Reforms in VUmc School of Medical Sciences Amsterdam: Student engagement, a Minor elective semester and stakeholder collaboration in improving the quality of assessments

Abstract

Background: At VUmc School of Medical Sciences, major curricular reforms occurred in 2005 and 2015, related to the introduction of a Bachelor-Master structure, a new legislation from the Ministry of Education, the changing societal context, and taking note of students’ and teachers’ needs.

Summary of work: Along with the introduction of the Bachelor-Master system, the period between 2005 and 2009 saw the movement from traditional lecture-based teaching to small group teaching in a competency-based curriculum, in which the students were responsible for their learning. Student engagement grew through students’ designing learning modules and conducting some of the teaching. In the Bachelor program, an elective “Minor”, was designed to broaden and deepen the knowledge of our students beyond the core learning outcomes, in a discipline of their choice. The examination board (EB), responsible for maintaining the quality of assessment, was split into the General EB, which handled overall strategy issues, and the Executive EB, which handled student requests and monitored the quality of assessments.

Lessons learned: Students develop a sense of what education is about if they are provided opportunities in designing teaching and conducting it. A Minor elective in the medical study can provide the students with an opportunity to learn outside the medical field. Collaborative working between different stakeholders in a medical school is crucial for safeguarding the quality of assessments. Curricular reforms need time to be accepted and integrated into the culture of the medical school. The educational vision needs to be refreshed regularly in alignment with the changing societal context.

Introduction

The Dutch medical education context and the reforms in the last decade:

The objectives of undergraduate medical education in the Netherlands are described by the legislated Dutch Blueprint for Training of Doctors 2009 (van Herwaarden et al. 2009). All medical schools go through an accreditation cycle every six years. The Accreditation Organisation of the Netherlands and Flanders (NVAO) is an independent body that is commissioned by the Dutch and Flemish (Northern, Dutch-speaking part of Belgium) Governments to perform a quality check of the medical education in these two regions. NVAO appoints a review committee, which visits all the medical schools and provides an objective assessment report of the quality of their education.

The Dutch Government signed the Bologna Declaration in 1999 (van den Broek et al. 2010). As a consequence, a major reform was effected from 2003 by all Dutch medical schools to implement the Bachelor-Master (BaMa) structure. This structure was introduced so that students who did not want to continue their medical study could stop at the Bachelor to join another profession.

Table

Practice points

Curricular reforms need time to be actualized. The educational vision needs regular refreshment to align with the changing societal context. Student engagement in teaching is invaluable. Opportunities for students to learn beyond the scope of medical topics are purposeful and appreciated. Safeguarding the quality of assessments in a medical school requires collaboration between different stakeholders.

In 2009, another major reform was introduced. CanMeds competencies were formally integrated into the Blueprint for Training of Doctors, leading all medical schools to implement a competency-based curriculum (ten Cate 2007; van Herwaarden et al. 2009).

Currently, all Dutch medical schools have competency-based, vertically integrated (early patient contact) curricula with a BaMa structure (3 years Bachelor and 3 years Master of Medicine programs) (ten Cate 2007).

Another important reform related to student selection for medical school. This has gradually changed from a 100% weighted lottery-based admission (before 2000) to 100% selection-based admission from 2017 (Wouters et al. 2017).

All medical schools introduced reforms in their schools in line with the above-mentioned changes and also initiated extra reforms particular to their own educational vision.

The context of curricular changes at VUmc School of Medical Sciences, which is located in Amsterdam, is one of the eight medical schools in the Netherlands and has 2100 medical students studying in the Bachelor and Master programs of Medicine. In 2005 and 2015, it undertook major curricula reforms.

The curricular reform in 2005 included the introduction of the BaMa structure and a new educational vision related to student-centered learning. This educational vision was built into a small group teaching based, competency-based curriculum.

