Summary. Political and social development in Europe will lead t o increased mobility o f doctors between countries as well as opening u p new possibilities and horizons for educational institutions. I n this emerging process the charge that universities are too traditional t o change may not be valid when the virtues o f academic traditions in Europe arc considered. When those virtues arc taken into account, they are seen to facilitate the integration o f more current goals for fLiturc developnient into undergraduate medical curricula. The use o f external examiners between different countries i n Europe will promote greater quality in European medical cducatioti. K c y words: ’educational, medical, undergraduate; curriculum; educational status; schools, mcd; European Economic Comninnity
Introduction T h e European C o m m u n i t y Directives (Conimission o f the European Communities 1075) serves as a base line for European collaboration in niedical education. Further collaboration can be achieved through current exchange prograninics, including Erusmus and Tempus, and also through more extensive use o f external cxaminers. These efforts -- if supported by the medical faculties - offer new dimensions of mobility and improved quality o f medical education i n Europc. The future Europe without frontiers will have its free trade-market, free labour-market, new currency (the E C U ) , ctc. The educational institutions, as bearers o f European culture, including C:orrespondcncc: Dr Jsrgcn Nystrup, Nordic Federation for Medical Educdtioti, tltgshospttalet, Tagens \;ci 18, DK-2200 Copenhagen, Dcnmark.
the universities, will face new horizons with different possibilities The form which a n c ~ v Europe conies to assume will be dependent on active involvcmcnt o f European universities, of which the niedical schools are part. Wdl this transition be possible? In foreseeing this emerging process, ~ v found c it necessary t o review the history of univcrsitics arid the academic tradition in Europe. It thcil bccanic apparent that certaln strengths of the past could be enhanced and incorporated in setting the goals and planning the activities for future development. If these strengths arc shown t o have bearing, it can tie claimed that the iniputation that ‘the universitics arc too traditional to change’ is not valid because o f the constructive effects o f traditions.
Some characteristics of European university education Europe is a region with signtkicant differences d r c dcfinitc bonding forces, bascd on strong coninion culturdl similarities, present III rcgard to the political systems, the social values and the cducational traditions o f Europc,.
among its ndtionb. Ncvcrthclcss, thcrc
EdurnlIorral c-l{/tuw
I n Europc, once rned~cal school tias Iiecn entered, or the first sclcctioti examinations in universities without W ~ M E ~ I Iclartsus Z have been passed, niedical students a r e generally provided with a framework for their studies a n d arc subscqucntly tested before q~ial~ficatioiisarc given. Based on their results, students rcccivc permission to proceed t o further studies. ‘The fittest will survive. Postgraduate credentials arc
Medical education in a new Europe based on research and documented relevant clinical experiences. This century-long university tradition in Europe builds on respect for the individual student, faith in adult learning, and belief in learning as a personal process. The European concept as outlined above has resulted in medical schools of very high standards able to compete intcrnationally in respect of research, teaching and the production of dedicated and skilful doctors. This learning culture is the counterpart of the concept: academic freedom. In Europe university studies are in principle free ofcharge, which means that students in most European countries do not have to pay any tuition fees. Admission procedures vary among European medical schools, though most of them only require certain high-scoring grades from secondary school. Some countries, mostly Mediterranean, still accept an unlimited intake into their undergraduate medical curricula. Russia, also part of which belongs to the European sphere, produces far too many doctors. In some European countries there is a nation-wide policy aiming at broadening the application pool, making it possible for people with all kinds of social and economical backgrounds to apply to universities. That policy perhaps increases the chances to enter university of gifted persons, who otherwise would remain untapped in the stratum of non-applicants who are, however, suited for the medical profession. Formerly, shared courses in comparative anatomy and biology were usual between departments of anatomy and departments of biology outside the medical faculty. Today, preclinical medical departments rely on close collaboration with the faculty of natural science. Current research is integrated and interdisciplinary, extending across faculties. This trend will most certainly continue, not the least facilitated by new discoveries in biology and engineering. Education normally reflects current research, with the result that undergraduate programmes in turn must allow students to cross disciplinary boundaries to a greater degree than is presently the case. This will lead to uniquely differing profiles ofscholars, as a result ofthe combination of the medical curriculum with selected courses in other university departments, including natural sciences, engineering, economies, business, social sciences or the humanities. Such linkages,
351
moreover, are in. line with European university tradition extending across a century. In contrast, North-American medical schools can perhaps be perceived as according emphasis to the progress ofeach individual student. Learning environments are created which seek to offer tailor-made tutorials to meet the need of individual students. The large tuition fees in medical schools tend to foster narrow goal-orientation at the cost of wider intellectual curiosity. In this academic climate, every student is carefully guided, stimulated and evaluated. This educational approach achieves a level of scholarly attainment which might not be achieved as a result of the medical school programme in itself. Group identity
Europe has a social tradition which regards populations as comprising varying groups with special needs or particular attributes. The group more than the individual is then in evidence. It can be difficult for the individual citizen to obtain special rights. In the same way, university students can be regarded as classes, or collectives. It is difficult for the individual student to initiate a specific dialogue with the system. The existence o f a national health policy which provides free medical care to its citizens implies that medical students in Europe are confronted with a completely different perception of their role a!< future doctors. There are no special privileges for the individual patient. All individuals belong to the same collective of potential patients. Primary health care remains the major goal for most medical curricula in Europe. Existing national health policy with a relatively high degree of central administration makes it possible to base medical education on health needs. In principle, all that is required is serious negotiation between the minister for health and the minister for education, so that their government departments are coordinated for medical training purposes. The health care system in North America is in contrast to Europe, in that it is decentralized and depends very much on private enterprise. This makes it difficult to plan medical education at a federal level with the overall perspective of coordinating medical education with health care needs of populations.
