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Pediatric otorhinolaryngology anno 2008: Towards European standards for training?
International Journal of Pediatric Otorhinolaryngology 73 (2009) 839–841
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric otorhinolaryngology anno 2008: Towards European standards for training? Carel Verwoerd a,*, Patrick Froehlich b, Danuta Gryczynska c, Gabor Katona d, Anne Pitkaranta e, Alec Blayney f a
Department of Otorhinolaryngology, Erasmus MC, Erasmus University, Rotterdam, The Netherlands Department of Otorhinolaryngology, Hopital E. Herriot, Lyon, France Department of Otorhinolaryngology, University Medical Hospital, Lodz, Poland d Department of Otorhinolaryngology and Bronchology, Heim Pal Hospital for Sick Children, Budapest, Hungary e Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland f Department of Otorhinolaryngology, Children’s University Hospital, Dublin, Ireland b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 January 2009 Received in revised form 19 February 2009 Accepted 19 February 2009 Available online 25 March 2009
The Union Europe´en des Me´decins Spe´cialistes (UEMS) has been promoting harmonization of specialist training programs in Europe. Anticipating a future contribution to a European standard for training specialists for tertiary care of children with otorhinolaryngology (ORL)-related problems this Round Table was organized by ESPO. The presentations refer to six European countries. The number of ORL specialists (including pediatric ORL specialists) appeared to vary from 8 to 1 per 100,000 inhabitants, suggesting significant differences as far as their contribution to health care is concerned. Numbers for pediatricians vary from 12 to 3 and for family doctors from 50 to 100 per 100,000. In two countries pediatric ORL has the status of an official sub-specialty for tertiary care, requiring at least 2 years of additional training for qualified ORL specialists. In three other countries specific centers for pediatric ORL are present, although the sub-specialty has no official status. In the last a center for pediatric otorhinolaryngology has not yet been established and facilities for training in pediatric ORL are not available. For each country various aspects of current practice of tertiary ORL care for children are presented. It is concluded that a European standard for pediatric ORL could be most useful, if it would not only refer to current diagnostic and therapeutic skills but also to relevant scientific knowledge and skills. However, it should be recognized that the relevance of today’s standards is restricted, as medicine and medical technology are rapidly developing. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric otorhinolaryngology Specialist training ORL specialisation European standards
1. Towards European standards? Since the early fifties of the 20th century pioneers in pediatric otorhinolaryngology (ORL) were active in European countries like Italy, Poland, Hungary, Czech Republic, Slovak republic, England and France. A review in 1996 including 28 European countries demonstrated substantial differences concerning the number of ORL specialists per 100,000 inhabitants and the professional status of Pediatric ORL [1]. Similar figures were published in 2005 [2]. Since harmonizing specialist training programs within the European Union has been promoted by the Union Europe´en des Me´decins Spe´cialistes (UEMS), the ORL-HNS section of this organization published a list of diagnostic and therapeutic (surgical) techniques, which should be required for general otorhinolaryngologists in all European countries. Later an ‘ad
* Corresponding author. Tel.: +31 10 521 8380. E-mail address: [email protected] (C. Verwoerd). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.02.018
hoc’ subcommittee chaired by Alec Blayney (Ireland) presented a preliminary ‘‘overall skeleton plan for training in Europe in pediatric ORL’’ to be altered, expanded or significantly changed, depending on the academic input of the European Society of Pediatric Otorhinolaryngology (ESPO). Anticipating a contribution to this project ESPO organized a Round Table to discuss pediatric otorhinolaryngology, as currently practiced and managed in six countries and representative for various parts of Europe, at the 8th International Conference of ESPO in Budapest, June 2008. 2. Medical professionals involved in care for children with ORL problems: quantitative aspects Family doctors, pediatricians, general ORL specialists and pediatric ORL specialists may contribute to medical care for children with ORL-related problems. The number of ORL specialists per 100,000 inhabitants appeared to vary from 7.7 in Hungary, 7.1 in Poland, 6.2 in
C. Verwoerd et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 839–841
840
Table 1 Number of ORL and pediatric ORL specialists, pediatricians and family doctors per 100,000 inhabitants.
