sou · H1B315 · 2013-03-12 00:00:00 — Detta systemperspektiv på läkarutbildningen sam- manfattas i Figur 2 ovan och är centralt för våra förslag. Goda examinationsformer, kontinuerlig bedömning av stu- denternas prestationer och fortlöpande återkoppling ger, enligt utredningen, trygghet åt de studerande i deras kommande yrkes- roll. Utredningen ser att samverkan mellan universiteten och landstingen är nödvändig för att skapa förutsättningar för detta. Om lärande i vården och introduktion i yrket Det är nödvändigt att se läkarutbildning som ett livslångt lärande på läkarprogrammet till slutet av den yrkesverksamma perioden. Förutsättningarna för studenternas lärande i vården behöver stärkas, och vi förslår att sjukvårdshuvudmännens medverkan i medicinsk utbildning tydliggörs i hälso-och sjukvårdslagen (HSL). De olika faserna i det livslånga lärandet bör planeras så att de bygger vidare på varandra. Detta, menar vi, är särskilt angeläget för den efter legitimation. Den framtida läkarrollen påverkas även av ökande global rörlighet hos patienter, befolkning och hälso- och sjukvårdspersonal. Med en genomtänkt och individ- anpassad introduktion i sjukvården förbättras patientsäkerheten och kvaliteten i vården. Detta gäller inte minst den stora gruppen läkare med utländsk examen och svensk legitimation. är det viktigt att framhålla att introduktionen också behöver ses som en möjlighet för lärande i vården, genom kunskap från dem som genomgått utbildningen i och från läkare med erfarenhet från vårdverksamheter i andra länder. Sjukvårdshuvudmännen, , lärosätena och de profes- sionella organisationerna bör gemensamt ta ställning till hur introduktion till arbete i hälso- och sjukvården kan utvecklas och utformas. Vi menar att det är angeläget att introduktionen är flexibel och kan anpassas utifrån den enskilda läkarens tidigare kunskaper, erfarenheter och behov. Lärande i vården är centralt, och ytterst är det verksam- hetschefens ansvar att den aktuella arbetsplatsen utvecklas till en god lärandemiljö. Delaktighet, kompetensutveckling och ett enga- gerat ledarskap utgör hörnpelare för att skapa en lärandemiljö på en arbetsplats. visar erfarenheter att lärandet inom hälso- och sjukvården inte är enkelt. I det vardagliga arbetet kan det vara svårt att prioritera tid till reflektion i syfte förändra och förbättra. Förslagen om förändrad omfattning av läkarexamen och anpassade krav för legitimation, i kombination med de nya målen, ställer krav på intensifierat utvecklingsarbete inom de universitet som har tillstånd att utfärda läkarexamen. Det kan handla om bland annat förändringar av kursplaner, utvecklade examinationsmetoder samt fortlöpande omvärldsanalys i nära samverkan med företrädare för hälso- och sjukvården. Ett såväl nationellt som globalt perspektiv är i detta sammanhang angeläget. Utmaningen ligger i att enas om vad som bör prioriteras för den blivande läkaren, och att fokusera på lärande med inriktning på kompetens, förståelse och sammanhang. Vi menar att staten bör stödja införandet av den nya läkar- utbildningen, och föreslår att regeringen tillsätter en samrådsgrupp som får till uppgift att ta fram en strategi med syfte att främja samverkan mellan lärosäten, landsting och andra intressenter. Våra förslag är inriktade på att skapa en läkarutbildning som bättre stämmer överens med hälso- och sjukvårdens, den medicinska forskningens och kunskapssamhällets framtida behov. De nya målen för läkarexamen med ökad betoning på centrala profes- sionella kompetenser och kunskap om kvalitets- och patientsäker- hetsarbete, bör bidra till en säkrare och mer effektiv hälso- och sjukvård. Även de ökade förutsättningarna för en snabbare väg till specialistläkare bör kunna vara kostnadsbesparande för staten och samhället. Den nya utbildningen kommer att ha en rad fördelaktiga konse- kvenser för såväl patienterna som för sjukvårdshuvudmännen. De nya målen lyfter fram kommunikativ förmåga, vetenskapligt för- hållningsätt och kunskap om patientsäkerhet och kvalitet i hälso- och sjukvården. Med lärosätenas ansvar för utbildningen fram till examen och legitimation ökar förutsättningarna för en vetenskapligt förankrad utbildning av hög kvalitet, hela vägen fram till behörighet för yrket. Förslagen förutsätter att samverkansformerna mellan hälso- och sjukvård och lärosäten utvecklas och intensifieras. Vi menar också att det är angeläget att den handledarkompetens som finns inom sjukvården tas till vara när nya arenor för stu- denternas lärande utvecklas. Utredningens förslag innebär att landstingens skyldighet att tillhandahålla tjänster för AT upphör. Inledningsvis kan förslagen få vissa konsekvenser inom de verksamheter där AT-läkarna utgjort en viktig resurs. De blivande läkarnas rättssäkerhet har varit en viktig utgångspunkt för arbetet. Utan krav på allmäntjänstgöring efter examen kommer studenterna att i högre grad än kunna förutsäga när de kan erhålla legitimation. Förslaget innebär att kraven för läkarexamen ökar i omfattning men att den sammanlagda tiden fram till legiti- mation minskar. Utredningen bedömer att förslaget uppfyller minimikraven för läkarutbildning i det s.k. yrkeskvalifikationsdirektivet (Europa- parlamentets och rådets direktiv /36/EG av om erkännande av yrkeskvalifikationer). utbild- ning och legitimation kan därmed en svensk läkare påbörja speci- aliseringstjänstgöring i ett annat land inom EU/EES. Detta medför att läkare med svensk examen får likvärdiga förutsättningar till en internationell karriär, jämfört med studenter inom de flesta andra EU/EES-länder och på flera andra håll i världen. För en läkarstudent som följer den normala studiegången och har fullt studiemedel kommer skuldsättningen att öka något. Vi bedömer att förslagen endast i liten utsträckning påverkar läkar- studenternas ekonomiska trygghet vid sjukdom och arbetslöshet, jämfört med . The Inquiry on Education in proposes the fol- lowing changes in education: That the degree of of Science in Medicine (MSc Medi- cine) be extended by one term to include six years of study (360 higher education credits) and that for the degree, the student must demonstrate the knowledge and skills required for full registration as a doctor of medicine (MD). That should form the basis of the licence to practise without a period of further mandatory practical service and that the system with the internship after the degree is to be abolished. A new qualification descriptor that more extensively than previ- ously emphasises scientific and professional skills and the ca- pacity for decision-making. The proposals create the conditions for a coherent programme with a clear scientific basis and well-considered progression; i.e., where knowledge and clinical skills are continually broadened and deepened. In 2011, The Swedish Government appointed a one-man inquiry on the renewal of education in . According to its terms of reference, the scope for review is all education and training preceding the licence to practise. To qualify for a licence to practise, doctors must currently (2013) complete a mandatory internship (allmäntjänstgöring /AT) following their degree. Promoting health in the future – new education We have chosen to give the report the title Promoting health - education for the future. By highlighting the concept of health, we want to draw atten- tion to the overarching objective of education for practising doc- tors of medicine. education must be a scientifically-based professional education that trains students professionalism, while simultaneously stimulating their interest in research and the future development of the health and services. The Inquiry stresses the importance of an understanding of the condi- tions in society that affect the health of individuals and different groups, from both a national and a global perspective. We consider that the future role of the doctor will include a greater focus on health-promotion and illness-prevention efforts in collaboration with other actors. The Inquiry takes social responsibility by adopting societys long-term needs as its point of departure and emphasises the importance of a systems perspective on education and the future role of the doctor. Its proposals are strongly based on international developments in education within health care and medicine. Tomorrows doctors must be able to work and undertake research both in and in other coun- tries. The proposals are also clearly linked to other phases in the life-long learning of doctors. The title of the report relates to our points of departure in working with the Inquiry. These have comprised the national ob- jectives in the legislation for the health and services, for public health policy and for higher education. This has meant that we have given priority to: the patient and citizen perspective, with a focus on health, and good care, the student perspective, with a focus on education of a high quality. We have also been influenced by international developments in health and care systems and education. The Inquirys analysis of the present situation We have made an effort to throw light on todays situation, both with regard to developments within the health and services and the various stages leading to the licence to practise. Back- ground material has been collected from several areas, including material regarding the historical development of the doctors role and education, and conditions affecting students learning within the various sectors of the health and services. Valu- able viewpoints and information have been gained from the agen- cies, organisations and interest groups that the Inquiry has con- sulted. Based on an analysis of the present situation, the Inquiry finds that: education needs to be more clearly based on future global needs in health and services, research and the overall knowledge society, in order to promote students learning, the path towards the licence to practise medicine needs to be more extensively char- acterised by progression and the integration of basic sciences and clinical sciences, it is important that the health and services prioritise learning and the scientific basis of their activities. Health and services have undergone considerable changes since education was last the object of central government review. These include demographic developments, the disease pan- orama and the organisation of health and services in com- bination with an increasingly rapid growth in knowledge. Univer- sities and other higher education institutions (HEIs) have also undergone major reforms and HEIs now have more scope than previously to govern the way in which their activities are to be shaped. Learning outcomes for and thus for programmes need to be more clearly based on the needs of the health and services, research and the knowledge society as a whole. Cooperation and communica- tion between HEIs and the health care sector need to be strength- ened to be able to deal with future common challenges, such as those relating to course learning outcomes and examinations. Progression is of key importance in all education. In the struc- ture of todays education, with the requirement of at least 18 months of internship after the of Science degree, there is a risk that important training in key skills is postponed and does not clearly build on the knowledge and skills that the student ac- quired before gaining the degree. The long period of internship after the degree has been considered to be valuable in many ways, but standards across the country appear to have been uneven and the link between the objectives of cine and those of internship is unclear. We believe that internship has become redundant and give several reasons for this in the report. Six years for a degree and licence to practise The Inquiry proposes that in- clude a total of six years of study (360 higher education credits) and that for the degree, the student must demonstrate the knowledge and skills required