The bachelor-master structure (two-cycle curriculum) according to the Bologna agreement: a Dutch experience
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Tijdschrift voor Medisch Onderwijs, maart 2010 | Vol. 29, nr. 1, p. 16-21
The bachelor-master structure (two-cycle curriculum)
according to the Bologna agreement: a Dutch experience
J.B.M. Kuks
Summary
The Groningen Medical Curriculum is an example of a two-cycle curriculum with a
course leading to the Bachelor’s degree followed by a course at the end of which students
receive a Master’s degree in medicine. Moreover a third cycle is in the offing, in the form
of a PhD trajectory for students who wish to pursue a career in research. The Groningen
curriculum is based on the CanMEDS competency model. In addition to describing the
Groningen curriculum, the author comments on the opportunities and threats offered by
the bachelor-master structure. A plea is made for more vigorous collaboration in work-
ing towards a more uniform European medical curriculum with room for specific local
features at the discretion of individual universities. (Kuks JBM. The bachelor-master
structure (two-cycle curriculum) according to the Bologna agreement: a Dutch experi-
ence. Netherlands Journal of Medical Education 2010;29(1):16-21)
The fist medical master in Europe degree structure (bachelor – master – doc-
The Bologna medical master is a reality: torate), 2) quality assurance and 3) recog-
On September 17th, 2009 the first official nition of qualifications and periods of
graduation ceremony of Medical Masters study. As a consequence, the European
in Europe took place at the University higher education area can become a real-
Medical Centre of Groningen (UMCG). ity, enhancing student mobility and creat-
This festive event is a landmark in the im- ing a transparent degree structure based
plementation of the bachelor-master on a uniform credit system.2
process that was initiated with the signing It seems self evident that these concepts
of the Bologna declaration. The bachelor- deserve a warm welcome, and at first
master structure has been embraced by sight there are no a priori weaknesses.
all eight medical faculties in the Nether- However, potential threats and difficulties
lands,1 and in 2003, Groningen University have been identified and concerns regard-
was the first to introduce a two-cycle ing the Bologna reforms of medical edu-
medical curriculum: ‘G2010’. cation have been voiced. Nowadays many
Does the graduation ceremony of the medical schools have a curriculum that is
Groningen medical masters really mark a characterized by clinical medicine as a
milestone on the road to implementation clearly identifiable thread, running
of the Bologna process or would it be a through the curriculum from start to fin-
more appropriate comment to repeat ish. Although basic science does have a
after Shakespeare: ‘What’s in a name?’ prominent place, it is taught within the
context of clinical problems.3 Thus the
The Bologna process: strengths, old system with basic science in the first
weaknesses, opportunities, threats cycle and clinical medicine in the second
The strength of the Bologna reforms is cycle has been effectively abandoned, but
that they concentrate on 1) a three-cycle the advent of the bachelor-master system
16 Undergraduate Medical EducationBologna: a Dutch experience | J.B.M. Kuks
could be perceived as heralding the return in a different subject, and students with a
of the olden days of separate preclinical Bachelor’s degree in a subject related to
and clinical curricular phases. A second medicine could enter the medical master
threat is undesirable uniformization. For, programme, either directly or after com-
if the many differences between Euro- pleting a transitional programme.
pean medical schools are all levelled out,
schools will be at risk of losing the very The Groningen G2010 competency
features that make them stand out among based curiculum
the other universities. In other words, To meet the Bologna objectives the
schools stand to lose their unique identi- Groningen curriculum planning group
ties and defining characteristics. Thirdly, designed a two-cycle curriculum, consist-
there is the problem of multilingualism as ing of a three-year bachelor programme
a barrier to mobility of medical students and a three-year master programme, each
within Europe. Because it is considered being the equivalent of 180 European
crucial for medical education to be pa- Credit Transfer and accumulation System
tient centred, most components of med- (ECTS) credits, or 60 credits per year.
