gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Medical Education in Germany – Work in Progress

editorial medicine

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  • corresponding author Götz Fabry - Albert-Ludwig-Universität Freiburg, Abt. für Med. Psychologie, Freiburg/Brg., Deutschland; GMS Z Med Ausbild, stellv. Schriftleiter, Erlangen, Deutschland
  • corresponding author Martin R. Fischer - Klinikum der Ludwig-Maximilians-Universität München, Institut für Didaktik und Ausbildungsforschung in der Medizin, München, Deutschland; GMS Z Med Ausbild, Schriftleiter, Erlangen, Deutschland

GMS Z Med Ausbild 2014;31(3):Doc36

doi: 10.3205/zma000928, urn:nbn:de:0183-zma0009280

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zma/2014-31/zma000928.shtml

Received: July 25, 2014
Revised: July 25, 2014
Accepted: July 25, 2014
Published: August 15, 2014

© 2014 Fabry et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Editorial

As the most important committee to advise the federal and state governments regarding issues of science, research and higher education the German Council on Science and Humanities (“Wissenschaftsrat”) once again addressed medical education. Currently Manfred Prenzel a renowned educational scientist chairs the committee. In its report “Recommendations on the advancement of medical education in Germany” that was published July 11th, 2014 the Wissenschaftsrat presents the results of a survey on the reformed medical education programs in Germany and infers recommendation for all medical education programs in the country [1]. In doing so, the most important finding of that paper is already illustrated: The clause in the German Medical Licensure Act from 1999 allowing reformed medical education programs proved its worth. The overall goal of the clause was to test forward-looking educational interventions in medical education and to gain experience regarding the transferability of these innovative formats to “traditional” medical education programs. The resultant possibility to break the tight constraints of the Medical Licensure Act was certainly one of the most important reasons for the dynamic development regarding medical education within the last two decades. This development sparked manifold changes not only within the actual reformed tracks but also well beyond them.

The overall conclusion of the Wissenschaftsrat about the different attempts to reform medical curricula with regard to their structure, content, and methods is quite positive. The report is not based on a final evaluation in a strict sense which is mainly due to the well-known methodological difficulties that are connected with comparison studies on a curricular level. It is controversial for instance if a seemingly obvious criterion such as the performance in the national exams is adequate and sophisticated enough to be used as an outcome variable in such studies. However, despite these limitations and in accordance with insights from the international literature on these issues the Wissenschaftsrat sees enough evidence for a positive evaluation of the core principles that are implemented within the surveyed programs i.e. competency and patient orientation, vertical and horizontal integration as well as innovative teaching, learning and assessment methods (problem-based learning in particular).

For all of those who took part in the development of medical education over the last two decades the report comes as no surprise. On the one hand it continues the line of argument the Wissenschaftsrat initiated in its “Guidelines to a reform of Medical Education” published in 1992 that stimulated a controversial discussion back then [2]. On the other hand the present report takes on the most important issues and insights regarding medical and health professions education that are currently discussed worldwide. Against this background the Wissenschaftsrat regards the following principles of utmost importance for the advancement of medical education: Programs should be competency-based instead of discipline oriented. Curricula should be integrated (i.e. organ- or theme-centered) and patient-oriented, interlocking basic sciences and clinical aspects more tightly. Scientific competencies and research skills should be more emphasized by designing specific educational interventions that should be longitudinally integrated in the curriculum. In addition, students should be obliged to do a small scientific project and a final thesis independently. With regard to the ever growing division of labor and multiprofessional collaboration in healthcare interprofessional competencies are needed that also demand specific educational formats that must be developed, implemented and evaluated. To support medical schools in developing specific profiles and priorities on the one hand and to give students the opportunity to follow their own interests on the other hand the Wissenschaftsrat finally recommends to reduce the overall content of the national exams and to implement curricula with core and elective content. Some further recommendations relate to structural aspects: To facilitate students’ exchange between different medical schools and to give students as well as schools a better feedback on performance the first national exam (M1) should again become an obligatory element but installed after the third (instead of the second) year to pay tribute to the more integrated nature of the future curricula. Especially the exchange of students between the reformed medical education programs has been hindered in the past due to the quite individual nature of their curricula which is one of the few but important critical points addressed in the report. It is also suggested to enhance the practical content of the M1-exam by using OSCEs and OSPEs in addition to the already established written MC-format. With regard to the final national exam (M3) the report recommends keeping the traditional format of the oral viva despite its methodological weaknesses since the limited resources preclude using alternative formats in the foreseeable future. However, the committee advises the medical schools to standardize the demands of the final exam more. Finally, the report suggests to split the final year into four instead of three parts to allow for more individualization on the students’ side. Rotations in internal medicine and surgery should still be mandatory but students should be allowed to spend the remaining two parts in one or two specialties of their choice. General practice might also benefit from this change as students might be more inclined to do a rotation in general practice when they still can do another elective rotation of their choice.

