Neurology residency training in Europe the current situation

European Journal of Neurology 2011, 18: e36 e40 EFNS FORUM doi:10.1111/j.1468-1331.2010.03219.x Neurology residency training in Europe the current situation W. Struhal a,b,c, J. Sellner a, V. Lisnic b,l.vécsei b,e.müller d and W. Grisold c a European Association of Young Neurologists and Trainees (EAYNT); b Education Committee, EFNS; c European Union of Medical Specialists/European Board of Neurology (EBN); and d European Federation of Neurological Societies (EFNS) Keywords: European residency, manpower, neurology education, neurology residency, postgraduate education Received 14 August 2010 Accepted 24 August 2010 Introduction: Little is known about neurological training curricula in Europe. A joint approach by the European Federation of Neurological Societies (EFNS), the Union of European Medical Specialists/European Board of Neurology and the European Association of Young Neurologist and Trainees was established to explore the spectrum of neurology training in Europe. Methods: In 2006, a questionnaire-based survey on neurology curricula as well as demographic data was designed by WS and WG and distributed by the EFNS to the national delegates of the EFNS, which comprises all European countries and Israel. Results: By 2009, delegates from 31 of 41 countries (representing 76% of 505 million) had returned the questionnaire. A total of 24 165 specialists (46% women) were registered in the 31 countries. This corresponds to an average of 6.6 neurologists per 100 000 inhabitants (range 0.9 17.4/100 000 inhabitants). Duration of training in Europe was on average 4.8 years, ranging from 3 to 6 years. The number of residents interested in neurological training exceeded the amount of available training positions. Performance of neurological trainees was regularly assessed in 26 countries (84%), usually by recurrent clinical evaluation. Board examinations were held in 24 countries (77%). Considerable differences were also found in manpower (0.9 17.4 neurologists/ 100 000 inhabitants) and working conditions (e.g. average weekly working hours ranging from 30 80 h/month). We found a significant positive correlation between manpower and theoretical training hours. Conclusion: Considerable differences exist in training curricula of European countries. These data might provide the basis for European training and quality assurance initiatives. Introduction The European Union (EU) includes 27 countries with 500 million citizens [1]. It has harmonized a single market with free movement of citizens, goods, services and finances. Despite many efforts of political, economical and social integration, EU member countries still have different educational standards. Differences in national neurology curricula were reported previously [2,3]. Pontes [4] demonstrated in 2001 extensive divergence of national residency training in neurology. Yet, once qualified in one European country, neurologists are licensed to work within all countries of the EU. Therefore, training standards and minimal training requirements are necessary and consequently, a European core curriculum was presented in 2005 [5]. This study aimed at characterizing the status quo of neurology residency training in Europe. We collected data on pregraduate and postgraduate training as well as working conditions during residency. Furthermore, we evaluated manpower to search for possible relations between the number of trained neurologists and training conditions in a given country. We suggest that analysing the differences in neurological educational programmes is the first step in the attempt to adjust quality standards for neurological training within the EU and hence improve neurological care in Europe. Correspondence: Dr. W. Struhal, General Hospital of the City of Linz, Krankenhausstr. 9, A-4020 Linz, Austria (tel.: +43 732 7806 73 347; fax: +43 732 7806 74 6866; e-mail: walter.struhal@akh.linz.at). Methods A questionnaire-based survey on European neurology curricula and conditions of residency training was e36 European Journal of Neurology Ó 2010 EFNS

