The Dutch Case

Developments in Medical Education in the Netherlands

prof dr Herman JM van RossumFree University of Amsterdam

PortoFebruary 24th 2007

Groningen

Nijmegen

Maastricht

Rotterdam

UtrechtLeyden

Amsterdam AMCAmsterdam VU

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 Teachersprocess shorter programs? new professions? pilot studystructure other umbrella: together with all health professions

IndependentLearning

Selection

Competencies

Medical education: a continuum

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Primary Secundary GP

Pub

Specialist

Undergrad

BolognaCompetenciesAccountabilityEfficiency

Quality Assurance

Medical Practice

IndependentLearning

Selection

Competencies

Medical education: a continuum

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Primary Secundary GP

Pub

Specialist

Undergrad

BolognaCompetenciesAccountabilityEfficiency

Quality Assurance

Medical Practice

Medical education and Health Care

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Primary Secundary GP

Pub

Specialist

Undergrad

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

“Market”

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 Teachersprocess shorter programs? new professions? pilot studystructure other umbrella: together with all health professions

Blueprint: Final Learning Outcomes

Basic curriculum

Blueprint

LAWFormats content

VUmc Compass CURRICULUM

Blueprintclinical conditions

competencies

VUmc

8 roles31 competencies

ConsultGive informationLiterature searchTeam work…

20 clusters188 conditions

Sore throat ShockProteinuriaDyingMisabusePreconception careEarly detection of …

17 domains> 150 concepts

Apoptosis Bio-psychosocial model DNA-repair StressHomeostasis EthicsAdaptation AutonomyFeedforward Laws …

concepts

CanMEDS

Calgary

Translation Blueprint into program

Tasks in practice

Curriculum

Professional field

Exercise tasksStudy tasks

Scientific field

Clinicalconditions

Competencies

Concepts

content

content

behaviour

behaviour

Concept of the translation

Rotterdam

Leyden

Amsterdam AMC

Groningen

Nijmegen

Maastricht

Utrecht

Amsterdam VU

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

medical expert

professional scholar

collaborator communicator

healthadvocate

manager

self reflector

VUmc-CompassVU doctor:Competentwith passion.

MD

bachelor

Structure and characteristics new curriculum

1. grown-ups: similarities and differences

2. development of humans: man and wife

3. mechanisms of deseases

4. basic doctors skills

5. health care settings as working environment

6. choices in health care and in research

sem 1: 20 w sem 2: 20 w

MD

bachelor

Health care settings in new curriculum

MD

bachelor

Science in new curriculum

MD

bachelor

Assessment in new curriculum

MD

bachelor

Characteristics new VUmc-curriculum

sem 1: 20 w sem 2: 20 w

medical expert

professional scholar

collaborator communicator

healthadvocate

manager

reflector

Didactic learning environmentScientific settingHealth care settingFormal assessmentPortfolio assessment

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 Teachersprocess shorter programs? new professions? pilot studystructure other umbrella: together with all health professions

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 followersUK: medicine does not want to followFrance: 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 41999 Bologna One European Higher Education Area by 2010 292001 Prague Quality Assurance framework 332003 Berlin Peer review for Quality assurance 402005 Bergen Adoption of standards and guidelines ENQA 452007 London ??

Ten action lines of Bologna now1. System of comparable degrees2. 2 cycles:

- Bachelor: 3 jaar with possibility of outflow- Master

3. Creditsystem: ECTS4. Mobility of students and teachers5. Quality assurance: visitations and accreditation6. European dimension in the programmes

7. Third Cycle: the doctorate with PhD8. Acknowledgement of grades and study periods

/supplements of certificates9. “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?

Rotterdam

Leyden

Amsterdam AMC

Groningen

Nijmegen

Maastricht

Utrecht

Amsterdam VU

Bologna in the Netherlands

All Universities comply...but ... the 2-cycle!

Medical deans are split: 5-3

Unclear what will happen in 2010

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 Teachersprocess shorter programs? new professions? pilot studystructure other umbrella: together with all health professions

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

University

Faculty

Departments

number of Studentsnumber of Diplomasnumber of PhD’sand strategic research compartment

Model

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

Funding of the University Hospital

Ministry of Health

Routine Care BudgetAcademic Care Budget

Budget for the academicworkplace function:Clinical Education, Training, Clinical Research

Care sources

University Hospital

~ 260 M Euro~ 50 M Euro

Integral budget VUmc (2004)

• Ministry of Education 28• Ministry of Health 50• Care sources 260• Contract research 25• Various 8

_______ 370 M Euro

ADVANTAGES

One board of directorsOne employerOne management for the three main tasks: education, research and careMultidisciplinary research (preclinical combined with clinical)The use of common lab. facilities and specialised personnelMore flexibility because of larger budget

Merging: to do or not to do?

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 marriageso far, but ...

what about the children? the student and the patient?

What should the dean take care of?

region

dean

secundaryschool

IN OUT

learn

teach

steer

patientstudent

Steering

Execution

organize

teacher

leaders

!UMC

+50%?

Staff / boards

Vocational programs

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 outpatient

doctor

patient

History takingPhysical examinationFirst consultation

operation

Patient care

Health care system

in outpatient

History takingPhysical examinationFirst consultation

operation

Patient care

TOO SIMPLE !management of care

doctor

patient

integrated management

Education and vocational trainingIn the health care system

in

doctor / teacher

assistant

clerk

Vocational training

education

outpatient

patient

History takingPhysical examinationFirst consultation

operation

Patient care

steering

support

Now the dean has his basic structureand the time for teachingand the organization?

What about the learning needsof the students and assistants?

STUDENT TEACHERTASK

Prepareshimself

LISTENSreflects

Gives JUDGMENT

DOES LOOKS

GivesFEEDBACK

The heart of clinical teaching

IN practiceTask descriptionOrganization of settingTeacher-training

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

Knows

Shows how

Knows how

Does

Pro

fess

iona

l aut

hent

icity

Pro

fess

iona

l aut

hent

icity

Cognition

Behaviour

facts and concepts

problem solving

skills labs

practice

Training of competencies: Miller

Knows

Shows how

Knows how

Does

?

??

2007

Training of doctors should be on the top

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 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 Teachersprocess shorter programs? new professions? pilot studystructure other umbrella: together with all health professions

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. Competency based (CAN-meds)2. Portfolio mandatory3. Regular assessment sessions4. KPB’s (mini-CEX): 10 a year5. 360° Judgment on performance6. Knowledge tests7. Teach the Teachers programs

Postgraduate Medical Education: content

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: process

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

Rotterdam

Leyden

Amsterdam AMC

Groningen

Nijmegen

Maastricht

Utrecht

Amsterdam VU

The dream for the next decade

8 regions linked to the UMC’scovering all HC-professions

Conclusions

1. University Medical Centers are powerful structures in which care, research and education can be managed successfully. But what aboutthe 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.

‘Ο βίος βραχύς,

ή δε τέχνη μακρή,

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

Ars longa, vita brevis

Hippocrates 450-370

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Thanks for your attention!

Let us work together in educating the new generation of doctors

Hippocrates 450-370

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

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Medical PracticeUniversity

Prof. SchoolsP. Assist

Nurse P

Ministry of Health is stimulating...

shorter postgraduate medical training programs (eg hospital doctors)more physician assistant programsmore nurse practitioner programs

in order to ....make Health Care more efficient and cheaper.

Postgraduate Medical Education: process