ical programmes require communication A special effort was made to bring the
with patients, and patients want to pre- curriculum in line with the competencies
sent their complaints and concerns in of the Canadian Medical Education Di-
their own language or even their own re- rectives for Specialists (CanMEDS),
gional dialect. Thus mobility is up against which were making their entrance on the
a language barrier. And finally: will it ac- medical education stage at the time
tually be feasible to set uniform objectives G2010 was being developed. In order to
for medical education in the whole of Eu- make this possible, the CanMEDS com-
rope? For example: in the Netherlands, re- petencies (see Table 1), which are de-
cent medical graduates have very limited scribed as physician roles and were orig-
experience with obstetrics and much of inally designed for postgraduate training,
the learning in that area is deferred until were adapted for undergraduate medical
postgraduate training. Would this be ac- education. This resulted in a rosette of
ceptable in other countries as well? seven competencies with three domains
And last but not least, Bologna offers each, arranged around a centre of re-
opportunities. The Bologna reforms quired medical knowledge as presented
imply uniform quality assurance, trans- in the table. The three domains were de-
parency of degrees and uniform objec- fined in such a way that the first level
tives for medical education, the high pri- could be fully covered during the bache-
ority of which is strongly stressed by lor period.
student delegations. Furthermore, in ad- The G2010 programme is patient ori-
dition to flexibility of movement of med- ented from the very beginning. Each week
ical students within Europe, mobility of of the bachelor programme starts with a
students between medical and other pro- session in which a patient is present who
grammes might be enhanced by wide- has a clinical problem that is related to
spread adoption of a uniform bachelor- that week’s topic. For example, a patient
master structure. Students not wanting to with muscular dystrophy is present in a
continue their medical studies after session introducing a topic featuring the
achieving their Bachelor’s degree would anatomy, histology and physiology of the
be able to switch to a master programme musculoskeletal system.
17 Undergraduate Medical EducationBologna: a Dutch experience | J.B.M. Kuks
There is a great deal of attention paid to are stressed in the first bachelor year;
basic sciences but other competencies are clinical topics with links to basic science
addressed too, such as communicating topics are stressed in the second and third
with patients with a chronic disease, bachelor years; dual learning in a skillslab
choices concerning diagnostic work up, setting, in parallel with clerkships, is the
recent developments in neuromuscular focus of the first master year; regular
sciences, clinical examination, therapeu- clerkships constitute the programme of
tic (im)possibilities, public health issues the second master year; and a 20-week
concerning patients with severe disabili- clinical elective and a 20-week research
ties and reflection on the autonomy of de- elective form the programme of the third
pendent patients. master year.
Not only do students attend lectures
A spiral curriculum structure they also take part in practical workshops
The G2010 curriculum has a spiral struc- and in tutorials in which 10 students
ture4 and addresses the vectors attitude, work, guided by a teacher. This small
cognition and skills. Topics are revisited group format starts in the first year and
at increasing levels of difficulty as stu- continues until the last year. It is aimed at
dents’ competencies increase. Basic sci- development of different competencies,
ences and their links to clinical problems such as the use of scientific research
Table 1. CanMEDS competencies.
Competencies Domains
1 Communicative skills 1 Communication with other students
2 Communication with patients
3 Communication with medical colleagues
2 Clinical problem solving 1 Problem description
2 Rational diagnostics
3 Functional and effective treatment
3 Using knowledge and science 1 Methods and techniques
2 Scientific foundation of medicine
3 Science and society
4 Patient investigation 1 History taking
2 Clinical examination and investigations
3 Treatment strategies
5 Management strategies 1 Aims and possibilities of treatment
2 Making a choice and a start
3 Continuity and adjustment
6 Social and community 1 Non-biological factors in health and disease
context of health care 2 Screening and prevention
3 Health care organization, law, history
7 Reflection 1 Self and professional
2 Ethics and moral decision making
3 Medical philosophy
18 Undergraduate Medical EducationBologna: a Dutch experience | J.B.M. Kuks
methods, clinical problem solving accord- master programme after completing a
ing to Barrow’s5 notions of problem-based one-year graduate entry programme.
