MED-NET Conference 1997. Rotterdam, the Netherlands.
Proceedings 3.2.

Curriculum innovation in medicine: case history Nijmegen

R. Holdrinet, J. Bulte, B. Oeseburg and M. de Moel (Nijmegen, The Netherlands)

Summary

A new medical curriculum was started at the Faculty of Medical Sciences of the University of Nijmegen in 1995. During the preparation of the new curriculum attention was mainly focused on the formulation of the objectives of the various study blocks.

After explaining briefly the principles underlying the curriculum, we will present in which way the dialogue on the objectives was conducted at Nijmegen. Next a rough description is given of the way the objectives are translated into self-study assignments. In doing so we will also emphasise the significance of the core textbooks. Finally, a few remarks will be made on the implementation process.

Reforming of the Undergraduate Medical Curriculum at Nijmegen

The Faculty of Medical Sciences started the introduction of a new medical curriculum in 1995. Two years of the curriculum have been completed now. After a period of thorough groundwork, broad support of the Faculty staff was obtained for this reformation. The formulation of educational goals played an important role during the preparation period (1).

In this curriculum, as in the former curriculum, a basically omnivalent medical diploma is adhered to. In the framework of the six-year basic medical education no explicit differentiation will occur which may affect any subsequent advanced programmes. 80 Percent of time is devoted to the core curriculum and 20 percent to an elective curriculum.

Principles of the Nijmegen Medical Curriculum

In elaborating the curriculum concept, the faculty accepted the following principles:

• The performance of a doctor should be prompted by an attitude which is principally determined by 'solidarity with and concern for sick people'.
• The undergraduate medical course is seen as the first part of the continuous medical education (advanced training and refresher courses are still to follow). Though undergraduate medical training is extremely important, there are limits to it as well, which are also determined by its position with respect to the continuous education process.
• The six-year undergraduate course is not enough for the student to acquire all medical and paramedical knowledge, skills and experiences. So by definition the course is incomplete. In educational terms this implies that methods for a continuous acquisition of knowledge, on continuous updating of skills (particularly cognitive skills) and on the ongoing development of attitudes, should be emphasised.
• There is a need for a stronger scientific orientation than we have had in the past, because the process of clinical problem analysis is by nature identical to the process of science. Consequently, professional preparation and scientific training need to be linked in basic medical education.
• The concept of the Nijmegen curriculum provides a core curriculum and an elective curriculum. In the core curriculum the emphasis is on professional preparation. This implies that the core curriculum focuses on theoretical and practical training in the process of solving medical problems in a scientific manner. The elective curriculum on the other hand helps the student to become familiar with scientific practice. This is an objective every student should achieve, it does not necessarily mean that the contents of the studies have to be the same for every student.
• The educational process concentrates on the student's own study activities: active acquisition of knowledge, training and orientation. The curriculum should inspire and stimulate the student, and challenge him/her to display commitment. Not just the average student, but also the highly talented one.
• It is the teacher's responsibility to facilitate and supervise the learning process. Teaching activities and methods are not suggested by convention, but are always based on deliberate choices. Theoretical and practical teaching methods should be linked as much as possible.
• An important condition for the success of the new curriculum - just because education and supervision need conscious planning and implementation - is a thorough educational equipment of teachers. Professional skills training of teachers is crucial and will therefore become an important element in the implementation of the new curriculum.

Goals Giving Direction to (Medical) Education

It seems obvious that educational objectives should direct the educational process. Unfortunately, this is not always put into practice.

For several reasons it is of major importance - especially in medical education - to pay explicit attention to the formulation of educational objectives and to make sure that they guide the educational process as much as possible.

In the curriculum strategy the goals and the main features of the contents are defined and documented on the basis of core books. This linking of goals to accurately defined literature is also a clear indication for a problem-oriented (patient-oriented) curriculum approach. A problem-based educational model, in which the student or tutorial group largely determine their own learning goals and learning route, was emphatically rejected. In the Nijmegen curriculum the learning goals were carefully formulated in advance.

Medicine is a discipline which has seen a very rapid increase and broadening of knowledge. This resulted in rapid growth of the number of specialisation and in a great and differentiated need of training. In the context of this development the question that increasingly presents itself is: What are the general aspects of medicine which are important for every doctor and which will have to be acquired during the initial phase of his/hereducation (i.e. knowledge, social-cognitive and medical-technical skills, as well as attitudes).

