Specialist training in psychiatry in Europe – Results of the UEMS-survey

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European Psychiatry 23 (2008) 157e168 http://france.elsevier.com/direct/EURPSY/

Original article

Specialist training in psychiatry in Europe e Results of the UEMS-survey Winfried Lotz-Rambaldi a, Ines Scha¨fer a, Roelof ten Doesschate b, Fritz Hohagen a,* a

Department of Psychiatry and Psychotherapy, University of Luebeck, Ratzeburger Allee 160, D-23538 Luebeck, Germany b Stichting Adhesie, GGZ midden Overijssel, Deventer, the Netherlands Received 21 February 2007; received in revised form 19 November 2007; accepted 17 December 2007 Available online 10 March 2008

Abstract According to the aim of the Treaty of Rome from 1957 which postulated the free movement of workers throughout the European Union, the European Board of Psychiatry in the UEMS (European Union of Medical Specialists) carried out a comprehensive survey of training in psychiatry, including all member countries in order to evaluate the present state of training in psychiatry in each. The survey should indicate whether the training requirements [UEMS Section Psychiatry. Charter on training of medical specialists in the EU: requirements for the speciality psychiatry. European Archives of Psychiatry and Clinical Neuroscience 1997;247(Suppl.):S45e7; UEMS Section Psychiatry. Charter on training of medical specialists in the EU: requirements for the speciality psychiatry. ; 2003 [last revision]] have had an impact on the actual conditions of training in psychiatry in the member countries. We gathered 22 questionnaires from 31 national representatives involved and 424 questionnaires completed by the chief of training and the representative of trainees at the responding training centres from 22 countries. The results give an overview about the practice of training in psychiatry in many European countries. While there are great differences between the training centres in different countries, apparent progress towards developing high standards in training in psychiatry has been made. Ó 2008 Elsevier Masson SAS. All rights reserved. Keywords: Specialist training; Education; Survey; European Union; Education in Psychiatry; Psychiatry in Europe

1. Introduction In the context of the European unification process, in 1957 the Treaty of Rome postulated the free movement and employment of workers throughout the European Union (EU, former European Economic Community, EEC). According to this global and ambitious aim, on 20 July 1958, one year after the Treaty of Rome was signed, in Brussels the UEMS (European Union of Medical Specialists) was created by the representatives delegated by the professional organizations of medical specialists of the six member countries of the then recently established European Community (EEC). One of the aims of the UEMS is to encourage the implementation of uniform training requirements in the whole of Europe. In 1993, the Charter on Training of Medical * Corresponding author. Tel.: þ49 451 500 2441; fax: þ49 451 500 2603. E-mail address: [email protected] (F. Hohagen). 0924-9338/$ - see front matter Ó 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2007.12.001

Specialists in the European Community (EC) was adopted by the UEMS. It forms a framework for the harmonisation of postgraduate specialist training in the EU within each medical speciality. After the adoption of the Charter on postgraduate training, the 30 UEMS Specialist Sections and two Subsections began their work to specify the training requirements in their speciality to be included in Chapter 6 of the Charter. This task was completed in 1995, and the present European Training Charter for medical specialists gives a complete picture of the consensus on training programmes that has been reached within the medical specialist professions in the European Union. In 1992, the UEMS Board of Psychiatry was established as a working group of the UEMS Section of Psychiatry with a particular focus on training matters. To ensure the most effective method of cooperation, it was decided from the outset that the Section and Board would be composed of the same members but would have separate, albeit inter-related, agendas [3].