352
J . Nystrrrp G D . Ma"rrerison
Current impairments and improvements in progress The concerns most strongly expressed by national authorities, medical teachers (both basic scientists and clinicians), medical studcnts and health care administrators involved in curriculum affairs, are redressed in the GPEP Report (Association of American Medical Colleges 1984) and in the Edinburgh Declaration (World Federation for Medical Education 1988). Although all d o not agree with these principles, enough do, and it is fair to state that changes have occurred and plans arc being made that seek to overcome the obstacles to necessary change. The problems in adjusting the training o f doctors and medical school programmes to health-carc needs of countries vary among nations. In some countries defccts are not as prominent as thcy are in other areas. A brief overview o f measures that have been taken or are under way would include innovative mcdical school programmes, such as those in Maastricht (Holland), Linkoping (Sweden), W i t t d H e r d c c k e (Germany), Tromso (Norway), and Bari (Italy) just to mention some. improvements have consisted o f clarifying goals, objectives and content, and important planning documcnts have resulted. Modern procedures have been developed for assessing knowledge, clinical skills and attitudes in place of conventional examinations. Teaching-learning modes have been changed to promote activc learning and small-group methods. Students have been provided with incrcased assignments, practical experiences in hospitals, gcneral practice consultations, or home visits to patients. Thus curricula have come to include an emphasis on health as well as disease; human dcvelopmcnt, communication, optional in-depth studies, and elcctives have all become more frequent. Many innovative and creative teaching-lcarning approaches have emerged, stimulated by altered curricula and journals of medical education, annual meetings, and national and international task-forces. All these means arc used for disseminating results from projects for improving medical education. The background for these improvements varies from formal decisions in the medical faculties to initiatives taken morc locally by teachers and students. Strengthening
curriculum committees in order to makc them more decisive in their relation to the faculties, and increasing the importancc given to teaching ability when appointing and promoting medical teaching staff to academic positions, are two of the priorities to be met i n order to counter obstacles to innovations.
