Background to this commentary
The “Masterplan for Medical Studies 2020” published in March 2017 came unexpected
for many members of the Society for Medical Education (GMA). The document, which in
part promises profound changes to admission to medical studies, medical programs’
structure and content, as well as the federal licensing exam, raised questions that
were discussed intensively in the committees of the GMA. The basic thrust of the indicated
readjustment of medical studies seemed to point in the right direction and some of
the innovations which had been hard-won by lecturers and faculty seemed to be confirmed
by the announced measures. But the GMA committees also made criticisms; that the Masterplan
for Medical Studies 2020 left central terms and concepts undefined, did not fully
take into account the relevant evidence for the measures and failed to address some
relevant topics.
Process
Against this background, the Advisory Board of the GMA decided in September 2017 to
write a joint commentary on the Masterplan for Medical Studies 2020 in order to stimulate
internal debate, to contribute to the overall discussion through the perspective of
its committees and to draw attention to possible ambiguities. The individual committees
were free to decide whether and how they wanted to contribute to this project. In
that sense, this commentary is not a political statement on the content of the Masterplan
for Medical Studies 2020 but rather a contribution to the scientific discourse about
its contents1. 14 committees submitted their comments by spring 2019. These, as well
as the present summary, have been approved by the Advisory Board and Executive Board
of the GMA.
An attempt at a summary
Only by severely condensing the content was it possible to summarize the commentaries
of the 14 contributing committees. We invite you to read the explanations of the individual
committees in their entirety, they are included as attachment 1 (in German) to this
summary. The nature of the commentaries also differs significantly. A review of the
evidence available for the proposed measures of the Masterplan for Medical Studies
2020 was, of course, only possible where measures have been specifically designated
and desired goal and the path to it are described in equal measure. Some committees
discuss the more general ideas of the Masterplan for Medical Studies 2020, while others
identify gaps in the argumentation or evidence and suggest how to address them.
Admission to studies
Regarding new rules for admission to medical studies which have been called for, the
Masterplan for Medical Studies 2020 states concrete, measurable goals. The Student
Selection Committee examines the evidence on the effectiveness of the measures mentioned.
Consequently, the prognostic potential of some of the proposed selection criteria
for successful completion of studies beyond the school-leaving grade is limited and
the alternative measurement methods beyond knowledge tests have not been conclusively
validated. The proposed additional criteria may already be taken into account in the
university selection process under current legislation. The existence of suitable
selection criteria for the identification of future rural doctors is questioned critically
and possible ways of designing the curriculum in a way that arouses interest in rural
practice among students are referred to (see attachment 2 – in German).
Strengthening General Practice
The Primary Care Committee examines the evidence on the effectiveness of the measures
to strengthen General Practice formulated in the Masterplan for Medical Studies 2020.
International literature shows that the effectiveness of curricular interventions
to increase the attractiveness of rural areas improves if they are introduced early
and in a longitudinal fashion. The Committee’s research on the effectiveness of a
quota of rural doctors and student selection, as well as that of the Student Selection
Committee, shows that only the rural origins of applicants may be predictive of future
practice in rural areas. The Committee further lists – based on the international
literature – how curricular programs should be designed to encourage career choices
in General or rural practice. These program elements range from positive role models
to the active involvement of students in patient care, flanked by infrastructural
and didactic aspects (see attachment 3 – in German).
Restructuring of medical studies
Central to the planned restructuring are the competence orientation of medical studies,
its practical orientation, the strengthening of General Practice and practical exams.
The Practical Skills Committee welcomes the emphasis on practical skills including
communication and the associated expansion of simulation-based teaching, which will
not only increase the practical relevance but also contribute to greater patient safety.
The Committee would like to remind that the necessary resources for the development
of the skills labs will also have to be ensured for the planned clinical practical
exams. The potential of interprofessional practical training formats, which has been
left out of the Masterplan, should be given more consideration (see attachment 4 –
in German).
