1.1 The first edition of The Catalogue
The need to establish a Swiss Catalogue of Learning Objectives for Undergraduate Medical Training (henceforth “The Catalogue”) had arisen in the late nineteen-nineties in the course of the procedures to obtain international accreditation and mutual recognition of diplomas. Up until that date, there were only a few paragraphs of a federal law dating back to 1887 (since then amended only twice) to guide Swiss medical schools on the choice of learning objectives. In the year 2000 the Joint Commission of the Swiss Medical Schools (SMIFK/CIMS) therefore entrusted a working group with the task of creating a catalogue of study objectives. Taking the Dutch “Blueprint 1994, the Training of Doctors” as starting point, this working group developed The Catalogue and in November 2001 presented it in electronic form to the SMIFK/CIMS, which decided to:
- introduce The Catalogue for a trial period of two years.
- issue a printed version
- make it available on the internet
- engage on a revision after two years
After being ratified by all five Swiss medical faculties, the SMIFK/CIMS in March 2002 declared The Catalogue as defining the contents of the final federal examination starting with the academic year 2003/04. To optimize its availability and to allow a flexible use e.g. by making possible searches for groups of objectives The Catalogue was published in a database format and with free access in the internet (www.smifk.ch). It was also made available in a PDF-format and in a print version.
1.2 The second edition of The Catalogue, its legal basis, and the definition of goals of undergraduate training
The new Federal Act of 23 June 2006 on University Medical Professions, which has become effective in September 2007, defines the goals of undergraduate, postgraduate and continuing education for university medical professions (articles 4, 6, 7, 8). Starting in the year 2011, a new Federal Exam at the end of the undergraduate period will ascertain that the candidates have reached the goals and objectives and are prepared to enter any of the approved postgraduate specialty training programs (article 14). An Ordinance on the Federal Examinations for University Medical Professions is in preparation. In addition to settling numerous details of the exam, the ordinance refers to The Catalogue as defining the scope of the examination.
The new law and ordinance will be important, since they confer a solid legal foundation to The Catalogue and define the level to be reached by the undergraduate training: The Federal Exam establishes that the graduate fulfils the conditions for entering any of the requested postgraduate programs. This implies indirectly that additional training under supervision must follow the Diploma, before medicine may be practiced independently. The Catalogue will also be an essential prerequisite for the accreditation of the curricula of the five Swiss medical faculties.
1.3 The reasons for a second edition of The Catalogue
In the four years of its use The Catalogue had well served its purpose to help students, teachers, curriculum planners and examiners. However, as one may expect, experience with the application of The Catalogue also uncovered weak points and provoked a number of criticisms (see section 1.4). This had been anticipated, and SMIFK/CIMS asked the Working Group in March 2002 to remain in charge to prepare a new edition in due time, taking into account the experience gained by the use of the first edition. In November 2003 SMIFK/CIMS approved of the Working Group’s plan for the revision of The Catalogue. To this purpose the Working Group held more than 30 formal meetings and numerous smaller meetings between 2004 and 2008.
1.4 Changes in the second edition
As for the first edition The Working Group was composed of a representative from each Swiss medical faculty, one representative from the Swiss Society of General Medicine, two representatives of the Federal Office of Public Health and one representative of the Institute of Medical Education.
As outlined below, The Working Group reviewed every chapter of the first edition of The Catalogue in order to address the criticisms that had been voiced.
1.4.1. Chapter 3 (“Profile of the Doctor”) and chapter 4 (“General Objectives”)
Criticisms arose from two sources, namely on one hand from specialists in medical ethics and on the other hand from politicians and the Federal Office of Public Health, which at that time was preparing new legislation (see above). They criticized that The Catalogue put too much weight on knowledge and skills and too little on social competence, attitudes, and ethical aspects. These criticisms were in large part due to the fact that users of The Catalogue tended to skip chapters 3 and 4, and to jump directly to the “Discipline Related Objectives” presented in tabular form. This was however furthered by the fact that the chapters 3 and 4 only made up 8 pages in total, whereas the “Discipline Related Objectives” constituted with 105 pages almost 70% of the whole Catalogue.
The Working Group took the criticisms seriously, and it decided to re-write the two chapters from scratch, defining the objectives in slightly more detailed and in operationalized form and combining them into one chapter, the new Chapter 3: “General Objectives”. Furthermore, SMIFK/CIMS offered two seats in the Working Group to the Swiss Federal Office of Public Health, which commissioned the Institute for Medical Education of the University of Bern to provide a text for this new chapter.
This text relies for a substantial part on the “CanMEDS 2005 Framework” and on the British “Curriculum for the foundation years in postgraduate education and training”, using also other similar frameworks for Outcome-Based Medical Education such as the “ACGME Outcome Project”, the „Global Minimum Essential Requirements” (GMER) of IIME and the “Project Professionalism” of ABIM. Ethical issues were included after several meetings and discussions with the “Specialized Panel on Medical Ethics” of the Swiss Academy of Medical Sciences.
