in february 2007 , the board and the assembly of deans of medical schools of the dutch federation of university medical centres decided to institute a project group to revise the 2001 medical education blueprint . the main reasons for undertaking this project were developments in medical scientific disciplines , such as biotechnology and genetics , and developments in medical education , such as the introduction of the bachelor - master structure and the ongoing modernization of postgraduate speciality training programmes . in revising the 2001 blueprint the project group was specifically asked to establish the attainment levels of both the bachelor and the master programme in medicine , to consider whether the canmeds   model or a similar competency profile could also be serviceable in revising the new framework for medical education and to reconsider the level of detail of the revised 2001 blueprint , aiming to find formulations that are realistic and testable and that facilitate external accountability for programme content . framework was thought to reflect bettter the nature of the document ) . on august 12 , 2009 , the 2009 framework for undergraduate medical education in the netherlands was presented to the dutch minister for health . a translation in english is available from the website of the dutch federation of university medical centres ( http://www.nfu.nl/fileadmin/documents/raamplan2009engelstalige_versie.pdf ) . the 2009 framework consists of nine chapters : introductionexplanationdevelopments in dutch and european legislationstages , cycles and levels in medical education in the netherlandsmaster s degree programme in medicine : target profilemaster s degree programme in medicine : competenciesmaster s degree programme in medicine : issues relating to illness and healthbachelor s degree programme in medicine : profile and learning outcomesbasic sciences in the medical curriculum developments in dutch and european legislation stages , cycles and levels in medical education in the netherlands master s degree programme in medicine : target profile master s degree programme in medicine : competencies master s degree programme in medicine : issues relating to illness and health bachelor s degree programme in medicine : profile and learning outcomes basic sciences in the medical curriculum in an appendix the final document also includes a skills list . in 2002 , the bachelor - master structure was introduced in the dutch system for higher education , establishing bachelor s degree and master s degree programmes as independent study programmes . this change followed in the wake of the signing of the bologna declaration in 1999 . this declaration , signed by 29 european countries , aims to promote greater overall convergence in higher education in europe , based on a two - cycle degree structure . in the transitional period , permission to use the protected title of physician and qualification to perform certain actions reserved for physicians are linked to registration in the individual health care professions act register . registration is only open to those who have completed the degree programme in medicine and therefore to those who , following the introduction of the bachelor - master structure , have obtained the master of science ( msc ) degree on completion of the master s degree programme in medicine . the project group decided to define students learning outcomes upon completion of the master s degree programme in terms of competencies . a competency is defined as the ability to adequately perform a professional activity in a specific , authentic context , using an integrated body of knowledge , understanding , skills and professional behaviour . after careful consideration , the canmeds model was chosen , because , firstly , this model involves an excellent and useful division into physicians roles and competencies in a variety of professional situations , and secondly , this model is also used in the framework of the modernization of postgraduate specialty training . together , the seven roles or competency domains in the canmeds model constitute the target profile in chapter 5 of the 2009 framework ( see table 1 ( tab . the profile is elaborated in terms of key competencies and their constituent sub - competencies . as the project group felt that bachelor students in medicine do not yet operate in an authentic professional setting , the bachelor s degree programme is described in terms of knowledge , skills , and behaviour and not competencies . knowledge and understanding relate to the basic sciences , the foundation of medicine in the natural sciences , and aspects of behavioural and social sciences . the 2001 blueprint included a list of clinical conditions which comprised about 330 clinical conditions in all . issues relating to illness and health was more appropriate to the wide - ranging field in which today s physicians are operating , as a fair share of physicians work is not directly patient or disease related . the list of issues described in chapter 7 has been subdivided into several categories . the first and most voluminous one comprises the complaints that induce patients to consult their physician . the next two , smaller , categories deal with findings upon physical and additional examinations . the introduction of a list of issues meant that the list of clinical conditions that was included in the 2001 blueprint was not to return in the 2009 framework : on the one hand , the contemplation of each issue would involve a series of clinical presentations anyway , and , on the other hand , a list of clinical conditions would require ceaseless maintenance in the wake of ongoing developments in medical disciplines . in the 1994 blueprint and the 2001 blueprint , the project group felt that the aspect of required knowledge had been somewhat eclipsed by lists of problems , clinical conditions and skills . right from the start , the project group wished to give the basic sciences a more prominent place in medical education . the model of competencies selected by the project group also carried the risk of outlining required knowledge only implicitly . therefore , in the 2009 framework , a separate chapter is devoted to basic sciences in the medical curriculum dealing with both the foundation of medicine in the natural sciences and aspects of the behavioural and social sciences . spot - checking at the eight dutch medical faculties showed that all medical faculties still