Conclusions The inherent assets of the century-old European university tradition are highly relevant for obtaining improvements now sought in medical education, in keeping with the Edinburgh Declaration. Some of the key concepts to be nurtured are: adult learning, flexible academic pathways including disciplines other than traditional medical subjects. There is a need for educating broad-based medical graduates ready for further specialization rather than educating doctors who arc too narrowly oricntcd towards the technical skills of thcir specialty. Basic medical education must lead to students able to study independently, with a scientific attitude, prepared to be reflective doctors, and to assume responsibility for life-long learning by individual initiatives, with openness to control and monitoring from colleagues and governing bodies. In order to achievc those goals, the necessary curricular changes must be flexible and integrated, based on new combinations of curricular elements. The European Community framework of directives for medical education allows room for much discussion about improvement in medical education. The main thenics in this present discussion are: integration of basic sciences and clinical subjects; enabling students to understand scientific methods; early exposure to patients; active learning; in-depth studies; the reform of examinations to assess also the higher cognitive levels ofknowledge, clinical skills and attitudes; more use of proper educational technology; rewarding teaching competence by making educational ability a Lritcrion for promotion; setting up dcpartrnents of cducational research and development; diversified evaluation methods to monitor better the educational process. Medical education is a forcniost asset in terms of both teachers and students. The culture of
Medical education in a new Europe higher learning in European medical schools, as outlined above, allows for optimism about the task ahead in the new Europe. To support the education of doctors in Europe without boundaries, medical teaching institutions must support the exchange programmes of Erasnius, Nordplus and Tempus. These government-funded programmes make it possible for teachers and students to work temporarily in a European country other than their own. For over a century Nordic cultural cooperation, for example, has built on free exchange ofideas, projects and labour among the people in the Scandinavian countries. Experience from such Nordic collaboration shows that efforts to establish common rules and identical curricula are not always beneficial. Nevertheless, striving for higher standards stimulates individual faculties and nations to seek higher quality, and often culminatcs in substantial change in educational settings. Several associated matters must then be dealt with: the need for electives; language training for medical students; the need for agreed standards of competence on graduation among the countries; examination of the feasibility between countries of student exchange; and consideration of the desirability for staff and student exchange. The goals and objectives stated for medical schools and postgraduate training programmes should be discussed among the medical schools and countries of Europe. Regional Associations are critically important promoting agencies for medical education, notably the Association for Medical Education in Europe (AMEE), subregional organizations such as the Nordic Federation for Medical Education, and national associations with international membership in addition, the Association for the Study of
353
Medical Education of the UK (ASME), and the Association of Catholic Medical Faculties in Italy, to mention only a few. Cross-national communication is essential, to exchange new educational knowledge and experience and permit discussion critically. At the political level a better awareness is required of the prime importance of life-long learning in medicine. The setting up of units or departments for medical education research and development will ensure provision of educational expertise at both the undcrgraduate and postgraduate levels, and stimulate mcdical staff to attain increased educational competence. More professional evaluations of training programmes will result in addition. The use of external examiners, among the individual medical faculties in each country, and between different countries in Europe will be a force in increasing mobility of medical educators and promoting greater quality in European medical education.
References Association of American Medical Colleges (1984)
Physitriansfor the Twenty-First Century. T h e GDEP Report. Association o f American Medical Colleges, Washington DC. Commission of the European Communiites (1975) Directives of June 16, 1975. Bulletin no. L 16730.6.'75. Commission of the European Committees, Brussels.
World Fcderation for Medical Education (1988) World Confr.rence on Medical Education, Edinburgh, 7-12 August 1988, Report. World Federation for Medical Education, Edinburgh.
Received 2 August 1991; editorial comments to authors 5 A u p s t 1991; accepted f o r publication 25 February 1992
Introduction T h e European C o m m u n i t y Directives (Conimission o f the European Communities 1075) serves as a base line for European collaboration in niedical education. Further collaboration can be achieved through current exchange prograninics, including Erusmus and Tempus, and also through more extensive use o f external cxaminers. These efforts -- if supported by the medical faculties - offer new dimensions of mobility and improved quality o f medical education i n Europc. The future Europe without frontiers will have its free trade-market, free labour-market, new currency (the E C U ) , ctc. The educational institutions, as bearers o f European culture, including C:orrespondcncc: Dr Jsrgcn Nystrup, Nordic Federation for Medical Educdtioti, tltgshospttalet, Tagens \;ci 18, DK-2200 Copenhagen, Dcnmark.
the universities, will face new horizons with different possibilities The form which a n c ~ v Europe conies to assume will be dependent on active involvcmcnt o f European universities, of which the niedical schools are part. Wdl this transition be possible? In foreseeing this emerging process, ~ v found c it necessary t o review the history of univcrsitics arid the academic tradition in Europe. It thcil bccanic apparent that certaln strengths of the past could be enhanced and incorporated in setting the goals and planning the activities for future development. If these strengths arc shown t o have bearing, it can tie claimed that the iniputation that ‘the universitics arc too traditional to change’ is not valid because o f the constructive effects o f traditions.