1.4.2. Chapter 5 (“Problems as Starting Points for Training”)
The Working Group reviewed each of these objectives, but made only a few minor changes to this chapter. This is now Chapter 4.
1.4.3. Chapter 6 (“Explanation of Levels and Letters of Discipline-Related Objectives”)
The definitions of the levels were revised, especially the levels of the skills, and they were transferred to the new Chapter 2: “How to use this Catalogue”
1.4.4. Chapter 7 (“Discipline- Related Objectives”)
The listing of clinical objectives according to medical disciplines was criticized for
favoring sectorial over integrated clinical reasoning. The Working Group conceded that
grouping of objectives according to bodily regions or according to signs and symptoms
might foster integrated thinking. However, university hospitals are still organized
according to traditional disciplines, and the Working Group reasoned that a different
classification would render the organization of teaching more difficult; the classification
according to traditional disciplines was therefore left as it was. These lists of “Clinical
Pictures” and “Further Knowledge” now constitute the new Chapter 6.
Another criticism was that the Discipline- Related Objectives were too numerous.
All the Clinical Pictures were reviewed with the aim to reduce their number. The Wor- king Group achieved this in the following way:
- It submitted each Clinical Picture to six experienced physicians, two general practitioners (representing the faculty of the sections for general practice of the 5 Medical Faculties), two general surgeons and two general internists (heads of medium-sized teaching hospitals). These six physicians were asked to rate each Clinical Picture on a scale of 1 to 4 as to prevalence (or incidence) and criticality, high criticality meaning that a disease may be rare, but knowledge about it could be life saving.
- The average score of the six raters was calculated for every Clinical Picture.
- Clinical Pictures with a low ranking of both prevalence and criticality were deleted if a Specialty Panel of five university specialists in the corresponding discipline agreed (see section 1.7., list of specialty panel heads).
- If the panel disagreed with the deletion, the objective was left in place in most instances
In few instances new Clinical Pictures were added and obsolete nomenclature was corrected.
As a result of this approach the number of Clinical Pictures decreased from 1540 to 1330 (including quite a few Clinical Pictures mentioned twice or more times, in different disciplines, as before). Without these duplicates the total number of Clinical Pictures is now 1220.
All Skills were reviewed, regrouped, standardized and amended and then submitted to the responsible persons for teaching of skills in the five faculties. The Working Group made in particular the following changes:
- All skills which have to be actively performed by the student, thus corresponding to
the earlier levels 3 and 4, e.g. history taking, physical examination, were grouped
together in one single list and put into a new separate Chapter 5: “General Skills”.
Consequently only two (instead of four) performance levels were defined.
- Skills with the former level 1 or 2 (“only theory“ / “seen or have had demonstrated”), e.g. gastro- duodenoscopy, were relocated under “Further Knowledge”, since they implied no “hands-on” experience by the student.
These measures reduced the number of skills from 600 to 350 (all levels) or from 280 to 170 (former levels 3 and 4).
Radiology and Nuclear Medicine: The Working Group felt that the learning objectives covering general aspects of radiology, such as principles of imaging techniques, radioprotection, radiotherapy, should remain in The Catalogue, but that specific radiological pictures could be deleted, because they were part of the “Clinical Pictures”, analogous to data from clinical chemistry, pathology and microbiology.
Pharmacotherapy: The first edition of The Catalogue listed as objectives knowledge of individual drugs, as well as of principles of pharmacotherapy (pharmacokinetics etc.) Analogous to radiology, the Working Group considered individual drugs as being part of clinical pictures. The new version only contains general principles of pharmacotherapy.
The number of items under “Further Knowledge” was so reduced from 590 in the first edition (even with the addition of the former skills on level 1 and 2) to 460 in total and 430 without duplicates.
Reduction of number of items
The total number of items under Skills, Clinical Pictures and Further Knowledge was
reduced from 2730 to 1960 (including duplicates), a reduction by 30%.
Without duplicates the total number of “General Skills” (170), “Clinical Pictures” (1220) and “Further Knowledge” (430) now adds up to 1820.
The print version of the first edition of the catalogue contained an Alphabetical Index. The Working Group decided to do without it, since The Catalogue will be used in its PDF version or as a database, which allows for easy searching of any terms.
The chairman of the Working Group feels that the preparation of the second edition was more time consuming than that of the first edition. The requested reduction of the number of objectives, especially the “Clinical Pictures”, was particularly cumbersome, since criteria for deletion of objectives had to be defined. The rating of criticality and incidence finally was chosen as the most useful method. But despite this rating, some specialists objected strongly to any deletion in their specialty. Many specialists erroneously placed postgraduate objectives at the undergraduate level, ignoring that many objectives can and should be taught during postgraduate training, which in most specialties lasts almost as long or in some specialties even much longer than undergraduate training.
