gms | German Medical Science

The organisers have asked me to look into the future of medical education. I will do it by projecting trends, which can be seen at the moment; it is not the intention to be very prophetic as experiences inspire to scepticism regarding validity of prognoses for medical education.

Medical Education is under influence of a number of trends, which also dominate other types of higher education (table 1 [Tab. 1]).

Globalisation of medical education is becoming of increasing importance as part of international developments in medicine and the mobility of the medical profession.

The increasing internationalisation of the medical profession raises the question of safeguarding the practise of medicine and the use of the medical workforce. Standards in medical education, quality assurance and accreditation are probably the most important keywords in the actual debate of medical education policy.

Similar activities can be seen in higher education in general with initiatives coming from e.g. UNESCO and OECD.

Table 2 [Tab. 2] shows a number of European initiatives regarding harmonisation and quality assurance, including initiatives from the European Commission in form of the Medical Directive and the endeavours by the Advisory Committee on Medical Training (ACMT) to formulate principles for medical education. The Bologna process and the activities of the European Association for Quality Assurance in Higher Education (ENQA) should also be mentioned.

The ten themes of the Bologna Process (table 3 [Tab. 3]), which is now spreading its influence beyond Europe, are already to some extend being incorporated in present university activities, e.g. supplement of diplomas, the ECTS system and the free movement. Promotion of European co-operation and consideration of the European dimension as well as life-long learning are principles, which should not be of any problem to medical education. Some of the issues will be covered by the MEDINE project (see later).

In discussing the consequences of the Bologna Process for medical education, it should be emphasised, that the Bologna Declaration was only signed by ministers of education; it is not a law or an international convention. It should also be remembered that so far there has been no dialogue with ministries of health, medical faculties, the medical profession or medical students. Until now, there has been rather limited interest in the Bologna issue among medical educators.

In February 2005, the World Federation for Medical Education (WFME) and the Association for Medical Education in Europe (AMEE), in co-operation with the Association of Medical Schools in Europe (AMSE) and the World Health Organization (WHO) Office for the European Region, published a statement on the Bologna Process and medical education.

Especially, the statement deals with the two-cycle (bachelor + master) question, which raises problems for medical education. The statement underlines (table 4 [Tab. 4]), that the Bologna Process must not invalidate attempts to integrate the medical curriculum. Otherwise, the Bologna Process is considered a most valuable contribution to quality improvement of medical education.

Presently, it seems that we can expect different national attitudes and solutions to the relationship of medical education and the Bologna Process in Europe. Switzerland seems to follow the intentions of the Process, but with the important deviation that the three + two years (bachelor + master degrees) will not result in recognition as a medical doctor, which will require another year of clinical training. Denmark has already introduced the bachelor degree, but this was done without changing any parts of the planned integrated curriculum. In Poland, it is claimed that the Bologna Process is not relevant to medicine, and in Sweden that the two-cycle system is not relevant for university studies leading to professional titles. Finland (and Germany?) has postponed decisions on the Bologna Process and medicine until 2010, and in the United Kingdom they are presently ignoring the problem.

The overall objective of the new EU Directive on recognition of professional qualifications (table 5-9 [Tab. 5] [Tab. 6] [Tab. 7] [Tab. 8] [Tab. 9]), which for medicine is a continuation of the previous medical directive 93/16/EC, is the mutual recognition and free movement of medical doctors. Essentially, the requirements of the EU Directive have not been changed since the first medical directives of 1975.

In 2004, a new European project (Thematic Network MEDINE) was formed, based on a considerable EU-grant. The project includes five Task Forces (table 10 [Tab. 10]). Of these, Task Force III, chaired jointly by the World Federation for Medical Education (WFME) and the Association of Medical Schools in Europe (AMSE), deals with formulation of European standards in medical education throughout its continuum, quality assurance and accreditation (table 11 [Tab. 11]).

The objectives of Task Force III will be to define European quality assurance standards in medical education, using the WFME global standards as a template.

When talking about standards, we must be aware of differences in medical education. Looking at the present trends in the development of the medical education worldwide, a number of dissimilarities between regions and countries can be enumerated determined by the basic conditions for medical education (table 12 [Tab. 12]).

Although the situation might be different in Europe, we will need to discuss to which extent it is feasible to define common standards for European countries or if it is necessary to operate with modifications for different sub-regions of Europe, e.g. the Nordic countries, North West Europe, Central Europe, South Europe and East Europe. In any case, Europe outside the European Union will need separate treatment.

The need for standards in the European scene is determined by certain challenges for medical education (table 13-14 [Tab. 13] [Tab. 14]), the rapid increase in new medical schools and implications of internationalisation, as expressed by a growing number of exchange programmes for students and teachers and the migration of doctors.

One paramount problem worldwide is the rapid increase in the number of new medical schools, which have serious consequences for the quality. Over the last ten years, we have seen an increase of medical schools of about 100 per year. Many have been established on foundations of insufficient resources, many are lacking sufficient clinical settings and many do not have a research attainment. A new trend has been the rise of commercialised medical schools in the form of "for profit" medical schools, the main goal of which is the easy and convenient production of graduates. Such schools particularly attract students who are academically unqualified to enter well-established schools, but who are affluent.

Some European countries have insufficient medical manpower planning, being dependent on university study places in other countries or active recruitment of doctors from abroad. However, external and internal brain drain is presently not a big problem for Europe, but is influencing the health manpower situation in other parts of the world. In Africa, it has developed into a catastrophic situation. Also brain export is now a reality, some countries deliberately producing medical doctors for export in return for other commodities. Such doctors are not always allowed to work in their own country, which probably tells something about the quality.