VUmc implemented the CanMeds competencies in a longitudinal fashion in an educational domain called professionalism (Mak-van der Vossen et al. 2013). This domain included the seven CanMeds roles and an eighth role called the “Reflector” (Whitehead et al. 2014). Pharmacotherapy education was also introduced as a longitudinal theme in the curriculum stimulated by a WHO Working Committee Report that students lack the knowledge of pharmacotherapy (Orme et al. 1990; Richir et al. 2008). Due to the BaMa structure and legislation which obligated the Bachelor curricula to prepare students for more than one of the Master’s programs, scientific (research-based) development of medical students was integrated as an important educational goal of the medical school. International clerkships were offered to students for developing a broad perspective through working in a different geographical and cultural context. In 2012, a Department of Research in Education was established to investigate the curricular practices and innovations.

In the rest of the article, we describe in detail three key developments that we think have been very important for the development of VUmc and will be interesting for the readers.

A description of the key developments over the past 10 years

Student engagement in teaching

Why this was done – Student autonomy is at the core of the educational vision of our Bachelor and Master of medicine programs. Some students identify additional themes for knowledge and skills than those specified by the Dutch Blueprint for Training of Doctors 2009. We encourage such students to develop a theme-based educational module, along with a business/practical plan. These are then presented for approval to the Bachelor or Master Program Directors before implementation.

What was done and how – The “First Aid Education” module was developed by students with an interest in first aid and traumatology. Senior students teach juniors about first aid and common emergencies. This module comprises eight hands-on training sessions, one theoretical assessment, and one objective structured clinical examination. The students who developed this module recruit and train the trainers (fellow students), and develop and conduct the assessments themselves. A staff member of traumatology, who was also a certifying member of the National First Aid Organization, approved the module and the assessment. On passing the assessment the students are awarded a first aid certificate. The student teachers are able to conduct this module in half the budget in comparison with that of faculty conducting the same course. The training is conducted in the evening when the trainers, as well as the skills training facilities, are freely available.

In the “VUsap” module, senior students teach anatomy dissection to juniors. Through selection, students are recruited for VUsap. VUsap is conducted as an extra-curricular summer course for four groups of 16 students each to dissect human extremities, head and neck, abdomen, or thorax. They discuss anatomical images and visit the hospital to study clinical case histories with an experienced specialist. At the end of the two weeks, students perform a theoretical and a practical assessment.

The Department of Pharmacotherapy education with the help of student teachers developed the “Learner-Centered Student-Run Clinic (LC-SRC)”. Teams comprising one Master and two Bachelor students conduct LC-SRC. These teams perform patient consultations. The clinic runs in the Internal Medicine and the General Practice Outpatient Departments. It uses near-peer teaching as well as remote supervision by a specialist or general practitioner. Each group of students performs a patient consultation focusing on proposing either a new management plan or changes in the existing management plan (Schutte et al. 2017).

The “E-learning initiative for teaching clinical reasoning” was produced by the Mobile Learning Initiative, in which 30 students and 25 staff members of our medical school collaborated and constructed 20 modules and 60 cases concerning 20 major health problems. These modules are available on I-tunes, can be used free of charge on many mobile devices and can be consulted during the clerkships.

In September 2017, an extra-curricular Student Teaching Qualification training trajectory of six European Credits (i.e. 168 h) was implemented at the VUmc. Students already involved in teaching are selected for this training. They have to complete at least 14 h of independent teaching during this training trajectory of 9 months. They are taught the didactic principles of teaching and learning, types of curricula, how to develop study material and other topics in medical education. They conduct teaching, read and appraise medical education literature, and make an educational portfolio. Their educational portfolios are assessed at the end of the training by faculty who has obtained the Basic or Senior Teaching Qualification. If they are successful, they are awarded a Student Teaching Qualification. This Qualification was developed to make students feel valued for their teaching.

Evaluation of the reform – For the last 5 years the First Aid module has been a highly rated course in Bachelor Year 1; in student evaluations, it scores 4.0 and 4.2 on a scale of five for the content of the course and the quality of the student teachers, respectively. The quality of the assessment carried out in this module, which is monitored by the institutional examination board (EB), is good.

The success of LC-SRC is clear from how the patients evaluated the provided care, teachers’ and students’ satisfaction and perceptions of its feasibility (Dekker et al. 2015).

The mobile learning initiative has received an innovation prize and will be piloted in September 2018.

The student teaching qualification is just completing its pilot phase, so we do not have any formal evaluation of the whole program, but the preliminary student feedback on the individual sessions is positive.

