European Journal of Neurology 2001, 8: 381384

NEWS

EFNS Task Force on postgraduate neurological training Survey of the current situation of postgraduate neurological training in Europe
Celso Pontes (Chairman)
In May 1996, the Education Committee of the EFNS appointed a Task Force to examine postgraduate neurological training in the dierent European countries, in order to further development of a core curriculum and guidelines for clinical practice training in this area. The nal aim is to achieve a uniform curriculum for the European Specialty in Neurology. The Task Force was duly set up and a questionnaire was sent with a covering letter from the Educational Committee to all EFNS member societies, the European Board of Neurology and task force members. The questionnaire addressed three main issues. To what extent is neurology considered an important and independent specialty? What is the pre-clinical education in neurology background? How is the postgraduate education performed? Thirty-six countries were included in this survey: Albania, Austria, Belarus, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, UK, Greece, Hungary, Iceland, Ireland, Israel, Italy, Latvia, Luxembourg, Moldavia, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the Ukraine. There were 47 replies from 29 countries. Regrettably, no information was received from seven (Belarus, Bulgaria, Finland, Iceland, Moldavia, Russia and the Ukraine). After receiving the answers, we realized that the questions could have been better formulated. Some were not clear enough and others could be answered in two dierent ways. However, the majority of the repliers were able to overcome these diculties.
Pre-graduate medical education Graduation

Generally speaking, pre-clinical medical education is shorter than the period reserved for the clinical education. The exceptions are Turkey and the Netherlands with four pre-clinical and two clinical years. We do accept, however, that dierent interpretations might be given as to what is understood as pre-clinical and clinical education. As for the duration of the full pre-graduate program, the number of years set for this diers from country to country, ranging from a maximum of 7 years in Belgium, 6 years in France and to a minimum of 4 years in other countries. After that and with the nal evaluation, the student is graduated.
Postgraduate general practice education

Furthermore, the majority of countries have a period of compulsory postgraduate hospital training before a medical graduate can become a fully licensed or certied physician and enter independent clinical practice. This training varies from 1 to 5 years in the Czech Republic, 5 years in Germany and 1 year in the UK, Ireland, Italy, Poland and Romania. This compulsory hospital training is not required in Greece, Hungary, Spain, and Turkey or in Switzerland, although it will be implemented in these countries (Table 1).
Postgraduate specialty education

Analysis of the answers

Neurology as a specialty

Some countries recognize dierent categories of specialists in neurology, and some repliers admitted that, in several countries, there is more than one kind of clinical preparation with a supercial level and a higher sophisticated one. This was the case of the Czech Republic, Estonia, Georgia and Poland (Table 2). Entrance examination requirements In 14 countries, graduates in medicine have to pass an examination before they can begin specialist training, but it is not the case in the other 14. Some of these examinations are the same as those that are taken at the end of the compulsory pre-graduate hospital training before a physician becomes fully licensed to practice. Postgraduate specialty training in neurology is compulsory in every country and although its duration

Neurology is recognized as an independent medical specialty of its own in all countries concerned, although in some, such as Austria and Belgium, it can also be associated with another specialty (i.e. neuropsychiatry). As there are no graduate training facilities in Luxembourg, this country was not included in the group of repliers. Although Luxembourg recognizes neurology as an independent specialty, they have no facilities to give a full training, however, a 1-year postgraduate training is available.

2001 EFNS

381

382

News

Table 1 Postgraduate training in hospital before full registration that allows the right to independent clinical practice/certication after this period Internship Albania Austria Belgium Croatia Czech Republic Denmark nia Esto France Germany Georgia UK Greece Hungary Ireland Israel Italy Latvia Luxembourg The Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland Turkey
a b

Table 2 Entrance examination requirements for specialist training Albania Austria Belgium Croatia Czech Republic Denmark Estonia France Germany Georgia UK Greece Hungary Ireland Israel Italy Latvia The Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland Turkey No No (being changed) Yes Yes No No Yes Yes No No Yes No Yes Yes Yes Yes No No No Yes Yes Yes No No Yes Yes No (being changed) Yes

Number of years 2 3 1 3 5 1,5 2

Examination + + + + + + + +a +b + + )b ) ) + + + + + ) + ) + + ) + )c )

+ + + + + + + +a + + + ) ) + + + + + + + + + + + ) + ) )

2 1

1 5 1 4 3 1,5 1 2 1 3 2 2

It will be not necessary if you enter a post graduate specialty training. Not all answers coincident. c Beginning very recently a compulsory post graduate training of 2 years before certication. + = Yes, ) = No.

