Medical Education 1993, 27, 299-303

Medical specialization in Europe: the way forward Promotion of educational quality

HANS KARLE, JORGEN NYSTRUP & HENRY WALTON§

Nordic Federation f o r Medical Education and 5 World Federation for Medical Education

Summary. The medical specialties are being intensively reconsidered in the countries of Europe. The important need is for promoting improvement of educational training program- mes. Evaluation and improvement of specialist training programmes is the priority and not the setting up of qualifying examinations. The first necessity is to safeguard 20 years of evolution in postgraduate training. Support for the edu- cational process is essential, to a much greater extent than occurs at present, if standards are to be improved and the confidence ofthe public is to be retained. The EC medical education system is the only existing international structure in medical education which is controlled by law, and is on that basis alone of the greatest interest.

Key words: specialties, medical/*educ; edu- cation, medical/stand; education, medical/ trends; specialties, medical/stand; specialties, medical/trends; Europe

Introduction

Medical education is challenged by all but un- manageably rapid political change in the Euro- pean context. In only a few years 22 new countries have come into being. At the same time, many initiatives have been taken and many forces are at work which will increase collabor- ation and exchange between European countries. The Single European Act and the completion of the Single Internal Market have been a reality

Correspondence: Dr Hans Karle, President, Nordic Federation for Medical Education, Department of Internal Medicine and Haematology, Copenhagen County Hospital, Herlev Ringvej 75, DK 2730 Herlev, Denmark.

since January 1993, and further integration will occur among the countries of the European Community (EC) in line with the Maastricht Agreement and the modifications already in progress before that. Furthermore, greater coor- dination between the EC and the European Free Trade Association (EFTA) countries in the EOS agreement will include adoption by these additional countries of the EC directives on medical education; with the enlargement of the EC an as yet undetermined number of new member states are to be accepted. Finally, a major challenge of great significance presents with the opening up of Eastern Europe.

These vast political developments carry great implications for the medical profession. Some may demur that establishing the Single Market in 1976 for medical doctors did not at once usher in dramatic consequences. As still further European integration takes place, transnational exchange of doctors and medical students will inevitably be extended, with mutual recognition of degrees and qualifications, and greater collaboration in medical education, medical services and medical sciences.

Given these complex circumstances, and the fact that the EC directives specify only loose requirements, it is understandable that many doctors who are responsible for, or interested in, medical education are concerned about the need for harmonization of education and the develop- ment of common standards. The European Union of Medical Specialists (Union Europienne des Medicins Specialistes) already has proposals before it of a system of European Boards for the different Monospecialist Sections. The aim of UEMS is to guarantee a high quality of medical care in the EC, by ensuring that the

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training of the specialist doctors in the field of each specialty is raised to the highest attainable level.

The model for establishing a system of Euro- pean Boards derives from the North American tradition. Boards are being set up for each of the different specialties. Before accepting such a system without further question, the essential aspects of European postgraduate medical edu- cation must be reviewed to determine how applicable a Board System is and if it can be reconciled with preservation of good European practice.

The aim of this paper is to address this question, and to review various approaches which could ensure high standards of quality in specialist training in Europe, acceptable to all the countries concerned.

Current medical educational structures in Europe

Specialization in the major disciplines of medi- cine and surgery began at the start ofthis century, and grew rapidly after the Second World War, promoted by the vast progress of the medical sciences. The setting up of structures responsible for postgraduate medical education followed slowly, and concern with the objectives and methods of specialist training is recent in most European countries. Postgraduate education was until recently considered as no more than apprenticeship, the by-product of the work as a medical doctor. This mode of evolution goes far to explain the great differences of specialist training systems among countries, reflecting the dissimilar development of the various health care systems.

An overview reveals great differences in allo- cation of responsibility for postgraduate medical training among European countries. In some, such as Norway, Germany, and certain countries in Central Europe, the medical profession itself exercises a major role through its medical associ- ations. In other countries, Great Britain an example, designated professional bodies such as the Royal Colleges, distant from the medical associations, exert the major influence. In yet other countries, such as Sweden, the Government i!irough its Ministry of Health and Social Welfare, in conjunction with the regional

county administration, has the major power. In Finland and in Southern Europe postgraduate training was made the responsibility of the universities. Major postgraduate institutes are a feature of Central and Eastern European specialist training. Such institutes may be private bodies, and then be connected with a major private hospital; in Eastern Europe the institutes have been public but with a high degree of autonomy which, in effect, under present politi- cal conditions renders them ‘private’.

Patterns of postgraduate training

The differences between the European countries in respect of duration, methods of teaching, and evaluation of postgraduate medical education follows certain identifiable patterns. One promi- nent feature differentiates the countries of north- west Europe from southern Europe. Specialist training in north-west Europe has traditionally been based on an apprenticeship appointment in hospital departments extending over several years. In contrast, in southern Europe a uni- versity-based structure, dominated by theoreti- cal courses over shorter periods, without specific requirements for practical training, has been the general pattern.