Some characteristics of European university education Europe is a region with signtkicant differences d r c dcfinitc bonding forces, bascd on strong coninion culturdl similarities, present III rcgard to the political systems, the social values and the cducational traditions o f Europc,.
among its ndtionb. Ncvcrthclcss, thcrc
EdurnlIorral c-l{/tuw
I n Europc, once rned~cal school tias Iiecn entered, or the first sclcctioti examinations in universities without W ~ M E ~ I Iclartsus Z have been passed, niedical students a r e generally provided with a framework for their studies a n d arc subscqucntly tested before q~ial~ficatioiisarc given. Based on their results, students rcccivc permission to proceed t o further studies. ‘The fittest will survive. Postgraduate credentials arc
Medical education in a new Europe based on research and documented relevant clinical experiences. This century-long university tradition in Europe builds on respect for the individual student, faith in adult learning, and belief in learning as a personal process. The European concept as outlined above has resulted in medical schools of very high standards able to compete intcrnationally in respect of research, teaching and the production of dedicated and skilful doctors. This learning culture is the counterpart of the concept: academic freedom. In Europe university studies are in principle free ofcharge, which means that students in most European countries do not have to pay any tuition fees. Admission procedures vary among European medical schools, though most of them only require certain high-scoring grades from secondary school. Some countries, mostly Mediterranean, still accept an unlimited intake into their undergraduate medical curricula. Russia, also part of which belongs to the European sphere, produces far too many doctors. In some European countries there is a nation-wide policy aiming at broadening the application pool, making it possible for people with all kinds of social and economical backgrounds to apply to universities. That policy perhaps increases the chances to enter university of gifted persons, who otherwise would remain untapped in the stratum of non-applicants who are, however, suited for the medical profession. Formerly, shared courses in comparative anatomy and biology were usual between departments of anatomy and departments of biology outside the medical faculty. Today, preclinical medical departments rely on close collaboration with the faculty of natural science. Current research is integrated and interdisciplinary, extending across faculties. This trend will most certainly continue, not the least facilitated by new discoveries in biology and engineering. Education normally reflects current research, with the result that undergraduate programmes in turn must allow students to cross disciplinary boundaries to a greater degree than is presently the case. This will lead to uniquely differing profiles ofscholars, as a result ofthe combination of the medical curriculum with selected courses in other university departments, including natural sciences, engineering, economies, business, social sciences or the humanities. Such linkages,
351
moreover, are in. line with European university tradition extending across a century. In contrast, North-American medical schools can perhaps be perceived as according emphasis to the progress ofeach individual student. Learning environments are created which seek to offer tailor-made tutorials to meet the need of individual students. The large tuition fees in medical schools tend to foster narrow goal-orientation at the cost of wider intellectual curiosity. In this academic climate, every student is carefully guided, stimulated and evaluated. This educational approach achieves a level of scholarly attainment which might not be achieved as a result of the medical school programme in itself. Group identity
Europe has a social tradition which regards populations as comprising varying groups with special needs or particular attributes. The group more than the individual is then in evidence. It can be difficult for the individual citizen to obtain special rights. In the same way, university students can be regarded as classes, or collectives. It is difficult for the individual student to initiate a specific dialogue with the system. The existence o f a national health policy which provides free medical care to its citizens implies that medical students in Europe are confronted with a completely different perception of their role a!< future doctors. There are no special privileges for the individual patient. All individuals belong to the same collective of potential patients. Primary health care remains the major goal for most medical curricula in Europe. Existing national health policy with a relatively high degree of central administration makes it possible to base medical education on health needs. In principle, all that is required is serious negotiation between the minister for health and the minister for education, so that their government departments are coordinated for medical training purposes. The health care system in North America is in contrast to Europe, in that it is decentralized and depends very much on private enterprise. This makes it difficult to plan medical education at a federal level with the overall perspective of coordinating medical education with health care needs of populations.
352
J . Nystrrrp G D . Ma"rrerison
Current impairments and improvements in progress The concerns most strongly expressed by national authorities, medical teachers (both basic scientists and clinicians), medical studcnts and health care administrators involved in curriculum affairs, are redressed in the GPEP Report (Association of American Medical Colleges 1984) and in the Edinburgh Declaration (World Federation for Medical Education 1988). Although all d o not agree with these principles, enough do, and it is fair to state that changes have occurred and plans arc being made that seek to overcome the obstacles to necessary change. The problems in adjusting the training o f doctors and medical school programmes to health-carc needs of countries vary among nations. In some countries defccts are not as prominent as thcy are in other areas. A brief overview o f measures that have been taken or are under way would include innovative mcdical school programmes, such as those in Maastricht (Holland), Linkoping (Sweden), W i t t d H e r d c c k e (Germany), Tromso (Norway), and Bari (Italy) just to mention some. improvements have consisted o f clarifying goals, objectives and content, and important planning documcnts have resulted. Modern procedures have been developed for assessing knowledge, clinical skills and attitudes in place of conventional examinations. Teaching-learning modes have been changed to promote activc learning and small-group methods. Students have been provided with incrcased assignments, practical experiences in hospitals, gcneral practice consultations, or home visits to patients. Thus curricula have come to include an emphasis on health as well as disease; human dcvelopmcnt, communication, optional in-depth studies, and elcctives have all become more frequent. Many innovative and creative teaching-lcarning approaches have emerged, stimulated by altered curricula and journals of medical education, annual meetings, and national and international task-forces. All these means arc used for disseminating results from projects for improving medical education. The background for these improvements varies from formal decisions in the medical faculties to initiatives taken morc locally by teachers and students. Strengthening
curriculum committees in order to makc them more decisive in their relation to the faculties, and increasing the importancc given to teaching ability when appointing and promoting medical teaching staff to academic positions, are two of the priorities to be met i n order to counter obstacles to innovations.
