| J.A. GRUWEZ* **
* Prof. Emeritus K.U.L. – Former Chairman of Surgery,
Academic Hospital, Leuven – Honorary President of the European Board of
Surgery – Member of the Management Council UEMS.
** Lecture delivered at the Euro China Centre for
Business Cooperation in Brussels, on Friday 19 Augustus 2005.
EUROPE – MUTUAL RECOGNITION
The European Union is an institutional framework for the construction of
a United Europe. Since May 1, 2004, this construction has been enlarged to
25 countries and a population of 450 million. A comparison of the situation
before the enlargement shows that the Europe of 15 already largely exceeded
the U.S. and Japan populations. The gross domestic product in 2001 however
was still lower than the Japanese and American G.D.P.
The percentage of the G.D.P. devoted to health-care is in Europe (8,9 %)
slightly more than in Japan (7,8 %), but considerably lower than in the
United States (13 %). The Public percentage of health expenditure per capita
is much more important in Japan (78 %) and in Europe (73 %) than in the U.S.
(44 %).
In 1975 the E.C. Directive 75/362 was issued, establishing freedom of
migration for (u.m.) medical doctors and equivalence of certificates,
diplomas and recognitions by the national competent authorities. The opening
of borders and the mutual recognition of professional medical degrees
necessarily led to the introduction of some European regulations with the
aim of creating a certain degree of harmonisation.
THE SPECIALITIES
However these regulations mentioned essentially nothing but the
specialities that were recognised and the minimum length of training.
17 specialities are recognised in all member countries with a minimum
training-length of 5 years (general surgery, orthopedics, neurosurgery,
urology, plastic surgery, internal medicine), with a training-length of 4
years (OBGYN, respiratory medicine, neurology, psychiatry, histopathology,
pediatrics, clinical radiology, oncology-radiotherapy), or with a
training-length of 3 years (anesthesiology, ORL, ophtalmology). Further 35
specialities recognised in at least 2 member countries with training-lengths
of 5, 4 and 3 years again.
Minimum 5 year training: cardiothoracic surgery, vascular surgery,
pediatric surgery, gastro-enterological surgery, accident and emergency
surgery, maxillo-facial surgery, neuropsychiatry. Minimum 4 year training:
clinical biology, biological haematology, microbiology-bacteriology,
chemical pathology, immunology, cardiology, gastro-enterology, rheumatology,
general haematology, radiology, tropical medicine, child psychiatry,
geriatrics, nephrology, infectious diseases, public health medicine,
clinical pharmacology, occupational medicine, dental oral and maxillo-facial
surgery, clinical neurophysiology, nuclear medicine. Minimum 3 year
training: dermato-venereology, allergology, endocrinology, physiotherapy,
stomatology, general haematology.
These minimal lengths of training were from the beginning very low in
comparison to the standards of countries like Great-Britain, Belgium,
Holland, Germany. The fact that, despite the intense efforts of the European
Professional Organisation of Specialists (UEMS), of which we will speak
later, the E.C. (European Community) did not follow the recommendations for
actualisation of these figures, sufficiently proves that the Community (and
the Council of Ministers) had little or no concern for the intrinsic quality
of the training.
Table … is not up to date, but it shows clearly the disparity in
nationally recognised medical specialities in the European Countries.
Obviously this is a major handicap for the harmonisation of specialised
medicine in Europe.
EUROPEAN TRAINING SCHEMES
Not only is there a difference in numbers of specialities in each
country, or a difference in length of the training, but trainingschemes have
different outlines. As an example we will comment on the Surgical Training
Programmes.
The British scheme starts with 2 foundation-years after graduation as
doctor, focusing on a broad range of clinical skills and interpersonal and
management skills. They are followed by 2 basic surgical training-years
during which the candidate specialist is familiarised with the generalities
in Surgery and the basic surgical skills.
Next come years 1 to 3 of the Higher Surgical Training with continuous
and end of year assessments, where level 1 of procedures (varicose veins and
inguinal hernia) has to be reached, followed by year 4 to 6 of H. S. Tr. (Higher
Surgical Training) and level 2 and 3 of procedures and again continuous and
end of year assessments. A portfolio of satisfactory assessment of technical
skills leads to the Certification of Completion of Specialist Training (C.C.S.T.).
(Total of 10 years after graduation).
The French system implies a competitive entrance examination (Internat)
at the end of Medical School (40 % get Internes des Hôpitaux) and the choice
of a Speciality and the city where to train, according to the rank in the
examination. The first part is a 3 year surgical residency training (=
Commun Trunk = Diplôme des Etudes Spécialisées) leading to a Diploma in
General Surgery. The 2nd part is again 3 years in an area of specialisation
(Digestive – Orthopedic – Vascular Surgery, etc.) providing a Diplôme d’Etudes
Spécialisées Complémentaires. Another year is needed before, at the end of 7
years, the title of “Ancient Chef de Clinique Assistant” is obtained, giving
access to 2 possibilities:
1. Private practice
2. Academic career ( a “Diplôme d’Etudes Approfondies” is needed and
obtained via a 2nd competitive examination).
