2010; 32: 316–318

The Bologna process, medical educationand integrated learning

ALLAN CUMMING

University of Edinburgh, UK

Abstract

The Bologna Declaration, signed in 1999 by all European Ministers of Education and currently in a phase of active implementation

in Europe, specifies a three-cycle degree structure – Bachelor’s, Master’s, Doctorate – for all disciplines in Higher Education. The

application of this model to medical education has been opposed on various grounds. In particular, a ‘Ba/Ma’ model for

undergraduate medical degrees has been viewed as undoing recent progress towards fully integrated learning of basic and clinical

medical sciences. However, this can be overcome by the use of a learning outcomes framework, agreed at European level, that

reinforces the primarily medical nature of both degrees and which requires integrated teaching, learning and assessment at every

stage. With this proviso, application of the Bologna principles to medicine can help to drive educational development and quality

enhancement in European medical education.

Introduction

The Bologna process is a European initiative to enhance the

quality of higher education in Europe, to promote conver-

gence and harmonisation of higher educational systems and

structures, and to create a European Higher Education Area by

2010 (European Commission 2009). The original Declaration

was signed in June 1999 by the Ministers of Education for 29

European member states, including the UK. There are five

primary action lines in the Bologna process. In brief, they

include:

. Creating a three-cycle system of higher education degree

qualifications, each of which would be necessary for

progression to the next level. These are described as

Bachelors, Masters and Doctorate degrees, with each

normally equating to two or three years of study.

The ‘Dublin Descriptors’ are a set of generic statements

describing the level of academic achievement appropriate

to each cycle, agreed at a conference of the Joint

Quality Initiative in Dublin in 2004 ( Joint Quality Initiative

2004).

. A framework for qualifications describing the typical

learning outcomes for each cycle and discipline (Tuning

Project 2004).

. A European credit transfer system (ECTS).

. A common format for characterising and documenting

degree qualifications (the Diploma Supplement).

. Developing European quality assurance standards for

higher education.

The European Ministers for Higher Education continue to meet

every 2 years to monitor and promote the Bologna process,

and there are now 45 signatories to the Declaration. The UK

has recently been the official lead country for promoting the

Bologna process, and a European Bologna Process Summit

meeting was held in London in May 2007.

Implementation of the Bologna principles across Europe is

highly variable. Some countries, such as Belgium, have fully

adopted these systems, and now declare their Higher

Education provision to be ‘Bologna compliant’. In other

countries, including the UK, little has been done actively to

align with Bologna principles. It should be noted that for many

subject areas, higher education in the UK is already to some

extent compatible with the three-cycle model. Major excep-

tions to this include professional degree qualifications, such as

medicine, veterinary medicine and dentistry. In the UK, and in

most European countries, a primary medical degree qualifica-

tion is awarded after 5 or 6 years of study, and is usually at the

level of an ordinary Bachelor’s degree. A minority of graduates

go on to complete degrees at Masters or Doctoral level.

The Bologna Declaration andmedical education

The application of Bologna principles to medical education in

Europe has become a controversial topic, with strongly held

polarised views. For example, the World Federation of Medical

Education and the Association for Medical Education in Europe

published a position statement in 2005 opposing the applica-

tion of a two-cycle model to primary medical degrees

(Christensen 2004; WFME/AMEE 2005). However, some

countries have implemented the three-cycle model for med-

icine with no apparent difficulty. Medical students are awarded

a Bachelors degree in Medicine after three years and a Masters

degree in Medicine after a further two or three years of study.

Third cycle is taken to represent an additional research-based

degree qualification equivalent to an MD or PhD.

Correspondence: Allan Cumming, College of Medicine and Veterinary Medicine, Queens Medical Research Institute, University of Edinburgh, Little

France Crescent, Edinburgh, Lothian, EH16 4TJ, UK. Tel: 0131 242 9311; fax: 0131 242 9301; email: allanc@staffmail.ed.ac.uk

316 ISSN 0142–159X print/ISSN 1466–187X online/10/040316–3 � 2010 Informa Healthcare Ltd.

DOI: 10.3109/01421590903447716

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Three main arguments have been used to oppose the

application of the Bologna principles to medical degrees.

