MED-NET Conference 1997. Rotterdam, the Netherlands.
Proceedings 3.3.

A primer on major innovations in Medical Education in Europe

M. Albano (Bari, Italy) and G. Majoor (Maastricht, The Netherlands)

Introduction

Over the last decades reflection on the way medical students have been educated has prompted many European medical schools to adapt their curricula to new educational principles and to adopt new approaches to education and assessment. Major motivations for this are the need to cope with the expansion of medical knowledge and with anticipated changes in the health care system, the necessity to include new disciplines in the curriculum, and the demands to promote problem-solving abilities and better attitudes towards continuing education in medical graduates (1).

This highly condensed review discerns eight 'principles' of change, sometimes illustrated by different educational approaches matching the same principle. Just for the sake of guiding the interested reader some European medical schools which implemented that change have been mentioned as examples.

Some major changes

An important new principle being adopted by a growing number of schools is that of student-centred education (2). According to this radically different approach, the student rather than the teacher is given the primary responsibility for education. Consequently, students must assume an active role in collecting information and confirming their study progress. This principle has been put into practice by educational methods like problem-based learning (PBL), computer-assisted learning (CAL) and project-based learning.

PBL uses carefully selected and formulated problems as a starting point for students' study activities. Usually in small tutorial groups a written problem is analysed to probe the students' relevant pre-existing knowledge. Based on the knowledge present in the group the students generate hypotheses and then define (as learning objectives) what additional information is needed to test these. A few days are given to the students to acquire information matching their self-defined learning objectives. When the group meets again this information is exchanged and compared and a check is made whether the original problem is now better understood or can even be solved (3).

An evaluation method in line with this educational approach is the progress test. It is a written test (e.g. composed of true-false items) covering the full cognitive domain of medicine at graduate level. All students of all classes sit for one issue of the test at the same time. Longitudinally, results obtained with these tests show the progress in knowledge acquisition of each class and for any individual student. As of 1974 the Faculty of Medicine at Maastricht University (The Netherlands) has been the first in Europe to adopt this student-centred approach to medical education and assessment (4).

CAL is another example of a student-centred approach. Students respond to problems or questions presented by a computer programme and may be directed to relevant new information based on their responses (5). CAL may be most valuable to develop clinical reasoning in the students; programmes departing from clinical cases may also be used for assessment of students in the clinical phase of their studies (computer-based assessment)(6, 7). The Medical Faculties at the Universities of Nancy (France), Düsseldorf (Germany) and Pécs (Hungary) are some of the many schools in Europe that have introduced CAL as an addition to the educational formats used.

Project-based learning and project evaluation are student-centred learning and assessment methods, respectively, which depart from an assignment to students to develop and elaborate small projects (8). The approach has been worked out at the University of Roskilde (Denmark) but not yet for medical studies.

According to the principle of community-oriented education the educational programme of a medical school should focus on the priority health needs of the community to be served by the school's graduates. For the entire curriculum selection of topics for teaching and study are continuously checked for relevance against this dominant principle (9). This approach is greatly supported by students' learning experiences within communities, i.e. community-based education (CBE) (10). Assessment formats in CBE include observation by tutors and peers and writing of reports on e.g. research activities (11, 12). World-wide, medical schools adopting this approach have gathered in the Network of Community-Oriented Educational Institutions for Health Sciences (13). In Europe examples of community-oriented schools may be found in Linköping (Sweden) and Manchester (United Kingdom).

Integration (or multi-disciplinary teaching) is another new principle applied to medical curricula. With horizontal integration all relevant parallel disciplines are involved in teaching major topics (e.g. several basic science departments on metabolism); with vertical integration some clinical topics are already represented in the first years of the curriculum and basic sciences remain to be dealt with in the clinical phase  (14). Consequently, the tests given in such programme are also multi-disciplinary; on the other hand teaching and assessment methods may be conventional. The Faculty of Medicine at Leiden University (The Netherlands) provides an example of such curriculum.