The European perspective on training e37 carried out in the period from 2006 to 2009 with assistance of the Education Committee of the European Federation of Neurological Societies (EFNS). EFNS delegates of 41 European countries and Israel received the survey forms with 79 questions. The survey was divided into different parts including (i) national demographic data (six questions) and manpower, (ii) pregraduate school training (five questions), neurology training (62 questions) and (iii) exchange of trainees (four questions). Correlations were tested employing PearsonÕs correlation coefficient (SPSS Ò, SPSS Inc., Chicago, IL, USA; P < 0.05 was considered significant). Results By 2009, 31 of 41 delegates (76%) had completed and returned the survey. The major findings are presented in Table 1. Manpower The prevalence of board-certified neurologists in Europe is 6.6/100 000, ranging from 0.9 in United Kingdom to 17.4 in Georgia. Forty-six per cent of all neurologists were women. Italy has the lowest share of female neurologists (10%), whereas in Georgia, women are very well represented amongst neurology specialists (82%). On average, male neurologists in Europe retire at the age of 65, 2 years later than female neurologists. Employment is hospital based for 63% of all boardcertified neurologists. In nine countries (Belgium, Georgia, Greece, Iceland, Italy, Latvia, Moldova, Romania and Slovak Republic), only a minority of neurologists are hospital based. Whilst unemployment of neurologists is non-existent in most European countries, Greece (17%, 200/1200), Italy (10%, 350/ 3500), Latvia (12%, 34/274) and Moldova (16%, 50/ 320) have rather high rates of unemployed neurologists. Table 1 Data excerpt showing key details on manpower and training Country n/100 000 National training National training inhabitants programme structured Duration of training (years) Training in neurology (months) Structured teaching Obligatory logbook Rotation Assessment Total Board working examination hours Albania 2,9 * * 4 33 * * 60 Austria 9,6 * * 6 48 * * * 48 Belgium 6,5 5 60 * * * * 40 Bulgaria 11,7 * * 4 29 * * * 30 Croatia 6,2 * * 4 42 * * * * 40 Czech Republic 6,3 * * 5 51 * * * * * 43 Estonia 9,4 * * 5 25 * * * * * 40 Finland 6,3 6 48 * * 38 Georgia 17,4 * * 4 44 * * * * * 80 Germany 5,5 * * 5 36 * * * 40 Greece 10,9 * 5 36 * * * 39 Hungary 6,0 * * 5 42 * * * * 40 Iceland 6,5 5 48 * 40 Israel 4,7 * 5 42 * * * * 45 Italy 5,9 * * 5 30 * * * * 38 Latvia 12,0 * * 5 44 * * * * 40 Lithuania 8,9 * * 4 24 * * * * * 40 Luxembourg 4,6 4 48 Moldova 7,2 * * 3 24 * * * * the Netherlands 4,7 * * 6 * * * * 48 Norway 7,7 * 5 42 * * * * 38 Portugal 3,4 * * 5 24 * * 42 Romania 4,4 * * 5 36 * * * * 35 Serbia 4,3 * * 5 48 * * * * 35 Slovenia 4,2 * * 6 48 * * * * 40 Slovak Republic 12,5 * 5 46 * * * 40 Spain 4,4 * * 4 36 * * 56 Sweden 3,8 5 36 40 Switzerland 5,2 * * 6 36 * * * * 50 Turkey 2,0 * * 5 60 * * * * * 45 UK 0,9 * * 5 60 * * * * * 40

e38 W. Struhal et al. Pregraduate training The mean number of the annual students admitted to Medical school was 1352 (range 45 in Iceland 8900 in Germany). The mean number of hours of neurology training in pregraduate education was 114. Spain had the shortest (20 h) and Hungary the longest pregraduate neurological training (240 h). Neurology training Twenty-six countries reported to have a national training programme. A formal structure with timing and sequence of the training programme was reported in 22 countries. In 10 countries, a period of training at a university hospital is obligatory, whilst in nine countries, residents can choose to have their training at either academic or non-academic institutions. In 12 countries, neurology training is only offered at academic hospitals. Structured teaching was part of the curricula in 19 countries, a logbook was mandatory in 20. Details on outpatient training were reported from 26 countries. In countries in which the majority of neurologists are hospital based, residents have on average 32% of their training as outpatient training; in countries with a predominance of office-based neurologists, the equivalent figure is 36%. Training of special skills was assessed in the questionnaire as well. Three possible choices were given: Ôno trainingõ, Ôbasic trainingõ and Ôpractical trainingõ. Practical training was offered in all countries for stroke, extrapyramidal disorders, epilepsy and multiple sclerosis. Training within dementia was available in 23 of 31 countries, neuromuscular und spinal diseases in 28, neuroinfection in 26, neurotrauma and neurooncology in 19, genetic disease in 18, neurointensive care in 17, neurogeriatics in 14, neuroethics in nine and neuropalliative care in eight countries. Hands-on skills were assessed again by three choices: Ôno skillsõ, Ôbasic skillsõ and Ôpractical skillsõ. Practical skills were