The German System resulted from a reorganisation of the Training and of
the Surgical Specialities in 2003, due to the efforts of the German Society
of Surgery (Deutsche Geselsschaft für Chirurgie) and the Berufsverband der
Deutsche Chirurgen (BDC: German Surgeons Professional Association) and its
President: the late Professor Jens Witte, also, at that time, President of
the UEMS-Section of Surgery. 8 Surgical Specialities were recognised and
brought together in one Surgical Entity: 1) General, 2) Trauma and
Orthopedic, 3) Vascular, 4) Thoracic, 5) Abdominal, 6) Plastic, 7) Pediatric
and 8) Cardiac Surgery. After graduation the candidate enters a 2-year
Common Trunk of Basic Surgery at the end of which a Voluntary Exam is
possible. The 3rd year can be spent according to the preference of the
candidate (eventually in a neighbouring speciality). Then follows the
Subspeciality Specific Training during 4 years and a final Board Certifying
Exam. The total length of the training is 7 years.
These examples sufficiently illustrate the specificity of each national
system.
"In some countries postgraduate training is long and includes so much
practical experience that it is possible to obtain a senior post in a
hospital, or establish a private practice immediately after receiving a
specialist diploma. In other countries a specialist diploma only makes the
physician eligible for an intermediate post in a hospital." (Recommendations
of the ACMT).
RESPONSIBLE AUTHORITY
Here again we must experience differences. In many Southern Countries
(France, Italy, Spain) the Medical Faculties are responsible for the
postgraduate speciality training. In the Northern Countries the Profession
plays a major role in the postgraduate education: the Royal Colleges in the
U.K. and Ireland, the Professional Organisations in the Netherlands, Germany,
and partly in Belgium.
In other countries, the Ministry of Health is responsible.
Besides the minimal European requirements there is thus a great disparity
in selection, duration, the equation Basic / Higher Training, the core
content, the assessments, the balance between theory and practice, the use
of a logbook or a catalogue, etc, etc…
STATE OF TRANSITION
On the other hand training in Europe can be regarded as in a state of
transition.
The changes are driven by the changes in lifestyle, the ever increasing
feminisation, more and more stringent requirements (reduction of learning
curve just like for air-pilots), the quality expectations of the population,
also through a number of regulations of the European Union like the Working
Time Directive and the Court decision on the “on call” time, and evidently
the considerable development of technology.
HARMONISATION
40 years ago one of the aim of the UEMS was already to harmonise the
criteria and the training in Europe. Despite great efforts this only partly
succeeded. Reasons for this are:
1. The lack of concern of the individual member countries for adapting
their systems and for avoiding national modifications that do not match with
the European consensuses of the profession.
2. The insufficiency or even absence of European regulations beyond the
simple definition of the length of the training, without reasonable concern
for the content of it.
WORKING HOURS DIRECTIVE
A word about the European Directive on Working hours (Dir. 93 / 104 E.C.
23 nov. 1993; modif. by Dir. 2000 / 34 / E.C. 22 june 2000) requiring a
daily rest time of 11 hours - 1 rest day in 7 – a weekly working time of
maximum 48 hours and allowing the possibility of working with
reference-periods, and also about the point of view of the European Court of
Justice that “time during which the employee is obliged to be present at the
workplace” is to be considered as working time.
These regulations have been at the origin of difficulties everywhere, are
taken seriously in some and much less in other countries, but are mostly
considered as having a negative impact on the experience of the trainees.
The authorities should at least provide means to exempt trainees from
administrative and non-clinical assignments if they want to impose this
reduction of working time.
CME, CPD, PEER REVIEW, QUALITY ASSURANCE and CONTROL
15 years ago the quality concept, already popular in the industry invaded
medicine. What was considered part of the ethical obligations in medical
practice, namely lifelong learning, retraining, keeping abreast of
development, had now to be proven and demonstrated to the authorities and
the public. Belgium was among the earlier countries in Europe to follow this
trend. A system was set up, on a voluntary basis , granting several smaller
financial advantages to the "Accredited doctors". Each year a number of
credits must be acquired by following courses or attending scientific
activities. Membership of a local group for evaluation of medical practice
(Loc's) where Peer review is performed on the own practice of medicine or
surgery of the members is mandatory.
Similar Systems are currently applied in the different European
countries. In some CME is compulsory and in some (e.g. Netherlands) the
principle of Recertification every 5 or 7 years has been introduced. As
already mentioned the UEMS and its European Accreditation Council for
Continuing Medical Education play an increasingly important role, in close
collaboration with the CME authorities of the different European countries,
in assessing and securing the quality of CME on the European level.
