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The Treaty of Rome provides for the free exchange of persons, services, goods and capital within the European Community. Free exchange of persons and services within the medical sector has been achieved by mutual recognition of basic and specialist medical qualifications brought into effect by the Commission of the European Communities (EC) in 1975. The Directives have been consolidated in the Directive 93/16/EEC of 5 April 1993.
This Directive 93/16 specifies that Member States shall ensure that the training leading to a diploma, certificate or other evidence of formal qualifications in specialised medicine, meets a number of minimum quality criteria, including duration, content, setting and quality control. It also establishes that Member States shall designate the authorities and bodies competent to issue or receive the diplomas, certificates and other evidence of formal qualifications.
The UEMS (Union Européenne des Médecins Spécialistes) is the representative organisation of all medical specialists in the EC. The UEMS is constituted by the representative organisations of medical specialists in the member states of the EC and the EFTA countries as well as associate members and observers from other European countries. One of its statutory purposes is the formulation of a common policy in the field of training.
The UEMS Section of Rheumatology is the representative body of rheumatologists within UEMS. Members of the UEMS Section of Rheumatology are appointed by the appropriate professional organisations of the specialties in the EC member states and EFTA countries in accordance with UEMS rules of procedure.
The European Board of Rheumatology was set up by the relevant UEMS Section of Rheumatology with the purpose of guaranteeing the highest standards of care for rheumatological conditions in the EC member states by ensuring that the training of specialists is raised to an adequate level.
Working in cooperation with the European Commission, UEMS published and regularly updates the “Charter on Training of Medical Specialties in the European Union” outlining general requirements and guidelines for this purpose in member countries. This document is complemented by a section specifically devoted to each individual specialty, designed by the respective section. The Charter for Rheumatology training in the EU, presented below, was revised and approved in December 2006.
It is recognised that conditions and regulations under which medicine and rheumatology are practised are extremely variable between different countries and will remain so. However, harmonisation of specialist training in Europe is essential to guarantee standards of care and support freedom of movement of medical specialists among member countries. Guidelines on specialist training also represent a crucial opportunity to increase quality standards on behalf of patients.
UEMS CHARTER ON TRAINING OF MEDICAL SPECIALISTS IN THE EU: REQUIREMENTS FOR THE TRAINING OF MEDICAL SPECIALISTS IN THE SPECIALTY OF RHEUMATOLOGY (AS OF DECEMBER 2006)
This document describes the requirements for adequate training, which prepares specialists for practice of the specialty of rheumatology at an appropriate level in any Member State of the EC. The definition of the content of this training is necessary to further the harmonisation of training into medical specialties in the EC. This document first considers the general requirements for specialist training (sections 1–5), and secondly the specific requirements for rheumatology (section 6).
Rheumatology is that branch of medicine concerned with medical musculoskeletal disorders. This term includes systemic disorders of connective tissue, inflammatory arthritis, osteoarthritis, neck and back disorders, soft tissue (non-articular) rheumatism and non-traumatic bone disorders.
A rheumatologist is a medical specialist who has been recognised by the National Authority as having completed postgraduate training leading to theoretical and practical knowledge, professional competence and skills to diagnose, manage, rehabilitate and prevent medical musculoskeletal disorders.
REQUIREMENTS FOR TRAINING IN THE SPECIALITY OF RHEUMATOLOGY
Chapter 1. National Authority
Article 1.1. National Authority
At national level, the training of medical specialists is regulated by a National Authority, which can be a combination of competent professional or university organisations, a national board or a national governmental authority advised by a professional authority. It sets standards in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations. In some cases, the National Authority is organised regionally within the country with national co-ordination.
Article 1.2. Recognition of teachers and training institutions
The National Authority is responsible for selecting and approving training institutions and teachers at national level in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations.
Article 1.3. Quality assurance
The National Authority is responsible for setting up at national level a programme for quality assurance of training and of teachers and training institutions in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations.
Article 1.4. Qualification of medical specialists
The National Authority is responsible for implementing at national level a system of qualification of medical specialists in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations.