reported for lumbar puncture in 29, evaluation of CT and MRI scans in 19, scales and scores 14, EEG in 11, NCV and EMG in 10, cerebrospinal fluid diagnostics and ultrasounds in 8, intrathecal treatment and genetic counselling in 7, neuropsychology in 6, in autonomic nervous system investigations and speech trainings in 3 and botulinum toxin in 2 countries. Evaluation of training is available in 24 countries. Board examinations are held in 24 countries; these include written tests (nine countries), multiple choice questions (11) and oral examinations (19). Seventeen countries reported obligatory hospital rotation in their curricula. Internet access (at work) is regularly available for trainees of 29 countries (but not in Romania and Georgia). Libraries with neurological journals can be frequented on-site by residents in 27 countries, and text books are available in 26 countries. Twenty-five countries reported a structured proceeding for resident selection; residents were selected in 11 countries by means of an entrance examination, in 11 countries by interview of university or hospital representatives and in three countries by both. The general availability for residency positions in neurology was reported from 20 countries. There are not enough training positions available. On average, there are two applicants competing for one training position. Finland, Germany, Slovenia and Slovak Republic have as many applicants as training positions; in contrast, Greece reported 15 applicants per training position. Mean duration of training was 4.8 years, ranging from 3 years in Moldova to 6 years in Austria, Finland, the Netherlands, Slovenia and Switzerland. Residents had on average 41 months of obligatory neurology training (24 in Moldova, Lithuania, Portugal, 60 in Belgium, Turkey, United Kingdom). Average working hours for residents were 43/week (30 h in Bulgaria to 80 h in Georgia), of these, 33 h were spent with the patient (20 h in Italy and Bulgaria, 55 h in Albania), 7 h with theoretical training (1 h in Belgium, 24 h in Georgia) and 4 h per week were spent with science. There was a significant positive relationship between number of neurologists/100 000 inhabitants and theoretical training hours (P = 0.029). According to their national curriculum, on average, 2.4 night shifts per month were obligatory. No requirement for night shifts was reported from Italy, the Netherlands, Romania, Serbia and Switzerland. Residents had to do on-call duties in 19 countries. In 29 countries, the resident was on the payroll of the hospital or University. In Georgia, residents were obliged to cover the expenses of their training by themselves. Congress attendance was financially supported in 24 countries. A small number of residents went abroad each year (on average, 12 residents per country, most often the destination is within Europe or the United States). The majority went abroad for further education, about 1/5 for job opportunities or to improve income. Discussion Basic data on training curricula and working conditions of neurology residents and neurologists in 31 European countries comprising 505 million inhabitants were evaluated. Various differences with regard to practical training, hands-on training and training evaluation in

The European perspective on training e39 this study shed further light on the diversity of medical work and training in Europe. Indeed, neurological training and certification procedures differ amongst countries and are likely to reflect local needs and medical practice. These data indicate differences in extent and contents of training and may be considered by residents to value their national training curriculum. Of note, the findings of this study were retrieved by evaluating Ôsoft dataõ [6], i.e. information provided by national delegates of the EFNS, not national administrative bodies. However, these individuals occupy key roles in their national neurological society; hence, information provided by the delegates is based on their best knowledge and therefore most likely reliable. Manpower Board-certified neurologistsõ differences of 0.9/100 000 inhabitants to 17.4/100 000 inhabitants are remarkable. There is no ideal manpower ratio for neurology to date. Indeed, Europe has the highest neurologists manpower worldwide [7], in Eastern Europe even higher than Western Europe [8,9]. Significantly more theoretical training was offered to residents in countries with higher manpower. Whilst the reasons