Hungary Poland Finland France Netherlands Ireland a
ORL
PedORL
Ped
FamDr
Total population
7.7 7.1 6.2 4.1 2.1 0.8a
0.25 0.8 – – – –
11 13 10.6 9.8 8.0 3.0a
60 50 100 100 45 52
10.0 38.6 5.3 60.7 16.5 4.2
Consultants. Total population: 1,000,000.
Finland, 4.1 in France, 2.1 in the Netherlands, to 0.8 in Ireland (Table 1). The number for Ireland refers to consultants only and does not include senior registrars, who might be considered specialists in other countries. It is evident that the quantitative differences are substantial and indicate a difference in contribution to health care by ORL specialists in each of these countries. The numbers of pediatricians range from 8 per 100,000 inhabitants in the Netherlands to 13 in Poland. Marked differences concern the ratio between ORL specialists and pediatricians – in the Netherlands 1:4 compared to 1:2 in Hungary, Poland, Finland and France – which actually suggests a larger contribution of pediatricians in treating children with ORL-related problems in the Netherlands than elsewhere. The high number of Family doctors in Finland and France (100 per 100,000 inhabitants) might be related to the low population density in major parts of the country and consequently larger distances to the hospitals, where specialist care is available. Pediatric otorhinolaryngology has been recognized as an official sub-specialty in two of the countries represented at this Round Table. The numbers of pediatric ORL specialists in Hungary and Poland (0.25 and 0.50 per 100,000) are small compared to general ORL specialists, 7.7 and 7.1, respectively. Pediatric ORL specialists seem to be involved mainly in tertiary care. 3. Pediatric otorhinolaryngology: an official sub-specialty in Hungary and Poland
3.2. Poland In 1958 Pediatric ORL was approved by the government as a medical specialty. In 1961 a section of pediatric otolaryngology was installed by the Polish Society of ORL. The first textbook of Pediatric Otolaryngology in Poland was published by S. Kmita (Lodz) in 1967. A reform of health care by the Government in 1999 resulted in closure of all minor (sub)specialties, including pediatric ORL, and interruption of all training programs concerned. In 2004, however, pediatric ORL again acquired the official status of a sub-specialty. At present for fully trained ORL specialists the following program is required for sub-specialization in pediatric otorhinolaryngology: 2 years pediatric ORL in a qualified department; 2–3 months intensive care; 2 months pediatric neurology; 1–2 months in a neonatal department. 3–4 compulsory courses in pediatric audiology, pediatric phoniatry, endoscopy and ear surgery. 2 publications. Only 5 accredited University centers are qualified for training in pediatric ORL: the Medical Universities in Lodz and Poznan, and the Medical Academies in Lublin, Warsaw and Bialystok. Examination at the end of the program is both practical and theoretical (compiled by the National Commission, which is assigned by the Medical Center of Postgraduate Education in Warsaw). The number of pediatric ORL specialists in Poland equals 1 per 130,000 people. Their contribution to health care includes inpatient surgery of nose, ear, throat and larynx and out-patient care with audiologic, phoniatric and logopedic problems. Pediatricians (1 per 7600 inhabitants) usually treat URT infections, OMA, rhinosinusitis, allergic rhinitis and tonsillitis 4. Pediatric ORL without official status as medical sub-specialty in Finland, France, the Netherlands and Ireland 4.1. Finland
3.1. Hungary Qualified otorhinolaryngologists may be accepted for a 2 year full time residency: at least 1 year in a specialized pediatric ORLHNS department and 3 months in a pediatric ward; the remaining period is dedicated to pediatric audiology and phoniatrics. The examination at the end of this period deals with emergencies in pediatric ORL (bleeding control, foreign body removal from the airways, etc.) and common surgical procedures in children (adenoidectomy, tonsillectomy, mastoidectomy, tube insertion, myringoplasty, sinus puncture, FESS, laryngoscopy, bronchoscopy, oesophagoscopy, etc.). Both surgical skills and theoretical aspects are part of the examination, which generally takes 3 days. At the moment pediatric ORL training is only possible in University—(or affiliated) hospitals of Budapest, Debrecen, Szeged and Pecs. The first Pediatric ORL department was established in 1952 (Heim Pal Hospital, Budapest). Full time Pediatric ORL specialists (1 per 500,000 inhabitants) all work in Pediatric ORL University departments and/or specialized children’s hospitals engaged in tertiary care. General ORL specialists (1 per 12,500 inhabitants) are still allowed to perform most pediatric ORL-activities. Usually general practitioners (1 per 2000) and pediatricians (1 per 10,000) do treat children with acute otitis media, rhinosinusitis and pharyngitis. Audiology, phoniatrics, allergology and clinical immunology are recognized as sub-specialties in Hungary unlike head and neck surgery, neuro-otology, rhinology, otology and ORL traumatology.
