8), competency based (5/8) the Bologna process: restructuring the program (5/8) Integration of medical faculties and hospitals (8/8)

Postgraduate education
content process structure Revising all programs; competencies, Teach the Teachers shorter programs? new professions? pilot study other umbrella: together with all health professions

Conclusions

Blueprint: Final Learning Outcomes
Blueprint Formats content LAW

Basic curriculum

Translation Blueprint into program
20 clusters 188 conditions

clinical conditions

Calgary

Blueprint
CanMEDS

Sore throat Shock Proteinuria Dying Misabuse Preconception care Early detection of …

VUmc Compass CURRICULUM

competencies

8 roles 31 competencies
Consult Give information Literature search Team work …

17 domains > 150 concepts Apoptosis DNA-repair Homeostasis Adaptation Feedforward

concepts
Bio-psychosocial model Stress Ethics Autonomy Laws …

VUmc

Concept of the translation
Professional field
content behaviour

Clinical conditions
Tasks in practice Study tasks Exercise tasks

Competencies

behaviour

Curriculum
Concepts
content

Scientific field

Groningen

Amsterdam VU Leyden

Amsterdam AMC
Utrecht

Rotterdam

Nijmegen
Content of Dutch Curricula • Common learning outcomes • Eight different curricula • More electives (about 20%) • More research training (about 10%)

Maastricht

VU doctor: Competent with passion.

VUmc-Compass
self reflector

professional

scholar

health advocate

manager

collaborator medical expert

communicator

Structure and characteristics new curriculum
sem 1: 20 w sem 2: 20 w

1. grown-ups: similarities and differences
2. development of humans: man and wife 3. mechanisms of deseases bachelor 4. basic doctors skills

5. health care settings as working environment 6. choices in health care and in research MD

Health care settings in new curriculum

bachelor

MD

Science in new curriculum

bachelor

MD

Assessment in new curriculum

bachelor

MD

Characteristics new VUmc-curriculum
sem 1: 20 w sem 2: 20 w
professional health advocate collaborator medical expert reflector

scholar manager
communicator

bachelor

MD

Didactic learning environment Scientific setting Health care setting Formal assessment Portfolio assessment

Developments in Medical Education in the Netherlands
Medical education in the Netherlands: a continuum, many stakeholders

Undergraduate medical education
content process structure Blueprint (8/8), competency based (5/8) the Bologna process: restructuring the program (5/8) Integration of medical faculties and hospitals (8/8)

Postgraduate education
content process structure Revising all programs; competencies, Teach the Teachers shorter programs? new professions? pilot study other umbrella: together with all health professions

Conclusions

Undergraduate Medical Education: process
The Bologna declaration process

- is a declaration, not a law, nor a treaty - countries are free to participate and to what degree - countries can make their own laws and regulations - the reasons for participation are varied, mainly political
Eastern-Europe: Denmark/Belgium: UK: France: Netherlands: want to join the European „club‟ quick followers medicine does not want to follow what is Bologna? split response by deans, not a political item yet

History of the Bologna process
Year Place Topic # countries

1998 1999 2001 2003 2005 2007

Sorbonne Bologna Prague Berlin Bergen London

Harmonising of higher education in Europe One European Higher Education Area by 2010 Quality Assurance framework Peer review for Quality assurance Adoption of standards and guidelines ENQA ??

4 29 33 40 45

Ten action lines of Bologna now
1. 2. System of comparable degrees 2 cycles:
- Bachelor: 3 jaar with possibility of outflow - Master

3. 4. 5. 6. 7. 8.

Creditsystem: ECTS Mobility of students and teachers Quality assurance: visitations and accreditation European dimension in the programmes

Third Cycle: the doctorate with PhD Acknowledgement of grades and study periods /supplements of certificates 9. “Learning Outcomes”, final goals? competencies? 10. Longlive learning: national qualification structures, European qualification framework

The Bologna process
The main question about the 2-cycle item is whether medical bachelors have relevant options to choose from other than the medical master program? If not, why should medical schools put so much effort in establishing two programs with the entire bureaucratic burden going along with it? Here is the answer of the deans ...

