1. Tuning (Medicine) 2007 MEDINE Thematic Network

3. THE TUNING PROJECT “HARMONISATION OF LEARNING OUTCOMES FOR HIGHER EDUCATION” Funded by European Commission Funded by European Commission Learning outcomes/ competences for graduates Learning outcomes/ competences for graduates Generic and subject-specific outcomes Generic and subject-specific outcomes Europe-wide survey and consultation → consensus Europe-wide survey and consultation → consensus

6. The Tuning Project (Medicine) - process and methods Review of existing outcomes / competency frameworks Existing institutional or national learning outcomes/competency frameworks reviewed by the Project steering group Development of draft framework Preliminary draft learning outcomes/competency framework for Tuning (Medicine) generated by the Project steering group

7. The Tuning Project (Medicine) - process and methods Tuning (Medicine) Task Force workshops - Budapest (April 2005) Amsterdam (September 2005) Edinburgh (February 2006) Prague (May 2006) [Genoa (September 2006) – mapping workshop] Members of Tuning (Medicine) Taskforce sequentially reviewed draft framework and progressively refined it in the light of expert opinion Also: presentations at Learning and Teaching Support Network UK (Nov 2005), Chinese Association for Medical Education (Dec 2005), European Medical Students Association (July 2006), Rektors of German Medical Schools (Oct 2006)

8. The Tuning Project (Medicine) - process and methods Web-Based Opinion Survey Tuning methodology - include academics, graduates and employers. Rate learning outcomes for importance for graduates in the discipline. Ratings combined and outcomes arranged in a rank order. Informs the formulation of final Tuning report. Questionnaire based on draft learning outcomes, incorporated into the Surveymonkey.com on-line survey instrument, translated into German and French. Through MEDINE Network, primary contacts identified for each European member state. Asked to identify respondents under each heading and circulate the url. In later stages, url sent to all members of Network to increase number of respondents. Respondents rated 115 learning outcomes/competences on four point Likert scale as essential, very important, quite important or not important for primary medical degree.

9. The Tuning Project (Medicine) - process and methods First section - 29 generic outcomes for Higher Education degrees, from previous phases of “parent” Tuning Project”. Minor amendments made to take account of specific requirements of medical practice. Second section - 12 discipline-specific Level 1 outcomes which together describe the competences required of medical graduates. Third section - for each Level 1 outcome, discipline-specific Level 2 outcomes (74 in total) Fourth section - 39 knowledge domains and 14 practice settings in which students might gain experiential learning. Information regarding respondents - background (academic, graduate, employer, student or other), country and institution. Free text comments - qualitative analysis using the NVivo7 software tool.

10. The Tuning Project (Medicine) - process and methods Ratification of findings by MEDINE Thematic Network. AGM of MEDINE Thematic Network, Oslo, May 2007. Informed by the analyses and by agreement of the Task Force members, low-scoring outcomes may be omitted from the final Tuning document outcomes framework, or new outcomes added derived from the free text comments. Validation of Tuning Outcomes by Expert Panel. Presentation of final outcomes framework at Sectorial Validation Conference, Brussels, June 2007. Expert Panel invited by the European Commission to review the outcomes framework, meet members of Task Force, leading to a Validation statement for the discipline. Same process for each health-care Tuning project (medicine, nursing, physiotherapy, occupational therapy). Final report to the European Commission. At the conclusion of MEDINE Thematic Network, October 2007.

