The course left out in the cold

Abstract

Education ministers hope that students and staff will be able to move freely between European universities by 2010. But medicine is being left behind, as Toby Reynolds explains

European education ministers have big changes in mind for higher education. Their vision sees students moving between Europe's universities, taking courses that all count towards comparable qualifications, and, as a result, finding it easier to move around as employees. Governments hope that promoting this agenda will make their universities more attractive around the world and deliver a supply of high quality graduates to the workplace.

They signed up to the idea with a declaration in Bologna in 1999.¹ Since then, despite a low profile in some countries, the wheels of the Bologna process have been turning steadily, bringing closer the goal of a common European higher education area by 2010.

Medicine, however, seems to have been left behind. It is not that medical educators disagree with the Bologna process's main points, and indeed it would be hard to argue that more exchange within European institutions, more comparable qualifications, and overall higher standards would be a bad thing.

The most obvious problem is that in the Bologna model, harmonisation of the course of study across Europe has meant countries adapting their curriculums to fit a two cycle model, with a three year bachelors degree and a two or three year masters. Ministers agreed to this from the outset, and have reaffirmed it since then, even though it has required considerable upheaval in the many countries where longer study culminating in a masters level degree has been the norm. By the time education ministers met in London in May this year, most declaration signatories were well on the way to making the necessary changes.

Fitting to the model

The two cycle model is meant to make it easier for students to move after their bachelors degree either to the job market or to further study in another geographical or subject area. Those who want to continue up to masters level in their original subject can do so, but students who do not are no longer forced to carry on or miss out completely. But this fails to recognise inherent differences between the study of medicine and that of most other subjects, medical educators say.

“The aim would be that you would have people entering into a bachelors programme and at the end of the three years they would have amassed a certain number of credit points. They would then be able to take their credits and go off to do the next two years, the masters, in another European institution,” says Gareth Williams, dean of the faculty of medicine and dentistry at the University of Bristol. Professor Williams is also coordinator of MEDINE, a network set up to look at how European initiatives such as the Bologna process can be best applied to medical education, although he stresses he does not speak for the group:

“It was felt that within Europe there wasn't enough exchange of ideas and exchange of people, exchange of students. Bologna was also seen as a way of raising the standards in areas of Europe that are bad, by exposing them to best practice elsewhere and by raising students' expectations. The basic concept is actually quite a good one, and it is applicable to lots of humanities and even the basic sciences. The trouble is that it doesn't actually lend itself to lots of medical curricula.”

That is largely because medical education in most European countries has moved away from the division between preclinical and clinical study that could have easily fitted into a two cycle course. The curriculum is now more integrated, with clinical and communication skills and contact with patients introduced early in the course.

“Most medical schools are now striving towards complete integration of the basic sciences and the clinical sciences,” says Hans Karle, president of the World Federation for Medical Education. “This will be a problem with this two cycle system, because then you will immediately try to separate the two parts into the basic sciences followed by the clinical sciences.

“Of course that was actually the traditional way of teaching in the past. In all parts of the world we are trying to introduce this integration, and I think it would be harmful to this process if we were not allowed to plan the medical curriculum as a one tier system.”

In addition, medical schools might take on more bachelors candidates than they intended to allow on to the masters programme. As the world federation points out, it is not clear what other employment or course of study would be suitable for bachelor students who did not go on to finish medical studies. And even if courses were split into two, different national quality assurance and certification criteria and language barriers would probably make mobility between different countries' medical education systems difficult.

Notwithstanding these objections, several countries are adapting their medical education systems to fit the Bologna model. Switzerland has switched to a two cycle system, with theoretical mobility between its medical schools after the bachelor stage. Denmark has introduced a bachelors degree for all medical students after three years of study, although its curriculum is still integrated and no-one is expected to leave at that point. And Spain, France, Austria, Belgium, and the Netherlands have also considered ways to introduce the two cycle system.

Concerned by the implications of this trend, the world federation called in 2005 for medical schools to be able to opt out of the two cycle system.² But higher education ministers at the London meeting in May did not mention this point.³ “It doesn't appear anywhere in the ministerial communiqué. It appears that it is a subject that wasn't covered,” says David Gordon, president of the Association of Medical Schools in Europe.

Since the Bologna model does not carry the enforceable weight of an international treaty, the realisation of its aims is down to the legislative will of signatory governments. As such, UK medical schools are unlikely to be forced to use the two cycle model, Professor Gordon says. “I don't think it could creep up on us and happen without warning. I think there is enough understanding that things have to be done sensibly.”