Official sub-specialty training in pediatric otorhinolaryngology is unknown in Finland. The Finnish health care system is based on a very hierarchical system. The five University central hospitals treat nearly all the difficult cases in this country with 5.3 million inhabitants. In each university hospital at least one otorhinolaryngologist has acquired knowledge and skills in treating these patients. Otologic interventions like cochlear implants are primarily the domain of colleagues with a special interest and training in otology. The system has two major drawbacks. One of them is that due to the long distances in the large country (338,145 km2) the children are mainly treated in the nearest University Hospital. Since some of the serious and difficult pediatric otorhinolaryngological problems are very rare, it is very hard for the junior ORL specialist to obtain adequate sub-specialist training within the catchment area of each university hospital. 4.2. France Presently there are only 5 tertiary care centers for pediatric otorhinolaryngology in France (3 in Paris, 1 in Marseille, 1 in Lyon). In recent years otorhinolaryngology has become almost exclusively a surgical specialty. Moreover, the younger generation tends to ‘‘more or less’’ specialize in a sub-specialty like Pediatric ORL. The national society is entitled Socie´te´ Francaise d’ORL et de Chirurgie cervicofaciale (SFORLCCF). Sub-specialties have their own society under the umbrella of the national society. The French
C. Verwoerd et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 839–841
Pediatric Otorhinolaryngology Society (Association Francaise d’ORL pe´diatrique—AFOP; www.afop.fr) was founded in 1992. Currently, AFOP has 135 national and 22 international members. It organizes 2 meetings a year, one combined with the national ORL meeting. AFOP and other sub-specialty societies play a role of increasing importance; they are the official bodies to which the national ministry of health is asking for developing ‘‘good practice’’ guidelines and establishing recommendations (including treatment and indications). The future goes clearly towards reinforcement and development of specific pediatric ORL practice. At present pediatric ORL is still a small sub-specialty as far as number of medical doctors is concerned. Unfortunately the increasing workload without additional human resources is making the subspecialty less attractive than other sub-specialties within ORL. The French Societies of Anaesthesiology and Pediatric Anaesthesiology have established recommendations on protection of the airway during tonsillectomy, age for surgery and profile of surgical centers. Neonatal and pediatric intensive care units, close to surgical operating rooms, are becoming required. In recent years costs of insurance for practicing pediatric anaesthesiology have increased and the number of anaesthesists performing pediatric anaesthesia has decreased, while new pediatric hospitals open their doors. Restraints due to required pediatric anaesthesia specifications push parents and their children towards other not exclusively pediatric hospitals. At the same time the establishment of new pediatric hospitals continues.
2.
3.
4.