Conclusions The inherent assets of the century-old European university tradition are highly relevant for obtaining improvements now sought in medical education, in keeping with the Edinburgh Declaration. Some of the key concepts to be nurtured are: adult learning, flexible academic pathways including disciplines other than traditional medical subjects. There is a need for educating broad-based medical graduates ready for further specialization rather than educating doctors who arc too narrowly oricntcd towards the technical skills of thcir specialty. Basic medical education must lead to students able to study independently, with a scientific attitude, prepared to be reflective doctors, and to assume responsibility for life-long learning by individual initiatives, with openness to control and monitoring from colleagues and governing bodies. In order to achievc those goals, the necessary curricular changes must be flexible and integrated, based on new combinations of curricular elements. The European Community framework of directives for medical education allows room for much discussion about improvement in medical education. The main thenics in this present discussion are: integration of basic sciences and clinical subjects; enabling students to understand scientific methods; early exposure to patients; active learning; in-depth studies; the reform of examinations to assess also the higher cognitive levels ofknowledge, clinical skills and attitudes; more use of proper educational technology; rewarding teaching competence by making educational ability a Lritcrion for promotion; setting up dcpartrnents of cducational research and development; diversified evaluation methods to monitor better the educational process. Medical education is a forcniost asset in terms of both teachers and students. The culture of
Medical education in a new Europe higher learning in European medical schools, as outlined above, allows for optimism about the task ahead in the new Europe. To support the education of doctors in Europe without boundaries, medical teaching institutions must support the exchange programmes of Erasnius, Nordplus and Tempus. These government-funded programmes make it possible for teachers and students to work temporarily in a European country other than their own. For over a century Nordic cultural cooperation, for example, has built on free exchange ofideas, projects and labour among the people in the Scandinavian countries. Experience from such Nordic collaboration shows that efforts to establish common rules and identical curricula are not always beneficial. Nevertheless, striving for higher standards stimulates individual faculties and nations to seek higher quality, and often culminatcs in substantial change in educational settings. Several associated matters must then be dealt with: the need for electives; language training for medical students; the need for agreed standards of competence on graduation among the countries; examination of the feasibility between countries of student exchange; and consideration of the desirability for staff and student exchange. The goals and objectives stated for medical schools and postgraduate training programmes should be discussed among the medical schools and countries of Europe. Regional Associations are critically important promoting agencies for medical education, notably the Association for Medical Education in Europe (AMEE), subregional organizations such as the Nordic Federation for Medical Education, and national associations with international membership in addition, the Association for the Study of
353
Medical Education of the UK (ASME), and the Association of Catholic Medical Faculties in Italy, to mention only a few. Cross-national communication is essential, to exchange new educational knowledge and experience and permit discussion critically. At the political level a better awareness is required of the prime importance of life-long learning in medicine. The setting up of units or departments for medical education research and development will ensure provision of educational expertise at both the undcrgraduate and postgraduate levels, and stimulate mcdical staff to attain increased educational competence. More professional evaluations of training programmes will result in addition. The use of external examiners, among the individual medical faculties in each country, and between different countries in Europe will be a force in increasing mobility of medical educators and promoting greater quality in European medical education.
References Association of American Medical Colleges (1984)
Physitriansfor the Twenty-First Century. T h e GDEP Report. Association o f American Medical Colleges, Washington DC. Commission of the European Communiites (1975) Directives of June 16, 1975. Bulletin no. L 16730.6.'75. Commission of the European Committees, Brussels.
World Fcderation for Medical Education (1988) World Confr.rence on Medical Education, Edinburgh, 7-12 August 1988, Report. World Federation for Medical Education, Edinburgh.
Received 2 August 1991; editorial comments to authors 5 A u p s t 1991; accepted f o r publication 25 February 1992