(1) Medical education is adequately served by institutional

and national standards and regulation; trans-

national procedures decreed by the European

Commission are unnecessary. This ignores the long

standing requirement under European law for mutual

cross recognition of medical degree qualifications, and

the requirement to consider all European medical

graduates on an equal basis for medical appointments

in any country. The ramifications of this legal require-

ment are more keenly felt in the UK than elsewhere in

Europe, because of the relative absence of language

barriers. Increasing number of applications from

European medical graduates through the UK MTAS

system for posts at Foundation and Specialist Training

level and recent concerns in the media about the

competence of migrating doctors, emphasise the sig-

nificance of this law. Protection offered by national

employment laws is legally questionable and difficult to

implement. Assessing the relative merits and ranking of

applicants for posts fairly in the current context of

‘un-harmonised’ medical degrees is extremely difficult.

These issues are by no means confined to the UK and

seem likely to represent an increasing problem across

Europe.

(2) The three-cycle model would inevitably create a large

number of graduates with Bachelor’s degrees in

Medicine, whose employment prospects and place in

health care delivery systems would be unclear. The

counter argument is that the Bachelor’s degree in

Medicine would be the necessary prerequisite to

proceed to a Master’s degree in Medicine (at which

level graduates would be licensed to practise medi-

cine). It is therefore very difficult to envisage why such

graduates would not wish to progress to a Masters level

qualification. For the small number of students who

wished to terminate their medical studies after 3 years,

such an exit route is already commonly available

(usually entitled Bachelor’s in Medical Science) and can

be a useful lead into a number of health care related

employment areas. Clearly, the ratio of places on

medical Bachelor and Master’s degree programmes

would be relevant, and would require responsible

action and use of appropriate admission policies by

universities and medical schools. It may be that

‘capping’ the number of funded places in both

programmes at national level would be appropriate.

(3) The award of a Bachelors degree after three years of

medical study would be inevitably disintegrative. This

is the most commonly quoted argument against a three-

cycle model for medicine. It is claimed that it would

undo the massive progress towards integrated teaching,

learning and assessment that has happened in most

progressive European medical schools over the past 15

years. The spectre is raised of a return to the Flexnerian

model of 3 years of context-free basic science study,

followed by a sudden switch to clinical medicine.

Aspects of curriculum design, such as early clinical

contact and experience, learning the clinical relevance

of science teaching at the point of delivery, early

acquisition of basic clinical skills and a curriculum-level

focus on personal and professional development are all

said to be at risk.

One answer to such considerations lies in the principle of

outcomes-based education (Harden 2002). In the absence of

specified learning outcomes/competences for the Bachelor

and Master’s qualifications, it would certainly be open to

medical schools, should they wish it, to recreate a sequential,

two-block medical curriculum.1 This is illustrated in

Figure 1(a). Most authorities would regard this as a retrograde

step. However, if appropriately designed learning outcomes

for both the Bachelor and Master’s degree qualifications can be

agreed across Europe, then in fact the opposite may be the

case. For example, let us imagine that an agreed learning

outcome for the Bachelors degree was ‘be able to measure

blood pressure and interpret the findings’. This would require

that all medical schools include practical skills teaching in

blood pressure measurement, and consideration of associated

clinical factors, in the first three years of study. This would be a

positive development and a positive aid to integration for

many sectors of medical education in Europe, and is illustrated

in Figure 1(b).

The Tuning Project is a Higher Education sector-wide

initiative to develop learning outcomes/competences for

degree qualifications in Europe, linked to the qualifications

framework action line of the Bologna process. With financial

support from the European Commission through the MEDINE

Thematic Network, a Taskforce led by the University of

Edinburgh has developed a framework of learning outcomes

for primary medical degree qualifications in Europe (Cumming

& Ross 2008). The next step of this project is to work back

towards an agreed outcomes framework for first cycle

Bachelors’ degrees in Medicine. If this is successful, it should

become a vehicle to reinforce and further promote the

principle of integrated learning of medicine, and to assist

curriculum planners to design up-to-date programmes which

are aligned with best educational principles.

Conclusion

It can be argued a priori that it is unacceptable to award an

Ordinary Bachelors degree to medical graduates after 5 years

of study and with 300 ECTS credits. This fails to acknowledge

the duration or the level of study which our medical graduates

carry out. In the UK, the final year of most medical degree

courses are credit rated at Master’s level, and medical degree

courses are now recognised by the UK Borders Agency as

equivalent to Masters study for incoming students.