The increasing internationalisation of medical education offers a number of advantages (table 15 [Tab. 15]), but on the other hand we should also be aware of disadvantages, reservations and challenges (table 16 [Tab. 16]).

Prerequisites for the internationalisation process are important (table 17 [Tab. 17]).

In the first decade of the twenty-first century, a number of innovative trends in medical education can be found around the world (table 18 [Tab. 18]).

The classical two-phase division of the medical curriculum in basic sciences and clinical sciences is now increasingly being substituted by a number of new curricular models, defined by either organisation of the content, the teaching and learning methods, the approach of teaching and learning or from the point of view of learning objectives or social responsibility of the institution (table 19-20 [Tab. 19] [Tab. 20]).

Also in the management of medical education developments are appearing in many regions (table 21 [Tab. 21]).

Topics, which might become of interest in medical education in the future are listed in table 22 [Tab. 22].

With the process of "best evidence medical education" an initiative has been taken to introduce a scientific approach to medical education in order to stimulate research in medical education and narrow the gap between "opinion-based" and "evidence-based" teaching and learning.

The WFME launched an ambitious programme on International Standards in Medical Education in 1997. The programme was presented in a position paper published in the journal Medical Education in 2000.

The working process used consisted of three international task forces with experts from all five continents. Members of the Task Forces were selected on the basis of their expertise with geographical coverage an important consideration.

The process led to the development of the Trilogy covering WFME Global Standards for Quality Improvement in (a) Basic Medical Education, (b) Postgraduate Medical Education and (c) Continuing Professional Development (CPD) of Medical Doctors (table 23 [Tab. 23]). The Trilogy was the essential background material for the WFME World Conference in Medical Education entitled: Global Standards in Medical Education for Better Health Care, which took place in Copenhagen March 2003. The conference resulted in consensus worldwide on the standards programme and gave WFME a renewed mandate.

The aims and specific objectives of the WFME project on global standards emerge in table 24 [Tab. 24] and 25 [Tab. 25].

In the early stages of developing of the Trilogy, it became clear that specifying global standards in any restricted sense would exert insufficient impact, and indeed would have the potential to lower the quality of medical education. Thus, a lever for change and reform had essentially to be incorporated. This led to the concept of the WFME standards to be framed to specify attainment at two different levels: (a) basic standards or minimum requirements; and (b) standards for quality development.

All three documents operate with nine closely related areas (table 26 [Tab. 26]) and standards are defined at the two levels for about 35 sub-areas in each of the documents.

The definitions used for the two levels are shown in table 27 [Tab. 27] and 28 [Tab. 28], and table 29 [Tab. 29] gives a concrete example from the document in basic medical education.

Global standards can be used as a tool for quality assurance and development in different ways. The primary intention of WFME was to provide a new framework against which medical schools/educational institutions (in CPD: Individual Doctors and the Medical Profession) can measure themselves in voluntary institutional self-evaluation and self-improvement processes.

The process described can be further developed by inclusion of evaluation and counselling from external peer review committees. WFME considers a combination of self-evaluation and peer review to be the most valuable method.

Finally, depending on local needs and traditions, the global standards can also be used by national or regional agencies dealing with recognition and accreditation of medical schools/educational institutions and programmes (table 30 [Tab. 30]).

At the World Conference 2003, the WFME was encouraged to proceed further with its programme on Global Standards. The implementation process is presented in table 31 [Tab. 31].

The WFME standards in basic medical education have been validated in 36 medical schools in 24 countries. The conclusions from this process show that the standards are realistic and adequately divided between basic and quality development levels, that there is a need for local specification and supplements in some institutions, and that the use of the standards in institutional self-evaluation is a positive event with lasting constructive consequences.

Pilot studies on the two other sets of standards are now also being conducted in institutions/organisations.

There are increasing experiences of using the WFME standards in institutional self-evaluation and peer reviews.

According to the information so far, the WFME standards in basic medical education are influencing medical education in a number of countries and the WFME standards have been used as a template for national and regional standards as well as being incorporated in national accreditation procedures. This development includes not only major existing accreditation systems, like LCME in North America, GMC in the United Kingdom and AMC in Australia, but also new systems (Switzerland, Ireland, Central Asian Republics, Malaysia, China, Egypt, Sudan, the Gulf-region, Bangladesh, etc.).

Returning to the question of how European standards can be developed, table 32 [Tab. 32] illustrates ways for adapting the global standards to the European scene.

The interface between medical education and health care delivery systems is of high interest. In 2004, WHO and WFME decided to establish a joint policy on promotion of health systems performance through improvement of health professions education.

Recently, a new WHO-WFME strategic partnership was established to pursue a long-term work plan designed to have a decisive impact on medical education in particular and ultimately on health professions education in general.

The first practical result of the partnership was to set up an international Task Force on accreditation. The Task Force met in Copenhagen in October 2004, and formulated a common policy on accreditation (table 33 [Tab. 33]).

In May 2005, the WHO/WFME guidelines for accreditation were published. Conclusions from the guidelines are shown in table 34 [Tab. 34]. The guidelines can be found on http://www.wfme.org.

There are groups working for an European accreditation system trying to transfer the LCME system in North America to Europe without recognising the traditional differences in medical education and in the attitudes to recognition or accreditation within Europe. At the moment it is not realistic to work for such a common accreditation system for reasons mentioned in table 35 [Tab. 35].

However, we should consider to have sub-regional solutions to assist countries with one or a few medical schools.

A new WFME project related to accreditation offers a package for assistance in establishing accreditation, comprising national specifications of standards, assistance in institutional self-evaluation, external review, site visits and recommendations regarding procedure information can be found on http://www.wfme.org.

Concluding remarks are presented in table 36-37 [Tab. 36] [Tab. 37].