Reforms of the pre-graduate curriculum for medical students: the Bologna process and beyond.

For several years, all five medical faculties of Switzerland have embarked on a reform of their training curricula for two reasons: first, according to a new federal act issued in 2006 by the administration of the confederation, faculties needed to meet international standards in terms of content and pedagogic approaches; second, all Swiss universities and thus all medical faculties had to adapt the structure of their curriculum to the frame and principles which govern the Bologna process. This process is the result of the Bologna Declaration of June 1999 which proposes and requires a series of reforms to make European Higher Education more compatible and comparable, more competitive and more attractive for Europeans students. The present paper reviews some of the results achieved in the field, focusing on several issues such as the shortage of physicians and primary care practitioners, the importance of public health, community medicine and medical humanities, and the implementation of new training approaches including e-learning and simulation. In the future, faculties should work on several specific challenges such as: students' mobility, the improvement of students' autonomy and critical thinking as well as their generic and specific skills and finally a reflection on how to improve the attractiveness of the academic career, for physicians of both sexes.

Le rôle de la matérialité dans l'apprentissage de la lecture : aspects du curriculum enseigné, pratique enseignante et développement chez l'élève : une étude de cas à l'école primaire française

Notre étude consiste en une recherche longitudinale pour laquelle une cohorte d'élèves a été suivie depuis la Grande Section de l'école maternelle française (élèves de 5-6 ans) jusqu'au Cours Élémentaire 1re année de l'école élémentaire française (élèves de 7-8 ans) dans des situations ordinaires de classe. À ces niveaux scolaires, l'un des principaux objectifs du curriculum est l'apprentissage de la lecture. Nous considérons que l'élève construit les compétences de lecture à acquérir, i.e. les compétences caractérisant son développement potentiel, en s'appuyant sur les compétences caractérisant son développement actuel (Vygotski, 1934/1997). Lorsqu'il apprend à lire, l'élève a à sa disposition des moyens sémiotiques relatifs à la connaissance des objets et leurs usages, ainsi qu'aux gestes et leur signification (Moro & Rodriguez, 2005), ce que nous appelons globalement la matérialité. En conséquence, dans cette recherche, nous faisons l'hypothèse que ces premières habiletés relatives à la matérialité, constituent une ressource dans les situations d'enseignement- apprentissage de la lecture. Nous réalisons une étude de cas dont le recueil des données, à caractère ethnographique, est constitué de moments de classe enregistrés en vidéo, et ce, quatre fois par année scolaire. Ces douze enregistrements vidéo sont complétés par deux entretiens semi-directifs et un entretien d'auto- confrontation ; ils sont aussi mis en lien avec les Instructions officielles (programmes scolaires). L'analyse est à la fois macrogénétique et microgénétique. Pour chaque observation, concernant l'analyse macrogénétique, nous réalisons le synopsis à partir duquel nous sélectionnons des épisodes significatifs porteurs de matérialité. Les épisodes significatifs sont constitués des événements remarquables dont les analyses microgénétiques nécessitent l'utilisation d'outils, à savoir les tableaux des matérialités et les photogrammes. Notre étude montre que la matérialité permet aux élèves de devenir lecteurs et que les formes de cette matérialité changent en fonction de l'avancée des acquisitions des élèves et des dimensions de la lecture (code et compréhension) à apprendre. - Our research consists of a longitudinal study in which one group of pupils in ordinary classroom situations has been followed from the top level of French pre-elementary school (5- to 6 year-old pupils) to the second level of French primary school (7- to 8 year-old pupils). For these three school grades, one of the main objectives in the curriculum is learning to read. We consider that pupils build their new reading skills, i.e. the skills characterizing their potential development, by relying on skills characterizing their actual development (Vygotski, 1934/1997). When learning to read, pupils yet have at their disposal semiotic abilities related to knowledge both of material objects and their uses, and of basic gestures and their meaning (Moro & Rodriguez, 2005), all of this we sum up under the term of materiality. Consequently, in our research, we make the hypothesis that the children's basic abilities related to materiality constitute a resource in teaching-learning situations. We have chosen to carry out a case study. The data collected consist of videos of class sequences carried out four times a year for three years. These twelve videos are supplemented by two semi- structured interviews with the teacher, one "self-confronting" interview in which the teacher is brought to discuss her actions and by the analysis of the ministry's school curricula. Our analysis is both macrogenetic and microgenetic. For each teaching sequence, on the level of macrogenetic analysis, we have made up the synopsis from which we have selected significant episodes in terms of materiality. The significant episodes are composed of remarkable events the microgenetic analysis of which requires the use of tools such as materiality boards and photograms. Our study shows that materiality enables pupils to develop reading skills and that the forms that materiality takes on change according to the pupils' acquisition progress and the aspects of reading (code and comprehension) still to be learned.