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Over the years, the Board has focused on the main task of providing standards for training in psychiatry in accordance with contemporary knowledge, current developments, and ethical issues. In this task, it has been crucial to recognise cultural and structural differences in order to achieve common and achievable goals for training. As a first step, the European Board initiated an exploratory survey of the training standards in its member countries. As expected, the results revealed that there were large differences between the member countries. As a next step, the Board developed training requirements which should be the standard for all members of the section ([4]: approved in Strasbourg on 15.04.2000; [5]: last revision approved in Berlin on 11.10.2003). The principal aim of these requirements is to achieve a multidimensional approach to the diagnosis and treatment of psychiatric disorders that is appropriate to the complex nature of psychiatric disorders, taking into account the neurobiological, social and psychotherapeutic dimensions. This multidimensional approach, together with the standards defined in the requirements for psychiatric training, is intended to contribute towards the attainment of comparable high standards of psychiatric training and patient care throughout Europe [1]. The requirements for the speciality psychiatry affect the following areas, which are amended by an appendix and a glossary (see Table 1). At their meeting in April 2004, held in Edinburgh, Scotland, the European Board of Psychiatry agreed that to continue its work on standardisation and harmonisation of training in psychiatry across Europe, it was vital to find out the current state of implementation of the recommended training requirements in all European training centres providing full training in psychiatry. Therefore, a comprehensive survey of training in psychiatry was carried out that included all member countries, associate members, and observers. The survey should show whether the training requirements have had an impact on the actual conditions of training in psychiatry in the member countries. 2. Material and methods The European Board of training in psychiatry has developed a questionnaire to collect all the relevant data, bearing in mind its requirements for training in psychiatry. After an initial draft version was tested and revised by the Board in 2004, the survey was sent out to all national representatives and all national training centres in the countries represented at the UEMS Section and Board of Psychiatry with the help of the national representatives (see Table 3: 28 member countries, Turkey as an associate member, and Croatia and Israel as observers). The survey consists of two parts. Part One was to be completed by the national representative on the European Board of Psychiatry. Part Two was to be completed by the chiefs of training and the representatives of trainees at all training institutions in the Member States. Both parts together reflect the matters of the above-named training requirements for the speciality psychiatry published by the UEMS Board of Psychiatry (see Table 2).

Table 1 Synopsis: training requirements for the speciality psychiatry Training requirements for the speciality psychiatry Article 1: central monitoring authority for psychiatry 1.1 Monitoring authority 1.2 Recognition of teachers and training institutions 1.3 Quality assurance 1.4 Recognition of quality 1.5 Manpower planning Article 2: general aspects of training in psychiatry 2.1 Selection and access to the training of psychiatrists 2.2 Interruption of training 2.3 Training duration 2.4 Definition of common trunk 2.5 Practical training 2.6 Supervision 2.7 Implementation of training programme/ training logbook 2.8 Numerous clauses 2.9 Training abroad within the EU 2.10 Funding Article 3: requirements for training institutions 3.1 Recognition for training institutions 3.2 The size of training institutions 3.3 Quality insurance of training institutions Article 4: requirements for teachers 4.1 Qualification of the chief of training 4.2 Training programme Article 5: requirements for trainees 5.1 Experience 5.2 Language 5.3 Sub-specialisation/special fields of interest

The survey was sent by the national representatives to all the training institutions in the member countries. Both parts were also to be linked to the website of the European Board of Psychiatry, where chiefs of training or representatives of trainees could download it for completion (www.uemspsychiatry.org). A glossary is available consisting the details of terms used in the questionnaire. The questionnaire could be completed online and returned by email to the respective national UEMS delegate. In February 2005, a reminder was sent to Table 2 Survey of specialist training in psychiatry: table of contents Part One e 56 items 1. 2. 3. 4. 5. 6.

General aspects of training in psychiatry Requirements for trainers Sub-specialisation Practical training Logbook Theoretical training

Part Two e 78 items 1.

General questions

2. 3. 4. 5. 6. 7.

Requirements for training centres Requirements for trainers Training in psychotherapy Training in community psychiatry Training in old-age psychiatry Training in leadership and management Logbook Supervision in psychiatric training Theoretical training

8. 9. 10.

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all countries that had not participated in the survey up to this time. Finally all completed questionnaires were sent to the University of Luebeck, Germany, Department of Psychiatry and Psychotherapy, where an electronic database was generated and the data were analysed. 3. Results 3.1. Part One Concerning Part One, which was completed by the national representatives of all Member States, 22 questionnaires were sent back (see Table 3). 3.1.1. General aspects of training in psychiatry 3.1.1.1. Selection and access to training in psychiatry. The selection procedure for trainee candidates in psychiatry is regulated both by an official body and by the training centre in seven countries. In several other countries the selection procedure is regulated either by an official body (n ¼ 6) or by a training centre (n ¼ 5). Only four countries declare that it is regulated neither by an official body nor by a training centre. 3.1.1.2. Duration of training. In almost all countries (n ¼ 20), a national training scheme exists with a mean duration of 5 years (range: 3e7 years). Nearly half of the countries (n ¼ 10) offer the possibility of part-time training. All of the 20 national training schemes include a training period in neurology, which is mandatory in one half and optional in the other half. In addition, 17 of the 20 training schemes foresee a training period in internal medicine, but which is mostly optional. 3.1.1.3. Definition of common trunk. Except for one case, in all responding countries there is a compulsory common trunk with a mean length of 3.2 years (range: 1e5 years). Table 4 displays the components of the mandatory practical training. If it is specified that the average maximum duration of flexible training amounts to 16.4 months. In most countries, the chief of training has to approve the subject of flexible training. 3.1.1.4. Rotation. In all but one country, rotation between the different sections of the training centre is compulsory and with Table 3 Responding and non-responding countries, Part One (n ¼ 31) Responding countries, Part One (n ¼ 22)