for full registration as a doctor of medicine. The Inquiry therefore proposes new learning outcomes in the qualification descriptor. We also propose that provide the basis for the licence to practise, without requiring further training stages or practical service after the degree. As a consequence of this, the Inquirys proposals in- clude phasing out the current structure for internship after the degree. This means that the HEIs that are authorised to award will be responsible for students having the skills required to be able to independently exercise their profession when they gain their degrees. Apart from the specific learning outcomes for , the stu- dent must also achieve the learning outcomes of the Higher Edu- cation Act pertaining to education at the second level. education must be planned and implemented with a fo- cus on the skills that a student must have achieved when awarded the degree and a licence to practise. We therefore believe that basic sciences and clinical sciences must be more extensively integrated to promote the progression of students learning, i.e. a gradual in- crease in the degree of difficulty in the training of their clinical skills. The following principles of particular importance for modern education were identified at an early stage of the Inquirys work: progression throughout the entire programme with a clear sys- tems perspective and focus on learning results, integration of basic sciences, clinical sciences and the training of clinical skills throughout the entire programme, a focus on professional development, a scientific approach, interprofessional teamwork and the ability to participate in im- provement efforts, the taking of social responsibility, marked by a global perspective, student-activating learning methods, examinations in order to document the professional skills ac- quired and continual formative evaluation, in order to enable each student to achieve his or her individual development po- tential, long consecutive periods of integrated clinical learning to enable training of professional skills, opportunities for more extensive and in-depth studies on an individual basis. The higher education institutions are responsible for, and are free to govern the design of the educational process. The way in which the programme is planned is, however, of great importance for students' ability to have achieved the expected learning outcomes when they are awarded their degrees. This, we believe, means that clinical training should be introduced at an early stage in the pro- gramme and be seriously integrated into the theoretical parts of the programme. The parts of the programme that comprise integrated clinical training will be crucial for quality, in combination with the use of scientifically-based assessment and examination methods. All parts of the integrated clinical training are to be included in courses, with clear learning outcomes and examinations that pro- vide students with feedback on their professional development. One consequence of the proposal is that the requirement for in- ternship after the degree will cease to apply. The entire process towards a prospective doctors full registration will be integrated into the HEIs system for quality follow-up and responsibility for quality will thus become clearer. With this proposal, we place par- ticular emphasis on decision-making and the training of The Inquiry stresses the importance of enabling the skills and experience built up in connection with the internship system to be made use of to benefit county councils and universi- ties in the new education. Cooperation on the development of good arenas for integrated clinical training will be necessary. Other alternatives that were considered We have considered some possible alternative models for the pro- cess leading to licence to practise. Two of these are: maintaining the present structure with the requirement for internship after the degree, but taking measures to ensure quality, a six-year education as a requirement for a licence to practise according to the principles of the Inquirys main pro- posals but specifically allocating the final year for clinical train- ing in different sectors of the health and services. The Inquirys overall assessment is that these alternative modules lead to improvements in certain respects, but do not create the conditions for change that are necessary for an appropriate and fully quality-assured education. We argue that some of the most important principles for education that is adapted to the needs of the health and services in the future, are based on clear progression. Responsibility and the level of difficulty of the prospective doctors training must increase successively in order to promote their learning. By making the HEIs responsible for the quality of education up until the higher education qualification and the licence to practise, the entire process leading up to the full registration as a doctor of medicine is covered by the HEIs requirements for a scientific basis. This, in turn, provides better conditions for well-considered progression. New learning outcomes with the emphasis on professional skills and a scientific basis The Inquiry proposes several new or modified learning outcomes for education. The emphasis lies on core professional skills, such as the ability to communicate, social responsibility, capacity for cooperation and the ability to participate in research and development work. A global perspective and a health-promot- ing approach are other aspects that have been highlighted. The aim of the new qualification descriptor is, on the one hand, to highlight relevant professional skills and on the other, to relate more clearly to the objectives for good care. The proposal contains more learning outcomes than previously, which the Inquiry con- siders may be able to facilitate both the design of education programmes, examinations and future external quality control. The