Topics in public finance: social security and taxation

Summary The field of public finance focuses on the spending and taxing activities of governments and their influence on the allocation of resources and distribution of income. This work covers in three parts different topics related to public finance which are currently widely discussed in media and politics. The first two parts deal with issues on social security, which is in general one of the biggest spending shares of governments. The third part looks at the main income source of governments by analyzing the perceived value of tax competition. Part one deals with the current problem of increased early retirement by focusing on Switzerland as a special case. Early retirement is predominantly considered to be the result of incentives set by social security and the tax system. But the Swiss example demonstrates that the incidence of early retirement has dramatically increased even in the absence of institutional changes. We argue that the wealth effect also plays an important role in the retirement decision for middle and high income earners. An actuarially fair, but mandatory funded system with a relatively high replacement rate may thus contribute to a low labor market participation rate of elderly workers. We provide evidence using a unique dataset on individual retirement decisions in Swiss pension funds, allowing us to perfectly control for pension scheme details. Our findings suggest that affordability is a key determinant in the retirement decisions. The higher the accumulated pension capital, the earlier men, and to a smaller extent women, tend to leave the workforce. The fact that early retirement has become much more prevalent in the last 15 years is a further indicator of the importance of a wealth effect, as the maturing of the Swiss mandatory funded pension system over that period has led to an increase in the effective replacement rates for middle and high income earners. Part two covers the theoretical side of social security. Theories analyzing optimal social security benefits provide important qualitative results, by mainly using one general type of an economy. Economies are however very diverse concerning numerous aspects, one of the most important being the wealth level. This can lead to significant quantitative benefit differences that imply differences in replacement rates and levels of labor supply. We focus on several aspects related to this fact. In a within cohort social security model, we introduce disability insurance with an imperfect screening mechanism. We then vary the wealth level of the model economy and analyze how the optimal social security benefit structure or equivalently, the optimal replacement rates, changes depending on the wealth level of the economy, and if the introduction of disability insurance into a social security system is preferable for all economies. Second, the screening mechanism of disability insurance and the threshold level at which people are defined as disabled can differ. For economies with different wealth levels, we determine for different thresholds the screening level that maximizes social welfare. Finally, part three turns to the income of governments, by adding an element to the controversy on tax competition versus tax harmonization.2 Inter-jurisdictional tax competition can generate at least two potential benefits or costs: On a public level, tax competition may result in a lower or higher efficiency in the production of public services. But there is also a more private benefit in the form of an option for individuals to move to a community with a lower tax rate in the future. To explore the value citizens attach to tax competition we analyze a unique popular vote for a complete tax harmonization between communities in the third largest Swiss canton, Vaud. Although a majority of voters would have seemingly benefited from replacing the current tax rate by a revenue-neutral average tax rate, the proposal was rejected by a large margin. Our estimates suggest that the estimated combined perceived benefit from tax competition is in the range of 10%.