If accompanied by the creation and application of suitable

learning outcomes/competency frameworks, application of

the Bologna three-cycle system to medical education can bring

clarity to this historically confused and confusing area, enable

a more equable assessment of graduates from different

countries in relation to employment and actively encourage

Bologna process and medical education

317

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the integration of clinical learning with medical sciences at all

stages of the student journey.

Declaration of interest: The author reports no conflicts of

interest. The author alone is responsible for the content and

writing of the article.

Notes on contributor

ALLAN CUMMING BSc, MBChB, MD, FRCP is Director of Undergraduate

Learning and Teaching and Professor of Medical Education, University of

Edinburgh, and a nephrologist in the Royal Infirmary of Edinburgh. In the

MEDINE Thematic Network he led the Tuning (medicine) Task Force,

which developed learning outcomes/competences for European medical

graduates (http://tuning-medicine.com).

Note1. For the purposes of current work on European medical

degrees, the following definitions of ‘learning outcomes’ and

‘competences’ are applied. Learning outcomes are set and

described by teaching staff, and in this case refer to the whole

degree programme and relate to the point of graduation. They

are normally described with a hierarchy of levels, with a top

level consisting of large domains of learning, and more

detailed outcomes within each of them. Competences are

acquired by, and belong to, students or graduates. For a

graduate who has successfully completed a degree

programme, their competences should be at least equivalent

to the prescribed learning outcomes. Thus when referring to

the point of graduation, identical descriptors can be used. In

this paper, the term ‘learning outcomes’ will be used.

References

Christensen L. 2004. The Bologna process and medical education. Med

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Cumming AD, Ross MT. 2008. The Tuning Project (medicine) – Learning

outcomes/competences for undergraduate medical education in

Europe. Edinburgh: The University of Edinburgh. [Accessed 2009

October 19]. Available from: http://www.tuning-medicine.com

Harden RM. 2002. Developments in outcome-based education. Med Teach

24:117–120.

Joint Quality Initiative 2004. Shared ‘Dublin’ descriptors for Short Cycle,

First Cycle, Second Cycle and Third Cycle Awards. [Published 2009

October 14].Available online at: http://www.jointquality.nl/

The European Commission, Directorate of Education and Culture 2009. The

Bologna process -–Towards the European Higher Education area.

[Accessed 2009 October 14].Available from: http://ec.europa.eu/educa-

tion/policies/educ/bologna/bologna_en.html

The Tuning Project 2009. Tuning educational structures in Europe.

[Accessed 2009 October 14]. Available from http://tuning.unideusto.

org/tuningeu/

World Federation for Medical Education and the Association for Medical

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Education. [Accessed 2009 October 19].Available from: http://

www2.sund.ku.dk/wfme/

(a)

year 1

Per

cent

age

1st cycle degree(Bachelor’s in Medicine)

year 2 year 3

Basic Science

year 1

2nd cycle degree(Master’s in Medicine)

year 2 year 3

Clinical Medicine Medicalpractice

year 1

3rd cycle degree(Doctorate in Medicine)

year 2 year 3

Science (Research)

0

20

40

60

80

100

(b)

year 1

Per

cent

age

1st cycle degree(Bachelor’s in Medicine)

Graduating Learning Outcomes50% Science, 50% Clinical

year 2 year 3 year 1

2nd cycle degree(Master’s in Medicine)

Graduating Learning Outcomes20% Science, 80% Clinical

year 2 year 3

Basic Science

Medicalpractice

year 1

3rd cycle degree(Doctorate in Medicine)

Graduating Learning Outcomes80% Science, 20% Clinical*

year 2 year 3

Science (Research)

0

20

40

60

80

100

Clinical Medicine Clinical Medicine

Basic Science

Clinical Medicine

Figure 1. The Bologna process and integrated medical education. (a) A possible model of the Bologna process applied

to medical education in the absence of agreed Learning Outcomes/Competences for each cycle, leading to loss of integration.

(b) A possible model of the Bologna process applied to medical education with agreed Learning Outcomes/Competences for each

cycle, leading to enhanced integration.

Note: *This would recognise the specific nature of a Doctorate in Medicine, as opposed to a PhD in another subject.

A. Cumming

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