But is this the most relevant item? What about quality assurance and learning outcomes?

Groningen

Amsterdam VU Leyden

Amsterdam AMC
Utrecht
Bologna in the Netherlands

Rotterdam

Nijmegen

All Universities comply... but ... the 2-cycle! Medical deans are split: 5-3

Unclear what will happen in 2010

Maastricht

Developments in Medical Education in the Netherlands
Medical education in the Netherlands: a continuum, many stakeholders

Undergraduate medical education
content process structure Blueprint (8/8), competency based (5/8) the Bologna process: restructuring the program (5/8) Integration of medical faculties and hospitals (8/8)

Postgraduate education
content process structure Revising all programs; competencies, Teach the Teachers shorter programs? new professions? pilot study other umbrella: together with all health professions

Conclusions

Undergraduate Medical Education: structure
DEVELOPMENT in the LAST TWO DECADES Merge of Medical Faculties and University Hospitals: all eight medical faculties now have been fused into University Medical Centers

The 8 Faculties of Medicine ...
- all have 350-400 new students a year - are identically financed by the Ministry of Education - all comply with the national Blueprint 2001 - work together: quality assessments of education and research - each have their own type of program from complete problem-based to all kind of mixed curricula; all have early patient contacts.
- all have one principal 800-1000 bed University Hospital.

Funding of the Medical Faculty
Ministry of Education
number of Students number of Diplomas number of PhD’s and strategic research compartment

University Model
Faculty

Departments

28 M Euro/Year (40% Education - 60% Research)

Funding of the University Hospital
Ministry of Health Care sources

Budget for the academic workplace function: Clinical Education, Training, Clinical Research

Routine Care Budget Academic Care Budget

~ 50 M Euro ~ 260 M Euro University Hospital

Integral budget VUmc (2004)
• • • • • Ministry of Education Ministry of Health Care sources Contract research Various 28 50 260 25 8 _______ 370 M Euro

Merging: to do or not to do?
ADVANTAGES
One board of directors One employer One management for the three main tasks: education, research and care Multidisciplinary research (preclinical combined with clinical) The use of common lab. facilities and specialised personnel More flexibility because of larger budget

Merging: to do or not to do?
FEARS and possible DISADVANTAGES
Culture differences (democratic versus hierarchical)

David vs Goliath sentiments („Care will eat us all‟) Drifting away from the rest of the University The loss of Academic character and status

A battle? ... or ...

... a (happy) marriage?

The development of UMC‟s
The main question was whether the academic processes of research and education would survive, perish or flourish when they had to compete with the demands of health care. Would it be Academia or Health Care, David or Goliath?

Here is the answer of the deans ...

Conclusions of the deans
In the Netherlands the UMC is a success formula! - well organised education of high standard - productive research helped by the flexibility of bigger budgets - basic research not sacrificed at the altar of care - new forms of integrated management developed
Prerequisites and conditions - Most Deans have changed into professional executives! - Charter with a well defined relation of University and UMC - Clear and accepted role of the Dean in the Board of Directors of the UMC i.e. responsible for Education and Research as well as for the selection of new academic staff - Separate Budgets for Education and Research

Deans are happy about the marriage so far, but ... what about the children? the student and the patient? What should the dean take care of?

Vocational programs

Steering
Staff / boards

dean

UMC

!
leaders

steer

region

teacher student

+50%
patient

?

organize

teach

Execution
learn

secundary school

IN

OUT

Now the dean has his basic structure. What about the primary educational process? What should the dean take care of?
money alone ... or time of the doctors and their teaching qualities?

Health care system

in
patient

History taking Physical examination First consultation

operation

out

Patient care

doctor patient

TOO SIMPLE !
Health care system
management of care
History taking Physical examination First consultation

in
patient

operation

out

Patient care

doctor patient

Education and vocational training In the health care system
integrated management

steering

education

Vocational training
operation

in
patient

History taking Physical examination First consultation

out

Patient care
clerk assistant doctor / teacher patient

support

Now the dean has his basic structure and the time for teaching and the organization? What about the learning needs of the students and assistants?