Basic life support teaching in the second year pregraduate medical curriculum: quality of acquisition after 6 months

Purpose of the study: Basic life support (BLS) and automated externaldefibrillation (AED) represent important skills to be acquired duringpregraduate medical training. Since 3 years, our medical school hasintroduced a BLS-AED course (with certification) for all second yearmedical students. Few reports about quality and persistence over timeof BLS-AED learning are available to date in the medical literature.Comprehensive evaluation of students' acquired skills was performedat the end of the 2008 academic year, 6 month after certification.Materials and methods: The students (N = 142) were evaluated duringa 9 minutes «objective structured clinical examination» (OSCE) station.Out of a standardized scenario, they had to recognize a cardiac arrestsituation and start a resuscitation process. Their performance wererecorded on a PC using an Ambuman(TM) mannequin and the AmbuCPR software kit(TM) during a minimum of 8 cycles (30 compressions:2 ventilations each). BLS parameters were systematically checked. Nostudent-rater interactions were allowed during the whole evaluation.Results: Response of the victim was checked by 99% of the students(N = 140), 96% (N = 136) called for an ambulance and/or an AED. Openthe airway and check breathing were done by 96% (N = 137), 92% (N =132) gave 2 rescue breaths. Pulse was checked by 95% (N=135), 100%(N = 142) begun chest compression, 96% (N = 136) within 1 minute.Chest compression rate was 101 ± 18 per minute (mean ± SD), depthcompression 43 ± 8 mm, 97% (N = 138) respected a compressionventilationratio of 30:2.Conclusions: Quality of BLS skills acquisition is maintained during a6-month period after a BLS-AED certification. Main targets of 2005 AHAguidelines were well respected. This analysis represents one of thelargest evaluations of specific BLS teaching efficiency reported. Furtherfollow-up is needed to control the persistence of these skills during alonger time period and noteworthy at the end of the pregraduatemedical curriculum.

Stability of repeated student evaluations of teaching in the second preclinical year of a medical curriculum

RESUME L'étude de la médecine à la Faculté de l'Université de Lausanne est un cursus de six ans. Depuis la réforme générale du curriculum en octobre 1995, le programme de la deuxième année consacrée à l'étude de l'être humain sain a été transformé. L'enseignement intégré par système ou organe a été introduit en remplaçant l'enseignement par discipline. Parallèlement, un système d'évaluation de l'enseignement par les étudiants a été proposé. Il a été amélioré au fil des années et depuis l'année académique 1998-99, l'évaluation est devenue systémique et régulière. Notre étude présente et compare les résultats des évaluations de l'enseignement et des enseignants de neuf cours intégrés dispensés en deuxième année durant deux années académiques (1998-99 et 1999-2000). Une forte corrélation entre les résultats des deux années consécutives ainsi qu'une importante disparité des estimations à l'intérieure de chacune de deux années ont été observées. Ceci démontre un engagement sérieux des étudiants dans le processus d'évaluation, révèle la pertinence de leur analyse et leur bonne capacité de discernement. L'analyse de nos résultats montre que les évaluations effectuées par les étudiants peuvent constituer une source fiable d'informations et contribuer à l'amélioration du processus d'enseignement.

The development and pilot-testing of a training curriculum in adolescent medicine and health.

PURPOSE: To select and propose a set of knowledge, attitudes, and skills essential for the care of adolescents; to encourage the development of adolescent health multidisciplinary networks; and to set up training programs in as many European countries as possible. METHODS: The curriculum was developed by 16 physicians from 11 European countries with various professional specializations. In line with modern guidelines in medical education, it is a modular, flexible instrument which covers the main teaching areas in the field, such as basic skills (i.e. setting, rights and confidentiality, gender and cultural issues) as well as specific themes (i.e. sexual and reproductive health, eating disorders, chronic conditions). It consists of 17 thematic modules, each containing detailed objectives, learning approaches, examples, and evaluation methods. RESULT: Two international one-week summer schools were used to assess the feasibility and appropriateness of the curriculum. The overall evaluation was good, with most of the items surpassing three on a four-point Likert scale. However, it pointed to several aspects (process and content) which will need to be refined in the future, such as an increase in interactive sessions (role playing), and a better mix of clinical and public health issues.

