Zeitschrift für Hochschuldidaktik Nr. 1999/2
Medicine Study 2000
Alternatives for Learning and Assessment, Teaching and Evaluation
Richard MÄRZ (Vienna, Austria)
Editorial: Curriculum Reform in Austria: Learning from Others
In my student days we discussed the important question: "Why are love songs always so sad?" The answer that emerged was quite obvious in retrospect: happy lovers have more satisfying things to do than to write love songs. The same situation seems to apply to people engaged in curriculum reform: as long as things are in motion they seem simply too busy to write much about their activities. But this is surely a mistake, since writing forces the necessary reflection. The nagging question as to whether things are going well or simply going along needs to be addressed frequently in a process attempting to achieve fundamental change - and also in a relationship I might add.
The conferences in Graz were organised by Jörg Stein and myself to create just such a space for discussion and reflection among faculty members and students of Austrian medical schools. We had reached the conclusion that meaningful improvement of medical education in Austria was impossible without a fundamental reform of the system. But how could a system be changed which had proved remarkably resistant to change for a century? For help we turned to colleagues from abroad who had already gone through such a process. Over the years we received from them advice and insights which have certainly shaped our thinking.
The present volume contains a stimulating mixture of papers by international experts, loosely based on presentations they gave in Graz in April 1999. The title of the conference was "Medizinstudium 2000: Making Change Feasible - Curricular Innovation and Implementation". But we also added papers of Austrian colleagues who are working in the field and thus provide us with a check on reality.
Ralph BLOCH introduces the section on Curriculum Reform with a concise paper. After presenting his basic argument that form should follow function also applies to medical education he analyses the situation in Switzerland and presents his conclusion that a "top-down" curriculum is better able to meet the needs than a traditional, department-based structure. At the same time he points out the realworld difficulties of a structural nature that make reform such a slow process.
Since the Austrian situation is quite similar his arguments are easy to follow and transpose. Only his assertion that the goals of undergraduate medical education have shifted in the last few years from training a competent primarycarephysician to the education of a physician capable of entering the next stage of specialised training seems at first glance strange from a "modern" Austrian perspective. Here at long last the realisation has dawned that a university medical degree should not only certify knowledge but also that the graduate is competent to apply this training.
The goals of a medical education should be fundamental to all curriculum design considerations. As logical as this seems, in practice there is little enthusiasm in pushing too hard on this front. Indeed, the prevailing frame of mind can be characterised as "either and or". It must be admitted, however, that while there is no excuse for muddy thinking this is one area where global standards are not appropriate. Rather goals must be developed which fit the requirements and options of the society to be served.
A partial solution to the riddle posed by BLOCH can be found in the paper of Charles ENGEL. Here he applies the principle of considering the goals and then formulating a cohesive strategy for curriculum planning in a rigorous and yet convincing way. Even seemingly conflicting priorities like training for professional life immediately after graduation plus preparation for lifelong learning become manageable using this approach. At the end of the paper a necessary warning is sounded: even PBL will not be the magic bullet that solves all problems, especially if it is (mis)used in precisely this hope. The contribution of Henny BOSHUIZEN examines the development of medical expertise and derives valuable lessons about curriculum development from an examination of the way students learn. The paper draws on many years of work at the University of Maastricht performed by herself, Henk SCHMIDT, Geoffry NORMAN and to some extent Wim GIJSELAERS. As in the previous paper we must conclude that vexing problems of curriculum design which cannot be resolved using "common sense" (the commodity usually deemed sufficient for this area) become quite approachable if standard procedures of academic inquiry are applied. Her insight that "academic freedom without quality control [does not] deserve the epitaph 'academic'" is just the kind of painful medicine we need to help us engage in difficult discussions. A paper by Florian EITEL and Arthur TESCHE is next. The authors draw on their experience in implementing limited curriculum reform in Munich against a background arguably even more difficult than the one in Austria. They then extend the recent discussions on BEME (best evidence medical education) to suggest a curricular format they call Evidence-Based-Learning. Their concluding remark, that "quality teaching means teachers making themselves superfluous ..." is a bit at odds with the premise of the papers in the following section, but this is all to the good.