A tendency towards convergence in training methods has taken place during the past two decades.

The traditions which were prevalent in Eastern Europe have been modified by models from other countries. Modern principles of medical education have exerted increasing influence in all countries. Many forces have promoted this con- sensus, fostered by greater communication between the universities, medical societies and medical associations within the EC. The recom- mendations given in several reports of the Advi- sory Committee on Medical Training (ACMT) have clearly contributed.

Stages in training

Four stages in postgraduate medical training can usefully be identified, with national variations in terminology and specific requirements:

(1) the pre-registration (general medical training) phase;

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(2) the initial professional training (introduc-

(3) the specific specialization training phase;

(4) the higher training phase. Continuing medical education, the final stage,

which by definition follows on from the specialist training period, is lifelong.

tory) phase;

and

Another difference among countries is the varying extent of subspecialization, occurring within the specialization phase, which might or might not lead to recognition of independent subspecialist status.

Designated training posts in these four stages exist throughout Europe. Candidates qualify for these either through a membership examination (e.g. the Royal Colleges in Great Britain), or through holding of clinical posts, specified experience, or research. Part of the required postgraduate training might be required to take place in a university hospital, and part in district hospitals of the health care system.

In Eastern Europe and in the south of Europe it is common to require an affiliation to a postgra- duate institute. In the Scandinavian countries qualified trainees are offered national theoretical courses in their specialty of 3-6 days duration on 8-12 occasions during their specialization period.

Favourable trends

Postgraduate medical training, it goes without saying, concerns adult learning. Trainees have high inherent motivation to master the specialty they have selected for their future career. During specialist training the trainees must be exposed to the range of professional performance in which they require to become proficient. This require- ment has dictated that traditional specialist training programmes entail rotation from one clinical facility to another, with the demand that specified time periods be spent in various placements. Theoretical instruction, which follows on the basic curriculum of the medical school phase, is part ofpostgraduate training, the methods of instruction being theoretical semi- nars, courses of study, and required reading.

Educational goals or objectives have increas- ingly been specified to enhance the learning experience. Objectives serve as the basis for

directing the trainee, in place of stated periods of time in designated clinical placements. From January 1992, for example, the Government of Sweden has regulated specialist training by means of official educational objectives. Once trainees have fulfilled a minimum training period of5 years, they can become specialists, but only if the chief of the clinic certifies that the specified educational goals have been obtained.

The Swedish example demonstrates the trend, evident throughout Europe, whereby edu- cational objectives in postgraduate medical training are increasingly formulated. Stated objectives make systematic tuition possible, the trainees discussing their progress with tutors, and identifying areas in which they need further clinical experience, additional theoretical instruction, or research involvement. Regular two-person educational review meetings have become a valued component of postgraduate training.

During such tutorial review, the progress of the trainee is assessed, but in addition the quality is reviewed of the educational programme of the clinic. Documentation constitutes an ongoing record of the professional development of trainees, often in the form of check-lists, and is also a basis for assessment of their clinical competence.

Very considerable advance has been made in assessment techniques. Postgraduate educational programmes can be greatly improved if the trainees are properly assessed by valid methods, and if the training programme is also systemati- cally evaluated by appropriate means. In summary, the trainee performs clinical tasks independently, and receives personal monitoring and supervision regularly during the training period. Valid methods of assessment replace outmoded examinations, and are at the same time effective learning methods, serving to moti- vate trainees and reinforce their learning.

Ensuring quality of training

Postgraduate medical training in Europe, there- fore, from its beginnings as a simple appren- ticeship, has evolved to become- in principle- a highly sophisticated learning programme, the components of which are planned clinical placements, expert supervision, theoretical

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teaching, research experience, systematic assess- ment, and evaluation ofthe training programme.

The quality of postgraduate medical training is determined by the value ascribed to it and the resources allocated to it. Development of the specified learning experiences is paramount, to promote the subsequent systematic lifelong learning now required of all doctors.

The arguments for international Board-type examinations are a secondary consideration. High quality examinations are inevitably expen- sive. Attempts to set up European specialist examinations should not detract effort and resources from the learning programme which must be the priority. Investment of expertise, time and money in the dubious examination procedures appears unjustifiable for govern- ments and hospitals, and should not divert resources needed to promote educational oppor- tunities as an integral part of normal clinical work.

Moreover, there is now great emphasis being given to audit, the appropriate evaluation at the workplace of professional performance with feedback constantly provided about the quality ofthe practitioner’s daily work. Audit is based on systematic analysing of the outcomes of medical care. Such quality control of the doctor’s own clinical work provides motivation and might be the strongest factor in improving the quality of postgraduate training, while at the same time improving the health care services.