Non-responding countries (n ¼ 9)

Belgium Croatia Denmark Estonia Finland Germany Greece Hungary Ireland Latvia Malta

Austria Cyprus Czech Republic France Iceland Israel Italy Lithuania Luxembourg

Netherlands Norway Poland Portugal Slovakia Slovenia Spain Sweden Switzerland Turkey United Kingdom

159

Table 4 Components of the mandatory practical training Components

Countries (n)

In-patient short stay In-patient medium-length stay Emergency psychiatry Community psychiatry Liaison and consultation psychiatry In-patient long stay Child and adolescent psychiatry Psychiatric aspects of substance misuse Day hospital Old-age psychiatry Mental handicaps Learning difficulties

21 18 18 17 15 14 13 13 12 12 6 5

the exception of one country, rotation between training centres is possible. 3.1.1.5. Register. In all countries (except for one) trainees receive a certificate from a national authority upon completion of training. In 19 countries, a register of psychiatrists exists that is usually accessible to general public. Only in one-third of the countries do psychiatrists have to re-register at regular intervals. If so, this occurs in the mean every 5 years (range: 3e7 years). 3.1.1.6. Sub-specialisation. In 11 out of 23 countries, subspecialities in psychiatry are recognised. Table 5 lists the specified sub-specialities in psychiatry. 3.1.1.7. Practical training. In the great majority of cases, psychotherapy (n ¼ 18) and community psychiatry (n ¼ 19) are mandatory parts of the national training schemes, whereas in more than one-third (n ¼ 9) old-age psychiatry is not a mandatory part (Fig. 1). 3.1.1.8. Logbook. At the beginning of their training, trainees in two-thirds of the countries receive a copy of the respective national guidelines and a logbook. The logbook is a personal training file in which the different stages and the activities of training and the activities of trainees are recorded. But only in a minority of countries (n ¼ 5) do trainees receive a copy of the Charter on Training of Medical Specialists in Table 5 Sub-specialities in psychiatry Sub-speciality

Countries (n)

‘‘Child’’, ‘‘child and adolescent’’ ‘‘Forensic’’ ‘‘Alcoholism, addictology, substance misuse, alcohol and substance misuse’’ ‘‘Psychotherapy’’ ‘‘Rehabilitation’’ ‘‘Old-age’’, ‘‘geriatric’’ ‘‘Learning disability’’ ‘‘Biological’’ ‘‘Community’’ ‘‘Neuropsychiatry’’

8 5 4 3 3 3 2 1 1 1

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160 20

19

18

yes no

18 16

14

14 12 9

10 8 5

6

4

4 2 0 psychotherapy

community psychiatry

old age psychiatry

Fig. 1. Practical training: mandatory parts of training.

the EU. The majority of national representatives (n ¼ 17) confirm that the logbook includes elements described in the UEMS Charter on Training of Medical Specialists in the EU: Requirements for the Speciality of Psychiatry. 3.1.1.9. Theoretical training. Table 6 presents in descending order the results on the structured theoretical training in different areas offered in the national training scheme. 3.2. Part Two Part Two of the survey was to be completed by the chief of training and the representative of trainees at the respective training institutions. A total number of 424 questionnaires from 22 countries were sent back. Apart from Slovakia, Part Two questionnaires are available from all countries which responded to Part One. The greatest contingent of questionnaires

was filled out and sent back by the representatives of training centres in Germany, followed by the United Kingdom, Spain, Turkey, Norway, the Netherlands, Denmark, Austria and Switzerland; see Table 7). The following results are based on 424 questionnaires from all countries. Only if country-specific analyses are reported are they based on nine countries (Germany, UK, Spain, Turkey, Norway, the Netherlands, Denmark, Austria, Switzerland) with at least more than 10 valid questionnaires and a total number of n ¼ 388 questionnaires. 3.2.1. General questions Based on all countries 297 training centres (76%) offer full training, 164 centres (42%) offer higher specialist training, and only 97 centres (25%) offer part-time training (multiple answers per centre possible). Whereas in most countries full training predominates, in Denmark part-time training is also established, and in Norway part-time training is even more common than full training (Fig. 2). Training is carried out at psychiatric non-university hospitals (n ¼ 170, 43.3%), departments of a general hospital (n ¼ 147, 37.5%) and psychiatric university hospitals (n ¼ 140, 35.7%). An outpatient department is part of nearly all the training centres (93%), whereas only 70.7% of the centres have a community care programme (Fig. 3). Most of the training centres (61%) provide specialist training autonomously. If not, part of the training is carried out as well at a psychiatric university clinic (24.5%) or at other Table 7 Number of questionnaires from responding countries (Part Two) Country (n ¼ 22)