for this relationship are unclear, one might speculate that in countries with higher manpower, more time resources are available for teaching. Training Neurology has been increasingly implemented into modern medicine. This is also recognized by young doctors and on average, there are two doctors competing for one training position. Stroke and epilepsy are amongst the most common neurological diseases in Europe, and cognitive disorders are well represented. Also interdisciplinary work in stroke, internal medicine, neurooncology etc. becomes increasingly important. Despite the importance of neurology, presently, European curricula are far away from being harmonized to European standards. Concerning the duration of training, only five countries fulfil recommendations of training duration given by the Union of European Medical Specialists (UEMS) [10]. Apart from core competencies such as stroke, extrapyramidal diseases, epilepsy and MS, there is a wide variety on different training content, training framework, accessibility and assessment. This raises the question on quality assurance on European training. An important measure for quality assurance is examinations, which are introduced in 77% of the countries. To improve not only national but European training standards, the adoption of a standard recognized exit examination would be favourable. The Union of European Medical Specialists/European Board of Neurology (UEMS/EBN) examination potentially meets this aim. The examination was recently introduced to set standards and assurance for neurology training. It is currently a non-obligatory examination that has no legal standing (apart from Austria, where residents may currently replace the national examination by the European examination). Furthermore, recently UEMS/ EBN introduced a visitation programme, which might serve as quality assessment of individual training sites. The anticipated migration during residency because of training reasons has not started yet [11]. We can only speculate about possible causes, but divergence of training curricula may play a leading role. We did not take into account migration after residency, which might be more common, but no data are available. Working conditions There are national differences in working conditions and night shift obligations. Working hours vary considerably. Within the European working time directive, this might be subject to extensive changes. In summary, training of neurology residents in Europe varies widely with respect to manpower, training and training framework. However, whether varying curricula lead to different quality standards needs to be determined by future evaluations and are a critical issue for harmonization of European training curricula. This survey provides an insight into similarities and differences between national curricula, and may be an important aid for advancing harmonization of postgraduate education of neurology in Europe. Acknowledgement The authors thank the EFNS national delegates for completing this extensive questionnaire. References 1. First demographic estimates for 2009. http://epp.eurostat.ec.europa.eu/cache/ity_offpub/ks-qa-09-047/en/ KS-QA-09-047-EN.PDF 47.2009. 2. Reilly CE. Communications of the European Neurological Society. J Neurol 2000; 247: 582 586. 3. Facheris M, Mancuso M, Scaravilli T, Bonifati DM. Neurology residency training in Europe: an Italian perspective. Lancet Neurol 2005; 4: 258 262. 4. Pontes C. EFNS Task Force on postgraduate neurological training Survey of the current situation of post-

e40 W. Struhal et al. graduate neurological training in Europe. Eur J Neurol 2001; 8: 381 384. 5. Pontes C. Recommended core curriculum for a specialist training program in neurology. Eur J Neurol 2005; 12: 743 746. 6. Adler RH. Hard and soft data: a semiotic point of view. Schweiz Med Wochenschr 2000; 130: 1249 1251. 7. Janca A, Aarli JA, Prilipko L, et al. WHO/WFN Survey of neurological services: a worldwide perspective. J Neurol Sci 2006; 247: 29 34. 8. Bergen DC. Training and distribution of neurologists worldwide. J Neurol Sci 2002; 198: 3 7. 9. Lisnic V, Grisold W, Mu ller E. Manpower of neurologists in the post-socialist countries of Central and Eastern Europe. Eur J Neurol 2008; 15: e94 e98. 10. European Training Charter for Medical Specialists, UEMS 2007. http://admin.uems.net/uploadedfiles/872. doc. 2007. 11. Grisold W, Galvin R, Lisnic V, et al. One Europe, one neurologist? Eur J Neurol 2007; 14: 241 247.