11. TUNING MEDICINE – SURVEY RESULTS 10 th April – 30 th October 2006 1302 responses 830 English version 453 German version 19 French version All EU member states except Luxembourg, Estonia, Cyprus

13. Interpreting Survey Results Not Important Quite Important Very Important Essential Response Average ability to solve problems 1% (6) 5% (34) 28% (178) 66% (420) 3.59 Ability to design and manage projects 18% (113) 51% (319) 28% (175) 3% (20) 2.16 NI QI VI E 1 2 3 4 ↑ NI QI VI E 1 2 3 4 ↑

14. Austria32 Belgium24 Bulgaria1 Croatia3 Cyprus0 Czech Republic1 Denmark23 Estonia0 Finland10 France10 Germany353 Greece3 Hungary22 Iceland1 Ireland9 Italy5 Latvia2 Lithuania10 Luxembourg0 Macedonia0 Malta20 Netherlands17 Norway2 Poland22 Portugal62 Romania3 Serbia1 Slovakia84 Slovenia19 Spain68 Sweden34 Switzerland9 Turkey33 UK164 Ukraine1 Non-European7 Nationality un-specified169 RESPONDENTS BY COUNTRY

15. Category of RespondentTotals Academic464 Medical Graduate169 Graduate Employer19 Current Medical Student359 Other (e.g. other health professional, PG student, patient) 43 Category un-specified248 RESPONDENTS BY CATEGORY

16. Type of InstitutionTotals University with Medical School919 University without Medical School13 Medical Employing Institution (e.g. Health Service) 107 Professional Association20 Other Association (e.g. Charity) 8 Other (e.g. Other clinical institution, PG education, pharmaceutical company) 54 Affiliated institution un-specified181 RESPONDENTS BY INSTITUTION

17. Generic Tuning Competences (1) ability to recognise limits and ask for help 3.63 capacity for applying knowledge in practice 3.61 capacity to learn (including lifelong self-directed learning) 3.58 probity (honesty, maintaining good practice) 3.58 ability to make decisions 3.57 critical and self-critical abilities 3.41 interpersonal skills 3.37 concern for quality 3.35 ability to work in a multidisciplinary team 3.27 empathy 3.23

18. ability to solve problems 3.51 capacity to adapt to new situations 3.22 ethical commitment 3.21 capacity for analysis and synthesis 3.14 ability to work autonomously 3.10 ability to communicate with experts in other fields 3.09 capacity for organisation and planning (including time management) 2.87 appreciation of diversity and multiculturality 2.70 will to succeed 2.58 ability to teach others 2.54 knowledge of a second language 2.51 Generic Tuning Competences (2)

19. understanding of cultures and customs of other countries 2.49 ability to lead others 2.45 basic general knowledge outside med 2.45 initiative and entrepreneurial spirit 2.44 research skills 2.33 creativity 2.29 ability to work in an international context 2.24 ability to design and manage projects 2.22 Generic Tuning Competences (3)

22. carry out a consultation with a patient (history, examination...)3.77 provide immediate care of medical emergencies, including First Aid and resuscitation 3.66 assess clinical presentations, order investigations, make differential diagnoses, and negotiate a management plan 3.50 carry out practical procedures (e.g. venepuncture)3.36 communicate effectively in a medical context3.31 apply ethical and legal principles in medical practice3.26 prescribe drugs3.26 assess psychological and social aspects of a patient's illness3.17 apply the principles, skills and knowledge of evidence-based medicine3.02 use information and information technology effectively in a medical context2.93 apply scientific principles, method and knowledge to medical practice and research2.89 work effectively in a health care system and engage with population health issues2.83 Level 1 Competences/Learning Outcomes for medical graduates and practice of medicine in Europe

25. Ability to analyse and disseminate experimental results2.17 Ability to apply statistical analysis to data2.15 Ability to design research experiments1.81 Ability to carry out practical laboratory research procedures1.71 Ability to provide evidence to a court of law2.48 Ability to perform respiratory function tests2.53 [ Knowledge - The different types of complementary and alternative medicine and their use in patient care 2.26] LEVEL 2 - LOW RATED OUTCOMES

26. 'Ability to carry out a consultation with a patient' Ability to take a history3.80 Ability to carry out physical examination3.78 Ability to make clinical judgements and decisions3.51 Ability to provide explanation and advice3.37 Ability to provide reassurance and support3.30 Ability to assess the patient's mental state3.22 LEVEL 2 COMPETENCES/OUTCOMES

