The year 1999 saw the birth of the ‘Bologna Declaration’, which set the framework within which higher education was to develop in Europe. Its stated objectives were to establish a system of comparable and comprehensive degrees, to adopt a system based on two main cycles (graduate and postgraduate), to implement a common system of credits, to promote mobility (of students, lecturers, researchers and administrative staff) and to facilitate European cooperation in order to ensure quality with the aim of developing comparable criteria and methodologies. Yet, underlying the process there were other principles, other aspects, that were perhaps equally or more relevant: the declaration was focused on learner-centred education, competence-oriented education and targeted assessment processes in general and those involving competencies in particular.

Today, all Spanish faculties of medicine have their curricula adapted to Bologna. Different promotions have graduated from them and many have had their accreditation renewed by the ANECA (Spanish Agency for Quality Assessment and Accreditation) or by the respective autonomous quality agency.

In an editorial published by FEM in 2016 [¹] a series of questions were posed as the basis for a reflection on the development of the Bologna process in our faculties. This editorial takes up some of the points from that standpoint and, more specifically, the idea that curricula are not immutable entities. They should not be reviewed periodically but instead on a permanent basis. In fact, re-accreditation processes should serve precisely to assess how they have worked in a given period of time and, based on that assessment, to promote changes aimed at improving them. Let us not forget that one of the aims of Bologna is to improve quality and this must necessarily be carried out through assessments that allow for the renewal of accreditation.

Have any suggestions been made to introduce any significant modifications in the curricula that were initially proposed? Have any new competencies or new contents been considered in keeping with the latest scientific and methodological advances? Has any progress been made towards more integrated training programmes? Has any progress been made in the development and assessment of cross-cutting competencies, professionalism, bioethics, teamwork, training in research methodology, clinical reasoning, training in lifelong learning, health economics, and so on? Are active, student-centred methodologies at the heart of our curricula?

If anything was emphasised in the 2016 editorial, it was the subject of the assessment of competencies and the appropriate instruments with which to carry it out. The key, the paradigm shift, lies in moving from a sporadic delimited assessment, from a hermetic evaluation, to a global one that is prolonged in time and, in any case, multimedia. Rather than sporadic assessments, we must establish comprehensive programmes for the evaluation of competencies and of a multitude of other partial aspects.

In the majority of cases, in faculties of medicine each subject continues to assess its students as it deems most appropriate. Once all the subjects on the curriculum have been passed, a student graduates. This is not what Bologna is about. Can we be sure that a student who has passed the subjects independently has all the competencies set out in the curriculum? It is true that all faculties of medicine have developed and implemented an objective structured clinical evaluation (OSCE) that assesses competencies, and the efforts made by the Conference of Deans to develop this evaluation, in their respective faculties, must be acknowledged, but the OSCEs came into being more than forty years ago and research on assessment in medical education has given rise to new paradigms and new evaluation instruments.

Again: does a student who passes the OSCE at the end of rotation have all the competencies foreseen in the training programme? Impossible to say for sure. Have any remediation measures been implemented for students (if any) who do not pass? The OSCE, a test with a high educational impact, is a valid instrument, but it is just one more; the OSCE alone is not enough. There are valid, reliable instruments that are simpler and cheaper (the mini-CEX would be a good example) which allow for a more continuous and progressive assessment and, above all, which facilitate feedback with the student. The latter is very important because it is what makes it possible to move from the concept of the assessment ‘of’ learning to that of assessment ‘for’ learning [²]. We must stop thinking in terms of ‘single moments of assessment’ and move on to ’multiple moments of assessment’; assessment must shift from being single to progressive throughout the whole formative process. Assessment must stop belonging to the teacher and the institution, that is, it must cease to be an exam, and become an assessment programme.

These brief lines have attempted to review, with a critical spirit, what Bologna asked for twenty years ago and how far we have come since then. Are we doing it right? Could we do it better?