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Training for COPC in the Netheriancis and Around the World Ascots M. Creep THE MAASTRICHT PROGRAM The training of basic doctors in the Netherlands should fulfill the require- ments set forth in the academic statute. A basic doctor has 6 years training and is prepared for further specialty training in general practice (currently only 1 year), clinical specialty (4-6 years), and social medicine (4 years). In the Netherlands the students enter the universities straight after high school. The selection of medical students in the Netherlands is unique. After the high school national board, a weighted lottery is performed. Out of 6,000 interested high school graduates, 1,950 are placed in medical faculties. Only straight A students have a double chance in the lottery. In 1970 the Dutch government decided to start a new medical faculty that was community oriented and emphasized primary health care. In order to achieve these goals, the educational system of this faculty had tO be different. The traditional departmental system was abandoned in favor of a problem-oriented system. In 1974 an integrated innovative curriculum . . . was lnltlater .. EDUCATIONAL PRINCIPLES At Maastricht the basic philosophy emphasizes a preference for orienting medical education to primary care. The consequence of this position had to be presented in the teaching program; the problems presented needed to be typical of primary health care. It had tO give an answer tO the problems 250

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COPC in the Netherlands and Around the World 251 of the health care system. Based on this philosophy the following educa- tional principles were developed: problem-based orientation; independent learning; attitude development; evaluation; integration of theory and practice; and skills training. These principles led the founding fathers to design the following require- ments: 1. The teaching program mast relate to the knowledge and the interest of beginning students. The curriculum should be in line with the expectations of the students. It is important to know what the students expect and what motivates them to start medicine. The first block of 6 weeks is therefore devoted to introduction and orientation. It offers the students and the faculty the opportunity lo become acquainted with one another and with the program. Not only during the first weeks but throughout the whole program, the students' levels of knowledge and possible shifts in interest should regularly be made manifest, so that subsequent parts of the teaching program can be changed accordingly. 2. The teaching program mast constantly keep its final objective in sight. It was assumed that the real practice of medicine is the strongest motivation for the student. The program must constantly keep in view the relevance of the training in medical care and make that apparent to the student. Contact with the practice of medicine has to be built in from the beginning. In the early stages of training, skills are practiced. For this purpose a skills laboratory was started and has been gradually expanded. 3. The program mast ensure that theoretical learning wid be applied in prac- tice. No sharp distinction should be made between theory and practice. Whenever theory cannot be regularly applied in practice, there is the risk that the theory will be insufficient when the student requires it. The con- viction that the knowledge acquired must be kept alive and that the requisite skills must be constantly practiced implies that the program includes the reinforcement of skills until they are routine and second nature. By being confronted with progressively more complex health problems, the student will gain a broader and more realistic awareness of his own contribution. 4. The teaching program mast provide for the progressive refinement of the students' overall knowledge. This requirement implies that the program had to be organized concentrically, i.e., that particular areas reappear time and

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252 PART II PRACTICAL APPLICATIONS again with progressively more detailed and more refined presentation of problems. THE TEACHING PROGRAM The principles included in the basic philosophy and the requirements that followed from them allowed us to indicate the general lines of development of the teaching program. Topics specific to a particular specialty including the specialty of general practice- are included in the program. However, they are included only insofar as they are necessary for the training of a general physician who may later decide to specialize. The teaching program is oriented to the training of general physicians who fulfill the requirements set forth in the academic statute. The educational principles adopted and the requirements that flow from them, such as the emphasis on primary care, lead to a number of themes that run through the whole program. For the present, it is accepted that by the fifth and sixth year students must have acquired the following: practical experience in the solution of problems frequently encountered in primary care, problems not falling within the field of a specialist; and the ability to recognize unusual problems and to develop the most appropriate referral; students are not expected to have extensive knowledge of different specialties, but they should be able to make appropriate referrals of any health problem they encounter. In the courses of the first 4 years of training, the teaching program adheres to the following themes: The proklem-solving process is encountered in various phases. Dealing with health problems should foster a problem-solving ability. Independent of the complexity of the problem, the student should be equipped to: . formulate problems precisely in medical terms; . formulate general hypotheses; test relevant parts of the problem; and . formulate an adequate solution. i. The problem with which the student is confronted mast be progressively more complex. Even in the first year, students encounter complex health care problems, but the emphasis is on insight into what background knowledge is required. At the same time, students are confronted with simple problems, so that they have, by the end of the first year, some experience in inde-