Table 6 Different areas in which structured theoretical training is offered by the national training scheme Areas

Countries (n)

Scientific basis of psychiatry: biological, social and psychological aspects Psychopathology; examination of a psychiatric patient; diagnosis and classification; psychological tests, and laboratory investigations Specific disorders and syndromes Psychiatric aspects of substance misuse Psychopharmacology and other biological treatments Psychotherapies Child and adolescent psychiatry Legal, ethical and human rights issues in psychiatry Socialepsychiatric interventions Old-age psychiatry Community psychiatry Research methodology; epidemiology of mental disorders; psychiatric aspects of public health, and prevention Forensic psychiatry Diversity in psychiatry: gender, cultural and ethnic aspects, disability, sexual orientation Mental handicap Leadership, administration, management, and economics Medical informatics and telemedicine

22 22

22 22 22 21 20 20 20 19 18 18

18 17 14 8 6

Total (n )

Response (n)

Germany United Kingdoma Spaina Turkeya Norwaya Netherlandsa Denmarka Austria Switzerlanda

427 126 52 54 100 34 51 22 19

129 54 51 37 31 26 24 18 18

Ireland Sweden Finland Poland Belgium Croatia Estonia Greece Hungary Latvia Malta Portugal Slovenia

13 e 5 15 e e e 4 e e 1 e e

8

Total

923

409 424

a

a

Response (%) 30.2 42.8 98.1 68.5 31.0 76.5 47.1 81.9 94.7 6

5 5 2 1 2 2 1 1 1 1 1 15

61.5 e 100.0 33.0 e e e 50.0 e e 100.0 e e 44.3b

Countries with at least n > 10 valid questionnaires (n ¼ 388). Based on n ¼ 409 questionnaires from those countries for which response rates are known. b

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161

100

100

90

75.8% n=297

80

75

no partly reasonably yes

70

41.8% n=164

50

60

24.7% n = 97

40

25

48.8%

46.4%

50

31.4%

29.8%

30 18.9%

17.5%

20 10

0 partly training

full training

3.3%

3.9%

higher specialist training 0

Fig. 2. Type of training scheme.

psychiatric clinic(s) (26.0%) but only in a very few cases at a department of psychology (6.6%) or at other institutions (15.3%). Generally, the satisfaction with the national training programme is very high. A 77.8% of the chiefs of training, and a 78.6% of the representatives of the trainees are reasonably or totally satisfied with the national training programme (Fig. 4); greatest satisfaction in UK: chief of training 88.5%, representative of trainees 92.7%; least satisfaction in Turkey: 31.6% and 38.1%, respectively). 3.2.1.1. Requirements for training centres. Almost all of the responding training centres (97%) are recognised by an appropriate national authority. The number of trainees working in the centres who intend a career in psychiatry averages 15.6. In the centres there are a mean of 13 psychiatrists in a full-time position who act actively as educational supervisors, and in addition, 4.6 clinical psychologists who actively participate in the training of psychiatrists (Fig. 5). The process of individual training is evaluated at least twice a year at 66% of training centres (Fig. 6). In contrast to the

100

trainee-representative

chief

Fig. 4. Satisfaction with national training programme. Comparison chief vs. trainee-representative.

other countries, in Germany only 27% of the training centres are evaluated in this way. The access to resources is adequate: Nearly all the training centres provide access to a library (with psychiatric and medical literature) or to the internet (Cochrane, Medline, etc.). Concerning the quality assurance of training centres, twothirds of the centres (68.4%) have an internal system of clinical audit or quality assurance (very common in UK, the Netherlands and Switzerland) in which continuing medical education is always part of it. Half of the training centres (49%) are regularly visited by recognition visits by an external body. Only 33% of the training centres confirmed that the last recognition visit to the local training scheme was in accordance with the UEMS Charter on Visitation of Training centres (http://www.uems.net/ uploadedfiles/179.pdf) and it is very uncommon (14%) for the recognition visit team to use the European Board of Psychiatry Training Scheme Assessment Form (http://www. uemspsychiatry.org/board/forms/schemeAssess.pdf, Fig. 6). 25

93.3 n=363

20 M 15.6 SD 19.3

70.7 n=268 75

M 13.0 SD 15.4

15

50

10 M 4.6 SD 5.5 5

25

0 0 outpatient department

community care program

Fig. 3. Outpatient department and community care programme.

trainees who intend a career in psychiatry

psychiatrists in full time position

clinical psychologists

Fig. 5. Number of trainees, psychiatrists and psychologists.