Introduction of a Minor elective semester in the Bachelor curriculum

Why was this done – In 2015, in response to both external and internal incentives, we introduced a Minor elective in the Bachelor curriculum. The external driver was provided by the Ministry of Education, Culture, and Science, which passed legislation, obligating Bachelor curricula to prepare students for more than a single choice of Master’s program. This demanded scientific learning objectives to be integrated into the Bachelor of Medicine program. The internal driver was provided by student evaluation, which urged the faculty to introduce electives and opportunity for international exchange. This initiative was undertaken in order to better prepare our future doctors for a professional career in a rapidly changing scientific, clinical, and societal context.

This elective semester, called the Minor, was designed to broaden and/or deepen the knowledge of our students in a discipline of their choice. We prefer to call this a Minor elective semester rather than a student selected component, as termed in the literature (Riley 2009). This is because we have more electives, which can be called SSCs, like the research internship, the semi-doctor clerkship, and an elective clerkship, which include development of core learning outcomes of our curriculum. The learning outcomes of the Minor elective semester were beyond and separate from the core learning outcomes (Riley 2009).

What was done and how – The introduction of a Minor elective semester required that all medicine-specific learning objectives and Bachelor competencies were confined to five semesters of the Major program. By eliminating the duplication of topics, redefining the expected standard of knowledge in basic biomedical, social, and clinical sciences, and the academic core, we were able to achieve the expected learning outcomes in terms of academic performance and medical expertise. The scores of the first cohort (with the Minor elective semester in their curriculum) on the national progress test confirmed the validity and quality of our lean Major program. The focus of the Minor elective concerns how clinical observations lead to excellent science programs and how scientific findings find their way to the clinic at an ever-increasing pace. Twelve elective Minor modules were conceptualized in a bottom-up manner after an open call to all departments and our eight renowned research institutes. Next to modules on traditional topics like cardiovascular sciences, oncology, pediatrics, endocrinology/internal medicine, innovative modules that transcend the traditional clinical topics were generated. These included “Death and Dying” on the ethical and legal issues surrounding palliative care and end of life decisions, “Global health, diversity & conflict areas”, and “Personalized medicine” that focuses on the technical advances in imaging, diagnostics tools, and Nanomedicine. After the Minor, the students are required to write a scientific Bachelor thesis on a chosen topic from their Minor program.

The elective Minor can also be followed in unrestricted other disciplines at any other Dutch or international universities. The international exchange program is especially popular, with over 50 students (>15%) spending a semester abroad in 2017, mostly outside the European Union. A wide range of topics is chosen by the students, ranging from philosophy, law, and sociology to biomedical sciences and forensic criminology, complying with the idea of broadening their views, and skills outside of the field of medicine. Faculty also initiated two specific elective Minor programs with partner institutes. With Nyenrode Business University, a medically oriented Minor on “Leadership, finance, and management” was developed, in which 15 students take courses alongside the Nyenrode students. With Gadjah Mada University in Yogyakarta, the module “Global Health Indonesia” was developed, where 12 students collaborate with Indonesian medical students to perform field research in the rural medical posts of Java.

Evaluation of the reform – To ensure a certain quality and standard of the Minor electives, the Departments offering such electives were asked to write up their plans and learning outcomes, including the design of their assessment. These plans were evaluated and approved by the Bachelor Program Director using the following criteria:

1. The Minor module has no overlap with the regular courses of Bachelor or Master of medicine or with other Minor modules.

2. The Minor module is at the level 300 (i.e. equivalent to a 3rd-year subject).

3. The Minor module should have a clear set of learning outcomes that comply with the concept of “translating research from bench-to-bedside and back”.

4. The assessment program should have distinct elements that are consistent with the content of the modules. In addition to a final written exam with only open questions (not multiple choice) for 50% of the total marks, there should be presentations and several writing assignments (e.g. critical appraisal of a topic, research proposal) for the remaining 50%.

A formal online survey was conducted amongst the students to test whether there was interest in the topics generated by the departments. Only modules that were the first choice of at least 10 students in the survey were finally offered as a Minor elective.