Nevertheless, in most countries, lectures are given complementary to clinical practice. Therefore it appear that in most centers, neurology training is unstructured in the sense that it is not guided by set criteria regarding the clinical skills and scientic knowledge that ought to be compulsory if a standard level of competence is to be achieved. Curriculum Germany, Greece, Turkey, Portugal and the UK sent details of a structured curriculum for a postgraduate academic course in medical neurology. No other country did so. Other countries, however, referred to a neurology curriculum: Albania, Austria, Croatia, Georgia (in preparation), Israel (in Hebrew), Italy, Latvia, Norway, Poland, Slovakia, Slovenia, Spain, Sweden and Switzerland. The answers from Czech Republic, Denmark and Hungary were ambiguous as some repliers said there existed a curriculum and others said there did not. In most countries, however, it would appear that there is nothing more than a catalog of minimum requirements regarding abilities and skills. The surveys allow us to think that several countries are in a transition phase to a more organized process in terms of curriculum. The end of the postgraduate training in most countries (62%) is marked by an examination organized either by the national medical association or the

varies from 3 to 7 years, in most it lasts from 5 to 6 years. The shortest period corresponds to the rst degree of specialization that exists in some countries such as Slovakia. The longest referred to was 7 years, as indicated by some countries, but this appeared to include 1 or 2 years of other compulsory postgraduate studies (Table 3). Form of the postgraduate training In most countries, the government and/or the national medical association except for Albania x the form of the postgraduate training. In Sweden, the government has determined the minimum training period to be 5 years but allows it to be more. Maximum time is set to 7 years (Table 4). Almost all countries answered that the training given is both practical and theoretical, although it would appear that all does not implement an organized theoretical course as part of an organized curriculum.

2001 EFNS European Journal of Neurology 8, 381384

News

383

Table 3 Number of years required to be a trained neurologist Albania Austria Belgium Croatia Czech Republic Denmark Estonia France Germany Georgia UK Greece Hungary Ireland Israel Italy Latvia The Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland Turkey
a

Table 4 Form of postgraduate training Practical + organized curriculum Albania Austria Belgium Croatia Czech Republic Denmark Estonia France Georgia Germany UK Greece Hungary Ireland Israel Italy Latvia The Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland Turkey + + + + + + + + + + + + + + + + + + + + + + + + + + + + Practical

4 6 (4 neurology + 1 psychiatry + 1 internal medicine) 5 4 5 (3 + 3)a 7 (51/2)a 3 4 5 2 5 5 4 (now changing for 5 years) 4 5 5 4 6 5 6 5 5 3 (rst degree) + 3 (2nd degree) 3 (in process to be prolonged to 5 years) 4 5 6 4

Dierent responses.

respective government entity. Only in Denmark, Slovakia and Turkey is the examination organized by the teaching hospital alone. The descriptions given of the training programs in each country varied so greatly that it was rather dicult to obtain a global view. Although clinical neurology forms the bulk of all programs, it lasts up to 2 years in the Czech Republic, 3 years in most countries, 4 years in Belgium and Turkey, 5 years in the UK and 6 years in Poland. We also analysed the answers to the question of what sub specialties are considered to be part of the training of the clinical neurologist. From those, clinical neurology is denitely the longest (up to 4 years and between 34 and 36 months for the majority). Psychiatry and internal medicine, neurosurgery and clinical neurophysiology are also frequent. In some countries psychiatry is very much relevant to the curriculum; in others although being an optional choice, it still keeps a specic weight in terms of curriculum. Internal medicine is also a compulsive specialty but in some countries it must be carried out before the training period. In those countries where neurophysiology is obligatory, it is the fourth in terms of the occupied time. Most countries think that

neuropathology and neuroradiology should be part of the curriculum with a training period of several months. Neurosurgery is very important in some countries (6 months compulsive) and optional for others. Pediatric neurology is more requested than neuro-ophtalmology but less than the others previously referred. Psychiatry varies from only 1 month in the Czech Republic to 1 year in Austria and Germany; it is an optional subject in the UK. In the UK, at least 2 years of general internal medicine are required before starting on neurology; in many countries this subject is considered part of the training program and lasts from 3 months, as in Croatia, 6 months in Greece to 1 year in Austria.