Medical teachers have great medical expertise, sometimes in a broad, but, as is more often the case, in a very narrow field. From an educational point of view however, they often lack the competence or experience necessary to make a conscious choice as to which items from their subsector do belong to the core medical education and which do not. And neither do the majority of them spontaneously wonder in which way students can familiarise themselves with this material.

Educational goals can and have to be formulated at different levels. In the past decade discussions on the undergraduate medical course were mainly focused on the final attainment levels which were to be set for it (see below). These final attainment levels are of great importance as a general frame of reference. Raamplan 1994 (Blueprint 1994) (2) presents both a very generally formulated frame of reference in `profile of a doctor' (chapter 6) and a more detailed set of `general final attainment levels' (chapter 7). The list of problems in which the doctor will have to show his/her competence to use his/her knowledge and skills, chiefly specifies the situation in which the medical graduate will have to be able to demonstrate the knowledge, skills and attitudes he/she has acquired.

The Nijmegen 'document on core goals' has attempted to formulate objectives for specific blocks at a level as concrete as possible. The previously mentioned starting points were consequently applied. In addition, a link was made to the current debate on goals and objectives of education. 

The most concrete level of a goal is the fully specified learning objective. According to de Corte et.al. it is defined as: 'a valuable and desirable, realisable, lasting and specifically defined change in the behaviour of the students, which is mainly the outcome of education and which is expected to contribute to the realisation of more general educational goals in the students'.(3)

A major starting point for the restructuring of the Nijmegen curriculum is that education should provoke and even force students into an attitude of active self-study. This implies a `know-what-you-learn principle'. Camstra once again briefly summarised why it is necessary to be quite explicit on goals in educational practice: 'the function of explicitly formulated goals is not only that they guide teachers in creating the educational situation and developing evaluation instruments, but also that they convey to students what they are expected to learn, and how they are expected to know this material. The requirement that students should know what they must learn and how they have to master it, implies that this will have to be made clear to them.'(4)

During the development of the set of core goals at the University of Nijmegen, we looked for methods of formulation which, on one hand, were in accordance with the educational approach as outlined above and which on the  other hand, were in line with current medical terminology. Also we took into account the desired links with the list of core books and the check on the inclusion of items considered absolutely essential.

In this search for a workable method we obtained substantial external educational support.(5)

Nijmegen Dialogue on Goals: Method Followed

The participants in the dialogue can be divided into various categories, i.e. (a) the Board Committee Curricula Reform with its project group (to be seen as the pioneers in the process of curriculum restructuring of the faculty) (b) teachers from various departments, co-operating in multidisciplinary block preparation committees (highly specialised professional experts, but contributing to projects exceeding their specialisms) and, finally, (c) the Faculty Board and Council (to be seen as a body that commissions, decides and bears the final responsibility).

The course of this construction process, in the form of a dialogue, can be represented in a number of steps (see Table 1). It should be kept in mind that we are involved in an iterative process, in which by no means all committees were able to work at the same speed. Also the educational route for the first year had to commence (in the form of   course books), before the definition of goals for the complete four years were finished.

Relevance of a List of Core Books

After having consulted all departments, the curriculum committee established a compulsory list of core books.

The core books are definitely relevant for the discussion on goals. They reflect (with respect to structure as well as contents) a 'body of knowledge' of the medical discipline and related subjects which have been assembled over many decades. Since making this body of knowledge accessible and manageable to the medical undergraduate is one of the general goals of the medical study, a collection of core books can be looked upon as an important frame of reference for the goals.

Moreover, core books replace an inconvenient and inaccessible stock of syllabuses and readers. For a great many teachers (renewed) examination of core books from each others disciplines was an important experience, which turned out to be very helpful in designing study blocks in a multidisciplinary context.

Finally, in preparing the block, the relevance and extent of the subject matter selected by the block preparation committees was re-examined in the light of the formulated goals.(6)

Structure and courses of the Nijmegen Medical Curriculum

The initial phase of the undergraduate medical course consists of four study years of 42 credits each (1 credit being 1 week of 40 hours of study). The curriculum is divided into study blocks of 4 credits each. These blocks are given one after the other. Each block is concluded by a block test. The core curriculum contains 33 blocks, the elective curriculum 7 blocks. Table 2 summarises the contents of each block in the subsequent years of education.

