EDITORIAL

Bologna in Spanish faculties of medicine, six years on: some food for thought

Bolonia en las facultades de medicina españolas, seis años después: algunas preguntas para la reflexión

Jordi Palés-Argullós

Fundación Educación Médica. Universitat de Barcelona. E-mail: jpales@ub.edu

In the year 2009, most of the faculties of medicine in Spain began to implement their new curricula, after adapting them to what has been called the European Higher Education Area or Bologna Process, although some faculties took a year or two more to complete the change. Six years later, the first students pursuing their studies under these new curricula have graduated from most of our faculties and the rest will do so within the next two years. Likewise, this year sees the beginning of the process of renewing the accreditation of most of our centres by the National Agency for Quality Assessment and Accreditation (ANECA) and by the autonomic quality assurance agencies. Hence, this seems a good time to review what has happened and to ponder on it a little. In this editorial, I would like to pose some questions that may be of assistance in these considerations.

One of the key aspects of the Bologna process is competency-based training. And at this point we can put forward a series of questions to be considered: Have the final competencies that a graduate in medicine must acquire in six years' training been defined properly? Are these competencies well suited to those that they will later have to learn and develop during their specialist training? Has undergraduate instruction been adapted appropriately to match the new structure of the specialist training to come?

Our graduates undergoing training will practise the profession in the first third of the 21st century, within a highly changeable social context that is very different to that of the previous century. Medicine has changed in terms of its purposes (curing/preventing); demography has not followed the predicted patterns; we are constantly witness to epidemiological changes with the appearance, reappearance or disappearance of diseases; healthcare institutions need organising in new ways; technology surprises us every day with hitherto unimaginable innovations; medicine 2.0 is here; the economic crisis highlights the fact that resources are limited; the relations among medical professionals and between these and professionals from other health sciences modify the roles of all the players, and so on. All this will mean that medical professionals need to be in possession of competencies that are completely different to those required in the 20th century. Thus, have we taken these new competencies into account or have we carried over the same patterns from the last century? Have we modified the contents appropriately so that they fit the competencies that have been defined? Have those contents that are irrelevant to the established competencies been removed or do we still have bloated contents, many of which are of little use?

More questions: are we really taking into good account the so-called key skills or have we simply announced them in our curricula without providing any appropriate learning activities or ways of assessing them? And among them, have we taken into adequate consideration facets such as professionalism, bioethics, teamwork, research methodology training, clinical reasoning, training for life-long learning, health economics, and so forth?

Have we been aware of the fact that a competency-based curriculum is, by definition, an integrated curriculum and proceeded accordingly? That is to say, have we established not only a horizontal integration but also a vertical integration in which the traditional division between preclinical and clinical subjects has disappeared, thereby allowing the basic sciences to be explicitly represented throughout the whole curriculum, in the clinical settings, while at the same time the clinical aspects appear early on in the first years of training? The structure that was finally adopted for medical studies in our country - integrated bachelor's-master's degrees - was perfectly capable of accommodating this and offered a wonderful opportunity to do so. Quite a different matter is whether or not it has actually been achieved.

In any curriculum based on competencies there is always one key issue: their assessment. Are we assessing these competencies properly and with suitable instruments? The acquisition of competencies is an ongoing process. Accordingly, have we established integrated and progressive programmes for assessing competencies or are we still evaluating from our watertight compartments? Can we be sure that an objective structured clinical examination at the end of the supervised practice programmes guarantees that our graduates have acquired all the competencies programmed satisfactorily?

As regards the educational strategies used, have we opted for active methodologies or have we continued with traditional activities based essentially on the mere transmission of information and theoretical knowledge? And with respect to the practical clinical activities, have we fostered students' active participation in them?

And along with these questions, we could ask many more. In 2005, the Spanish Medical Education Society, in collaboration with all the medical education societies around the country and a number of renowned experts in the field, published a document [1] in which these and other issues were addressed. I think it is a very good idea to take another look at that document, which gave details of actions that it recommended for implementation along with the process that was then beginning, and to analyse whether they have been followed or not by faculties of medicine.

I have no intention of answering all these questions here and now or of expressing my own opinions, since that would go beyond the scope of an editorial. That is something I leave to our readers and, more especially, to the faculties of medicine, that is to say, to their teaching staff, their students and their governing bodies. I only pose these questions as a kind of script that I believe may guide a collective process of self-reflection and rigorous and constructive criticism, free of any complacency, whose results can used to act in consequence, with modifications made to anything that needs changing. Any curriculum, and above all one based on competencies, is not something unalterable. It must be continually evaluated, reviewed and modified in accordance with the results that are obtained, within the context of a mandatory process of quality assessment, in order to adjust it to the new realities. Every faculty of medicine is under the obligation to do so owing to its commitment to social responsibility.

References

1. Sociedad Española de Educación Médica (SEDEM), Associació Catalana d'Educació Mèdica (ACEM), Sociedad de Educación Médica de Euskadi (SEMDE) y Sociedad Aragonesa de Educación Médica (SADEM). Recomendaciones para un nuevo proceso de reforma curricular en las facultades de medicina españolas. Educ Med 2005; 8: 3-7.         [ Links ]