learning and reflection on working in Every year some 160 students apply for
health care. It thus supports coherence of admittance to this programme. After an
the spiral structure described above. admission test, approximately 40 students
start the programme and nearly all of
Knowledge and knowledge them finish it successfully after one year.
management The graduate entry programme combines
In the bachelor programme students are the second and third bachelor years and
introduced to basic science concepts that students are encouraged to study basic
are used during the master programme sciences too, depending on their knowl-
and thereafter. One of the aims of medical edge defects in that area.
education today is to prepare students to
be lifelong learners. This is essential in a The third cycle
rapidly expanding scientific field such as During the first years of the Bologna
medicine. Modern students are no longer process the aim was to develop a two-cycle
forced to digest the complete contents of bachelor-master programme, but in the
textbooks, which will be largely outdated course of time a third cycle was added: the
before long and are increasing in size con- PhD cycle. Not all medical students want
stantly. In a context of rapidly changing to earn a PhD degree, but students who
and expanding knowledge it is not suffi- show a marked interest in scientific re-
cient for students to acquire factual search can be spotted at an early stage.
knowledge, they also have to learn how to G2010 contains a bachelor honours pro-
manage knowledge. Consequently, skills gramme for research training which is
for lifelong learning should be given high equivalent to 30 ECTS credits. After com-
priority in medical education. In G2010, a pleting the honours course, students can
distinction is made between core knowl- apply for a place as a PhD student and
edge (which students must master and be take part in an extended programme, lead-
able to use without recourse to reference ing to a PhD degree and a Master’s degree
materials) and back-up knowledge (to be in medicine. About 10% of the students
acquired by studying set texts and read- undertake this Master’s/PhD degree track.
ings but not requiring rote learning). A For most of them this takes five years to
small part of all written exams consists of complete as opposed to three years for the
questions that must be answered without regular Master’s degree programme only.
using references (closed book section)
and the rest of the exams consists of open Quality assurance system
book questions related to subjects ad- In order to achieve and maintain a high-
dressed during lectures, practical work- quality programme, a continuous quality
shops and other educational activities. assurance process is in place. After each
module, student representatives produce
Graduate entry programme an extensive evaluation report in which
The G2010 curriculum was developed for they comment on the programme, the lec-
cohorts of 440 students. Students with a tures, other educational activities, the
Bachelor’s degree in subjects related to quality of readers and assignments, the
medicine, such as pharmacy, psychology validity of the exams and any other topic
and movement sciences, can enter the they consider relevant. The whole student
19 Undergraduate Medical EducationBologna: a Dutch experience | J.B.M. Kuks
population is surveyed and the teachers and levels of mastery, so we think that
are interviewed. The results of this much of our bachelor and master pro-
process are written up in a report, which grammes is quite new. As a consequence,
is discussed at several levels of the med- students with a Bachelor’s degree in a dif-
ical school. Student representatives and ferent subject are allowed to enter our mas-
core teachers prepare improvements to ter programme (including, by implication,
deal with the comments, and these are students with a Bachelor’s degree from an-
implemented when the module is next of- other medical school), students can enter
fered. Medical schools have to take part in the third, PhD, cycle, ECTS credits are
a mandatory national external quality as- used, a quality assurance system is in place
surance round every six years in order to and there is strong involvement of students
ensure re-accreditation of the curriculum. in curricular development. Finally, we have
just graduated our first master students.