Article 1.5. Manpower planning
The National Authority in cooperation with national professional and/or scientific organisations in the specialty concerned is responsible for developing a manpower planning policy at national level that aims at balancing demand and training for medical specialists in the EC member state concerned. The National Authority should be involved in the implementation of this policy.
Article 1.6. Register of medical specialists
The National Authority or its delegate is responsible for keeping a register at national level of medical specialists with data about their specialty, competences and other relevant matters. Medical specialists should practise one recognised specialty or group of related specialties only except in specifically permitted instances. The standard requirements for qualification in each specialty may not be lessened when a specialist is recognised in more than one specialty.
Chapter 2. General aspects of training of medical specialists
Article 2.1. Selection for and access to the training of medical specialists
Teachers and training institutions or other responsible bodies select and appoint trainees who are suitable for the specialty concerned in accordance with an established selection procedure. This selection procedure should be transparent, and application should be open to all persons who have completed basic medical training.
Article 2.2. Duration of training
The duration of training of medical specialists should be sufficient for training in the full range of the specialty and for independent practice of the specialty after completion of training. Training should by preference take place in a full-time appointment. For part-time training an individually tailored programme should be approved by the National Authority.
Article 2.3. Common trunk
For internal medicine and related specialties, for surgical specialties and for paediatric specialties general training in fundamental knowledge and skills will take place in common trunk training for the respective specialty. All trainees should have training in administration, management and economics of specialised medicine.
Article 2.4. Training programme, training logbook
Training should take place following an established programme with specified contents approved by the National Authority in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations. The different stages of training and the activities of the trainee should be recorded in a training log-book.
Article 2.5. Quality assurance
The National Authority together with the teachers and training institutions should implement a policy of quality assurance of the training. This may include visits to training institutions, assessments of the training, monitoring of the logbook or other means. Visitation of training institutions by the National Authority should be conducted in a structured manner.
Article 2.6. Numerus clausus
The National Authority should implement regulation of access to training in any specialty in accordance with national manpower planning projections in the EC member state.
Article 2.7. Training abroad in the EU
Trainees should have the opportunity to be trained in recognised training institutions in other EC member states during their training with approval of their training programme by the National Authority of the country of origin. National Authorities can recognise training in non-EC countries if they so wish.
Chapter 3. Requirements for training institutions
Article 3.1. Recognition of the training institutions
Training institutions shall be recognised by the National Authority.
Article 3.2. Size of the training institution
Training should take place in an institution or group of institutions which together offer the trainee practice in the full range of the specialty with consultations and practical procedures that are sufficiently varied and quantitatively and qualitatively sufficient, including inpatient care, day care and outpatient (ambulatory) training. Allied specialties should be present to a sufficient extent to provide the trainee with the opportunity of developing his/her skills in a team approach to patient care. Subspecialised institutions may be recognised by the National Authority for periods of the training.
Article 3.3. Quality assurance of the training institution
The training institution should have an internal system of medical audit or quality assurance, including features such as mortality conferences, reporting of accidents in accordance with a structured procedure. Furthermore, various hospital activities in the field of quality control, such as infection control and drugs and therapeutics committees should exist. Visitation of training institutions by the National Authority should be conducted in a structured manner.
Article 3.4. Teaching infrastructure of the training institution
In the institution, the trainee should have space and opportunities for practical and theoretical study. Access to adequate national and international professional literature should be provided as well as space and equipment for practical training of techniques in a laboratory setting.
Chapter 4. Requirements for management of the training programme
Article 4.1. Qualification of the chief of training
The chief of training should have been practising the specialty for at least 5 years after specialist accreditation or should have completed a specific training programme before recognition as such. There should be additional teaching staff. The chief of training and the staff should be practising the specialty in its full extent. Sub specialised teachers may be recognised by the National Authority for periods during the training.
Article 4.2. Training programme
The training programme for each trainee should be structured in accordance with national rules and EC legislation as well as considering UEMS/European Board recommendations.
Article 4.3. Teacher/trainee ratio
The ratio between the number of qualified specialists on the teaching staff and the number of trainees should provide close personal monitoring of the trainee during his/her training and provide adequate exposure of the trainee to the training.