27. 'Ability to assess clinical presentations, order investigations, make differential diagnoses, and negotiate a management plan' Ability to recognise and assess the severity of clinical presentations3.56 Ability to order appropriate investigations and interpret the results3.39 Ability to make differential diagnoses3.46 Ability to negotiate an appropriate management plan with patients and carers 3.22 LEVEL 2 COMPETENCES/OUTCOMES

28. 'Ability to provide immediate care of medical emergencies, including First Aid and resuscitation' Ability to recognise and assess acute medical emergencies3.77 Ability to provide basic First Aid3.76 Ability to provide Basic Life Support and Cardio-Pulmonary Resuscitation according to European guidelines 3.76 Ability to treat acute medical emergencies3.44 Ability to provide Advanced Life Support according to European guidelines 3.15 Ability to provide trauma care according to European ATLS guidelines2.91

29. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to prescribe drugs' Ability to prescribe clearly and accurately3.39 Ability to match appropriate drugs to the clinical context3.36 Ability to review the appropriateness of medication and evaluate the potential benefits and risks 3.30 Ability to prescribe drugs to treat pain and distress3.21

30. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to communicate effectively in a medical context' Ability to communicate with patients3.75 Ability to communicate with colleagues3.53 Ability to communicate orally3.49 Ability to communicate in breaking bad news3.39 Ability to communicate with relatives3.33 Ability to communicate with disabled people3.31 Ability to communicate in seeking informed consent3.29 Ability to communicate in writing (including medical records)3.24 Ability to communicate in dealing with aggression3.17 Ability to communicate by telephone3.08 Ability to communicate with those who require an interpreter2.96

31. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to carry out practical procedures (e.g. venepuncture)' Ability to measure blood pressure3.62 Ability to carry out venepuncture3.52 Ability to administer oxygen3.40 Ability to carry out cannulation of veins3.37 Ability to carry out subcutaneous and intramuscular injection3.34 Ability to adminster IV therapy and use infusion devices3.31 Ability to carry out electrocardiography3.09 Ability to carry out suturing3.03 Ability to carry out blood transfusion3.00 Ability to carry out bladder catheterisation2.91 Ability to carry out urinalysis2.78 Ability to move and handle patients2.73 Ability to carry out respiratory function tests2.53

32. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to work effectively in a health care system and engage with population health issues' Ability to provide patient care which minimises the risk of harm to patients3.55 Ability to apply measures to prevent the spread of infection3.54 Ability to recognise own health needs and ensure own health does not interfere with professional responsibilities 3.29 Ability to conform with professional regulation and certification to practise3.22 Ability to receive and provide professional appraisal3.11 Ability to make informed career choices2.86

33. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to apply ethical and legal principles in medical practice' Ability to maintain confidentiality3.74 Ability to apply ethical principles and analysis to clinical care3.49 Ability to obtain and record informed consent3.31 Ability to certify death3.29 Ability to apply national and European law to clinical care3.04 Ability to request autopsy2.88 Ability to provide evidence to a court of law2.48

34. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to use information and information technology effectively in a medical context'. Ability to keep accurate and complete clinical records3.51 Ability to use computers3.49 Ability to access information sources3.44 Ability to store and retrieve information3.26

35. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to apply the principles, skills and knowledge of evidence-based medicine'. Ability to apply evidence to practice3.01 Ability to critical appraise published medical literature3.00 Ability to define and carry out an appropriate literature search2.95 Ability to generate evidence through clinical audit2.47 Ability to apply statistical analysis to data2.15

36. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to apply scientific principles, method and knowledge to medical practice and research' Ability to apply scientific principles to the practice of medicine3.01 Ability to analyse and disseminate experimental results2.17 Ability to design research experiments1.81 Ability to carry out practical laboratory research procedures1.71