The Communicative and Social Competences Committee welcomes the proposed longitudinal
integration of communicative and social learning outcomes in medical education and
refers to content not mentioned in the Masterplan for Medical Studies 2020, such as
communication in intra and multidisciplinary or intra and multiprofessional teams.
It also calls for the design of this content be left to the universities themselves;
especially as corresponding or similar curricula have already been successfully implemented
at many teaching locations. Several arguments are made to support the position that
the priority given to the “National Model Curriculum Communication” referenced in
the Masterplan for Medical Studies 2020 is neither necessary nor desirable. According
to the Committee, there is no evidence to justify the implementation of a uniform
national curriculum for all faculties and thereby to override their respective curricular
content, design or priorities (siehe attachment 5 – in German).
Particularly in the context of clinical practical skills and competences, including
communicative and social learning outcomes, the use of standardized patients (SP)
has proven itself in teaching and examinations and an intensification of the efforts
in this area would be desirable. However, the Standardized Patients Committee also
explains how, in the event of a sudden and intensive expansion of SP programs in teaching
and assessment, special attention must be paid to compliance with the highest quality
standards. Interpretation sovereignty over the curricula e.g. communicative and social
competences must remain in the hands of faculties, just as they must be in defining
quality standards for SP-based teaching and assessment at universities (see attachment
6 – in German).
The Interprofessional Education Committee explicitly welcomes the fact that “multi-professional
working in teams” is specifically mentioned in the Masterplan for Medical Studies
2020 as desirable training content. However, it also mentions that the failure to
mention inter-professionalism thus ignores the need to learn and work together with
people from other health professions. The Committee also explains that inter-professional
examinations must become routine for a congruence of teaching, learning and assessment.
The demand for national curricula is viewed critically; it would be important to integrate
the programs already developed at the faculties. Moreover, the involvement of non-medical
teachers ought not to be sanctioned through capacity legislation (see attachment 7
– in German).
The Integrative Medicine and Perspective Pluralism Committee proposes concrete ideas
and didactic concepts for the design of the Masterplan for Medical Studies 2020 in
order to ensure that the individuality of patients in their health and illness needs
and experiences can better be taken into account in routine medical work. It also
advocates the teaching of patient-centered relationship design and communication as
well as the integration of practitioners’ self-care into medical studies (see attachment
8 – in German).
The Committee on Gender, Diversity and Career Development in Medical Education advocates
that diversity and gender competencies should be considered more extensively than
is the case to date not only as regards curricular redesign but also in university
didactics, assessment and student selection. With the emphasis on scientific competences
in medical studies, there would now be an opportunity to integrate diversity and gender
aspects here as well, so that graduates are trained regarding the need for gender-balanced
study cohorts and gender-specific and diversity-sensitive data analysis in their own
scientific activity. The opportunity to revise curricula as part of the Masterplan
for Medical Studies 2020 should also be used to design them so that study and family
become as compatible as possible, right through to part-time study models (see attachment
9 – in German).
The Committee for Cultural Competence and Global Health proposes to systematically
consider socio-cultural and international aspects of health, medicine and medical
practice in order to systematically implement the “consistent orientation towards
patients and their needs” as outlined in the Masterplan for Medical Studies 2020.
In order to do justice to the socio-cultural diversity of the population, the promotion
of cultural competences should be integrated into regular medical studies. There is
a need for courses which have not been discussed in the Masterplan so far but which
promote the ability to reflect and systematically consider social, ethical and moral
issues (see attachment 10 – in German).
The Faculty and Organizational Development Committee in Education also welcomes many
measures in the Masterplan for Medical Studies 2020 and notes that there is a need
for training and development for the meaningful implementation of many of the measures.
This need arises, as it were, through the planned closer integration of groups of
people from the area of general practice, non-academic hospitals or non-academic health
professions who to date have not been closely associated with universities. Also through
the consistent implementation of longitudinal curricula and competence-oriented teaching
and assessment formats. For this reason, established standards must be adhered to
and local circumstances taken into account. Due to their experience and strong networks,
the faculties would be capable of developing and implementing their own concepts for
fleshing out the measures envisaged in the Masterplan for Medical Studies 2020, provided
that the necessary funds were available for them (see attachment 11 – in German).
