National, European licensing examinations or none at all?

The unification of Europe in higher education in general and in medical education in particular is progressing. Since the Bologna declaration most of the European countries are in the process of introducing a two-cycle training programme in higher education that also affects medical training programmes (Patricio et al. 2008). Within the European legislature there is free mobility of professionals across the borders of Europe. To control for quality of education initiatives are taken across Europe to accredit higher education programmes (Dittrich et al. 2004) including medical training programmes (van Zanten et al. 2008). Within medical education the World Federation of Medical Education has been very instrumental in defining undergraduate and postgraduate standards of education which can be used for quality assurance or accreditation. The federation has developed global standards as well as European specification of these procedures (cf http:// www.wfme.org/). This harmonization of European medical education will develop further in the future ahead of us. Part of modern Europe is also the trend of mobility of the workforce (Jinks et al. 2000). This concerns both students as well professionals. An increasing number of schools in Europe start competing on the international market for recruiting their students, including, for example, my own institution. The question is: what is the voice of the patient in all this? How are the rights of the patient protected against this mobility? The patients will rightfully insist on the best of care. How is this guaranteed? There is increasing evidence that even with a European country medical schools produce different quality of medical graduates (McManus et al. 2008). What happens if we look at this from a European perspective? How different is a graduate coming from a medical school in Athens as compared to one from Tampere? Or from London compared to Warsaw? Even with the safeguards of accreditation of training programmes, we know, more or less for certain, that graduates will differ in proficiency across different schools and sites of training. The Rome treaty and the European legislation, however, is unequivocal. Principally professionals cannot be prevented to practice across the European boundaries. What implications does that have for the practice of health and the rights of the individual patient? One way of dealing with this issue of quality of graduates is to follow the North-American route of licensure examinations. By setting assessments at the end of undergraduate or postgraduate training programmes we can at least measure all our graduates against the same ruler and assure the public for some minimal level of competence. However, when I come to North America and explain that licensing examinations do not exist in my country, they sometimes congratulate me. The driving force of the licensure exams is definitely felt by schools and training programmes. If I speak to German students, I seldom hear any enthusiasm for the German system of fixed multiple exams during the undergraduate training programmes. Being part of an advisory board for a German school changing towards problem-based learning, I often encountered suggestions that these licensure exams are an actual impediment for any educational change. The question is whether standardized tests lead to standardized programmes. In the recent assessment literature one speaks of a paradigm shift by moving away from the ‘testing culture’ towards an ‘assessment culture’ (Gielen et al. 2003). Here we change from assessment of learning towards assessment for learning. By using the driving effect of assessment strategically it is advocated to embed assessment as much as possible with the learning itself (Wilson & Sloane 2000). Licensure examinations by definition separate the assessment from the ongoing learning. Will this lead to a conflict between the goals of the training programme and what is being tested in licensure exams? The licensure exams will probably measure those competencies and skills that are easily measured and may not include competencies and skills that are hard to measure. Will this not trivialize the ongoing learning? Could this not lead to a reductionistic harmonization of our training programmes preventing any pluriformity to further exist? Is pluriformity not at the heart of the European spirit and should this not be respected in our education programmes? The question about the utility of (European) licensure examinations was addressed in a symposium at the last AMEE meeting in Prague last year. In this issue of Medical Teacher we will report on this discussion. First we have a representative from the North-American continent. Don Melnick, President of the National Board of Medical Examiners, will describe the situation in the US, the arguments that have lead to their licensure procedures and the benefits that this approach had in his view (Melnick 2009). Being long enough in the assessment business, it is interesting to note how much the US licensure exams have changed over the