37. LEVEL 2 COMPETENCES/OUTCOMES 'Ability to assess psychological and social aspects of a patient's illness'. Ability to assess psychological factors in presentations and impact of illness 3.12 Ability to detect alcohol and substance abuse, dependency3.11 Ability to detect stress in relation to illness3.03 Ability to assess social factors in presentations and impact of illness 3.01

38. The Tuning Project Not about identity or conformity (the European Commission values diversity) Identifying common ground to build on “Just a little more tuneful”

40. 'Basic Sciences' Normal function (physiology)3.55 Normal structure (anatomy)3.35 Normal body metabolism and hormonal function (biochemistry)3.13 Normal immune function (immunology)3.07 Normal cell biology2.61 Normal molecular biology2.51 Normal human development (embryology)2.36 KNOWLEDGE OUTCOMES

41. 'Behavioural and social sciences' Psychology2.87 Human development (child/adolescent/adult)2.76 Sociology2.41 KNOWLEDGE OUTCOMES

42. 'Clinical Sciences' Abnormal structure and mechanisms of disease (pathology)3.40 Infection (microbiology)3.36 Immunity and immunological disease3.04 Genetics and inherited disease2.83 KNOWLEDGE OUTCOMES

43. 'Drugs and prescribing' use of antibiotics and antibiotic resistance3.42 principles of prescribing3.30 drug side effects3.22 drug interactions3.18 use of blood transfusion and blood products3.12 drug action and pharmacokinetics3.08 individual drugs2.89 the different types of complementary and alternative medicine and their use in patient care 2.26

44. KNOWLEDGE OUTCOMES 'Public Health' disease prevention3.14 lifestyle, diet and nutrition2.98 health promotion2.83 screening for disease and disease surveillance2.79 disability2.72 gender issues relevant to health care2.64 epidemiology2.61 cultural and ethnic influences on health care2.55 resource allocation and health economics2.40 global health and inequality2.33

45. 'Ethical and legal principles in medical practice' rights of patients3.30 rights of disabled people3.16 responsibilities in relation to colleagues3.11 KNOWLEDGE OUTCOMES

46. 'Role of the doctor in health care systems' laws relevant to medicine2.91 systems of professional regulation2.73 principles of clinical audit2.59 systems for health care delivery2.58 KNOWLEDGE OUTCOMES

47. PRACTICE SETTINGS ALL MEDICAL GRADUATES SHOULD HAVE EXPERIENCED CLINICAL WORK IN THESE AREAS care of acutely ill patients in Casualty / Accident and Emergency units3.51 care of general (internal) medical patients in medical admission units3.48 care of general surgical patients in surgical admission units3.20 care in the community/family practice/primary care3.13 care for elderly patients3.08 care for sick children3.04 care for the dying, palliative care2.91 care for mentally ill patients2.83 obstetric and gynaecological care2.81 care for critically ill patients in Intensive Care Units2.71 care of patients with specialised medical conditions (eg haematology, renal medicine)2.56 anaesthetic care2.54 rehabilitation medicine2.40 care of patients with specialised surgical conditions (eg cardiac surgery, urology)2.39

49. WORLD FEDERATION FOR MEDICAL EDUCATION TASK FORCE (2000) Defining international standards in basic medical education. Report of a Working Party, 1999, Medical Education, 34(8), 665-675.

50. The WFME standards 1.4 EDUCATIONAL OUTCOME Basic standard: The medical school must define the competencies that students should exhibit on graduation in relation to their subsequent training and future roles in the health system. Quality development: The linkage of competencies to be acquired by graduation with that to be acquired in postgraduate training should be specified. Measures of, and information about, competencies of the graduates should be used as feedback to programme development. Annotations: Educational outcome would be defined in terms of the competencies the students must acquire before graduation. Competencies within medicine and medical practice would include knowledge and understanding of the basic, clinical, behavioural and social sciences, including public health and population medicine, and medical ethics relevant to the practice of medicine; attitudes and clinical skills (with respect to establishment of diagnoses, practical procedures, communication skills, treatment and prevention of disease, health promotion, rehabilitation, clinical reasoning and problem solving); and the ability to undertake lifelong learning and professional development.