The Digitization – Technology-Assisted Learning and Teaching Committee notes that
the digitization of medicine and the entailed necessary measures for medical studies
in Germany are not mentioned in the Masterplan for Medical Studies 2020. It is stated
that the meaningful and comprehensive use of digital teaching and learning technologies
is needed in education. In addition to concrete references to learning and teaching
methods supported by technology, information technology infrastructure should also
be available. Teaching staff should be better trained in media pedagogy and didactics.
The Committee also urges the consistent dissemination of digital competences in health
and patient care and proposes a national digitization strategy for medical studies
(see attachment 12 – in German).
The Assessment Committee welcomes the Masterplan for Medical Studies 2020 in the hope
that this will result in meaningful corrections to the examination culture in medical
studies. Consistent competence orientation would first and foremost mean the integration
of formative assessments into learning routines, assisted by mentoring, feedback and
reflection. The Masterplan for Medical Studies 2020 may result in a curriculum watershed
which will allow faculties to re-orient the way teaching, learning and examinations
are synchronized. In this context, it is noticeable that the Masterplan for Medical
Studies 2020, demands the teaching of e.g. communicative and scientific competencies
but that these remain unmentioned as regards assessment. This omission must not lead
to such content being ignored in the formative as well as summative examination canon.
The promised reduction in graded course certificates is welcomed, as too many sanctioning
exams preclude a learning-friendly exam culture. However, reduction in the number
of course certificates must also be reflected in an actual reduction of examinations.
Overall, the question is raised as to whether grading examinations is necessary at
all. For example, the question of whether a student has attained the educational goal
outlined in §1 Section 1 Sentence 1 of the German Medical Licensure Act is dichotomous
in nature and does not require grading. Likewise, there is a call for consistent criterion-referenced
definition of performance standards in assessment, this too an imperative of competence
orientation. It is also stated that consistent competence orientation of medical studies
questions the rationale of having a medical program’s subjects defined by traditional
disciplines (see attachment 13 – in German).
To assess the success of the measures formulated in the Masterplan for Medical Studies
2020, the Teaching Evaluation Committee notes that common evaluation goals and methods
should be agreed at an early stage. Only in this way will it be possible to reach
meaningful conclusions on the effectiveness of the measures or the achievement of
goals. Even before the measures of the Masterplan for Medical Studies 2020 result
in any adjustments to the licensing regulations or other regulations/laws, they should
be reviewed for their applicability and effectiveness, including their cost-benefit
ratios. In addition, the Committee proposes approaches to evaluation for higher-level
measures (competence orientation, constructive alignment) but also refers to areas
where methods still need to be established for meaningful evaluation (scientific competencies).
Finally, areas are identified which must be carefully evaluated under any circumstances,
e.g. the quality of teaching by staff which hitherto had only been somewhat or not
at all integrated into university teaching or examiner qualifications, e.g. for the
federal licensing exam. The means that sufficient means to carry out these evaluations
must be made available (see attachment 14 – in German).
Lastly, the Educational Research Methodology Committee urges a careful analysis of
change processes. Since curricular interventions which are effective in one setting
might not be generally effective in other settings, transfer processes should be evaluated
and scientifically monitored. Since it cannot be assumed that the expertise or the
means for this are available at all teaching locations, suitable additional resources
for institutionalized scientific monitoring should be made available for this purpose
(see attachment 15 – in German).
Discussion
The commentaries of the committees organized by the scientific Advisory Board of the
GMA show there is confidence and hope that the implementation of the measures outlined
in the Masterplan for Medical Studies 2020 may not only lead to an improvement of
medical studies but also health care in Germany. Setting the course towards more competence
orientation, strengthening General Practice, scientific competences, communication
and team work and reforming assessment, etc. allow for some optimism. Nevertheless,
the Masterplan for Medical Studies 2020 leaves a lot open that in the view of the
committees requires further clarification.
