The Dutch Case Developments in Medical Education in the Netherlands prof dr Herman JM van Rossum

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 Amsterdam AMC Leyden Utrecht Rotterdam Nijmegen Maastricht

Developments in Medical Education in the Netherlands Medical education in the Netherlands: a continuum, many stakeholders Undergraduate medical education Postgraduate education Conclusions content Blueprint (8/8), competency based (5/8) process the Bologna process: restructuring the program (5/8) structure Integration of medical faculties and hospitals (8/8) content Revising all programs; competencies, Teach the Teachers process shorter programs? new professions? pilot study structure other umbrella: together with all health professions

Independent Learning Selection Quality Assurance Competencies Competencies Accountability Efficiency Bologna Medical education: a continuum 4 12 18-19 27 30-33 65 Primary Secundary Undergrad GP Pub Medical Practice Specialist

“Market” Education Health Care Medical education and Health Care 4 12 18-19 27 30-33 65 Primary Secundary Undergrad GP Pub Medical Practice Specialist • Two Ministries are financing: Education and Health Care. • Health Care: from individual doctor-patient health relation to Care ‘market’ • Providers Hospitals, homes, clinics • Brokers Insurance companies • Employees Doctors and other personnel

Formats content Blueprint: Final Learning Outcomes Blueprint LAW Basic curriculum

clinical conditions competencies concepts Translation Blueprint into program Calgary Blueprint 20 clusters 188 conditions Sore throat Shock Proteinuria Dying Misabuse Preconception care Early detection of … CanMEDS VUmc Compass CURRICULUM 8 roles 31 competencies Consult Give information Literature search Team work … 17 domains > 150 concepts Apoptosis Bio-psychosocial model DNA-repair Stress Homeostasis Ethics Adaptation Autonomy Feedforward Laws … VUmc

content behaviour Competencies Clinical conditions behaviour Concepts content Concept of the translation Professional field Tasks in practice Study tasks Exercise tasks Curriculum Scientific field

Groningen Amsterdam VU Amsterdam AMC Leyden Utrecht Rotterdam Nijmegen Maastricht • Content of Dutch Curricula • Common learning outcomes • Eight different curricula • More electives (about 20%) • More research training (about 10%)

VUmc-Compass VU doctor: Competent with passion. self reflector scholar professional manager health advocate collaborator communicator medical expert

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

reflector scholar professional manager health advocate collaborator communicator medical expert Characteristics new VUmc-curriculum sem 1: 20 w sem 2: 20 w bachelor Didactic learning environment Scientific setting Health care setting Formal assessment Portfolio assessment MD

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: want to join the European ‘club’ Denmark/Belgium: quick followers UK: medicine does not want to follow France: what is Bologna? Netherlands: split response by deans, not a political item yet

History of the Bologna process Year Place Topic # countries 1998 Sorbonne Harmonising of higher education in Europe 4 1999 Bologna One European Higher Education Area by 2010 29 2001 Prague Quality Assurance framework 33 • Berlin Peer review for Quality assurance 40 2005 Bergen Adoption of standards and guidelines ENQA 45 2007 London ??

Ten action lines of Bologna now • System of comparable degrees • 2 cycles: - Bachelor: 3 jaar with possibility of outflow - Master • 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 • “Learning Outcomes”, final goals? competencies? • 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 Amsterdam AMC Leyden Utrecht Rotterdam Nijmegen Maastricht Bologna in the Netherlands All Universities comply... but ... the 2-cycle! Medical deans are split: 5-3 Unclear what will happen in 2010

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.

number of Students number of Diplomas number of PhD’s and strategic research compartment Model 28 M Euro/Year (40% Education - 60% Research) Funding of the Medical Faculty Ministry of Education University Faculty Departments

~ 50 M Euro ~ 260 M Euro 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 University Hospital

Integral budget VUmc (2004) • Ministry of Education 28 • Ministry of Health 50 • Care sources 260 • Contract research 25 • Various 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?

Steering ! UMC region Execution Vocational programs dean Staff / boards steer organize leaders +50%? teach teacher patient student 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 History taking Physical examination First consultation operation in out patient Patient care doctor patient

TOO SIMPLE ! Health care system management of care History taking Physical examination First consultation operation in out patient Patient care doctor patient

steering integrated management education Vocational training support Education and vocational training In the health care system History taking Physical examination First consultation operation in out patient Patient care clerk assistant doctor / teacher patient

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?

TASK The heart of clinical teaching TEACHER STUDENT Prepares himself Gives FEEDBACK DOESLOOKS LISTENS reflects Gives JUDGMENT IN practice Task description Organization of setting Teacher-training

Behaviour practice skills labs Professional authenticity problem solving Cognition facts and concepts Training of competencies: Miller Does Shows how Knows how Knows Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

? Does Shows how Knows how Knows ?? Training of doctors should be on the top 2007

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

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 ... • 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

The Dutch Case Developments in Medical Education in the Netherlands prof dr Herman JM van Rossum