51. 2.1 CURRICULUM MODELS AND INSTRUCTIONAL METHODS Basic standard: The medical school must define the curriculum models and instructional methods employed. Quality development: The curriculum and instructional methods should ensure that students have responsibility for their learning process and should prepare them for lifelong, self-directed learning. Annotations: Curriculum models would include models based on discipline, system, problem and community, etc. Instructional methods encompass teaching and learning methods. The curriculum and instructional methods should be based on sound learning principles and should foster the ability to participate in the scientific development of medicine as professionals and future colleagues. 2.2 SCIENTIFIC METHOD Basic standard: The medical school must teach the principles of scientific method and evidence-based medicine, including analytical and critical thinking, throughout the curriculum. Quality development: The curriculum should include elements for training students in scientific thinking and research methods. Annotation: Training in scientific thinking and research methods may include the use of elective research projects to be conducted by medical students. 2.3 BASIC BIOMEDICAL SCIENCES Basic standard: The medical school must identify and incorporate in the curriculum the contributions of the basic biomedical sciences to create understanding of the scientific knowledge, concepts and methods fundamental to acquiring and applying clinical science. Quality development: The contributions in the curriculum of the biomedical sciences should be adapted to the scientific, technological and clinical developments as well as to the health needs of society. Annotation: The basic biomedical sciences would - depending on local needs, interests and traditions - typically include anatomy, biochemistry, physiology, biophysics, molecular biology, cell biology, genetics, microbiology, immunology, pharmacology, pathology, etc.

52. 2.4 BEHAVIOURAL AND SOCIAL SCIENCES AND MEDICAL ETHICS Basic standard: The medical school must identify and incorporate in the curriculum the contributions of the behavioural sciences, social sciences, medical ethics and medical jurisprudence that enable effective communication, clinical decision making and ethical practices. Quality development: The contributions of the behavioural and social sciences and medical ethics should be adapted to scientific developments in medicine, to changing demographic and cultural contexts and to health needs of society. Annotations: Behavioural and social sciences would - depending on local needs, interests and traditions - typically include medical psychology, medical sociology, biostatistics, epidemiology, hygiene and public health and community medicine etc. The behavioural and social sciences and medical ethics should provide the knowledge, concepts, methods, skills and attitudes necessary for understanding socio-economic, demographic and cultural determinants of causes, distribution and consequences of health problems. 2.5 CLINICAL SCIENCES AND SKILLS Basic standard: The medical school must ensure that students have patient contact and acquire sufficient clinical knowledge and skills to assume appropriate clinical responsibility upon graduation. Quality development: Every student should have early patient contact leading to participation in patient care. The different components of clinical skills training should be structured according to the stage of the study programme. Annotations: The clinical sciences would - depending on local needs, interests and traditions - typically include internal medicine (with subspecialties), surgery (with subspecialties), anaesthesiology, dermatology & venereology, diagnostic radiology, emergency medicine, general practice/family medicine, geriatrics, gynaecology & obstetrics, laboratory medicine, neurology, neurosurgery, oncology & radiotherapy, ophthalmology, orthopaedic surgery, oto-rhino-laryngology, paediatrics, pathological anatomy, physiotherapy & rehabilitation medicine and psychiatry, etc. Clinical skills include history taking, physical examination, procedures and investigations, emergency practices and communication and team leadership skills. Appropriate clinical responsibility would include health promotion, disease prevention and patient care. Participation in patient care would include relevant community experience and teamwork with other health professions.