used this list , sometimes with minor adjustments . after discussion in the project group , the skills list from the previous blueprint , with minor adjustments , was added to the appendices to the 2009 framework . the project group was asked to pay special attention to finding formulations that are realistic and testable and that allow external accountability for medical education programme content . this prompted the project group to clearly define the competencies in terms of levels that are to be attained . medical education in the netherlands involves a training sequence with two stages that medical students pass through in succession . the first stage of this training sequence comprises two cycles : a three - year bachelor s degree programme in medicine , followed by a three - year master s degree programme in medicine . in the second stage of the training sequence , following upon completion of the bachelor and master programmes , medical graduates undertake postgraduate specialist training to become medical specialists in primary or secondary healthcare . having completed that stage , medical practitioners then engage in lifelong learning activities both in practice and in formal continuing education courses . the levels linked to the successive stages can be called starter level , beginning practitioner level and experienced practitioner level . after completion of their bachelor programme in medicine , medical students can be characterized as starters . these students have mastered a basic body of knowledge and understanding of scientific disciplines that are relevant to their subsequent professional practice . they have also acquired a set of basic skills and are able to show appropriate professional behaviour in training - related situations . they are able to apply knowledge , skills and behaviour in dealing with issues that involve a relatively low level of complexity . after completion of the master programme in medicine , medical graduates can be characterized as beginning practitioners . newly graduated physicians demonstrate a basic competence in practice , possess an integrated body of knowledge , skills and professional behaviour and can handle issues involving higher levels of complexity . medical graduates are capable of performing independent consultations but only perform these under supervision during postgraduate medical training . after a number of subsequent years of further schooling , training and experience in medical specialist training in the discipline of their choice , physicians operate independently without supervision . an element of independent practice is participation in interprofessional coaching activities and lifelong continuing - education courses . in the 2009 framework , the levels of proficiency to be achieved in the bachelor and master programmes in medicine are defined in a five - level structure ( see table 2 ( tab . the project group also had to consider the level of difficulty of the issues that are presented to students . on the one hand , these are medical factors , such as typical and atypical presentations or co - morbidity problems ; on the other hand , these are contextual factors from the psychosocial model . the level of difficulty is then codetermined by the availability of standard solutions to a problem and the applicability of protocols and guidelines . the level of difficulty also lies in the degree to which different physician roles must be integrated in dealing with the issue in question . graduates in medicine must be able to handle issues involving varying - including higher - levels of difficulty , with the proviso that the degree of required supervision increases with the degree of difficulty of the case presented . in this respect , there is one sub - competency incorporated in the role of medical expert that is of particular importance : students ability to recognize and name the personal limits to their knowledge and skills and to decide in time if , and , if so , when a third party needs to be called in , including their supervisor . the 2009 framework states that graduates in medicine must have mastered all issues related to illness and health that are included in the list at least at level ii . some of the issues , depending on the specifics of individual training programmes , will be included in additional competency testing at higher levels . the formulations of sub - competencies specify the levels ( iii , iv , or v ) that have to be attained . to illustrate the assignment of levels some examples are given in table 3 ( tab . major changes are the definition of competencies , the indication of the levels of competency to be attained and the introduction of a list of issues related to health and disease . the 2009 framework will be used as the basis for accreditation and for a revision of the legislation that outlines the educational requirements of physicians . laan , md phd , is professor of rheumatology and medical education , radboud university medical centre , institute for medical education , nijmegen , the netherlands.r.r.m . leunissen , msc , is senior staff member , radboud university medical centre , institute for medical education , nijmegen , the netherlands.c.l.a . van herwaarden , md phd , is professor of pulmonology and former dean of the radboud university medical centre , nijmegen , the netherlands . laan , md phd , is professor of rheumatology and medical education , radboud university medical centre , institute for medical education , nijmegen , the netherlands . leunissen , msc , is senior staff member , radboud university medical centre , institute for medical education , nijmegen , the netherlands . van herwaarden , md phd , is professor of pulmonology and former dean of the radboud university medical centre , nijmegen , the netherlands .
the 2009 framework defines the joint dutch national learning outcomes to be attained by medical students after completing their three - year master programme in medicine . 
 the framework thus helps to guarantee to society at large and to patients in particular that medical graduates who are starting out as practitioners have attained a certain professional level . 
 this level is the aggregate of the physicians target profile , physicians ( sub- ) competencies to be achieved and the list of issues relating to illness and health . 
 in addition , the framework also defines the profile of the bachelor and the learning outcomes of the bachelor programme in medicine .