Section 5. Requirements for trainees
Article 5.1. Experience
To build up his/her experience, the trainee should be involved in the treatment of a sufficient number of outpatients (ambulatory) and inpatients and perform an adequate number of procedures of sufficient diversity.
Article 5.2. Language
The trainee should have sufficient linguistic ability to communicate with patients and to study international literature and communicate with foreign colleagues.
Article 5.3. Logbook
The trainee should keep his/her personal log-book or equivalent up to date according to national rules and EC Directives as well as considering UEMS/European Board recommendations.
Chapter 6. Requirements specific for the specialty of rheumatology (UEMS section and board of rheumatology)
These recommendations are to be considered in the context of chapters 1–5.
Article 6.1. General rules on monitoring, accreditation and quality management of postgraduate training
6.1.1. The Monitoring authority at the European level is the UEMS Section of Rheumatology/European Board of Rheumatology.
6.1.2. Accreditation of training institutions, including number of training posts, is at the level of National Authorities, taking into account the present recommendations (Articles 6.2 and 6.3).
6.1.3. Accreditation of individual training posts by the National Authorities should ensure that each training post satisfies the training requirements within this charter.
6.1.4. Accreditation of trainers is at the level of National Authorities, taking into account the present recommendations (Article 6.4).
6.1.5. National Authorities should ensure that appropriate quality management procedures encompassing all aspects of postgraduate training are in place, taking into account the present recommendations.
Article 6.2. General aspects of training in rheumatology
6.2.1. The trainee must have completed and qualified in basic training as a physician before commencing specialist training as a rheumatologist. Selection will be according to UEMS Charter 2.1, Article 1.
6.2.2. A minimum duration of 6 years of training is recommended. Training must normally be undertaken on a full-time basis. Interrupted or part-time training should be compensated for by extra time.
6.2.3. Training in rheumatology consists of a “common trunk” in internal (general) medicine, followed by specific training in rheumatology.
Internal (general) medicine should be for a minimum of 2 years, in posts recognised for training in internal medicine, after which the trainee should have acquired appropriate knowledge, training and experience in the care of general and acute medical conditions.
Specific training in rheumatology should include a minimum of 3 years of clinical training in posts approved for training in rheumatology. One of the 6 years could be spent in research or in rheumatology related disciplines.
6.2.4. Training periods in different European countries, as under Article 2.7, are encouraged. Exchange visits within and between European countries are also encouraged.
6.2.5. The trainees must be provided with sufficient time, facilities and support to participate in research. They should acquire research skills and be encouraged to present and publish scientific papers. Study leave must be provided to enable them to attend national and international courses and conferences.
6.2.6. Training should include clear and feasible objectives for competencies in the following seven roles: 1. Medical expert, 2. Communicator, 3. Collaborator, 4. Manager, 5. Health advocate, 6. Academic/scholar, and 7. Professional.
6.2.7. The number of specialist trainees should relate to both the need for future specialists and the facilities of training available in such a way as to guarantee the quality of training.
Article 6.3. Requirements for recognition of institutions for specific training in rheumatology
6.3.1. The process of recognition as a training institution is at the national level and should respect recommendations in this charter.
Rheumatology training may take place in a single institute/centre or in a network of institutions/centres working together to provide training in the full spectrum of clinical conditions and skills listed in the curriculum.
This should include a hospital or institute that provides academic activity and is recognised for training in internal medicine and surgery.
Each participating institution must be individually recognised as a provider of a defined section of the curriculum.
6.3.2. The training centre(s) must provide sufficient clinical admissions and outpatient referrals to ensure adequate experience of the full spectrum of rheumatic diseases. The trainee should be involved in the management of new patients, follow-up patients and inpatients.
6.3.3 The training centre or network must offer ready access to medical imaging, bone densitometry and to laboratories for haematology, histopathology, clinical chemistry, microbiology, clinical immunology and diagnostic neurophysiology. There must be suitable instruments for training in polarising light microscopy and, ideally, capillaroscopy and musculoskeletal ultrasonography.
There should be appropriate allied health professional support, which might include nurses specialising in rheumatology, occupational therapists, physiotherapists, social workers, aids and appliances.
