gms | German Medical Science

Introduction: In this contribution it is intended to assess the option of a 3+3 Bachelor/Master structure for undergraduate medical education. Actually, a lot of countries have not implemented this structure to undergraduate medical education. Moreover, some of the countries that implemented the structure did it but not based on clear arguments about content and educational design of the curriculum. They applied simply the format of 3+3 to an existing curriculum. The question arises whether the implementation of such 3+3 BA-MA structure is appropriate for medicine.

Target point: The quality of the educational project: Traditionally, in the previous century, the study of medicine was based on a first cycle of 3 years, completed with the basic natural and basic medical sciences physics, chemistry, biology, physiology, anatomy, pharmacology, biochemistry, etc. All these disciplines thoroughly studied with little, if any relation to clinical practice and care. In the second cycle (three to four years) diseases were studied, very often starting from disciplines as pathology, pathological physiology, etc. Late in the curriculum there was the first patient contact through clinical demonstrations and clerkships, mostly in hospitals.

The result of such curriculum was, as assessed in different international accreditation procedures, that students were ill prepared in clinical skills, patient communication, clinical decision-making, and patient management. So, ‘learning’ mostly happened by ‘doing’ in the third cycle (specialty training). There a classical ‘expert-apprentice’ strategy was used.

Starting from the Seventies in the last century reflections about this approach led to more patient integration in the curriculum: Problem-based learning, as it was developed in McMaster (Canada), Newcastle (Australia), Maastricht (The Netherlands), demonstrated how patients with their problems could be used in order to understand basic mechanisms of disease and to train students from the very beginning of their study in clinical decision making, clinical and technical skills, and communication skills. The development of evidence-based medicine in the Nineties reinforced this integration, as the importance of clinical epidemiology in undergraduate training increased.

A consequence of this development was that the traditional 2-cycle structure was no more appropriate. Accreditation committees advised medical faculties strongly to think about the curriculum as a continuum of six years with a ‘spiral’-learning strategy, starting from the first year onwards, problem-based and patient-and-community oriented.

Now, the Bologna structure requires that to go back to the two-cycle design that has been just left in the last two decades. This does not seem very logical: A high quality training and education programme in medicine requires an integrated, problem-based, and patient-oriented curriculum that develops continually during the six year of undergraduate training, and mixes theory and practice from the very beginning on. The traditional pre-clinical/clinical dichotomy is no more relevant in a modern medical curriculum.

The 3+3 BA-MA structure: The actual problems with the 3+3 BA-MA structure are that there is first no societal ‘output’ for Bachelors in medicine after the first three years of the curriculum; they cannot start a professional career. Moreover, the ‘Master of Medicine’ after six years is not allowed to take responsibilities in health care independently. Such Master is ready for the next training phase: specialty training of three to six years according to European regulations.

The Bologna Recommendations require clear ‘objectives’ for a Bachelor Degree: these are very difficult to define, as all faculties use a different sequence in their undergraduate training and a different mix of 'normal' and 'pathological' sequences in the different study years. So, to define the objectives for the ‘Bachelor of Medicine’ based on basic medical sciences and uncertain clinical subjects is nearly impossible. Actually, the Bachelor Degree is just an artificial ‘stop’ that in some faculties is pragmatically being used for extra recruitment from other disciplines. But of course, in the actual ‘credit saver transfer system’ a Bachelor Degree is not needed to organize this kind of extra recruitment from other disciplines.

A comprehensive integrated and problem-based medical curriculum does not fit into the Bachelor/Master dichotomy.

Conclusion: Looking at the Bologna Recommendations and the Dublin Descriptors on the one hand, and on the needs for a modern, integrated undergraduate medical curriculum on the other hand leads to the conclusion that a 3+3 BA-MA structure is not appropriate. If the principles as suggested by the Bologna Recommendations are applied in a consistent way medical training should consist of six years of Bachelor-training followed by a variable number of years in Master training leading to, for example, a Master in family medicine, in specialized medicine as gynaecology, surgery, in occupational medicine and so on. If for cosmetic reasons or for reasons of ‘similarity’, the 3+3 BA-MA structure will be chosen, one has to be aware that this is both conceptually and from an educational viewpoint not the best thing to do.