53. The worth of an intellectual construction is to be found in its value as an ideal…. That it also has potential for full realization is a further, but not the exclusive, benefit. Socrates (as reported in Plato, The Republic, book 4, 360 BC)

54. WHAT IS A EUROPEAN MEDICAL GRADUATE? “Basic medical training: admission to basic medical training shall be contingent upon possession of a diploma or certificate providing access to universities or equivalent institutes which provide higher education, and shall comprise a total of at least six years of study or 5500 hours of theoretical and practical training provided by, or under the supervision of, a university.” “Basic medical training: admission to basic medical training shall be contingent upon possession of a diploma or certificate providing access to universities or equivalent institutes which provide higher education, and shall comprise a total of at least six years of study or 5500 hours of theoretical and practical training provided by, or under the supervision of, a university.” http://europa.eu/scadplus/leg/en/cha/c11065.htm Universal cross-recognition of primary medical qualifications within Europe Directive 2005/36/EC of the European Parliament and of the Council of 7 September 20052005/36/EC

55. European medical education – out of tune? Wide variation in admission standards and selection procedures Wide variation in admission standards and selection procedures Degree programmes vary from 4 to 7 years (or longer) Degree programmes vary from 4 to 7 years (or longer) May involve one, two, or three degrees May involve one, two, or three degrees Graduation may or may not = license to practise Graduation may or may not = license to practise No agreement on graduating learning outcomes/competences No agreement on graduating learning outcomes/competences ?? “a system of easily readable and comparable degrees”

56. The Scottish doctor http://www.scottishdoctor.org

57. Tomorrow’s Doctors 2002 http://www.gmc-uk.org/med_ed/default.htm The UK Doctor

58. BLOCH, R. & BURGI, H. (2002) The Swiss Catalogue of Learning Objectives, Medical Teacher 24(2), pp. 144-150. BLOCH, R. & BURGI, H. (2002) The Swiss Catalogue of Learning Objectives, Medical Teacher 24(2), pp. 144-150. METZ, J.C.M., STOELINGA, G.B.A. et al. (1994) Blueprint 1994: Training of Doctors in The Netherlands, Objectives of Undergraduate Medical Education (Nijmegen, University Publications Office). METZ, J.C.M., STOELINGA, G.B.A. et al. (1994) Blueprint 1994: Training of Doctors in The Netherlands, Objectives of Undergraduate Medical Education (Nijmegen, University Publications Office). GUAL, A., PALÉS, J., PARDELL, H. & ORIOL-BOSCH, A (2005). Doctors in Spain. An old country, old and new structures, and a new future. The Clinical Teacher 2 (1), 59-63. GUAL, A., PALÉS, J., PARDELL, H. & ORIOL-BOSCH, A (2005). Doctors in Spain. An old country, old and new structures, and a new future. The Clinical Teacher 2 (1), 59-63. + many others The national European doctor

59. The US doctor

60. The global doctor

61. CURRICULUM CONTENT – Scientific method Basic biomedical science Behavioural and Social Sciences and Medical Ethics Clinical Sciences and Skills The WFME standards

62. LEARNING OUTCOMES FOR MEDICINE – OUT OF TUNE? Vary enormously in – Overall structure Overall structure Level of detail Level of detail Content Content Application - theory v practice, accreditation Application - theory v practice, accreditation

63. TUNING TASK FORCE, MEDINE 2 Aims of the Tuning (Medicine) Task Force will be: To build on the work of the current network, MEDINE. To consider how the “Dublin Descriptors” and the Bologna 3 cycle model can be integrated with the new Tuning (Medicine) competency framework. To investigate how competences for 1st and 3rd cycles might relate to those for primary medical qualifications. To apply new systems for mapping other competency frameworks to Tuning. To develop new systems for categorising competences and defining level statements. To promote use of Tuning (medicine) tools within and outside Europe, linking with the Tuning Project and Tuning Latina America. To relate the Tuning competences to curriculum design, including a model core undergraduate medical curriculum which will allow students to achieve the Tuning competences at the point of graduation. To generate guidance on best practice in assessing theTuning (medicine) competences.