4.3. The Netherlands Most of the children with infectious diseases of ear, nose and throat are treated by family doctors. The University ORL departments are the only tertiary care centers for ‘‘special cases and special children’’. Full time pediatric otorhinolaryngologists are working in the University Children’s Hospitals in Rotterdam (Sophia Children’s Hospital) and Utrecht (Wilhelmina Children’s Hospital), and the Amsterdam University Medical Center (AMC). Tertiary care for children requires interdisciplinary consultation and/or cooperation with other pediatric sub-specialties, ranging from intensive care to thoracic surgery. Of paramount importance is the cooperation with pediatric anaesthesiologists, radiologists and highly qualified nurses! In some centers pediatric audiology and phoniatrics/logopedics may be integrated in pediatric ORL. The Dutch-Flemish Working Group for Pediatric ORL (NVWPO) was founded in 1995. One to 2 meetings per year bring together colleagues from the Netherlands and Belgium.
5.
841
pathology to clinical epidemiology with an input from medical and non-medical professionals. In clinical medicine pediatric otorhinolaryngology refers to medical care for children with ORL-related problems, provided by general physicians (1st line) and ORL-HNS specialists (2nd line), and to ORL-HNS as practiced in referral centers (3rd line). The contribution of ORL specialists to (clinical) health care (2nd and 3rd line) in the countries discussed appears to be quite different, when comparing their number per 100,000 inhabitants. These numbers appeared to vary from around 7.5 in Poland and Hungary to 1 or 2 in Ireland and the Netherlands. The lower the number of ORL specialists the more they seem to be involved in surgery, and children with infectious diseases are treated more often by family doctors and pediatricians. Only in 2 countries (Hungary and Poland with a population of 10 and 36.4 million, respectively) with the highest numbers of ORL specialists in relation to the total population is pediatric otorhinolaryngology recognized by law as a sub-specialty. Program and length (2 years) of sub-specialization as well as final examinations are regulated at a national level. There might be a historic causal relation between the relatively high ‘‘density’’ of ORL specialists in these countries and the ambition of widely appreciated pioneers in the field. In countries with the smallest population (Finland and Ireland with 5.3 and 4.2 million inhabitants, respectively) only a few colleagues are practicing pediatric ORL at a tertiary level of care, and often on a part time basis. Most of them have been to other countries for specific training in pediatric ORL. Low population density and a relatively large country surface do not encourage sub-specialization. In France and the Netherlands (60.7 and 16.5 million inhabitant, respectively) tertiary care, including Pediatric ORL, is centralized in a relatively small number of university-linked Children’s hospitals. These hospitals provide most advanced technical facilities and tertiary care by surgical and non-surgical disciplines.
6. European standards
To obtain a consultant post in Ireland, currently it is mandatory to have spent 1–2 years abroad (Europe, North America or Australasia). This period may be used for a fellowship in a prominent center for pediatric ORL. Two pediatric hospitals in Dublin provide tertiary care to the country as a whole. All six colleagues attached to these hospitals have a dual role with a sister adult Teaching Hospital, so that their time is split half-and-half between the two.
Today – with more open borders – medical doctors trained in one country have the ambition to work in another country. Therefore, the UEMS proposed a harmonization of training programs for medical (sub)specialty in Europe. Anticipating a contribution to this project ESPO organized this Round Table as a ‘‘tour d’horizon’’ of current practice and professional status of Pediatric ORL in different parts of Europe. Obvious differences were demonstrated which should be respected when further formalizing European standards for sub-specialist training. Such a standard for Pediatric ORL should not only refer to current diagnostic and therapeutic skills but include relevant scientific knowledge and competence. Moreover, it should be acknowledged that the significance of today’s standards is limited, as medicine and medical technology are rapidly developing.
5. Discussion
References
1. ‘‘Pediatric otorhinolaryngology’’ may be defined in different ways. It is a scientific domain reaching from molecular
[1] C.D.A. Verwoerd, H.L. Verwoerd-Verhoef, Pediatric otorhinolaryngology training in Europe, Int. J. Pediatr. Otorhinolaryngol. 44 (1998) 71–72. [2] R. Grenman, R. Maw, Academic ENT in Europe, ENT News 13 (2005) 56–59.