What consequences can we expect from the report? First of all, it will certainly spark controversy despite its fair balance and thorough evidence base. Especially the clear-cut commitment to competency-based medical education and integrated curricula holds potential for conflict as can be witnessed in the current debate on the National Competency-based Catalogue for Learning Objectives in Medicine (NKLM) and Dental Education (NKLZ) which despite its still tentative nature is an important point of reference for the report. Although the Wissenschaftsrat still explicitly advocates the curricular responsibility of the different disciplines the corresponding professional associations worry that the breakup of clear disciplinary boundaries will make it more difficult to enforce their claims towards the medical schools. Apart from that, it is the politics turn to act since extensive tasks have to be completed: Further adjustments of the Medical Licensure Act are necessary and, additionally, the act regulating the capacity of students at each medical school also has to be adapted. Both issues are intensively discussed within the report and – as we all know from past experiences – both issues are Herculean tasks.

For the scientific community the report is also relevant, as the Wissenschaftsrat repeatedly points out the importance of medical education research and demands a respective structural development. In the future we will need better comparison studies for curricula and institutions even if this will be a long and cumbersome endeavor with regard to the methodological aspects. It will be necessary to agree at an early stage on outcome parameters far beyond the bare results in the national exams to allow for a better comparison and interpretation of different curricular models. Especially the career trajectories of medical graduates should be monitored more intensively. Examples for such medium- and longterm studies do exist and should be critically applied and refined in a collective effort [3]. Against this background the articles in the current (third) issue of the ZMA align very well. The position paper on education in primary care [4] and the recommendations on local assessments [5] demonstrate the ongoing commitment of the German Association for Medical Education (GMA) and its commissions to enhance the quality of medical education. The research papers on the other hand document a broad spectrum of research activities. Several studies address issues of scholarship. The paper by Heun et al. [6] contributes empirical evidence to the controversial discussion on doctoral theses in medicine while the contribution by Kötter et al. [7] addresses the conflict between clinical work and research activities in general practice residents. General practice certainly is a special environment in this regard due to its specific ambulatory structures. Another interesting paper by Raes et al. [8] investigates the contributions of German medical education researchers to the AMEE conferences. Despite a positive trend during the last couple of years there is still a lot room for improvement both with regard to quantity but also in terms of the type of studies. Clarification studies are still a rather neglected species but are desperately needed (that, by the way, is also exactly what the Wissenschaftsrat says in its report). Three other papers are dealing with student matters. Huhn et al. [9] inquired whether the results of assessments in medical education are connected to the geographical origin of students. Their findings are probably in line with the experience of many medical educators, namely that foreign student, especially from non-European countries have worse results and need more time for their studies. Such results might be used to tailor and offer specific supporting interventions. The evidence from the study by Jahnke et al. [10] shows that medical students are an important targeting group for the pharmaceutical industry as most of the students included in their study reported corresponding contacts. Thus, potential third party influence is an important issue that should be addressed in connection with professional competencies. The same holds true for another topic that is addressed in the review by Pander et al. [11], i.e. social media or rather Facebook. As the results from this article suggest there is still very little evidence showing the specific pedagogical or educational benefit or potential of social media. However, much more tangible is the question how medical students do and should behave in these virtual environments which again brings up fundamental questions of professionalism. Finally, a project report on using scarce educational resources creatively [12], a personal account by a medical student on rotations in foreign countries [13], and a book review [14] complete this issue of the ZMA.


Competing interests

The authors declare that they have no competing interests.


References

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