Porto 23 – 24 / Bologna – the Swiss case Peter M. Suter, Geneva

Bologna in medicine: the Swiss case. Chapters of my presentation: Swiss university landscape National and regional governance Medicine: reform since PBL, student autonomy, medical humanities Bologna as an opportunity to improve teaching and training of doctors for tomorrow One step further: earlier specialisation

Swiss Academy of Medical Sciences Foundation created by the Swiss Medical Faculties in 1947, supported + financed by the Federal governement Moral instance for ethical questions and the limits of medicine in general Edicts guidelines and directives for common problems and border areas Examples: Palliative medicine, definition of brain death, human dignity and limits for clinical research, role and training for ethical committees, etc.

Switzerland: 7.5 million inhabitants Universities

Swiss Universities: Have different sizes and budgets

Swiss Universities: governance and finances 2 Technical Universities: national governance (Council, headed by an academic manager) + financed by national budget 10 Cantonal Universities: governance, structure and management depending on cantonal laws, regulations, budgets and political bodies (and humors) 5 Medical Faculties within Cantonal Universities, coordination of teaching aspects by Swiss Medical Interfaculty Commission

Auto-financed 5,3 % Cantonal budget, DIP 43,5 % Cantonal budget, non-DIP 7,4 % National allocation 18,6 % SNRF 9,3 % Other non-public 16 % Sources of finances: University of Geneva AH/pt Source: Budget 2005

12 Swiss Universities + 5 Medical Faculties

Medicine in Switzerland Good results and accessibility Expensive health care services Shortage of Swiss MDs and other health care professionals Reform in curriculum (1995), Bologna (2006) A new law for medical professions

Health care expendiures in % of GDP (gross domestic product), Kocher G. Schweizerische Ärztezeitung (BMS) 87: , 2006.

High costs of health care … Numerus clausus introduced – - but only in the German speaking part of Switzerland

Total Femmes Hommes Number of medical diplomas per year Switzerland P.M. Suter / ea, selon statistiques Facultés de Médecine suisses, 2002

% % Medical Faculties - Students Diplomas per year 800 Posts, hospital physicians occupied with Swiss diplomees with foreign diplomees 3000 or % Physicians in private practice Students in medicine, diplomas, and MDs in Switzerland

In Medicine, in the 15 years before Bologna, important things happened: The expectations of students, patients and society have changed markedly, imposing The reform of the curriculum, which produced an earthquake (happening in a number of dynamic institutions), and New law defining training for the medical professions prepared

Reform of the curriculum – 1990ies Why ? Student dissatisfaction + insufficient results Changes in societal expectations New concepts: soft sciences, student autonomy Initiative of a few « young turks » in the faculty: lets take the « taureau par les cornes »

Medical practice – societal demands in Switzerland, late nineties Care of the patient in a global way Good communication and a relation of con- fidence with the patient and his family Provide benefit for the patient and the society: maximal care, economy, efficiency Observe and react to new demands.. (demography, etc)

… the scientific evidence linking biological, behavioural, psychological and social variables to health, illness and disease is impressive … US Institute of Medicine (IOM), March Improving medical education, enhancing the behavioural and social science of medical school curricula

Hard sciences: anatomy, physiology, microbiology, pharmacology. Soft sciences: behavioural, psychological and social factors, physician role and behaviour, physician-patient interactions, efficient communication, health policy and economics. The importance of soft sciences must be increased during all phases of training. Editorial, Lancet 2004, 363: 1247 The soft science of medicine

Reform of Swiss Medical Curriculum More human and social sciences. Increased student autonomy + responsability Problem based learning (PBL) Increased clinical contact from the beginning of the pregraduate formation – - follow-up of chronic patients - contact with community medicine Clinical skills and Savoir-être ….

