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versão impressa ISSN 1575-1813
Educ. méd. vol.15 no.1 Mar. 2012
The university we want (II). Seeking a proven improvement
La universidad que queremos (II). En búsqueda de una mejora contrastada
Director de la Fundación Educación Médica (FEM). Profesor de la Facultad de Medicina de la Universitat de Barcelona.
"The General Medical Council (GMC) protects the public by ensuring proper standards in the practice of medicine. We do this by setting andregulating professional standards not only for qualified doctors' practice, but also for undergraduate and postgraduate medical education and training [...]. A number of organisations are involved in managing and improving the quality of medical education and training."
GMC. Quality Improvement Framework; 2010
The last editorial of Educación Médica in 2011 made a case for why universities should give utmost priority to seeking improvement in quality before holding forth on the hackneyed notion of excellence. From a general but, at the same time, academic point of view, the purpose of these reflections is to delve deeper into what improved quality must mean for universities, and more particularly for faculties of medicine.
Without a doubt universities have advanced considerably in the last few decades: high-level research, new bachelor's and master's degrees, new curricula, new educational infrastructures and teaching staff with well-demonstrated capacities, although perhaps not fully qualified to carry out all the activities that are required of them. Despite the thorny little issues of day-to-day life, overall, universities are now much better than they were 25 years ago. But this overall improvement may well be hiding areas, like the training of physicians, where there has been no substantial improvement - or even no progress has been made whatsoever. The aim is not to look at whether training is good or bad, but rather whether there is room for improvement. Can universities improve physicians' education and training? Do we want to know if there is room for improvement or not?
The question is obviously a rhetorical one but the answer, at least to judge by the way the institutions behave, is surprising: no interest has been shown in finding out whether we can improve. The British General Medical Council (GMC), the body that regulates medical training, is thoroughly convinced that the measures to be corrected, and therefore improved, are not generated on a desk inside an office somewhere but, instead, arise from the analysis and evaluation of reality. The standardised instrument it uses, the Quality Improvement Framework (QIF) , enables us to reflect on two issues that must be of use to all: first, quality control and then the diversity of stakeholders.
Any quality control programme is based on a feedback loop. One action generates a result that, when analysed or evaluated, makes it possible to draw conclusions and hence, if necessary, introduce improvements in a new action. The fundamental reason underlying the improvement of research in the last 25 years is the fact that it is assessed, whereas the main reason teaching has stagnated in classical models lies in the lack of evaluation and control of quality. The GMC, following the indications of a task force set up over a decade ago and reappraised in 2004/5, has structured its responsibility to 'regulate' the evaluation and improvement of physicians' education and training in the QIF, which is based on and articulated around five principles, namely: proportionality, accountability, consistency, transparency and targeting.
Regulation has to be "proportional", only when it is needed and in proportion to the risk; it has to be "accountable", answering to society for the decisions it makes; it must be in relation to the accepted standards and therefore "consistent" with them; it must be easy for all citizens to use and understand -"transparent"; and it must be "focused on a target", aimed at a problem so as to minimise any collateral effects. The issue does not need to be developed further, since the QIF  document is available to anyone who is interested in reading it. But the preceding comments confirm the fact that the societies with the highest reputations as regards improvement in the quality of their universities maintain and update the assessment and regulation of university training with extremely demanding procedures. Ours, in contrast, remain highly bureaucratic and cumbersome.
The QIF also leads us to reflect on a second issue. In addition to the universities themselves, and in our case the faculties of medicine, should other stakeholders also participate in the control and improvement of quality? Again and again the university has happily adopted the popular expression "I am all right, Jack". Just a few weeks ago in the everyday media we saw how the principle of university autonomy was defended from political interference from the social council driven by alleged aggressors of the university. It is true, however, that shows of sensitivity on this matter have surfaced in the last year (not much more), where universities have displayed their concern about the way their governance. But going back to the subject of searching for a proven improvement in universities in general and in the training of physicians in particular, we must ask for and take into account the opinions of institutional stakeholders, professional associations, scientific societies, patients, learners, supply organisations, healthcare insurance companies, at least, and I see no reason not to include different kinds of companies within the health sector. The GMC says it quite concisely: 'a number of organisations are involved in managing and improving the quality of medical education and training'. Wouldn't it be a good idea to take notice of them?
Arcadi Gual Sala.
Departamento de Ciencias Fisiológicas I.
Facultad de Medicina.
Universitat de Barcelona.
1. General Medical Council. Quality Improvement Framework; 2010. [ Links ]