Even with a reduced load of objectives in the present catalogue, the knowledge and skills required from students remains enormous. It is the responsibility of the teachers and faculties that goals are set high, but not unrealistically so. Teachers in medicine should keep in mind that even such simple procedures as palpating the pedal pulses or eliciting an ankle reflex cannot be mastered within a few minutes.
1.6 Composition of the Working Group
During the work on the second edition of The Catalogue several members of the Working Group were exchanged. Two representatives from the Federal Office of Public Health joined the group.
|Chairman||H. Bürgi (Solothurn)||(2002 - 08)|
|Executive Secretary and representative of the Institute of Medical Education||B. Rindlisbacher||(2004 - 08)|
|Members and Institutions represented|
|University of Bern, Institute of Medical Education||R. Bloch
|(2002 – 04)
(2003 – 04)
|University of Geneva Faculty of Medicine||Ch. Bader|
|(2002 – 07)
(2007 – 08)
|University of Lausanne Faculty of Medicine||F. Bosman||(2002 – 08)|
|University of Bern Faculty of Medicine||V. Im Hof
A. E. Stuck
|(2002 – 06)
(2007 - 08)
|University of Basel Faculty of Medicine||H. Kaiser||(2002 – 08)|
|University of Zurich Faculty of Medicine||G. A. Spinas
|(2002 – 08)
(2003 - 08)
|Swiss Society of General Medicine||D. Lefebvre (Versoix)||(2003 – 08)|
|wiss Federal Office of Public Health||B. Sottas
|(2004 – 08)
(2004 - 08)
1.7 Heads of Specialty Panels for Discipline Related Objectives
The Specialty Panels were composed of five specialists in the corresponding discipline (one specialist from each of the five Swiss medical faculties), plus in some instances a specialist in private practice. The list of panelists was submitted for approval to the five deans, in order to assure that the panelists rightfully represented the given discipline in their faculty.
Dermatology: Prof. Renato Panizzon, MD, Lausanne
Ethics: Prof. Michel Vallotton, MD, Geneva, Prof. Lazare Benaroyo, MD, Lausanne
Forensic Medicine: Prof. Ulrich Zollinger, MD, Bern
General Practice: Danièle Lefebvre, MD, Versoix
Geriatrics (incorporated into Internal Medicine): Prof. Andreas Stuck, MD, Bern
Gynecology / Obstetrics: Prof. Wolfgang Holzgreve, MD and Eva Visca, MD, Basel
Infectiology (incorporated into Internal Medicine): Prof. Rainer Weber, MD, Zurich
Internal Medicine: Prof. Ulrich Bürgi, MD, Bern
Neurology (incorporated into Internal Medicine): Prof. Christian Walter Hess, MD, Bern
Ophthalmology: Prof. Beatrice Früh, MD, Bern
Otorhinolaryngology: Prof. Rudolf Häusler, MD, Bern
Pediatrics: Prof. Susanne Suter, MD, Geneva
Pharmacotherapy: Jules Desmeules, MD, Geneva
Pneumology (incorporated into Internal Medicine): Prof. Matthias Gugger, MD, Bern
Psychiatry: Prof. Werner Conrad Strik, MD, Bern
Public Health, Insurance- and Occupational Medicine: Prof. Matthias Egger, MD, and Nicole Bender, MD, Bern
Radiology and Nuclear Medicine: Prof. Borut Marincek, MD, Zurich
Rheumatology (incorporated into Internal Medicine): Prof. Peter Villiger, MD, Bern
Surgery: Prof. Daniel Candinas, MD and Stephan Vorburger, MD, MCR Bern
Skills: Peter Frey, MD, Bern
The first edition of The Catalogue relied heavily on the Dutch “Training of Doctors,
Blueprint 1994”, for which our Dutch Colleagues had waived the copyright in our favor. Much
of this material is still used in our second edition. The Working Group again wishes to
thank the authors of the Dutch Blueprint to let us rely on their pioneering work.
For the formulation of the “General Objectives” we relied mainly on the “CanMEDS 2005
Framework” and on the British “Curriculum for the foundation years in postgraduate
education and training”. We are grateful to the authors of these outstanding lists of
competencies that we were able to use their work.
The Working Group is extremely grateful that members from the Institute of Medical Education of the University of Bern (R. Bloch, P. Schläppi, B. Rindlisbacher) took over the onerous task to prepare the Power Point or Excel-Table projections for the meetings of the Working Group and to keep the electronic records of the changes that had been decided upon.
Mrs. S. Antonopoulos from the Institute of Medical Education succeeded Mrs. E. Walser for organizing the Working Group’s meetings and taking over the secretarial duties. Without this logistical support, The Catalogue could not have been finished in time. The final layout of The Catalogue was designed by Béatrice Boog from the Institute of Medical Education.