EORTC topics in neurooncology: The long path from a focus on neurological complications of cancer towards molecularly defined trials and therapies in neurooncology

Over the past decade a series of trials of the EORTC Brain Tumor Group (BTG) has substantially influenced and shaped the standard-of-care of primary brain tumors. All these trials were coupled with biological research that has allowed for better understanding of the biology of these tumors. In glioblastoma, EORTC trial 26981/22981 conducted jointly with the National Cancer Institute of Canada Clinical Trials Group showed superiority of concomitant radiochemotherapy with temozolomide over radiotherapy alone. It also identified the first predictive marker for benefit from alkylating agent chemotherapy in glioblastoma, the methylation of the O6-methyl-guanyl-methly-transferase (MGMT) gene promoter. In another large randomized trial, EORTC 26951, adjuvant chemotherapy in anaplastic oligodendroglial tumors was investigated. Despite an improvement in progression-free survival this did not translate into a survival benefit. The third example of a landmark trial is the EORTC 22845 trial. This trial led by the EORTC Radiation Oncology Group forms the basis for an expectative approach to patients with low-grade glioma, as early radiotherapy indeed prolongs time to tumor progression but with no benefit in overall survival. This trial is the key reference in deciding at what time in their disease adult patients with low-grade glioma should be irradiated. Future initiatives will continue to focus on the conduct of controlled trials, rational academic drug development as well as systematic evaluation of tumor tissue including biomarker development for personalized therapy. Important lessons learned in neurooncology are to dare to ask real questions rather than merely rapidly testing new compounds, and the value of well designed trials, including the presence of controls, central pathology review, strict radiology protocols and biobanking. Structurally, the EORTC BTG has evolved into a multidisciplinary group with strong transatlantic alliances. It has contributed to the maturation of neurooncology within the oncological sciences.

Basic life support teaching in the second year predraduate medical curriculum: quality of acquisition after 6 months

Purpose of the study: Basic life support (BLS) and automated externaldefibrillation (AED) represent important skills to be acquired duringpregraduate medical training. Since 3 years, our medical school hasintroduced a BLS-AED course (with certification) for all second yearmedical students. Few reports about quality and persistence over timeof BLS-AED learning are available to date in the medical literature.Comprehensive evaluation of students' acquired skills was performedat the end of the 2008 academic year, 6 month after certification.Materials and methods: The students (N = 142) were evaluated duringa 9 minutes «objective structured clinical examination» (OSCE) station.Out of a standardized scenario, they had to recognize a cardiac arrestsituation and start a resuscitation process. Their performance wererecorded on a PC using an Ambuman(TM) mannequin and the AmbuCPR software kit(TM) during a minimum of 8 cycles (30 compressions:2 ventilations each). BLS parameters were systematically checked. Nostudent-rater interactions were allowed during the whole evaluation.Results: Response of the victim was checked by 99% of the students(N = 140), 96% (N = 136) called for an ambulance and/or an AED. Openthe airway and check breathing were done by 96% (N = 137), 92% (N =132) gave 2 rescue breaths. Pulse was checked by 95% (N=135), 100%(N = 142) begun chest compression, 96% (N = 136) within 1 minute.Chest compression rate was 101 ± 18 per minute (mean ± SD), depthcompression 43 ± 8 mm, 97% (N = 138) respected a compressionventilationratio of 30:2.Conclusions: Quality of BLS skills acquisition is maintained during a6-month period after a BLS-AED certification. Main targets of 2005 AHAguidelines were well respected. This analysis represents one of thelargest evaluations of specific BLS teaching efficiency reported. Furtherfollow-up is needed to control the persistence of these skills during alonger time period and noteworthy at the end of the pregraduatemedical curriculum.

Needs, expectations, and concerns of medical students regarding end-of-life issues before the introduction of a mandatory undergraduate palliative care curriculum.

BACKGROUND: In the past, implementation of effective palliative care curricula has emerged as a priority in medical education. In order to gain insight into medical students' needs and expectations, we conducted a survey before mandatory palliative care education was introduced in our faculty. METHODS: Seven hundred nine students answered a questionnaire mainly consisting of numeric rating scales (0-10). RESULTS: Participants attributed a high importance to palliative care for their future professional life (mean, 7.51 ± 2.2). For most students, symptom control was crucial (7.72 ± 2.2). However, even higher importance was assigned to ethical and legal issues (8.16 ± 1.9). "Self-reflection regarding their own role as a physician caring for the terminally ill along with psychological support" was also regarded as highly important (7.25 ± 2.4). Most students were moderately concerned at the prospect of being confronted with suffering and death (5.13 ± 2.4). This emotional distress was rated significantly higher by female students (5.4 ± 2.4 versus 4.6 ± 2.4; p < 0.001). Seventeen percent of all students rated their distress as being 7 of 10 or higher, which indicates a considerable psychological strain in terms of dealing with end-of-life issues in the future. Professional or personal experience with terminally ill persons lowered these anxieties significantly (4.99 ± 2.34 versus 5.47 ± 2.5, p < 0.05). CONCLUSIONS: Medical students stated a remarkably high interest in learning palliative care competencies. Responding to their specific concerns and needs-especially with regard to the acquisition of emotional coping skills-may be key for the development of successful palliative care curricula.