The assessment reports for all the Minor electives and the Bachelor theses written by the students are evaluated by the institutional EB at the end of the year and recommendations will be made for improvement if necessary.

This innovation was successfully implemented with the aim to boost student intrinsic motivation for both science and medicine by offering them individual choices in learning (Kusurkar and Croiset 2014). The students perceived broadening their competence and skills outside of medicine as rewarding without compromising their medical skills in preparation for the Master program.

Safeguarding the quality of assessments through collaborative working between the education management, examination board, and educational policy advisors

Why was this done – In the Netherlands, every medical school is obligated to appoint an EB which is responsible for safeguarding the quality of all assessments and the sanctity of the medical degrees (Bachelor and Master of Medicine). At VUmc the workload of student requests for exemptions from certain examinations, resit examinations, etc., and complaints was very high (828 in 2012–2013), making it difficult for the EB to maintain an overview of the quality of assessments. Moreover, work was done in a repetitive manner by different stakeholders in the assessment chain (the Program Directors, EB, assessment experts, and examiners – See Table 1).

Table 1. Stakeholders in the assessment chain and their responsibilities.

Sr. no.	Stakeholder	Responsibilities
1.	The management of the educational institute (Director of VUmc School of Medical Sciences and the Bachelor and Master Program Directors)	Accountable for designing and implementing the curriculum including theassessmentsAccountable for the quality of the education offered and the degree awarded
2.	The assessment experts	Responsible for writing the assessment policy, assessment plan, and assessment manualResponsible for advising the examiners on the quality of their assessment questions (consulting services on demand)Responsible for training and advising examiners on newly introduced assessment types
3.	Policy advisors and quality assurance staff	Responsible for advising on educational implementation from the perspective of policyResponsible for the overseeing the plan-do-check-act cycle
4.	General examination board	Responsible for upholding the quality of assessments and the degree awarded and checking it from time to timeResponsible for appointing examiners and setting criteria for examinersResponsible for sampling the end products of the Bachelor and Master programsResponsible for advising the management on key documents like the assessment policy, assessment plan, and assessment manualResponsible for advising the management on specific training for examiners
5.	Executive examination board	Responsible for handling student requestsResponsible for regular monitoring of assessment quality and the quality of work of examinersResponsible for advising the general EB on key documents like the assessmentpolicy, plan, and manual with a specific eye on the practical details
6.	Examiners (appointed for this function by the EB)	Responsible for the quality of the assessments conducted
7.	Assessors	Responsible for making and contributing assessment questions to an examination

What was done and how – In 2014, the Director of VUmc School of Medical Sciences appointed policy advisors to restructure the EB and invested in training the people involved in assessments. This was set up as a project with a time plan and specific intermediate and end outcomes. One important activity was clarifying the roles and responsibilities of the stakeholders, laid down by the Higher Education and Research Act (Wet op de Hoger Onderwijs en Wetenschappelijke Onderzoek (Articles 7.12, 7.13 and 7.14 2018). This brought transparency in the expectations of stakeholders (the Program Directors, EB, assessment experts, and examiners), the work distribution and performance. The EB was split into two hierarchical bodies, the General EB, which looked after the policy and overall strategy issues, and the Executive EB, which looked into daily issues like the above-mentioned student requests and complaints, and monitoring of the quality of assessments. The General EB was set up to oversee the functioning of the Executive EB. This hierarchical structure worked in a complementary way because the two bodies had distinct roles and responsibilities, and this arrangement allowed for a strategic (high level) as well as a day to day (hands-on) overview and control on the quality of assessments. The first intervention for handling student requests was the introduction of an online submission portal. Every applicant had to choose the category for his/her request, submit the required documents and cite the article in the Higher Education and Research Act pertaining to the request. Any request outside of the provided categories was outside the scope of the EB. The support staff of the EB made an inventory of the types of student requests. The Executive EB set up a system for separating these requests into two categories, those which could be handled at the secretarial level and those which needed to be discussed in the Executive EB meetings. The Executive EB made protocols for the requests that could be handled at the secretarial level. Time saved because of all these interventions was deployed every quarter by the Executive EB toward monitoring every type of assessment that was used in the Bachelor and Master programs. This helped in early detection of problems and patterns related to the type of assessment used or the quality of the examiners for the particular assessment. Examiners with repeated problematic assessments were identified, addressed and received special training. The General EB handled strategic issues involving the type of assessments used and how they fit in with the curricular objectives, created standards for the appointment of examiners, organized training days for examiners, and conducted sampling of end products of the Bachelor (e.g. Bachelor thesis) and Master programs (e.g. the research internship performance). Through sampling, recommendations were provided to the Bachelor and Master Program Directors for improvement of the assessments. The Program Directors then implemented these suggested changes.