The heart of clinical teaching
STUDENT
Prepares himself
TASK

TEACHER
Gives FEEDBACK

DOES

LOOKS

LISTENS reflects

IN practice Task description Organization of setting Teacher-training

Gives JUDGMENT

Training of competencies: Miller

Professional authenticity

Does Shows how Knows how Knows

practice

Behaviour

skills labs

problem solving

Cognition
facts and concepts

Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

Training of doctors should be on the top
2007

?
Does

Shows how
Knows how

??

Knows

Can deans use allies?

Yes, they need help of their colleagues. How to mobilize the enthusiasm of the doctors, the professionals?

Developments in Medical Education in the Netherlands
Medical education in the Netherlands: a continuum, many stakeholders

Undergraduate
content process structure

Blueprint (8/8), competency based (5/8) the Bologna process: restructuring the program (5/8) Integration of medical faculties and hospitals (8/8)

medical education

Postgraduate education
content process structure Revising all programs; competencies, Teach the Teachers shorter programs? new professions? pilot study other umbrella: together with all health professions

Conclusions

Postgraduate Medical Education: content
Royal Dutch Society for Medicine took the decision ... to innovate all 33 programs according to modern educational principles: observation, feedback on behavior, varied assessment procedures ... 1. 2. 3. 4. 5. 6. 7. Competency based (CAN-meds) Portfolio mandatory Regular assessment sessions KPB‟s (mini-CEX): 10 a year 360° Judgment on performance Knowledge tests Teach the Teachers programs

Postgraduate Medical Education: process
A nation-wide pilot-study has started this year by two disciplines (Pediatrics and Obstetrics / Gynecology) financed by Ministry of Health

OBJECTIVES - to develop prototypes for educational formats - to improve educational expertise of program directors - to increase support / analyze resistance - to develop a model for quality assurance

Postgraduate Medical Education: structure

UMC’s and the Professional societies are creating regional expertise centers for medical education

- linked to the eight University Medical Centers - serving all Health Professions - together serving all regions in the Netherlands

Groningen

Amsterdam VU Leyden

Amsterdam AMC
Utrecht

Rotterdam

Nijmegen
The dream for the next decade

8 regions linked to the UMC’s covering all HC-professions Maastricht

Conclusions
1. University Medical Centers are powerful structures in which care, research and education can be managed successfully. But what about the primary educational process in the clinics? 2. The Medical professional organizations are creating a spirit of renewal and enthusiasm about education and training. 3. Regional centers for health care education should create the structure for clinical education of students and assistants AND to enable doctors to become competent clinical teachers.

Ars longa, vita brevis
„Ο βίος βραχύς, ή δε τέχνη μακρή,

Hippocrates 450-370

We have to work together in educating the new generation of doctors

Thanks for your attention!

Hippocrates 450-370

Let us work together in educating the new generation of doctors

Conclusions
1. More tuning between undergraduate and postgraduate education - for educational methods: new spirits in postgraduate programs - improving educational skills of clinical teachers - quality assurance methodology

2. Tuning between education of doctors and other HC personnel - educational methods - organization and governance 3. Tuning between policy of department of Education and department of Health Care at the operational level - merging medical faculties and University Hospitals - plans for eight regional medical education centers for all health care personnel, each linked to one of the eight Universities

Questions for the future?

1. Bologna process and medicine: when will the politics decide? 2. Will the marriage between University and Health Care last? 3. What will be the role of the doctor and the patient in the Health Care „market‟ ?

Will the patient profit from all these development?

New programs, cooperations
18-19 Undergrad 27 GP 30-33 65

Pub University P. Assist
Prof. Schools Specialist

Medical Practice

Nurse P

Postgraduate Medical Education: process
Ministry of Health is stimulating... shorter postgraduate medical training programs (eg hospital doctors) more physician assistant programs more nurse practitioner programs in order to .... make Health Care more efficient and cheaper.


				
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