From the bachelor-master pro- One might be tempted to think that every-
gramme to medical practitioner thing is perfect and nothing is left to be de-
The UMCG Bachelor’s degree guarantees sired. That, however, would seem to be a far
entry to the master programme. More cry from today’s reality.
than 90% of students obtain their Bache- Due to logistical reasons we are unable
lor’s degree and nearly all of them con- to admit more than a few students from
tinue with the master programme without other universities to our master pro-
interruption. So the annual cohorts of gramme, because most of our students
(about 400) master students consist of stay on at UMCG to continue their master
students who have completed the UMCG programme immediately or at most they
bachelor programme and students who are absent only temporarily to do an elec-
have completed the one-year graduate tive elsewhere.
entry programme (10%). In the Nether- Furthermore we used our own judge-
lands, a Bachelor’s degree does not grant ment in determining the learning out-
a vocational qualification and students comes for the bachelor programme. For
have to complete the medical master pro- even though medical education in the
gramme or another programme if they Netherlands has to meet the objectives set
wish to be able to use what they have out in the revised Framework 2009,3 the
learned in their work as a professional. committee revising the Framework has
The Master’s degree in medicine means not indicated how basic science knowl-
that students are licensed to practise med- edge is to be distributed over the bachelor
icine independently as a medical doctor. and the master programmes.
In G2010, clinical skills training does
So now the job has been done? not start until the first year of the master
In the foregoing I described the concept programme in order to make the medical
and the details of our G2010 curriculum, master programme more accessible for
which meets the objectives as described in students with non-medical Bachelor’s de-
the Bologna process. Did we really create a grees. Furthermore we feel that it is more
new curriculum or was it simply a matter effective to teach the skills for clinical en-
of sticking new labels on old items? We di- counters with patients at the very mo-
vided the G2010 curriculum into a bachelor ment when students actually have to use
and a master programme, and this meant them in the clinical setting,7 and this is
we had to (re)define our learning objectives not before the master period. Other Dutch
20 Undergraduate Medical EducationBologna: a Dutch experience | J.B.M. Kuks
medical schools offer clinical skills train- and hopefully will be persuaded to join
ing, and some schools even offer clerk- the Bologna process.
ships, much earlier in the curriculum. After this has been achieved, intra-Euro-
These differences thwart the uniformity pean mobility between medical schools will
of programmes required to successfully be greatly enhanced and European medical
implement the Bologna ideas, and more degrees will gain increasing recognition
congruence will be needed in this respect. and legal acceptance in the participating
The Dutch Framework 2009 merely states countries. Moreover, European medical
that in order to obtain the Bachelor’s de- schools with well-defined outcomes and
gree students must be able to examine a diplomas will be more attractive to non-Eu-
patient, but fails to specify any details of ropean immigrant students as well.
this requirement.
So, even if we wish to implement the References
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are only more complicated – with so far 3. Dutch Blueprint: Raamplan Artsenopleiding
less than 30% of the participating coun- 2009. Nederlandse Federatie van Universitaire
tries having made a commitment to im- Medische Centra. [The 2009 Framework for Un-
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lands. Utrecht: Dutch Federation of University
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In spite of these obstacles, I believe we JBM: One-year transitional programme increases
knowledge to level sufficient for entry into the
should not continue to develop medical
fourth year of the medical curriculum. Med Teach
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without looking across borders and tak- 7. Van Hell EA, Kuks JBM, Schönrock-Adema J,
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Bologna process – if only we would link cal performance. Med Educ 2008;42: 830-837.
hands and turn our words into deeds. The
next step will not be to try to adopt (parts The author
J.B.M. Kuks, MD PhD, is professor neurology and med-
of) each other’s programmes but rather to ical education, former director of the Medical Curricu-
discuss how we can face threats and re- lum, University Medical Centre Groningen (UMCG), the
solve problems, and then collectively Netherlands.
work towards consensus about minimum
Correspondence
requirements for a uniform bachelor-mas- Prof. dr. J.B.M. Kuks, neurologist, University Medical
ter curriculum to be offered by all univer- Centre Groningen, the Netherlands.
sities that are willing to put this system to E-mail: j.b.m.kuks@med.umcg.nl
the test. Thereafter the other medical
No potential conflict of interest relevant to this article was reported
schools will be able to see what is possible
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