Some time ago, a film resurfaced that in 1978 was made about the Skills-lab. Recently it was digitalized and made publicly available. Maastricht University is the cradle of this Skills-lab, an educational innovation which was to be copied widely in medical and interrelated curricula, both nationally and internationally. After over forty years, this is a perfect occasion to look back to the origin of this Skills-lab with Pie Bartholomeus, who instigated the film’s making. The photo materials are from his personal archive and the Maastricht University archive. Before providing the broader historical context of the Skills-lab’s development as an educational innovation, first a brief biographical sketch.
Born in Maastricht in 1946, Pie Bartholomeus graduated from Veldeke High School in this same city in 1964, after which he embarked on a study of medicine in Amsterdam. Ten years later he returned to Maastricht, now a family physician and father of two. He became closely involved in the establishment of the Skills-lab, together with Leon Lodewick, Henk Schmidt and many others. The Skills-lab, a facility for students to train their medical-technical and communicative skills, was a unique Maastricht experiment developed by trial and error.
As the Benjamin of seven children, Pie Bartholomeus grew up in a family of teachers: his father, his mother and his three sisters were all teachers. His father also became headmaster of a primary school and director of an evening trade school, where Sjeng Tans was a teacher of Dutch. Tans was a Catholic who held socialist views and who in late 1954 had been forced to resign from his teaching job at Veldeke, a Catholic high school, because of his activities for the Dutch Labour Party. The father of Bartholomeus, however, refused to fire Tans for his political views. At the time, his support caused quite a stir in conservative Catholic Maastricht. Later on, Tans would play a crucial role in the establishment of Maastricht University.
Pie Bartholemeus himself also had to defend his decision to study medicine at what was known as the ‘red’ University of Amsterdam. As he explained: “The then rector of Veldeke High School twice visited my mother, who had meanwhile become a widow, to convince her that I should go and study physics or mathematics, and that I should do so in Catholic Nijmegen. Today such plea would be inconceivable. But I’m glad that my mother let me do what I wanted to do. Amsterdam in the 1960s was great! Even though she was shocked to see me on TV during the Maagdenhuis occupation [the university’s main administrative building].” Nearly all lectures were boring, Bartholomeus felt, and most workshops were a waste of time. Although he experienced his medical internship as a relief (“finally contact with real patients, with actual practice”), the hierarchical hospital structure irritated him. Likewise, he disliked doing research or interventions on real patients without supervision other than from an older intern.
After his medical doctor exam, he opted for family medicine. In the early seventies, one could start as general practitioner right away. Bartholomeus: “I knew quite a bit about the most intricate and exotic clinical pictures, but what to do with a patient who goes to his family doctor saying ‘I feel so tired’, ‘I have fits of dizziness’? You were not prepared to deal with that. Right then, fortunately, an experimental family medicine curriculum was started in Amsterdam. Each week I worked four days in a practice (in Zaandam) and attended one day of training at the then newly established Family Physician Institute. I discovered that my allergy for education, on which I was brought up and which grew much worse during my time in college, receded and transformed into enthusiasm when during those six months I could actively participate in shaping my own training. Designing curricula is fun! When I read about the plans in Maastricht, I immediately thought: I want be part of that.”
In January 1975, Bartholomeus started in the department of healthcare research, a new field dealing with the “quality of healthcare” and ways to improve it. His area of attention was family medicine in primary care. With his then boss, Evert Reerink, “a born teacher”, he worked – even prior to his formal hiring – on a national refresher programme for family physicians on cardiovascular diseases. Family doctors had to learn, among other things, how to do blood pressure measurements (the differences in measuring technique and hence in results proved to be incredibly large). In response, they developed a standard in which it was described step by step how best to measure blood pressure. In January 1975, this standard could be used in the skills course for first-year students, where they received training in first aid and basic medical and laboratory skills, organized in part externally and taught by external experts. Despite many initial problems, students and instructors wanted to go on with it.
In February 1975, Reerink, who knew much about all sorts of educational innovation, notably in the US and Canada, wrote a proposal arguing the need for a “Skills-lab”, where medical students throughout their study could train a variety of skills. This idea was inspired by the “Skills-laboratory” he saw at a nursing school in East Lansing and elsewhere. Although experiments with various forms of medical simulation were underway in various places, this was mostly limited to activities within a specific medical specialty. Reerink’s proposal, whose development Bartholomeus witnessed from up close, was received enthusiastically, and in April 1975 it was decided to set up a project group and use a space in the old infirmary of the Jesuits Monastery. Leon Lodewick, a family doctor and coordinator of the skills course, was picked to set up the Skills-lab.
Bartholomeus: “Unfortunately, Lodewick let us know by late 1975 already that a family practice was hard to combine with the task of coordinating the Skills-lab. Because the hiring of a new coordinator involved a slow process and I more and more enjoyed contributing to the Skills-lab, I took on that task. I liked it a lot and it came with many special experiences, even if it was also quite a burden. My original intention was to do it for a period of four years, which would turn out to be fifteen years. Slowly but surely, and by trial and error, a programme was realized, whereby students could practice skills little by little, from simple to more complex, from simulation to as realist as possible: first on models and dummies, next on and with each other, and on simulation patients, and finally on real patients (specifically invited for that purpose). Eventually, the simulation patients programme, which started as experiment with colleagues and family members, whereby students in each course were given the opportunity to apply their knowledge and skills in a situation as real as possible, became a great success. More than 100 people from all walks of life regularly contribute(d) to it.”
Slowly but surely, the initiators managed to integrate the programme into the overall curriculum. The centrepiece was the so-called “adoption model”, whereby in each course students in their second, third and fourth year were ‘adopted’ by a family physician in whose practice they could meet patients relevant to the theme of the course. This was also a context for the students to apply the skills they learned earlier. After the number of students kept growing, the adoption model could no longer be sustained.
Much to the surprise of all involved, the standards developed in the Skills-lab, often illustrated with photos and drawings, soon found their way to students of other medical faculties. Lodewick integrated these standards in The physical examination. An atlas for general practice. Originally in Dutch, this publication proved a great success: within a short timeframe, as many as six translations appeared! Soon after its establishment, the Skills-lab was moved from the infirmary to the library wing of the Jesuit Monastery, and, in 1983, to the “temporary building” (which is still there) in Randwyck, and in 1991, finally, to the education building near the new hospital in Randwyck.
Bartholomeus: “Although there continued to be resistance to the Maastricht approach in most medical faculties in the Netherlands, interest in the Skills-lab method continued to go up, notably among higher vocational training facilities for healthcare in the Netherlands, as well as in many medical faculties abroad. The launch of the so-called ‘Transfer site skills training’ (Transferpunt Vaardigheidsonderwijs) – together with the universities for applied sciences in Heerlen/Maastricht and Arnhem/Nijmegen – was a major initiative.”
After fifteen years, it was time for a new coordinator of the Skills-lab. During a sabbatical Bartholomeus realized that physicians in developing countries depend even more on sound medical skills because of the lack of diagnostic equipment. Together with the Internationalization Office (MUNDO and later SHE cooperates), all sorts of skills projects have been initiated worldwide, such as in El Salvador, Kenia, Uganda, the United Arab Emirates (Al Ain) and Vietnam. A Skills-lab project was also set up in Indonesia, first one university in Yogyakarta but meanwhile all seventy-one medical faculties in that country have become involved in it. The Skills-lab method also managed to spread quickly through the many visitors of the Maastricht Skills-lab, in particular its visitor workshop. Bartholomeus: “In other countries, Maastricht University is perhaps better known for its Skills-lab than for its PBL.”