The reform in medical education includes: Integration of basic and clinical disciplines to facilitate problem-based learning (PBL) Recognition of social, ethic and community aspects of medicine Inclusion of economic and cost-effectiveness domains Development of clinical skills and self- recognition (« savoir-être ») Promotion of autonomous learning and life- long training

Reformed Medical Curriculum, Genève Example 1 st Year 2004/2005

Wave of the reform from and to the 5 Swiss Medical Faculties

+ the creation of a catalogue of learning objectives iawf.unibe.ch/slo/

Leitmotiv – New Swiss Law (Fleiner II) Tasks of the Physician (1998) Respects human dignity and automony; follows ethical principles for the wellfare of the patients Knows structures and function of the human organism Masters diagnosis and therapy of frequent diseases Is able to summarize and communicate observations Understands health problems in a global way; capacity to identify the elements of physical, psychological, social, economic, cultural and ecological origin; takes into account health for an individual and society Takes care of patients as individuals in their social environment Acts for prevention of diseases and for health promotion

Bologna in medicine: the Swiss case Chapters: Swiss university landscape National and regional governance Medicine: reform since PBL, student autonomy, medical humanities Bologna: a nightmare - or additional opportunity to improve teaching + training for the needs of tomorrow One step further: earlier specialisation

In Switzerland, the Bologna system had to be discussed, adapted and adopted by CRUS Conférence des recteurs des Universités Suisses: 2003/2004 CUS Conférence universitaire Suisse: December 4, 2004 Cantons adaptation to (11) different laws and autonomies of the universities Genève: french translation of « bachelor » and « master » had to be discussed in the parlament (grand conseil)

But: an important element in the University landscape could be preserved The relative autonomy of each university to organize the curriculum within the given framework - e.g. to introduce relevant reforms

Bologna in medecine - the Swiss case Now the technical part: structure and philosophy Basic principles of the Bologna system Better permeability for and to other branches Individual adaptation of curriculum to student wishes for career possibilities

Bologna - Basics Bachelor: 3 years, 180 ECTS Master: 2-3 years, ECTS Doctorate: 2-3 years ECTS – European Credit Transfer System students charge in hours, 1 ECTS = 30 h, 1 year = 60 ECTS = 1800 h (including self-learning, exams). This can be applied to medicine, to a reformed curriculum, to PBL, but good organi- sation and priority definition must be ensured.

Version PMS / PA Bologna + in Medicine Bachelor in Basic Medical Sciences Bachelor in Sciences, Arts, Economics, etc Credits Master in Sciences, Arts, Economics etc Master in Medicine Medical specialities Research + Teaching Other careers (industry, administration, etc) Student file Credits Doctorates, MD / PhD

Bologna allows to go further Earlier options for professional careers: - Do all speciality tracks need the same amount of knowledge in anatomy, biochemistry, genetics ? Early + more extensive contact with public health, research, etc. are needed

The concept of « Kern +Mantel » core parts and options

Year % 40% +Exam +Exam + Master thesis 40% Master in medical sciences Bologne in Medecine (CIMS): Nucleus + Options Integrated Master with mention MD-PhD 100% % 80% Exam Bachelor in Medical Sciences Optional modules Compulsory - nucleus MD-PhD program 2 –3 years Doctorate Pract/clinics Federal Exam MD working under Supervison (2 years) Year 6

Examples of optional modules Specific clinical tracks Programme MD/Ph International health Public health Law, Arts, Litterature etc.

Bologna in Medicine - Advantages for Basic Medical Sciences Maintaining a strong role in Bachelor Increased possibilities to include « Basic Sciences » in Master (options) Better possibilities by Bologna to motivate and train for research careers

Swiss Medical Faculties have undergone an in-depth revision by 3 distinct means: 1. Reform of curriculum (PBL, student autonomy, human sciences) since 1995, with new pedagogic concepts 2. Accreditation of all Med. Faculties by foreign experts – 2 nd time Bologna system introduced 2006

Will Bologna provide better doctors ? Not necessarily … But all efforts together have provided substantial improvements

Porto – River Douro Monte Rosa Glacier Thankyou !