The second contribution of Charles ENGEL is a systematic review of the uses and tools of formative assessment. The concept that formal examinations must not necessarily be summative in nature is new to Austria. The new medi-cal curriculum of the University of Vienna that takes effect on October 1, 2001 is the first to formally introduce formative assessments, although of course this has been done extensively on an informal basis. Interestingly enough, it was more difficult to convince the students than the faculty members of the legitimacy of this approach.
Most impressive about the article is the systematic connection made between the goals of the curriculum and the many uses of formative examinations. Required reading!
Evaluation has been a recurring theme in our discussions in Graz. The very first conference in 1995 dealt predominantly with this subject. In the following two conferences the initiative of the Austrian Rektorenkonferenz to evaluate all three Austrian Medical Schools in their entirety was covered rather critically. Gunhild SAGMEISTER moderated the self-evaluation phase of the evaluation and was thus one of the experts guiding the Rektorenkonferenz. At the 1997 Graz conference she led a workshop and participated in the plenary discussion but felt unable to contribute a paper until the process had been officially concluded. We are fortunate to be able to publish her description and insights of the process. This paper, however, should be read in conjunction with the three papers by MÄRZ, FULTON, and BRENNER and MORIGGL published in the 4/1998 issue of ZSfHD, to get an overall view of the process. The project of the Rektorenkonferenz was not a roaring success; there was plenty of blame to spread around. But the usual silver linings can be identified. Among them are the detailed and knowledgeable suggestions for future evaluation projects that SAGMEISTER outlines in her contribution. However, I think one point she makes must be stressed much more emphatically: the resources for such a process must be made available. It is no fluke that 7 - 10% of the overall costs are set aside for evaluation in externally financed projects; this is what a properly executed evaluation costs. Yet Austrian Universities still proceed under the assumption that evaluation is not an activity that must be budgeted for at the level of an individual staff member; even faculty time is unlimited and free.
The research study by Christiane SPIEL and Martin GÖSSLER provides an interesting contrast. Course evaluations were undertaken at all faculties of the University of Vienna. The instrument of individual student ratings was used exclusively, in part because it is this instrument which a new Austrian law prescribes. One of the conclusions of the study is that it makes little sense to use an identical evaluation for all faculties; this is interesting because it is pre cisely the approach the university administration has used during the last three semesters. The Medical School provided another "interesting" result: data collection proved to be impossible. The reasons given are very poor attendance at the lectures and untypical small-group work since student tutors play a large role.
In the discussion the authors examine the premises of the Austrian evalua-tion law quite critically. They raise the question whether an evaluation of courses provides meaningful data about the quality of teaching. I am tempted to add, thereby extending the remark of EITEL and TESCHE quoted above: does it tell us anything about the quality of student learning? The final two papers deal with staff development though from entirely different perspectives. William FULTON argues convincingly for the establishment of faculty development programs. So what else is new you might ask - except of course it does not happen. While at least lip service is being paid to the necessity for evaluation, there is currently no incentive in Austria, either positive or negative, for a faculty member to participate in staff development. Fulton not only examines the attributes of good teachers, he covers many different skills that could be developed and makes an impassioned plea to engage in selfreflection.
The second paper by Patrick MERL describes his experiences with a Masters of Medical Education program he is attending in Bern. If we are to succeed in establishing a professional approach to all levels of medical educa-tion we will need many graduates from programs such as the one in Bern. The volume concludes with the abstracts from the posters presented at the conference. They provided the backdrop for a stimulating evening of discussion and networking.
Speaking for all editors it is my privilege to extend our thanks to everyone who helped make the 1999 Graz conference a success. Among those who donated hard work are Anna Maria Uhlich, Aurel Botz and Patrick Merl. Among those who donated financial support are the Medical School of the University of Graz, the Governor and the State Government of Styria, the Mayor of the city of Graz as well as following companies: Gerot, Mac's Medical, Nestle and Octapharma. Thank you, your help is greatly appreciated. Ultimately though it was the hard work of all conference participants, staff and attendants alike, who made the conference such a memorable event. We left with the feeling that at last we were ready to tackle the serious work before us to achieve a meaningful reform of the medical curriculum in Austria.
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