Conclusions
This questionnaire show clear evidence that the methods used for Postgraduate Neurology Training vary considerably throughout Europe. The duration of the training, the global context of the curriculum, the requirements regarding the control, denition and supervision of the training itself are widely diverse from one country to another. This variability reects not only the dierences in pre-graduate education and, consequently, in the way

2001 EFNS European Journal of Neurology 8, 381384

384

News

young physicians are trained, but also the medicalneurological needs of each country (1). Therefore, each country ought to be permitted to dene the methods it wishes to apply to its training of neurologists, in view of its respective needs. Nevertheless it is important that minimum training and competency requirements are set, so that neurologists from dierent countries may move freely within Europe and that their competency can be accepted on an equal basis whether they do so as trainees or as practising physicians. That is our next task.
Task Force on Postgraduate Neurological Training Recommendations

Acknowledgement
The Task Force wishes to thank the following colleagues for their assistance in gathering this information: Albania Prof. Jera Kruja; Austria Prof. Kurt Jellinger, Prof. Wolfgang Grisold; Belgium Prof. Schoenen, Prof. Francis Jaumoulle; Croatia Prof. Dubravko Bozicevic; Czech Republic Prof. Pavel Kalvach, Prof. Zdenek Ambler, Prof. Otakar Keller; Denmark Prof.Per Soelberg Srensen, Prof. T.E. Kennedey, Prof. Per Hu bbe; Estonia Prof. Elmar Kaasik; France Prof. J.Y. Delattre, Prof. B. Grosshans; Germany Prof. Reinhard Hohlfeld, Prof. Hanns C. Hopf, Prof. Bertold Schalke; UK Prof. A. Hopkins, Prof. Richard Godwin Austen, Prof. Charles Warlow, Prof. Peter Humphrey; Greece Prof. Panagiota Dava zsef Czopf, ki, Prof. Joannis Milonas; Hungary Prof. Jo Prof. Imre Szirmai; Ireland Dr Hugh Stauton, Prof. R. Galvin; Israel Prof. N. Gadoth; Italy Prof. Antonio Federico; Latvia Prof. Gertrude Enina; Luxemburg Dr Alexandre Bisdor; The Netherlands Prof. J. Troost Norway Prof. Joan Aarli, Prof. Svein I. Mellgren; Poland Prof. Teofan M. Domzal; Portugal Dr Celso Pontes; Romania Dr Carolina Gubavu; Slovakia Dr Lubomir Lisy; Slovenia Prof. Anton Mesec, Prof. David Vodusek; Spain Prof. Portera Sanchez, Prof. Rafael Blesa; SWEDEN Prof. J. E. Olsson, Prof. Laas Forsgren, Prof. Hakan Lundth; Switzerland Prof. C.W. Hess, Prof. Ju rg Kesseelring; Turkey Prof. Rana Karabudak, Prof. Tulay Kansu; Georgia Prof. Janelidze Marina. E.F.N.S. Task Force on Postgraduate Neurological Training Celso Pontes (Dr), Chairman Members invited: Wolfgang Grisold (Prof), Eugeni I Gusev (Prof), Zdenek Ambler (Prof), Tulay Kansu (Prof), Jean-Yves Delattre (Prof), Peter Humphrey (Prof), Hakan Lundh (Prof), Hess (Prof), Boghdan (Prof).

1 Neurology must be recognized as an independent medical specialty. 2 Neurological postgraduate training facilities may be restricted to accredited training institutions according to medical national organization rules and following the recommendations of the European neurological representative organizations (e.g. EBN/UEMS, EFNS.). 3 A neurological core curriculum for general professional training must be considered. 4 A neurological core curriculum for postgraduate training must be implemented by all countries in order for the training neurologist to achieve competence to pre-dened objectives including solid clinical skills and experience in some of the neurological sub specialties. 5 Training in neurology should be in two or more centers. Training abroad should be possible by harmonization of the curricula. 6 Postgraduate curriculum must be mostly clinical training but also complemented by a program including Basic Neuroscience and Neurological sub specialties, Neurological Research and Legal and Ethical Issues in Neurology. 7 A minimum training period of 5 years is recommended with no less than 50% of that time on clinical neurology. Adequate time will be spent in psychiatry, neurosurgery and internal medicine and also clinical neurophysiology, neuroradiology and neuropathology. One year is available for options such as research, child neurology, neurological rehabilitation, etc. 8 A training record must be maintained for accreditation on the specialty. 9 Supervisor(s) are responsible for each of the training period(s) to approve the program of postgraduate training.

Reference
Hopkins A, Grisold W (1994). Neurological manpower and training in Europe. J Neurol 241:119124.

2001 EFNS European Journal of Neurology 8, 381384