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162

the training programmes comply with the training recommendations of the European Board of Psychiatry (Fig. 8).

100 90 80 66,4%

70 60 49,0% 50

33,6%

40 30

14,3

20 10 0 regularly visited by at least recognition visits twice a year by an external body

last visits in recognition team accordance with uses assessment UEMS charter form

Fig. 6. Recognition visits.

Furthermore, only 42% of the training centres state that trainees are consulted independently during recognition visits. Finally nearly all chiefs of training (89%) and representatives of trainees (89%) agree that recognition visits are useful. 3.2.1.2. Requirements for trainers. Concerning the qualification of the chief of training, 82.5% of the training centres report that the training director is required to have at least 5 years of experience as a psychiatrist (highest scores: Germany, the Netherlands, Switzerland, Austria, Turkey; lowest score: Norway 43%). Also, 83.5% of the centres state that the director is authorised by a national authority (Norway: 45%) (Fig. 7). In general, the training programme is individualised: 77% of the centres report that every trainee has an individual training programme (Fig. 8). While there is no doubt that the training programme complies with national rules (98% accordance), only 59% of

3.2.1.3. Training in psychotherapy. Psychotherapy is mostly (86%) a mandatory part of the training programme, other than in Turkey (35%), and partly in Austria (56%) and in Spain (60%) (Fig. 9). But there are still great differences concerning the extent of theoretical training and supervision in psychotherapy as a mandatory part of training. While 58% of the centres report that theoretical training in psychotherapy for at least 120 h is mandatory, the range runs from 12% (Turkey) or 18.4% (UK) to 100% (Netherlands). In the same way, mandatory supervision in psychotherapy for at least 50 h in total is very rare in some countries like Turkey (12%), Spain (31%) and the United Kingdom (31%; all countries: mean 62%). The number of hours of group supervision in psychotherapy averages 62.2 h (SD 55.9). Practical training in nearly all centres includes contact with individuals (97%), with families (86%), and with groups (80%). As regards the psychotherapeutic orientation, psychodynamic psychotherapy which is provided in 82% of the training schemes, dominates, followed by cognitive behavior therapy (68%), integrative psychotherapy (46%) and systemic psychotherapy (46%). Personal therapeutic experience is seen as a valuable component of psychotherapy training and training schemes should provide an opportunity for this. The purpose is to place the trainee in the position where the impact of his thinking and feeling as part of the interpersonal contact with patients can be explored and used therapeutically. Personal therapeutic experience is mandatory at 53% of the centres. Where mandatory, it averages 122 h. While it is very rare in some countries, in the Netherlands (100%, mean 60 h), in Switzerland (88%, 155 h) and in Germany (87%, 144 h) it is generally implemented. Funding is a very relevant aspect of training in psychotherapy. Half of the centres (48%) pay the full (27%) or partly

100 90

83.5%

82.5%

80

GER NET

70

SWI

60

AUS TUR

50 SPA 40

UKI

30

DEN NOR

20

all countries (n=22) 10 0 director >= 5 years experience

director authorised by national authority

Fig. 7. Qualification of director of training.

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163

100 90 77%

80

UKI DEN

70 NOR 59%

60

NET TUR

50 SPA SWI

40

GER 30 AUS all countries (n=22)

20 10 0 individ. program for every trainee

program complies with UEMS

Fig. 8. Training programme.

(22%) costs for psychotherapeutic experience. If it is paid for by the training scheme, the percentage averages 66%. In the Netherlands, it is paid for by all centres (mostly full coverage). Training in psychotherapy is publicly funded at 46% of the centres (full coverage at 35%, partial coverage at 11%, Fig. 10). The level of the trainees’ personal financial contribution differs among the countries and depends on various factors. If training in psychotherapy is not funded publicly in full, at 35% of the centres trainees have to pay from 2,500e5,000 V, at 30% of the centres less than 2,500 V, and at 24% of the centres 5,000e10,000 V. Trainees have to pay more than 10,000 V at 12% of the centres (especially in Austria, Switzerland and Germany, Fig. 11). 3.2.1.4. Training in community psychiatry. Training in community psychiatry is mandatory in two-thirds (65.8%) of

the training schemes, particularly in the Netherlands (100%) and in Spain (96%). Where it is mandatory, the mean duration of training is 10.6 months (SD 8.6) (Fig. 12). The multidisciplinary team generally includes a psychiatrist (90%) with the exception of Turkey. Where the team includes a psychiatrist, only in 45% of the cases is the psychiatrist required to have at least 5 years of experience in community psychiatry. While in the Netherlands, United Kingdom, and Denmark standard training in community psychiatry includes home assessments etc., for the remainder of the countries it is included only at 63% of the centres. 3.2.1.5. Training in old-age psychiatry. In 43% of the training schemes, training in old-age psychiatry for at least 6 months is mandatory (Fig. 13). It is both community- and hospital-based