Training needs in adolescent medicine of practising doctors: a Swiss national survey of six disciplines.

OBJECTIVE: To assess and compare the training needs in adolescent medicine of doctors within 6 specialties as a basis for the development of pre/postgraduate and continuing medical education (CME) training curricula. DESIGN: Cross-sectional postal survey. SETTING: Switzerland. PARTICIPANTS: National, representative, random sample of 1857 practising doctors in 6 disciplines (general practitioners, paediatricians, gynaecologists, internists, psychiatrists, child psychiatrists) registered with the Swiss Medical Association. MAIN OUTCOME MEASURES: Perceived importance of and training interest in 35 topics related to adolescent medicine listed in a self-administered, anonymous questionnaire. RESULTS: A total of 1367 questionnaires were returned, representing a response rate of 73.9%. Clear interest in adolescent medicine was reported by 62.1% of respondents. Topics perceived to be the most important in everyday practice were functional symptoms (71.4%), acne (67.1%), obesity (64.6%), depression-anxiety (68.1%) and communication with adolescents (61.7%). Differences between disciplines were especially marked for gynaecologists, who expressed interest almost exclusively in medical topics specific to their field. In contrast, other disciplines commonly reported a keen interest in psychosocial problems. Accordingly, interest in further training was expressed mostly for functional symptoms (62.4%), eating disorders (56.3%), depression-anxiety (53.7%) and obesity (52.6%). Issues related to injury prevention, chronic disease and confidentiality were rated as low priorities. CONCLUSIONS: Regardless of discipline, Swiss primary care doctors expressed a strong interest in adolescent medicine. Continuing medical education courses should include both interdisciplinary courses and discipline-specific sessions. Further training should address epidemiological and legal/ethical issues (e.g. injury prevention, confidentiality, impact of chronic conditions).

Finding an apprenticeship : hidden curriculum and social consequences

In Switzerland, the majority of students are oriented towards professional training after compulsory schooling. At this stage, one of the biggest challenges for them is to find an apprenticeship position. Matching supply and demand is a complex process that not only excludes some students from having direct access to professional training but also forces them to make early choices regarding their future sector of employment. So, how does one find an apprenticeship? And what do the students' descriptions of their search for apprenticeships reveal about the institutional determinants of social inequalities at play in the system? Based on 29 interviews conducted in 2014 with 23 apprentices and 6 recruiters in the Canton of Vaud, this article interrogates how the dimensions of educational and social trajectories combine to affect access to apprenticeships and are accentuated by recruiters using a "hidden curriculum" during the recruitment process. A hidden curriculum consists of knowledge and skills not taught by the educational institution but which appear decisive in obtaining an apprenticeship. By analysing the contrasting experiences of students in their search for an apprenticeship, we identify four types of trajectories that explain different types of school-to-apprenticeship transitions. We show how these determinants are reinforced by the "hidden curriculum" of recruitment based on the soft skills of feeling, autonomy, anticipation and reflexivity that are assessed in the context of recruitment interactions. The discussion section debates how the criteria that appear to be used to identify the "right apprentice" tend to (re)produce inequalities between students. This not only depends on their academic results but also on their social and cultural skills, their ability to anticipate their choices and, more widely, their ability to be a subject in their recruitment search. "The Subject is neither the individual, nor the self, but the work through which an individual transforms into an actor, meaning an agent able to transform his/her situation instead of reproducing it." (Touraine, 1992, p.476).