Since one of the general goals of the medical education is to provide  access to control over the body of knowledge to the medical undergraduates, the core books are regarded as an important frame of reference for these goals as well.

Block Book, Learning Route and Self-study Assignments

For each block a course book is made which serves as a guideline for the student.

Taking into account the goals, the available time and infrastructure, first of all a rough outline of the block is made; the '`learning route'. This is a survey of the block that functions as a kind of railway timetable, telling the student which goals will come up in which phase of the block and which learning activities they involve. It is carefully examined which objectives need self-study assignments. Only after the broad survey of the four weeks with the learning route has been finished, the construction of self-study assignments may be started.

Table 2
Instructional Courses Medical Training Years 1-4

With each self-study assignment the following aspects are described in the block book:

• The background to the assignment
• The goal of the assignment
• The precise instructions for performing the assignment
• The product to be achieved by the student
• The way in which the assignment will be evaluated.

The elective curriculum

Overall 7 periods of 4 weeks, divided over the 2nd, 3rd and 4th year, are reserved for elective courses. Several course-groups have been developed, each focusing on a specific topic, using a mainly scientific approach. In table 3 the general objectives of the this elective curriculum are listed. The various themes are summarised in Table 4.

An elaborated overview of the topics and objectives of the elective course-groups and of separate elective courses is described in a publication: "Keuze-onderwijs voor het doctoraal geneeskunde" (7)

Reforming of year 5 and 6 (clerkships)

The Nijmegen Faculty has mainly concentrated on the curriculum reform in years 1 - 4. After completion of this reform, attention will be paid to the restructuring of the clerkship programme in years 5 and 6. Discussions in this area have been started already.

Some Aspects of the Reform Process

A review of the past period suggests that, for the next few years, the curriculum innovation process within the faculty will be mainly concerned with three closely connected objectives for reconstruction:

• To make programmes for the basic medical course which focus on regained main lines of general medicine (formulated in learning goals).
• To make programmes aimed at different methods of studying, in which the student with an independent and active study approach is the main role player in a learning process guided by explicit goals.
• To put education back on the faculty agenda and to keep it there as the faculty's primary task.

An important instrument to this end is the development of competent educational management. A crucial element in the successful implementation of the new curriculum turned out to be a well-developed and  competent system of education management. The report 'Core Goals to be Attained up to the Master's Examination in Medicine' marks the transition from the conceptual phase in the reform process to the actual implementation. The reform process has not yet arrived at a stage of adjustment and consolidation.

Keywords

Curriculum reform
Core goals in medicine
General medicine

References

1. Holdrinet R.S.G., Oeseburg B., Bulte J.A., Leunissen R.R.M. (editors). Kerndoelstellingen tot het doctoraat geneeskunde (Core Goals to be Attained up to the Master's Examination in Medicine). Faculteit der Medische Wetenschappen KU-Nijmegen, Universitaire Uitgeverij, 1995.
2. Metz J.C.M., Pels Rijcken-van Erp Taalman Kip E.H., Brand van den - Valkenberg B.W.M.. Raamplan 1994 (Bleuprint 1994). Eindtermen van de artsenopleiding (Final Attainment levels of the Undergraduate Medical Course). Nijmegen: Universitair publicatiebureau, 1994.
3. De Corte E. e.a. Beknopte didaxologie. Groningen 1981. Pag. 33.
4. Camstra B. Bouwstenen voor onderwijs. (Educational Materials). Utrecht, 1981. pag. 38.
5. Nijmeegs instituut voor onderwijskundige dienstverlening IOWO (Nijmegen Institute for Educational Services): Project Managers Ms R.A.H. de Jong and Ms L. van Loosbroek.
6. Compare: Wijnen W.H.F.W. et al., Te doen of niet te doen. Advies over de studeerbaarheid van onderwijsprogramma's in het hoger onderwijs. (Do-able or not Do-able. Advice on the consumability of Higher Education Programmes). Ministerie van Onderwijs en Wetenschappen, 1992, p. 16.
7. Ginsel L.A., Thoben A.J., Holdrinet R.S.G., Oeseburg B., Moel M.P. de and Bulte J.A. Keuze-onderwijs voor het doctoraal geneeskunde;  doelstellingen en keuzeblokken (Elective curriculum for the Masters Examination in Medicine; Goals and Courses). Nijmegen 1997

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