It is noticeable that the central concept of competence remains undefined and thus
also that of competence orientation. As guiding concepts of the restructuring of medical
studies, competence-oriented training, practical training and examinations with practical
relevance are mentioned but are almost tautologically determined. Working scientifically
is described but not in the form of a definition, so that here too it remains open
whether, for example, unnamed aspects of the role of the “scholar” in the National
Competence-Based Catalogue of Learning Objectives (NKLM) are excluded or included.
The ability to work in a multi-professional team should be acquired but whether interprofessional
aspects are implied is not clear. Doctor-patient communication should be promoted
but communication in everyday clinical life is more than mere communication between
patients and medical staff. Such vagueness must be removed before implementing the
measures. Furthermore, other aspects are still not mentioned. This concerns the current
charged topic of the digitization of teaching and learning as well as gender, diversity
and socio-cultural aspects of medical practice. A systematic examination of gaps in
the Masterplan for Medical Studies 2020 could remedy this situation.
The concrete implementation of the measures may be met with a certain confidence,
as these have often already been anticipated in their intentions by faculties. Aligning
medical studies with medical competences is already codified in the current version
of the German Medical Licensure Act (§1 Section 1 Sentence 1) and ensuring practical
relevance in teaching and examination is already a reality at many faculties with
clinical examination courses in the skills labs and OSCEs. Thus, the Masterplan for
Medical Studies 2020 in many places confirms what faculties have already piloted in
recent years and makes this the new norm. However, interpretation sovereignty of university
programs is a constitutional task of the faculties and has been implemented successfully
by strong autonomous higher education institutions within the framework of the statutory
regulations in curriculum design as well as in faculty examinations. However, transfer
across the board will probably be a challenge for all faculties. Whether current capacities
will be sufficient everywhere for an implementation of the measures must be questioned
constructively. Here suitable means, for example for the initial overhead of curriculum
planning, didactic training, project management, the maintenance of curricular innovations
and their scientific monitoring/evaluation to successfully implement the Masterplan
for Medical Education 2020 must be made available.
To make these successes visible, several committees call for a definition of indicators
and targets. Before achievement of a target can be examined, establishing a baseline
would be sensible, which is why work on the Masterplan for Medical Studies 2020 begins
even before its implementation. In this context, it would be useful to obtain the
reference values referred to by the creators of the Masterplan for Medical Studies
2020, when they point out that more patient contact, earlier practical experience
and more effective handling of research results were necessary. It would be equally
interesting to know how they would describe the desired target states.
The use of the term masterplan implies a work of superordinate nature, following an
organizing principle, looking towards the future; a work that formulates goals and
describes actions or rules on how to achieve them. In some parts, this also applies
to the Masterplan for Medical Studies 2020. However, from the point of view of the
committees of the GMA, relevant measures in the Masterplan for Medical Studies 2020
must be set out in much greater detail before a promising reform of medical studies
in Germany can begin.
Contributed by (in alphabetical order): Daniel Bauer, Kai Schnabel
Note
1 The boundary between scientific and political perspectives was not always clear.
Analyzes of the possible implications of the measures and goals at university and
socio-political levels outlined in the Masterplan for Medical Studies 2020 could supplement
the present work.
Competing interests
The authors declare that they have no competing interests.
Supplementary Material
Explanations of the individual committees in their entirety [german]
Student Selection Committee [german]
Primary Care Committee [german]
Practical Skills Committee [german]
Communicative and Social Competences Committee [german]
Standardized Patients Committee [german]
Interprofessional Education Committee [german]
Integrative Medicine and Perspective Pluralism Committee [german]
Committee on Gender, Diversity and Career Development in Medical Education [german]
Committee for Cultural Competence and Global Health [german]
Faculty and Organizational Development Committee in Education [german]
Digitization – Technology-Assisted Learning and Teaching Committee [german]
Assessment Committee [german]
Teaching Evaluation Committee [german]
Educational Research Methodology Committee [german]