content of education programmes at the detailed level must be kept up-to date and be continually renewed, reviewed and developed. It is thus not appropriate, for a sustainable edu- cation, to propose learning outcomes in the qualification descriptor that are at such a detailed level that they risk rapidly becoming out of date. We therefore propose that the HEIs, in cooperation with each other and together with representatives of the health and services, and the professional organisations describe the learning outcomes at a more detailed level and that they regularly review them. Likewise, we want to encourage cooperation on the development of exami- nation formats and examination tasks. Since the Inquirys proposals mean that will form the basis of the licence to practise issued by and thus of the full registra- tion, several of the new learning outcomes in the qualification de- scriptor focus on decision-making. Some examples of these learning outcomes for the degree of of Science in Medicine are that the student shall demon- : a deeper capacity for professional conduct and approach vis-à- vis patients and their close relatives, with respect for the pa- tients integrity, needs, knowledge and experience, the ability to independently diagnose and initiate treatment of acute, life-threatening conditions, a deeper capacity, from a pathophysiological and psychosocial perspective, to independently diagnose the most common ill- nesses and together with the patient, deal with these, the capacity for leadership and interprofessional cooperation, both within the and health services and with professions from other sectors of society, the ability to initiate, take part in and implement improvement efforts and show the skills that are required to participate in re- search and development work. The proposal for a new qualification descriptor also aims at facili- tating future national quality evaluations. Teaching and learning in the various sectors of the and health services Developments in health and services, with a reduction in the number of hospital beds, an increasingly ageing population, and greater demands for quality and patient safety entail challenges for the parts of education programmes that are based in the health and services. Primary and emergency care services are therefore increasingly important arenas for students training to achieve many of the most core learning outcomes in the qualifica- tion descriptor and for the development of their clinical skills. There is also a trend in different parts of the country towards the increasing use of the front line of the health care system in con- nection with teaching and learning in these services. The Inquiry recommends longer, continuous periods of inte- grated clinical training in order to clearly give priority to clinical training and assessments of the students professional skills, and ability to cooperate with other professional groups in the health and services. Longer periods of training in clinical skills in the health and services will also enable an interest in clinical research and development work to be encouraged and made use of. Health and services that offer good conditions for students learning may affect the choice of their future vocational orientation and specialised service. Continual assessments of students' development Our proposal means that, when taking their degree, students must demonstrate the knowledge and skills required for full registration as a doctor. The HEIs will thus be responsible for ensuring that students achieve such a level of independence that the degree can form the basis of the issue by of licences to practise. We therefore stress that the use of different types of examination should be developed, particularly for the assessment of students skills in clinical decision-making and other professional competence, such as conduct and approach to- wards patients, and communication. The knowledge and skills that a newly licensed doctor needs must constitute the minimum level for what a student is expected to have demonstrated when awarded his or her degree. With this proposal, we also want to encourage a development towards en- suring that the education will give every student the chance to achieve his or her individual potential. Källa: Commission, 2010. Teaching and types of examination must be based on the expected learning outcomes of students, i.e., what a student must know when being examined, rather than on a traditionally subject-based structure. The learning environment that is to support the stu- dents efforts to achieve the necessary learning outcomes should be determined by the needs of society, the expected skills of the li- censed doctor and by the format of examination. This systems perspective of education is summarised in Figure 2 above, and is of key importance for our proposals. According to the Inquiry, good examination methods, continual assessments of students performance and regular feedback will provide security for students in their future professional role. The Inquiry regards cooperation between the universities and county councils as necessary in creating the conditions for this. On learning in the health and services and introduction to the profession It is important to regard education as life-long learning from the first day of studies until the end of professional life. The conditions for students learning in the health and services need to be strengthened, and we propose that the partici- pation in education programmes of the principals of health and services be clearly stipulated in the Health and Act. The different phases of life-long learning should be planned so that they build further on each other. This, we believe, is particu- larly important for the first period after the doctor has gained a licence to practise. The future role as a doctor is also affected by the increasing global mobility of patients, populations and health and services staff.