100 90

86% DEN

80

NET 70

NOR GER

60

SWI

50

UKI

40

SPA AUS

30

TUR 20

all countries (n=22)

10 0 Psychotherapy mandatory part of training

Fig. 9. Training in psychotherapy.

W. Lotz-Rambaldi et al. / European Psychiatry 23 (2008) 157e168

164 100 90

yes

80

partly

70 60

%

50 40 30 20 10

)

al

lc ou

nt rie

s

(n

=2 2

TU R

AU S

G ER

SP A

SW I

N ET

D EN

U KI

N O R

0

Fig. 10. Training in psychotherapy publicly funded.

at 63% of the centres with the exception of the United Kingdom, where it is standard (100%). There are no great differences between the countries concerning the question if training in old-age psychiatry provides an opportunity to work jointly with physicians in medicine for the elderly, which is confirmed by 66% of the centres. 3.2.1.6. Training in leadership and management. Only 40% of the training schemes include training in leadership and management on a theoretical level. Countries in which it is common are Norway, Denmark, and the Netherlands. Also such training on a practical level is very rare and is standard only in 35% of the centres other than in Denmark (92%). 3.2.1.7. Logbook. A logbook is used at nearly three-quarter (73%) of the training centres. What is noticeable is the low

rate of use in Switzerland (18%) where at the time when the survey was carried out no logbook was approved by the national authority but only by the individual training centres. 3.2.1.8. Supervision in training. There is day-to-day clinical supervision at most of the centres (90%). However, the number of hours of educational supervision per year, which is additional to clinical and psychotherapeutic supervision and deals with subjects such as attitude, progress in the profession, etc., varies greatly (mean 79 h per year, SD 122). 3.2.1.9. Theoretical training. Table 8 presents in descending order the results on structured theoretical training in different areas offered by the training scheme. Overall, the sequence of the areas and their importance is similar to the results reported by the national representatives

100 < 2500 € 2500-5000 € 5000-10.000 € > 10.000 €

90 80 70 60

%

50 40 30 20 10 0 AUS

SWI

GER

NET

DEN

NOR

UKI

TUR

Fig. 11. Trainees’ personal contribution to training in psychotherapy.

SPA

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165

100 90 80

NET 65.8

70

SPA DEN

60

%

UKI SWI

50

NOR GER

40

AUS 30

TUR all countries (n=22)

20 10 0 community psychiatry mandatory part of training

Fig. 12. Training in community psychiatry.

(see Table 5). However, child and adolescent psychiatry, which is part of 20 from 22 national training schemes, is offered only at 69% of the structured theoretical trainings in the centres. 4. Discussion 4.1. Method The survey is based on a questionnaire that was developed for the special purpose of reflecting the impact of the UEMS training requirements for the speciality psychiatry in the training centres in the EU. Because Part One of the questionnaire was filled out by two-thirds of the countries included (n ¼ 31), the results are valid only for the 22 countries responding.

With regard to the training centres (Part Two), the response rate amounts to 44.3% and ranges from 25e100%, depending on several factors like the number of training centres in the country and the commitment of the national representatives in demanding the questionnaires from the centres. Altogether we analysed 424 questionnaires from 22 countries. Germany (129 questionnaires), the United Kingdom (n ¼ 54), and Spain (n ¼ 51) which are the biggest participating countries contributed 55% of the whole sample of questionnaires. Thus, the results of the present survey might be slightly biased. Furthermore, the fact that Italy, Austria, France and the Czech Republic did not participate in the survey limits the representativity of the results for the whole of Europe.

100 90 80

UKI GER

70

AUS 60

%

NET NOR

50 42.7

TUR SPA

40

SWI 30

DEN all countries (n=22)

20 10 0 ... is for at least 6 months mandatory

Fig. 13. Training in old-age psychiatry.