4.4. Ireland
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric otorhinolaryngology anno 2008: Towards European standards for training? Carel Verwoerd a,*, Patrick Froehlich b, Danuta Gryczynska c, Gabor Katona d, Anne Pitkaranta e, Alec Blayney f a
Department of Otorhinolaryngology, Erasmus MC, Erasmus University, Rotterdam, The Netherlands Department of Otorhinolaryngology, Hopital E. Herriot, Lyon, France Department of Otorhinolaryngology, University Medical Hospital, Lodz, Poland d Department of Otorhinolaryngology and Bronchology, Heim Pal Hospital for Sick Children, Budapest, Hungary e Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland f Department of Otorhinolaryngology, Children’s University Hospital, Dublin, Ireland b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 January 2009 Received in revised form 19 February 2009 Accepted 19 February 2009 Available online 25 March 2009
The Union Europe´en des Me´decins Spe´cialistes (UEMS) has been promoting harmonization of specialist training programs in Europe. Anticipating a future contribution to a European standard for training specialists for tertiary care of children with otorhinolaryngology (ORL)-related problems this Round Table was organized by ESPO. The presentations refer to six European countries. The number of ORL specialists (including pediatric ORL specialists) appeared to vary from 8 to 1 per 100,000 inhabitants, suggesting significant differences as far as their contribution to health care is concerned. Numbers for pediatricians vary from 12 to 3 and for family doctors from 50 to 100 per 100,000. In two countries pediatric ORL has the status of an official sub-specialty for tertiary care, requiring at least 2 years of additional training for qualified ORL specialists. In three other countries specific centers for pediatric ORL are present, although the sub-specialty has no official status. In the last a center for pediatric otorhinolaryngology has not yet been established and facilities for training in pediatric ORL are not available. For each country various aspects of current practice of tertiary ORL care for children are presented. It is concluded that a European standard for pediatric ORL could be most useful, if it would not only refer to current diagnostic and therapeutic skills but also to relevant scientific knowledge and skills. However, it should be recognized that the relevance of today’s standards is restricted, as medicine and medical technology are rapidly developing. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pediatric otorhinolaryngology Specialist training ORL specialisation European standards
1. Towards European standards? Since the early fifties of the 20th century pioneers in pediatric otorhinolaryngology (ORL) were active in European countries like Italy, Poland, Hungary, Czech Republic, Slovak republic, England and France. A review in 1996 including 28 European countries demonstrated substantial differences concerning the number of ORL specialists per 100,000 inhabitants and the professional status of Pediatric ORL [1]. Similar figures were published in 2005 [2]. Since harmonizing specialist training programs within the European Union has been promoted by the Union Europe´en des Me´decins Spe´cialistes (UEMS), the ORL-HNS section of this organization published a list of diagnostic and therapeutic (surgical) techniques, which should be required for general otorhinolaryngologists in all European countries. Later an ‘ad
* Corresponding author. Tel.: +31 10 521 8380. E-mail address: [email protected] (C. Verwoerd). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.02.018
hoc’ subcommittee chaired by Alec Blayney (Ireland) presented a preliminary ‘‘overall skeleton plan for training in Europe in pediatric ORL’’ to be altered, expanded or significantly changed, depending on the academic input of the European Society of Pediatric Otorhinolaryngology (ESPO). Anticipating a contribution to this project ESPO organized a Round Table to discuss pediatric otorhinolaryngology, as currently practiced and managed in six countries and representative for various parts of Europe, at the 8th International Conference of ESPO in Budapest, June 2008. 2. Medical professionals involved in care for children with ORL problems: quantitative aspects Family doctors, pediatricians, general ORL specialists and pediatric ORL specialists may contribute to medical care for children with ORL-related problems. The number of ORL specialists per 100,000 inhabitants appeared to vary from 7.7 in Hungary, 7.1 in Poland, 6.2 in
C. Verwoerd et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 839–841
840
Table 1 Number of ORL and pediatric ORL specialists, pediatricians and family doctors per 100,000 inhabitants.