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COPC in the Netherlands and Around the World 253 pendent problem solving. To this end, students are assigned limited re- sponsibilities in real-life situations. For example, in their first year, students carry out laboratory techniques, apply dressings, become acquainted with instruments, and perform simple diagnostic procedures in the skills labo- ratory and occasionally in practice. In subsequent years, the emphasis shifts progressively tO: . acquiring an insight in health care problems and problem solutions that do not presuppose extensive background knowledge; . possessing the background knowledge necessary for frequently occur- ring health problems; . possessing the knowledge tO solve common problems; and knowing what knowledge is necessary for infrequently encountered health problems. 3. The teaching program progresses from the general to the specific. In the Maastricht program the traditional progression from cell to tissue to organ is reversed where possible. This reversal will lead to the desirability of studying microstructure in the light of a health problem. Details of mor- phology, physiology, and biochemistry will be more readily acquired when their relevance to health problems has been demonstrated. The principal topics and main approaches tO problems have been established in the first year, and the succeeding years are devoted to refining the students' knowl- edge of the integrative biomedical, clinical, and psychosocial sciences. 4. The teaching program should begin with health problems arid proceed to consideration of normal and abnormalfanctioning. The starting point is health problems rather than the disciplines within medicine. This approach gives rise tO distinguishing the following successive stages: . orientation and introduction (year 1J; . normal function and phases of life (year 2~; . abnormal functioning (year 31; and making the best possible diagnostic and therapeutic decisions (year 41. STRUCTURE OF THE LEARNING PROGRAM The teaching program or curriculum at Maastricht is comprised of units of 6 weeks' duration. In this way, ongoing evaluation is facilitated. The themes are composed by making use of knowledge from various disciplines. The contribution of the different disciplines is organized around health care problems. Thus, the input of the disciplines tO health care delivery can more easily be comprehended. The matrix system is used.

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254 PART II PRACTICAL APPLICATIONS Student participation is achieved through tutorial groups. Groups of eight students meet at least twice a week with a staff member to discuss health care problems. In the remaining time the problems are distributed among the group members to prepare the necessary problem solving. As studies advance, progressively more realistic situations are introduced. Beginning with solution of health problems on paper, students then advance to prac- ticing on models, and eventually they will be prepared to deal with actual patients. In the first year students will already-acquire experience in dealing with uncomplicated problems of real patients. All first-year students follow a common program. In the event that li- censing examinations become required by law, such standardization is nec- essary. After the first year, options can be introduced into the program. Electives are increasingly part of the program after the second year. The main principles of the curriculum are still in use after 8 years. It was possible to structure the organization in such a way that the chance to fulfill the requirements was high. Every study unit was prepared by a multidis- ciplinary project group called the planning group. Specialists in the same field were based in "capacity groups" (the former departments) in order to remain up to date in their specialty. In this way, it was hoped that the students would indeed get a broad view on medical problems and that "integrated teaching" would be achieved, using all the available capacity in each block. HOSPITAL INTERNSHIPS The original arrangement for hospital internships is not yet feasible. The intention was to let the students follow a number of patients on their way through the various departments in the hospital (x-ray diagnosis, operating room, intensive care ward, revalidation, etc.) from one of two possible home bases: internal medicine or surgery. Further, the internships would be expressly for the student's learning process; the students would make only a very limited contribution tO the hospital in terms of health care and administrative tasks. The fifth and sixth years the student would use his capacity for self- directed learning and problem solving. The patient would be the focal point of his attention and he would solve the problems by making a problem list and solving these problems one by one; he would not be limited by de- partmental boundaries. Efficiency and COStS aspects as well as psychosocial aspects of the patients' problems would be included. The student would use a problem-oriented medical record. These arrangements have not yet been realized. The faculty board is of the opinion that this will not be the case for some years to come. It seems