166

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Table 8 Different areas in which structured theoretical training is offered (n ¼ 379e 386 centres) Areas

Percentage

Psychopharmacology and other biological treatments Psychopathology, examination of a psychiatric patient, diagnosis and classification, psychological tests, and laboratory investigations Specific disorders and syndromes Scientific basis of psychiatry: biological, social and psychological aspects Psychotherapy Psychiatric aspects of substance misuse Old-age psychiatry Legal, ethical and human rights issues in psychiatry Socialepsychiatric interventions Community psychiatry Research methodology, epidemiology of mental disorders, psychiatric aspects of public health, and prevention Forensic psychiatry Diversity in psychiatry: gender, cultural and ethnic aspects, disability, and sexual orientation Mental handicap Child and adolescent psychiatry Leadership, administration, management, and economics Medical informatics and telemedicine

100 99

98 97

97 96 91 90 88 88 82

82 79

74 69 44

39

4.2. National training schemes (Part One) The training requirements of the UEMS [4,5] aim at contributing to a high standard in the whole of Europe to facilitate the interchange of psychiatrists. Several aspects have to be considered to guarantee an equal high standard in the respective European countries. A well-trained psychiatrist should have knowledge and experience in all relevant fields of patient care. A rotation between different sections provides the opportunity to get experience in several fields of psychiatry. Although a system of rotation between different sections of the training centre is highly desirable, in most countries it is not mandatory. Some obstacles to rotation have to be discussed at this point. The attachment of the trainee to a research group in the university setting, which makes continuity mandatory is in opposition to the idea of a rotational system. Also, the

continuity in the treatment of mentally ill patients is another very important aspect. A third point is that specialized disorder-oriented treatment concepts are only possible with a continuity of well-trained psychiatrists who can share their knowledge with the trainees. Theoretical training is the basis of training qualification and should cover all relevant aspects of psychiatry. Although this is the case in most European countries, some areas like learning difficulties and mental handicaps are often not included in the compulsory common trunk of national training schemes. Although mentally handicapped people are cared for separately outside the confines of psychiatry in many European countries and seen in the setting of an acute hospital mostly in instances of crisis intervention, this field represents an inpatient aspect of psychiatry. Psychiatry covers a broad spectrum and nowadays it is impossible that one psychiatrist has equal competence in every field of the discipline. Sub-specialities based on a comment trunk of general psychiatry are one way to cope with his problem and to allow psychiatrists to achieve high competence in different areas e.g. forensic psychiatry, addiction, child and adolescence psychiatry or other areas. In the last decade there has been a tendency to sub-specialisation in several countries. Sub-specialities in the countries are mainly in child and adolescent psychiatry, forensic and addiction psychiatry. There is no general agreement within the European Board of Psychiatry on the criteria relevant to the definition of a sub-speciality. A sub-speciality can be organised according to age (child and adolescent psychiatry, old-age psychiatry), illness (e.g. addiction), setting (e.g. community psychiatry) or intellectual capacity (learning disability, mental handicap). Furthermore, sub-specialisation bears a certain risk of fragmentation of psychiatry. The training requirements of the UEMS underline that psychotherapy is an integral part of psychiatry, recognised as equal with the biological and social dimension [4,5]. Thus, training in psychotherapy, social psychiatry, and oldage psychiatry are fundamental areas of psychiatry which are considered to be mandatory. Even though psychotherapy, community psychiatry, and old-age psychiatry some countries have not yet included. Especially the fact that psychotherapy has become an integral part of psychiatric practice might be one of the positive consequences of the discussion progress that has taken place in recent years in the European Board of Psychiatry. Generally, the survey validates a highly developed standard of theoretical training that covers most of the important areas of psychiatry. Some areas like mental handicaps, leadership, administration, management and economics, medical informatics and telemedicine should be introduced into the training curricula. 4.3. Training centres (Part Two) In addition to the training situation in the respective European countries at a national level, provided by the national representative of the respective European countries,

