gms | German Medical Science

For all degree programmes in Germany which end with a state examination (teacher, law, medicine) no regulations exist for the implementation of the Bologna-Process. National health is one major concern for all governments. The functioning and thriving of national health systems, the assurance of quality of care and patient safety depend among others on the regulation of the medical profession. Especially the medical education is strongly regulated by different laws. The Treaty of Rome, establishing the European Community, declares that member states are responsible for the specific conditions for taking up a profession within their national territory.

Within the European community supranational law, Directive 2005/36/EC of the European Parliament regulates the minimal standards of basic medical education for both duration and content. Basic medical training comprises a total of at least six years of study or (to be read as ‘and’) 5,500 hours of theoretical and practical training provided by a university. Content is broadly and unspecific described as knowledge of the sciences on which medicine is based, understanding of structure, function and behaviour of healthy and sick persons and adequate knowledge of clinical disciplines and practices and suitable clinical experience.

Germany is a federal republic. It comprises 16 Länder (states). The Federal Ministry of Health (Bundesministerium für Gesundheit, BMG), the ministries responsible for health of the Länder and the system of medical self-administration, the German Medical Association (Bundesärztekammer) and independent Chambers of Doctors (Ärztekammern) in the Länder are the main players in a complex governance system for the German Medical Regulation. The Federal Medical Practitioners Act (Bundesärzteordnung, BÄO) regulates the licensure of physicians. It authorises the BMG to conceptualise the Medical Licensure Act (Ärztliche Approbationsordnung, ÄApprO) and to introduce it with the consent of the Bundesrat (constitutional body of the Länder to participate in the legislation). This ensures and establishes common and equivalent standards for medical education in Germany which are necessary in the national interest. The ÄApprO regulates and specifies the minimal necessary content of teaching and assessment of student’s qualifications for receiving the license to practice medicine by the state. The first state examination (M1) takes place after two years of study manly devoted to natural sciences and social sciences. The second state examination (M2) takes place after six years of study. During the four years between both examinations students take courses in clinical subjects for three years. Credits of these courses are a prerequisite for admission to the practical year (Praktisches Jahr). The ÄApprO encourages the integration of clinical subjects into theoretical background of the natural sciences. It makes demands on the restriction of the theory overload. Only scientific content absolutely essential for the clinical understanding should be taught during the preclinical years.

§ 41 of the ÄApprO grants the development of alternative and innovative study courses. This requires a special study regulation on the part of the respective university and allows that the medical state examination may consist of only part two of the medical examination after six years of medical studies. The university has to provide evidence that the assessment of the content of the M1 examination is equivalent to the assessment in the regular curriculum. The first completely reformed curriculum in Germany has been piloted at the Charité Berlin [1].

There is no imperative to establish the Bologna-Process in the medical curriculum for Germany’s faculties. Some authors argue that it is alien to the system of medical education since most programmes in medicine are provided in a single cycle lasting 6 years. In addition the structure of the state examination with the first examination after two years and the second after six years is not in accordance with the 2-cycle system of the Bologna Process with a 3-year Bachelor study and a subsequent 2-year Master programme. Nevertheless with § 41 of the ÄApprO the lawmakers honour the autonomy of the universities and encourages the responsibility of their faculties for the medical education. Faculties who take this opportunity serious can make use of the ‘model-clause’ which provides a relative academic freedom to establish a Bologna friendly curriculum: modular structure, interdisciplinary teaching, and significant clinical content right from the beginning. Embedded in this curriculum which fulfils the requirements for the state examination after six years is the possibility to receive two university grades: the Bachelor Degree at the end of the sixth semester and the Master Degree at the end of the tenth semester. The acquisition of these degrees is voluntarily and has no influence on the study progress for the state examination. A little pejorative this has been called the ‘Bachelor/Master en passant’ [2]. The authors do not share the opinion, that these degrees are entirely useless to those who have gained those[2]. On the contrary they provide an opportunity to leave medical studies for those, who in the course of their studies changed their main interests. With a bachelor degree students can apply for an employment in the industry or in the administration or they can continue their studies in a great variety of master programmes ranging from public health or molecular medicine to law, politics, or journalism. Students with a Master Degree in medicine may pass on the practical year and go directly into research. As a matter of course the bachelor and master programme need accreditation.

Using the opportunity given by § 41 of the ÄApprO on the way to Bologna is an auxiliary construction and should not become a permanent solution. If politicians mean business with the implementation of the Bologna-Process in medical education they have to start a new legislative process as soon as possible. German medical faculties should not ignorantly abstain from the Bologna reform while North American Universities discuss it as an opportunity for international cooperation [3], [4].