The training centre/network must provide adequate space for training activities, including independent study, seminars and clinical demonstrations.
There should be easy access to leading rheumatology journals and appropriate scientific and clinical literature.
It is the responsibility of the centre to provide supervised training sufficient to meet the learning needs of the trainees throughout the training programme. This requires protected time for all the trainees and trainers.
The training centre/network should offer regular staff meetings, clinical conferences, combined clinics with, for example, orthopaedic surgeons, and pathology and radiology demonstrations.
6.3.4. There should be appropriate quality assurance systems in place that involve regular objective assessment of the quality of medical care as well as evaluation of the training programme and outcomes.
6.3.5. The training programme, with an appropriate detailed timetable, should be devised in advance and available for external scrutiny.
6.3.6. There should be a clear structure for the co-ordination of training.
The overall co-ordination of the rheumatology training programme should be led by an appointed programme director.
Each participating centre in a network should have a nominated chief of training (see Article 4.1) responsible for local educational activities.
Each trainee should have a named supervisor who provides tutorial support.
The programme director should have adequate experience/qualifications for a role in the management of education.
Chiefs of training and supervisors should all be practising clinical rheumatologists and fulfil the requirements expressed under Article 6.4.
Training should be accepted as a common responsibility by all members of the training centre.
6.3.7. Recognition as a training centre/network should be reviewed by National Authorities on a regular basis, at least every 5 years. Recognition should be based on structured multidimensional appraisal, including evaluation by trainees. There should be a written report.
Article 6.4. Requirements for recognition of the trainers
6.4.1. The Chief of Training must be recognised by the appropriate national educational and training authority and should fulfil the requirements of the European Board of Rheumatology (Article 6.4.2).
Recognition is to be granted for a period of 5 years at the same time as the training centre, after which renewing it may follow on the recommendation of an inspection committee at the time of the quinquennial reinspection of the training centre. They can only be recognised in this capacity if they have a major work commitment to the training centre/network.
6.4.2. Chiefs of training and supervisors must be recognised specialists in rheumatology and be in active clinical practice and in training in the centre/network.
Their educational roles and activities should be clearly defined in job descriptions.
In assessing their suitability, consideration should be given to their ethical attitudes to medicine as well as educational skills and attitudes. They should have recognised high standards of quality of medical practice and keep up to date in advances in theoretical and clinical rheumatology through continuous professional development.
6.4.3. The Chief of Training and Supervisors must have protected time to fulfil their educational roles and activities.
6.4.4. Quality management provisions for trainers should be in place, encompassing all qualities described under 6.4.1.and 6.4.2. Evaluation should include feedback by trainees.
Article 6.5. Requirements for trainees in rheumatology
6.5.1. The content and structure of training in rheumatology should be clearly described in a published national curriculum.
The curriculum should be supported by a specific portfolio that includes the personal log-book, notes on periodical assessments and continuing evaluation of progress.
The curriculum and portfolio must comply with the present charter and with the core curriculum and portfolio of the European Board of Rheumatology.
6.5.2. Each trainee should have a personal training programme and a named supervisor at the start of the training.
6.5.3. It is the trainee’s responsibility to keep their portfolio updated and seek opportunities to achieve and verify competency in all areas of the curriculum.
6.5.4. The training programme must provide the trainee with sufficient clinical experiences, technical procedures and other training opportunities to achieve all competencies described in the core curriculum.
The programme should include formative assessment as part of the training opportunities.
6.5.5. The programme must include specific ways to verify that the trainee has attained the required standards of all competencies stated in the curriculum. The portfolio should play a central role in the assessment procedures.
6.5.6. There must be regular documented appraisals of the trainee by their supervisor. These should be at least annual and incorporated in the portfolio. These appraisals must be discussed between the trainee and the supervisor and appropriate recommendations must be agreed and acted upon.
If, at any stage, the supervisor finds the trainee unsuitable to continue specialty training, this should be immediately discussed with the Chief of Training and the Programme Director.
6.5.7. Recognition of training should be given by the competent national authority on satisfactory completion of the training programme.
Competing interests: None.