Hungary Poland Finland France Netherlands Ireland a
ORL
PedORL
Ped
FamDr
Total population
7.7 7.1 6.2 4.1 2.1 0.8a
0.25 0.8 – – – –
11 13 10.6 9.8 8.0 3.0a
60 50 100 100 45 52
10.0 38.6 5.3 60.7 16.5 4.2
Consultants. Total population: 1,000,000.
Finland, 4.1 in France, 2.1 in the Netherlands, to 0.8 in Ireland (Table 1). The number for Ireland refers to consultants only and does not include senior registrars, who might be considered specialists in other countries. It is evident that the quantitative differences are substantial and indicate a difference in contribution to health care by ORL specialists in each of these countries. The numbers of pediatricians range from 8 per 100,000 inhabitants in the Netherlands to 13 in Poland. Marked differences concern the ratio between ORL specialists and pediatricians – in the Netherlands 1:4 compared to 1:2 in Hungary, Poland, Finland and France – which actually suggests a larger contribution of pediatricians in treating children with ORL-related problems in the Netherlands than elsewhere. The high number of Family doctors in Finland and France (100 per 100,000 inhabitants) might be related to the low population density in major parts of the country and consequently larger distances to the hospitals, where specialist care is available. Pediatric otorhinolaryngology has been recognized as an official sub-specialty in two of the countries represented at this Round Table. The numbers of pediatric ORL specialists in Hungary and Poland (0.25 and 0.50 per 100,000) are small compared to general ORL specialists, 7.7 and 7.1, respectively. Pediatric ORL specialists seem to be involved mainly in tertiary care. 3. Pediatric otorhinolaryngology: an official sub-specialty in Hungary and Poland
3.2. Poland In 1958 Pediatric ORL was approved by the government as a medical specialty. In 1961 a section of pediatric otolaryngology was installed by the Polish Society of ORL. The first textbook of Pediatric Otolaryngology in Poland was published by S. Kmita (Lodz) in 1967. A reform of health care by the Government in 1999 resulted in closure of all minor (sub)specialties, including pediatric ORL, and interruption of all training programs concerned. In 2004, however, pediatric ORL again acquired the official status of a sub-specialty. At present for fully trained ORL specialists the following program is required for sub-specialization in pediatric otorhinolaryngology: 2 years pediatric ORL in a qualified department; 2–3 months intensive care; 2 months pediatric neurology; 1–2 months in a neonatal department. 3–4 compulsory courses in pediatric audiology, pediatric phoniatry, endoscopy and ear surgery. 2 publications. Only 5 accredited University centers are qualified for training in pediatric ORL: the Medical Universities in Lodz and Poznan, and the Medical Academies in Lublin, Warsaw and Bialystok. Examination at the end of the program is both practical and theoretical (compiled by the National Commission, which is assigned by the Medical Center of Postgraduate Education in Warsaw). The number of pediatric ORL specialists in Poland equals 1 per 130,000 people. Their contribution to health care includes inpatient surgery of nose, ear, throat and larynx and out-patient care with audiologic, phoniatric and logopedic problems. Pediatricians (1 per 7600 inhabitants) usually treat URT infections, OMA, rhinosinusitis, allergic rhinitis and tonsillitis 4. Pediatric ORL without official status as medical sub-specialty in Finland, France, the Netherlands and Ireland 4.1. Finland
3.1. Hungary Qualified otorhinolaryngologists may be accepted for a 2 year full time residency: at least 1 year in a specialized pediatric ORLHNS department and 3 months in a pediatric ward; the remaining period is dedicated to pediatric audiology and phoniatrics. The examination at the end of this period deals with emergencies in pediatric ORL (bleeding control, foreign body removal from the airways, etc.) and common surgical procedures in children (adenoidectomy, tonsillectomy, mastoidectomy, tube insertion, myringoplasty, sinus puncture, FESS, laryngoscopy, bronchoscopy, oesophagoscopy, etc.). Both surgical skills and theoretical aspects are part of the examination, which generally takes 3 days. At the moment pediatric ORL training is only possible in University—(or affiliated) hospitals of Budapest, Debrecen, Szeged and Pecs. The first Pediatric ORL department was established in 1952 (Heim Pal Hospital, Budapest). Full time Pediatric ORL specialists (1 per 500,000 inhabitants) all work in Pediatric ORL University departments and/or specialized children’s hospitals engaged in tertiary care. General ORL specialists (1 per 12,500 inhabitants) are still allowed to perform most pediatric ORL-activities. Usually general practitioners (1 per 2000) and pediatricians (1 per 10,000) do treat children with acute otitis media, rhinosinusitis and pharyngitis. Audiology, phoniatrics, allergology and clinical immunology are recognized as sub-specialties in Hungary unlike head and neck surgery, neuro-otology, rhinology, otology and ORL traumatology.