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the survey aims at giving a more detailed picture gathering information from the training institutions in the countries. As already pointed out, the discussion of these data is limited due to a selection bias because the response rate in the respective countries was heterogeneous. Nevertheless, together with the information provided by the national representatives it gives an approximation of the training situation in the whole of Europe. Unfortunately, the national training programmes often do not comply with UEMS training recommendations. In this area, the UEMS should intensify its influence at the national level to guarantee high standard of training that really reflects the UEMS requirements. The training requirements of the UEMS underline the importance to provide part-time training due to the high percentage of female trainees. Part-time training should be possible for male and female trainees as is stated in the requirements for the speciality of psychiatry. Nevertheless only 25% of the training centres offer part-time training which makes it difficult to combine family life with training. The European Board of the UEMS has worked out guidelines for recognition visits which are regarded an important instrument to make sure that training quality in the training institutions is at a high standard at a national level. Although recognition visits are regarded as useful of nearly 90% of the chiefs of training and the representatives of training, just onethird of the countries have introduced more or less regular recognition visits. If recognition visits are carried out, they do not apply the European Board of psychiatry training scheme assessment form as published in the UEMS charter on visitation of training centres. As a consequence of this the UEMS European Board of Psychiatry offers help to introduce the charter on visitation by sending a committee to European countries asking for help which supervises the process of visitation according to UEMS standards. Such a process has started now in Germany [2]. Several reasons may account for the hesitation to introduce regular visitation of training institutions in the European countries. Economical boundaries may be a cause as well as the ‘‘feeling of being controlled’’. In contrast to this, the recognition visits should be a helpful approach to the training centre to realize a high-quality training. As noted above, training in psychotherapy has become an integral part of psychiatry in most European countries according to the UEMS training requirements. Nevertheless, the quantity and quality of training is quite different from one country to the other. This concerns the supervision as well as theoretical training or awareness and practical training. The heterogeneous standard in psychotherapy training reflects the different degree of integration of psychotherapy into psychiatry in the respective European countries. While in some countries psychotherapy is the domain of psychologists, in other countries psychotherapy is regarded as an integral part of the clinical competence of the psychiatrists. In countries where psychiatrists refer patients to psychotherapies and do not practise psychotherapy themselves the rate of mandated training in psychotherapy is generally lower.

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Psychodynamic psychotherapy continues to prevail in psychiatry, in contrast to other professions in European countries, e.g. psychologists, in whose training emphasis is more on cognitive behavior therapy and other evidence-based methods of psychotherapy. The dominance of psychologists in the field of cognitive and behavioural therapy or the psychiatrists who predominate are trained in psychodynamic psychotherapy may play a role when health assurance companies focus more or more on the cost effectiveness aspects of psychotherapy and prefer to reimburse short and effective psychotherapy methods. Psychotherapy training is still very expensive for trainees in several countries. It should be taken into consideration that in future the lack of young physicians in Europe will result in a competition between disciplines to get trainees. Expensive psychotherapy training can be an obstacle for motivating and inspiring young colleagues to go into psychiatry and psychotherapy. Psychotherapy training and personal psychotherapeutic experience, as mandatory parts of the training in psychiatry, should take place during working hours and should be paid for by the training institute or the authorities. Although community psychiatry and old-age psychiatry are also integral parts of the field training requirements in the respective European countries are very much heterogeneous and differ considerably in quality. Furthermore, training in leadership and management e both increasingly important areas of clinical practice e are widely neglected in the training in most European countries. Not even half of the training institutions beside the Scandinavian countries have included these topics in their psychiatric training. This is in contrast to the ‘‘profile of psychiatrists’’ which requires skills in communication with other professional groups, collaboration with other medical specialists, management skills in organizing outpatient and in-patient services and health advocacy to communicate with the public and to improve the health care system for mentally ill patients continuously. Nevertheless, it is worth mentioning that both, the chiefs of training and the representatives of trainees are generally highly satisfied with the national training programmes. To summarise, the survey has shown that the training requirements formulated by the European Board have been partly introduced in Europe. The integration of psychotherapy into psychiatry is a good example of this. Nevertheless, the survey showed also that training in Europe is still very heterogeneous, with different standards in the respective countries. Due to the aim of the European Board to harmonize training in psychiatry it is still on the agenda. Acknowledgements We greatly appreciate the efforts of all national representatives of The European Board of Psychiatry in carrying out this study. We also appreciate the help of Mrs. Joanna Carroll in distributing the questionnaires and communicating with the representatives involved in the study. We also would like to

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thank all those chiefs of training and representatives of trainees who participated in the study.

References [1] Hohagen F, Lindhardt A. Training in psychiatry: a European perspective. European Archives of Psychiatry and Clinical Neuroscience 1997; 247(Suppl.):S1e2 [editorial].

[2] Prinz R. Erste deutsche Klinikvisitation durch die UEMS. Nervenarzt 2005;76:371e2. [3] Saliba J, Katona C. European Union of Medical Specialists e activities of the Section and Board of Psychiatry. Psychiatric Bulletin 2002;26:224e7. [4] UEMS Section Psychiatry. Charter on training of medical specialists in the EU: requirements for the specialty psychiatry. European Archives of Psychiatry and Clinical Neuroscience 1997;247(Suppl.):S45e7. [5] UEMS Section Psychiatry. Charter on training of medical specialists in the EU: requirements for the specialty psychiatry, http://www.uemspsychiatry. org/board/reports/Chapter6-11.10.03.pdf; 2003. last revision.