Better standards

Some argue, however, that the Bologna process represents an opportunity for reform. “At a minimal level Bologna could mean that we simply award a bachelor of medicine degree to all of our students after three years of medical school, which in a sense wouldn't change anything, it would almost be a ghost degree,” says Allan Cumming, director of undergraduate learning and teaching at the University of Edinburgh's medical school.

“If you take medical students who have been at university for five or six years, they deserve something way beyond an ordinary bachelors degree, so I see it as desirable from that point of view.”

But he adds that such a change could also be an opportunity to modernise curriculums and particularly to start looking at what a student should have learnt on a course. “I think that if you have an appropriate set of learning outcomes for bachelor of medicine, which are clinical enough and medical enough, then it could actually be an aid to integration for those schools that currently just teach science for three years.”

The issue of learning outcomes touches on an important role for the Bologna model in improving medical education. Professor Cumming leads a group in the MEDINE network looking at learning outcomes, using a process called tuning. Tuning was initiated by a group of European universities in 2000 to identify common points of reference for generic and subject specific competencies.

“A lot of the role of Bologna is to tidy things up,” he says. “What medical degrees are called across Europe, how much study is involved, what kind of degree they are, whether or not they entitle the graduate to practise medicine. If you look across Europe there is no uniformity of practice, and in a situation where we are supposed to treat all European medical graduates equally for job applications, that to me is totally unacceptable.

“That's why we think our tuning project is quite important. We are starting to say these are areas of the curriculum that at least you mustn't have forgotten about completely. We are not being hugely prescriptive about exactly what the competencies or learning outcomes should be but at least here are the big headings that you have got to have.”

Dr Karle, who leads a MEDINE group looking at quality assurance standards, points out that the Bologna model is not about standardisation, rather about harmonisation and compatibility.

“People might get the feeling that the Bologna process is heading towards a common system of quality assurance, for instance a common European accreditation system of medical schools and their programmes. I don't think this is feasible in a foreseeable time,” he says. “We think that what is needed is to have approved standards and let medical schools work with these standards in their reform process, and then we could also use these standards in national accreditation systems.”

Many of the changes that will take place under the Bologna model were on the cards for European higher education anyway, Dr Karle says, especially items like transferable credits, enhanced mobility, and promotion of lifelong learning. In addition, he adds, medical education has been slowly moving towards greater harmonisation in Europe since the introduction of European Union directives recognising professional qualifications in 1975.

The Bologna model may just help that along, or it may prove a catalyst for more radical change, but coming from within the universities, not imposed from outside.

“What really matters is that all medical degrees in Europe are regarded as the same under European employment law when they patently are not,” said Professor Cumming.

“It will take a long time to alter that situation, but at least some sort of start ought to be made in my view. In order to make a start there has to be an acceptance that actually there is a European dimension to medical education, that it is not just a national issue or an institutional issue. That is what a lot of people take issue with, they say it has nothing to do with Europe.”

Bologna process

The Bologna process began officially in 1999 when education ministers from 29 European countries signed the Bologna Declaration, pledging to adopt a system of comparable degrees, based on undergraduate and graduate cycles.

They also promised to take steps to increase mobility of students, teachers, and researchers, including the adoption of a system of transferable credits, and to promote European cooperation on issues such as quality assurance and curriculum development.

Subsequent meetings have added the doctoral level as a third stage on top of the bachelors and masters degrees, and have called for the implementation of national qualification frameworks, among other objectives. The ultimate aim is to establish a European higher education area by 2010.

The process has been largely driven by higher education leaders, rather than by the European Commission, and remains a voluntary inter-governmental initiative. By the end of May 2007, 46 countries were signatories to the declaration.

• MEDINE

The Thematic Network on Medical Education in Europe (MEDINE) (www.bris.ac.uk/medine/) aims to address educational, institutional, and quality issues in European medical education within the framework of existing European initiatives such as the Bologna process and the European Credit Transfer System. Task forces work on five main activities:

• Agreeing core competencies/learning outcomes for medical education in Europe

• Developing a framework for international recognition of qualifications

• Developing quality assurance standards for the process of medical education for application in Europe

• Enhancing the transparency and public understanding of medical education

• Exploring and developing links between medical education and research.

MEDINE is supported by the European Commission and has more than 100 universities and organisations as partners.

European Credit Transfer System (ECTS)

The system was developed initially to allow students to count periods of study at other institutions towards degrees from their own universities. Credits are awarded in proportion to workload. A full year's study (1500-1800 hours) equates to 60 credits. Credits relate only to the work involved, and universities accept them for transfer on a voluntary basis. Medical educators, among others, have called for the credit system to include descriptors of a course's content and level alongside the amount of work required.