Official sub-specialty training in pediatric otorhinolaryngology is unknown in Finland. The Finnish health care system is based on a very hierarchical system. The five University central hospitals treat nearly all the difficult cases in this country with 5.3 million inhabitants. In each university hospital at least one otorhinolaryngologist has acquired knowledge and skills in treating these patients. Otologic interventions like cochlear implants are primarily the domain of colleagues with a special interest and training in otology. The system has two major drawbacks. One of them is that due to the long distances in the large country (338,145 km2) the children are mainly treated in the nearest University Hospital. Since some of the serious and difficult pediatric otorhinolaryngological problems are very rare, it is very hard for the junior ORL specialist to obtain adequate sub-specialist training within the catchment area of each university hospital. 4.2. France Presently there are only 5 tertiary care centers for pediatric otorhinolaryngology in France (3 in Paris, 1 in Marseille, 1 in Lyon). In recent years otorhinolaryngology has become almost exclusively a surgical specialty. Moreover, the younger generation tends to ‘‘more or less’’ specialize in a sub-specialty like Pediatric ORL. The national society is entitled Socie´te´ Francaise d’ORL et de Chirurgie cervicofaciale (SFORLCCF). Sub-specialties have their own society under the umbrella of the national society. The French
C. Verwoerd et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 839–841
Pediatric Otorhinolaryngology Society (Association Francaise d’ORL pe´diatrique—AFOP; www.afop.fr) was founded in 1992. Currently, AFOP has 135 national and 22 international members. It organizes 2 meetings a year, one combined with the national ORL meeting. AFOP and other sub-specialty societies play a role of increasing importance; they are the official bodies to which the national ministry of health is asking for developing ‘‘good practice’’ guidelines and establishing recommendations (including treatment and indications). The future goes clearly towards reinforcement and development of specific pediatric ORL practice. At present pediatric ORL is still a small sub-specialty as far as number of medical doctors is concerned. Unfortunately the increasing workload without additional human resources is making the subspecialty less attractive than other sub-specialties within ORL. The French Societies of Anaesthesiology and Pediatric Anaesthesiology have established recommendations on protection of the airway during tonsillectomy, age for surgery and profile of surgical centers. Neonatal and pediatric intensive care units, close to surgical operating rooms, are becoming required. In recent years costs of insurance for practicing pediatric anaesthesiology have increased and the number of anaesthesists performing pediatric anaesthesia has decreased, while new pediatric hospitals open their doors. Restraints due to required pediatric anaesthesia specifications push parents and their children towards other not exclusively pediatric hospitals. At the same time the establishment of new pediatric hospitals continues.
2.
3.
4.