Many medical schools have understood as a principle the need to provide practical skills training to their students prior to the clinical phase of their studies (15,16). Training programmes may address e.g. diagnostic, therapeutic, communication and laboratory skills. Some schools have integrated skills training throughout the entire pre-clinical curriculum (e.g. the Faculty of Medicine in Leeds, United Kingdom), others organise a condensed course between the pre-clinical and clinical phases of the curriculum (e.g. the Faculty of Medicine in Ulm, Germany). Objective structured clinical examinations (OSCE's) have proved to be a highly suitable approach for skills assessment. An OSCE is an assignment to the student to demonstrate within a pre-set time a certain skill (e.g. to take a blood pressure; or to examine the thorax) in the presence of an observer who scores a checklist (17).

In Faculties inspired by the principle of multi-professional education (e.g. the Faculty of Health Sciences in Linköping, Sweden and the Biomedical Campus, of the Free Institute in Rome, Italy) small groups consisting of students from different schools (e.g. Medicine, Nursing, Health Sciences) work jointly on common assignments (18). The approach aims to better prepare students for multiprofessional co-operation in their professional life.  No specific assessment method is needed with this approach.

Open Universities have been the first to follow the principle of open education where there are no restrictions of entrance qualifications and each student can learn individually and at any time about what (s)he is interested in (19). Open Universities and other schools following their example often use distance education as the dominant educational method (20). Opportunities for learning are provided in the absence of face to face help from teachers, but wherever the student lives or works information may be retrieved from written material, CD-ROM's, the Internet, etc. Students may sit for exams when they feel ready to do so; there are no specific assessment formats for distance education. Distance education has been applied in post-graduate, but not in undergraduate medical education.

The principle of competency-based education (21, 22) has recently been remodelled into task-based learning . Both may be defined as a strategy enabling the student to learn about a future professional task, to develop an understanding of areas related to the task, to look at the application of knowledge and skills in that context and to acquire generic competence as exemplified in the task. To assess the student's knowledge and skills, portfolio assessment and performance-based assessment (e.g. OSCE's), respectively, are recommended (23).

Discussion

The selection of "major innovations" in medical education presented above cannot be considered exhaustive because it is based on the subjective choice made by the authors.

In addition, it should be noted that the references cited in this paper all derive from the Anglo-Saxon literature. However, many European countries have national societies on medical or health professions education that publish journals or newsletters in the local language. Consequently, some interesting changes reported in those national reports may have escaped our attention.

Even taking these limitations into account, this paper illustrates the recent dynamics in the field of health professions education. No doubt the near future will see many more interesting innovations in this domain (24).

References

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2. Des Marchais JE, Hivon R. A "student-centred" educational programme: Theoretical considerations. Annals of Community-Oriented Education 1994; 7: 63-71.
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8. Illeris, K. Project studies at Roskilde University. In: Wassenberg M. & Philipsen H. (Eds.) Placing the student at the centre. Current implementations of student-centred education. 1997: Venhuis bNO, Eindhoven, The Netherlands.
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10. WHO Study Group. Community-based education of health personnel. Technical Report Series 746. 1987; World Health Organisation, Geneva, Switzerland.
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16. Scherpbier AJJA. A quality assessment of skills training. 1997: Datawyse/University Press, Maastricht, The Netherlands.
17. Harden RM, Stevenson M, Wilson Downie W, Wilson SM. Assessment of clinical competence using an objective structured examination. British Journal of Medical Education 1975; 1: 447-51.
18. Areskog N-H. Multiprofessional education at the undergraduate level: the Linköping experience. Journal of Interprofessional Care 1994; 8: 279-82.
19. Bosworth DP. Open learning. 1991, Cassell Educational Ltd., London.
20. Keegan D. Foundations of distance education. 2nd Ed.: 1990, Routledge Education, London, United Kingdom.
21. McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency-based curriculum development. An introduction. Public Health Papers 68. 1987, World Health Organisation, Geneva, Switzerland.
22. Burke J. Competency-based education and training. 1989; Falmer, London, United Kingdom.
23. Harden RM, Laidlaw JM, Ker JS, Mitchell HE. Task-based learning: an educational strategy for undergraduate, post-graduate and continuing medical education. Medical Teacher 1996, 18. Part 1: 7-13; Part 2: 91-8.
24. David TJ. The future for medical education. In Majoor GD et al. (Eds.) Med-Ed 21: An account of initiatives for change in medical education in Europe for the 21st century. 1996: Thesis Publishers, Amsterdam, The Netherlands.

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