The emphasis of medical review in the Euro- pean Community has been concerned, in the first place, with regulation of the medical profession in its member countries, to promote free movement of doctors. Such international pro- fessional exchange might also improve standards in medicine, provided the best is advocated rather than mere conformity. Shared informa- tion and exchange of ideas often do promote quality. The creation of a system of postgraduate training posts in all the different countries of Europe can be a major beneficial result of inter- national cooperation.

The holding ofscientific meetings which bring together senior researchers has long been a tradition in medicine. Postgraduate trainees should be encouraged to participate in such meetings. They should be enabled to participate in active research, which will help sustain and

improve the quality of medicine. Such research training, as already noted, should be provided as one of the components of all postgraduate medical training.

Official educational exchange programmes in Europe, such as ERASMUS and TEMPUS, will come to be valuable resources for postgraduate students and teachers. The medical teachers of Europe constitute a composite body of training staff. This human resource could certainly be used more effectively than occurs at present, through better planning. The creation of Euro- pean centres for postgraduate education has been proposed, to extend the educational influence of the associations of oncologists, general prac- titioners, public health specialists, etc. which currently strive to improve the quality of specialty training.

The basis for concern

In the free market of the European Community, postgraduate education might become subser- vient to market mechanisms, a potential dis- advantage in the long run. The present fear, however, is that unacceptably poor quality of training could emerge. A remedy sometimes proposed is more emphasis on international specialist examinations. Already such examin- ations are an integral component of specialist training in many countries. However, the pat- tern which is general in North America may not be the European solution. Indeed, such an American-style Board-certificate solution could be deleterious to the development in postgra- duate training, as it has evolved in most of Europe over the last 20 years. A constriction could be brought about in the wide-ranging responsibility which has been accepted for post- graduate medical training in Europe.

There is now general acknowledgement that doctors graduating from universities have merely started their medical education. It has been accepted, moreover, that part of the subse- quent postgraduate training process is a re- sponsibility of the health care system, particularly the hospitals. Indeed, many hospitals and regional health care areas have taken pride in creating educational programmes to attract well-motivated doctors. This development has been accompanied by guidelines and recom-

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mendations from the central authorities in each country. Considerable resources have been allo- cated to create the necessary infrastructures in postgraduate education, incorporating progress achieved in educational technology and forma- tive assessment techniques, such as tutoring, check-lists, log-books, etc.

Such developments could be arrested by opting for the ‘final test’ solution of a supra- national Board examination, with the logical prospect of future subsequent compulsory re- licensing examinations in addition.

At present, with the emphasis on free movement of doctors, a wider and increasingly open medical workplace is being created in Europe. Except for the attention given to specialist training in general practice, there has been extraordinarily little emphasis by the EC Medical Directives on improving quality. That is the more remarkable, as already emphasized, when the EC is the only international project in medical education, anywhere in the world, which is regulated by law. The way in which European postgraduate training ought to be nurtured needs to be thoroughly assessed before any implementation of additional community- wide examinations is imposed.

Present tasks

The priorities are clear. The initiative to imple- ment further progress in specialist training must come from the medical profession, and not await additional EC legislation. The EC directives should be revised, particularly the minimum duration oftraining required for mutual recogni- tion. The directives should be modernized, in keeping with the recommendations made over years by the Advisory Committee on Medical Training. The ACMT must continue to exert its influence on member states, to improve the quality of medical education and specialist training. Learning environments have to be nurtured. Educational structures have to be

created which are geared to the future. Trainees for the specialties should in certain respects be required to be more competent than their teachers. New, restructured assessment methods are to be developed and implemented, which will call for and give credit to independent learning. Control of learning at completion of specialist training is unhelpful and can actually be an obstacle; the foremost requirement is for proper attention to the learning and working environ- ment. Specialist examinations are big business. Setting up European specialist examinations of sufficiently high quality will call for intensive investment in testing expertise, derived from such European institutions as the Royal Colleges in Great Britain, or from the National Board of Examiners in the USA.

Europe would appear to have great oppor- tunities at the present stage of development of postgraduate education. Rather than recourse to obvious, inevitably costly, examinations, Euro- pean medical specialists must be educated and validly assessed. One way of raising and gen- eralizing the quality of postgraduate medical training would be to offer European postgra- duate courses regularly at various centres in Europe, with specified goals and programmes. A steering committee could allocate European resources, and make site visits to such designated centres. Attendance at such a postgraduate course should become a requirement for accredi- tation as a medical specialist in Europe (in addition to the national requirements). Such centres could also contribute to provide con- tinuing medical education after specialization, which will be a foremost educational commit- ment in the future.

Another way of assuring quality in post- graduate clinical training could be to establish European accreditation criteria, with provision of site visits to postgraduate teaching hospitals in Europe. Such supranational criteria have also been advocated by the UEMS organization of the EC.