4.3. The Netherlands Most of the children with infectious diseases of ear, nose and throat are treated by family doctors. The University ORL departments are the only tertiary care centers for ‘‘special cases and special children’’. Full time pediatric otorhinolaryngologists are working in the University Children’s Hospitals in Rotterdam (Sophia Children’s Hospital) and Utrecht (Wilhelmina Children’s Hospital), and the Amsterdam University Medical Center (AMC). Tertiary care for children requires interdisciplinary consultation and/or cooperation with other pediatric sub-specialties, ranging from intensive care to thoracic surgery. Of paramount importance is the cooperation with pediatric anaesthesiologists, radiologists and highly qualified nurses! In some centers pediatric audiology and phoniatrics/logopedics may be integrated in pediatric ORL. The Dutch-Flemish Working Group for Pediatric ORL (NVWPO) was founded in 1995. One to 2 meetings per year bring together colleagues from the Netherlands and Belgium.
5.
841
pathology to clinical epidemiology with an input from medical and non-medical professionals. In clinical medicine pediatric otorhinolaryngology refers to medical care for children with ORL-related problems, provided by general physicians (1st line) and ORL-HNS specialists (2nd line), and to ORL-HNS as practiced in referral centers (3rd line). The contribution of ORL specialists to (clinical) health care (2nd and 3rd line) in the countries discussed appears to be quite different, when comparing their number per 100,000 inhabitants. These numbers appeared to vary from around 7.5 in Poland and Hungary to 1 or 2 in Ireland and the Netherlands. The lower the number of ORL specialists the more they seem to be involved in surgery, and children with infectious diseases are treated more often by family doctors and pediatricians. Only in 2 countries (Hungary and Poland with a population of 10 and 36.4 million, respectively) with the highest numbers of ORL specialists in relation to the total population is pediatric otorhinolaryngology recognized by law as a sub-specialty. Program and length (2 years) of sub-specialization as well as final examinations are regulated at a national level. There might be a historic causal relation between the relatively high ‘‘density’’ of ORL specialists in these countries and the ambition of widely appreciated pioneers in the field. In countries with the smallest population (Finland and Ireland with 5.3 and 4.2 million inhabitants, respectively) only a few colleagues are practicing pediatric ORL at a tertiary level of care, and often on a part time basis. Most of them have been to other countries for specific training in pediatric ORL. Low population density and a relatively large country surface do not encourage sub-specialization. In France and the Netherlands (60.7 and 16.5 million inhabitant, respectively) tertiary care, including Pediatric ORL, is centralized in a relatively small number of university-linked Children’s hospitals. These hospitals provide most advanced technical facilities and tertiary care by surgical and non-surgical disciplines.
6. European standards
To obtain a consultant post in Ireland, currently it is mandatory to have spent 1–2 years abroad (Europe, North America or Australasia). This period may be used for a fellowship in a prominent center for pediatric ORL. Two pediatric hospitals in Dublin provide tertiary care to the country as a whole. All six colleagues attached to these hospitals have a dual role with a sister adult Teaching Hospital, so that their time is split half-and-half between the two.
Today – with more open borders – medical doctors trained in one country have the ambition to work in another country. Therefore, the UEMS proposed a harmonization of training programs for medical (sub)specialty in Europe. Anticipating a contribution to this project ESPO organized this Round Table as a ‘‘tour d’horizon’’ of current practice and professional status of Pediatric ORL in different parts of Europe. Obvious differences were demonstrated which should be respected when further formalizing European standards for sub-specialist training. Such a standard for Pediatric ORL should not only refer to current diagnostic and therapeutic skills but include relevant scientific knowledge and competence. Moreover, it should be acknowledged that the significance of today’s standards is limited, as medicine and medical technology are rapidly developing.
5. Discussion
References
1. ‘‘Pediatric otorhinolaryngology’’ may be defined in different ways. It is a scientific domain reaching from molecular
[1] C.D.A. Verwoerd, H.L. Verwoerd-Verhoef, Pediatric otorhinolaryngology training in Europe, Int. J. Pediatr. Otorhinolaryngol. 44 (1998) 71–72. [2] R. Grenman, R. Maw, Academic ENT in Europe, ENT News 13 (2005) 56–59.
4.4. Ireland