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COPC in the Netherlands and Around the World 255 that the rigid hospital organization is difficult to combine with a less de- partment-linked, free flow of interns through the hospital. Moreover, the faculty members admit that they had underestimated the degree of prep- aration the novel type of internships required from the medical and nursing staffs of the hospitals involved. For the time being, therefore, there is no alternative but to return to the more traditional system of internships. However, the problem-oriented medical record is in use, and efforts are being made to have the internships in general specialty areas and not in the subspecialist fields. EVALUATION Evaluation is mandatory, especially in a new school with an innovative curriculum. A system was developed to evaluate the progress of the students through formative and summative evaluation and to evaluate the curriculum through block and program evaluation. As independent learning is one of our leading principles, formative evaluation, or self-assessment, is very im- portant. The student should check that his/her progress is in line with the expected progress. In the beginning, it was thought that we could do without a summative evaluation, but by law it was necessary to develop some kind , . . Or an examination. A system was designed in which the progress of the various years could be measured, a kind of theoretical/final M.D. exam with all medical topics involved. Each student has to write the same exam, and, of course, the fourth-year student scores better than the first-year student. The advantage of this system is that the student is less inclined to study just for the exam, because he doesn't know what set of questions to expect, since all medical topics are involved. Recently, a project was started to follow up our young doctors in order to trace possible areas in which their knowledge is lacking. A group of experts (External Review Committee) was asked to help and advise us and evaluate the total educational system. They did this with a lot of enthusiasm and have helped us tremendously. Not only did we receive help from the External Review Committee, but also from the Network of Community Oriented Educational Institutions for Health Sciences, of which the faculty is the founding member. THE NETWORK OF COMMUNITY ORIENTED EDUCATIONAL INSTITUTIONS FOR HEALTH SCIENCES The World Health Organization (WHO) recognized that the innovators of such medical school curricula needed all the help they could get in reaching their goal. It decided to organize a meeting in Kingston, Jamaica, in 1979.

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256 PART II: PRACTICAL APPLICATIONS This meeting brought together key figures of 18 selected schools that departed from current or traditional educational forms, either by giving priority to community orientation or by using educational processes/meth- ods through which students were engaged in problem solving. These 18 were obviously preparing their students to provide a more effective con- tribution of total health care, to have an understanding of the health needs in their community, and to work with the community as well as with individuals to promote health care delivery systems wherein the relation between the community and the health care system could be reestablished. From this meeting emerged unanimous agreement that mutual benefits could be derived from founding and developing a network linking those schools already engaged in community oriented problem-based learning and other schools more or less committed to an innovative approach and showing willingness and ability to contribute to actual collaboration with . . . . . . participating institutions. It was emphasized that the proposed network could become an important vehicle for the recognition of the need for change in educational programs that encourages closer linkage to health services and the political will to recommend such change. Thus the network came to be founded. It orig- inally consisted of 18 founding members those present at the Jamaica meeting. It was stressed, however, that the network should not become a formal association, nor that it should be seen as an exclusive club, but rather provisions should be made for all those with genuine interest and active . . . commitment to solo. The members met again under the auspices of the Rockefeller Foundation in 1981 in Bellagio, Italy. The objectives of the meeting were to identify possible collaborative actions and to generate a plan of action. There was unanimous agreement that mutual benefits could be derived from the fur- ther development of the network by sharing information, resources, and endeavors to find solutions to common problems. The main objectives of the network can be formulated as follows: 1. Strengthen institutions in the realization of community oriented prob- lem-based programs and in the development of individuals to enhance staff capacity. 2. Develop appropriate technologies for implementing community ori- ented problem-based programs. 3. Promote community oriented problem-based learning so that other institutions could use such an approach. To give substance to these important principles, the network promoted actions by which participating institutions could make valuable input. More

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COPC in the Netherlands and Around the World 257 specifically, the following activities were planned to be carried out concur- rently: 1. Information exchange (ideas). 2. The establishment and development of five task forces. 3. Bilateral contacts (fellowships). 4. Exchange of staff and students. CONCLUSIONS The major question to be asked is: Are we succeeding in changing medical education for the better? No clearcut answer can be given as yet, because it takes some years to follow up the first group of Maastricht graduates. However, we hope we are going in the right direction. Emphasis on primary health care has not been outmoded yet. On the contrary, since health care costs are still increasing, the cry for cheaper health care has only become louder. Also the effects of the patient movement have become stronger in the sense that they want care closer to the people. The Dutch government is trying to find ways and means to control health care costs by new laws that try to establish a network of health care services that are more related and by closing hospitals. Control over the system will be on a regional level. As you well understand, it is not an easy road that leads to cooperation between institutions that have been completely independent and self-reliant before. But the golden days of everyone getting everything he or she wishes are something of the past. The network of community oriented institutions was established to help all the institutions to stay on this new road, and may we hope that the network will succeed in bringing together the new medical schools and in making them strong enough to row against the tide.