Evaluation of the reform – In 2017, we found that the workload of the EB had more than halved (student requests =364); the quality of assessments had improved and was being professionally monitored; problem-signaling happened well in time, and both short-term and long-term changes were actualized. Collaboration between the Program Directors, policy advisors, and the EB was key in making this a success.

The lessons learned in relation to the development described

The authors believe that the reforms at VUmc were successful on the basis of the “good” evaluation that was received from the Review Committee appointed by the NVAO in 2017. In their report, the Review Committee specified that the end qualifications of the Bachelor and Master programs, and the way the competency-based curriculum had been rolled out was done very well. This report also said that VUmc has defined a clear and unique profile of its students, which is, “confident, reflective, and competent doctors with empathy and an open mind towards the society/community”.

The Minor elective semester was much appreciated by the Review Committee in their report as strengthening not only the scientific development of the students but also the whole third Bachelor year. The mobile learning initiative was quoted to be a great innovation. The Report also stated that: (1) the quality of assessments was good and based on clear learning objectives, (2) the quality of assessments was being monitored diligently, and (3) the way of working ensured good quality of assessments. Thus, collaborative working between the Program Directors, Policy Advisors, and EB was crucial in improving and safeguarding the quality of assessments.

Through the student engagement in teaching initiatives, we believe that the students develop their competencies in the discipline they teach and also leadership qualities. The students who find teaching interesting gave feedback that they value the opportunities they get for this from the Bachelor and Master programs.

In all the curricular reforms, the one thing that became clear to us was that major reforms take time to be implemented and they need to be followed by a change in the way of thinking, and enculturation of the activity. Though we introduced autonomy in student learning in 2005, students started grasping and living this concept only from 2010. It took even more time for faculty to adjust to the small group teaching concept. In our research, we found that the perception of teaching and learning of faculty was still more teacher-centered than student-centered, even after 10 years of curricular change to small group teaching (Jacobs et al. 2014). The second important lesson we learned is that it is important for a medical school to refresh its vision from time to time and align to the changing societal context, e.g. the elderly population in the Netherlands is increasing which creates a need to train students to work in interprofessional teams and understand and treat multiple morbidities through rational drug prescribing. To address needs, such as this, yearly educational vision meetings, involving members of the management, teachers, clinical supervisors, students, policy advisors, etc. are arranged. This not only helps in refreshing the vision in a timely manner but also in its becoming a shared vision, which is generated in a bottom-up rather than top-down fashion.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Rashmi A. Kusurkar

Rashmi A. Kusurkar, MD, PhD, is Associate Professor and Head of the Department of Research in Education at VUmc School of Medical Sciences, Amsterdam.

Hester E. Daelmans

Hester E. Daelmans, MD, PhD, is Head of the Department of Skills Training and Program Director of the Master of Medicine at VUmc School of Medical Sciences, Amsterdam.

Anton Horrevoets

Anton Horrevoets, PhD, is Professor and Chair of Medical Biochemistry at the Department of Molecular Cell Biology and Immunology, and Program Director of the Bachelor of Medicine at VUmc School of Medical Sciences, Amsterdam.

Marian de Haan

Marian de Haan, MSc, is Head of the Department of Policy, Quality, and Innovation at VUmc School of Medical Sciences, Amsterdam.

Margreeth van der Meijde

Margreeth van der Meijde, MBA, is Vice-Dean of Education and Training at VUmc and Director of the Institute of Education and Training.

Gerda Croiset

Gerda Croiset, MD, PhD, was Professor of Medical Education and Director of VUmc School of Medical Sciences, Amsterdam, when this article was written.