UEMS - MANAGEMENT COUNCIL - SECTIONS - BOARDS.
In 1958, one year after the treaty of Rome, medical specialists from the
then 6 members countries of the European Economic Community (EEC) formed the
UEMS (European Union of Medical Specialists). The UEMS created Specialist
Sections in 1962 and European Specialty Boards in 1990-1991 (being the
working groups of the Sections, to deal with the problems of training,
continuing medical education and professional development, Peer-review and
quality assessment). The UEMS is a professional specialist organisation on
European level with the aim of defending the professional interests of
European Medical Specialists. In its Management Council each national member
organisation is represented by two delegates which elect an Executive
Committee. Each of the currently 36 Speciality–Sections and Boards are
equally composed of representatives of the different professional specialist
organisations in each member-state. Some years ago the M.C. (Management
Council) created Working Groups for Postgraduate Training, Relations with
the Section , Relations with patients, Patient Care, CME and CPD, Specialist
practice and the UEMS Website. During the last fifteen years several
Charters and Position Papers have been issued by the UEMS which have served
as benchmarks for European and national systems: the Charters on
Postgraduate Training, on CME – CPD, on Quality Assurance , on Visitation of
Training Centres, on Autonomy of Specialist Practice. Five Years ago the
European Accreditation Council for CME (EACCME) was set-up, in line with one
of the commitments of the UEMS which is to promote the free movement of
Doctors in the EU.
This body ensures the recognition of CME activities at European and
international levels and allows European Doctors to follow high-quality CME
activities around the world. It is meant as a clearing-house providing a
European approval for national or international CME – activities.
The UEMS is not an official body of the European administration. It is
mainly acting by lobbying in the E.C. – circles and with the national
authorities of the member states through its national delegates. The
influence of the UEMS has steadily grown. Pierre Pouyaud, Honorary President
of the UEMS, declared in 1983, at the 25th anniversary of the UEMS : "At the
end of this quarter of a century I can state that the UEMS is the
uncontested representative with the greatest audience of the medical
specialists in the X countries." As of today, 22 years later, with many more
member organisations from the 25 countries of the Union and a streamlined
structure, it is not presumptuous to qualify it as one of the strongest
medical organisations in Europe.
THE RELATIONSHIP BETWEEN G.P.'S AND MEDICAL SPECIALISTS
IN EUROPE AND BELGIUM
One of the respects in which the health-care systems operating in EU
member states differ is in term of the organisation of primary care.
Nevertheless, to a certain extent, all EU countries have primary care with
broadly similar characteristics: relatively good access, a generalist
profile, continuity of care and multidisciplinary cooperation.
Significant points on which differences exist are the presence or absence
of obligatory patient registration with a general practitioner and the
gatekeeper role of primary care. Promotors of this latter system pretend
that international comparative research has indicated that health-care
systems that have a stronger primary care system are more effective and more
efficient than those that do not.
Europe’s health-care systems may be divided into two broad groups on the
basis of the role played by the state in funding care. On the one hand the
national health service systems, or “State systems”, funded by taxation.
Such states are Denmark, Finland, Italy, Greece, Portugal, Spain, the UK and
Sweden. In the other systems health-care is treated as a form of social
security and funded by contributions (or premiums). This is the case in
Austria, Belgium, France, Ireland, Luxemburg and the Netherlands.
East European countries, where the Soviet System prevailed until 89,
migrate to Social insurance systems at different speeds.
Two typical characteristics of the state systems (but also of the Dutch
system) are the gatekeeping and the definition of the “first line”.
Gatekeeping means that direct access to the specialist is not possible.
The notion or definition of “first line” should be such that in Belgium f.e.
it would encompass the more than 7000 extramural specialists who work
outside the hospital and are directly accessible for the public.
The Belgian Health-care System is characterised by the free choice of
doctor, freedom of therapy, fee for service and personalised medicine.
Inquiries organised by 2 Sickfunds indicated that:
1. more than 85% of the Belgian population requires free access to the
specialist.
2. free access tot the specialist is not more expensive for the
health-care system.
Scientific studies indicating the dangers of diagnostic delay in the
gatekeeping system must be taken equally into account.
For all these reasons we Specialists, in Belgium, stand for an equal
independent position of both the General Practitioner and the Specialist. We
believe in a carefully thought out relationship between the G.P. and the
Specialist, with mutual respect and a well developed briefing-debriefing
system where the specialist expects an informative message from the G.P., if
it concerns a referred patient, and where the specialist would provide a
report to the G.P. of the patient, even if the patient has not been referred
to him.
CONCLUSION
Hopefully this realistic picture of a number of features of specialist
medicine in Europe and Belgium indicates that reshaping the Old Continent
with its numerous countries, regions, languages and deeply rooted customs is
a gigantic task. Clearly Europe can not yet be compared to a uniform piece
of cloth but is rather to be considered as a pleasant patchwork.
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