The Surgeon in Training - European Qualifications

In his recent article Prof. Ray Fitzgerald of Dublin raised some pertinent issues in relation to medical manpower in Europe. Having been directly affected in a positive way by the European Working Time Directive I can say that at the present time in a clearly defined geographical area with a population of 1.6 million and a birth rate of approximately 20 000 per annum that the EWTD has led to a better service and better working conditions by increasing the number of surgical consultants from three to five and the number of trainees from one to three. There is undoubtedly a better balance of work and leisure for both junior and senior staff. This model however may not apply to all other paediatric units in Europe but it is worth considering without the fear of abandoning old practices which seem to have served well in the past.

The real fear of course has been the impact on levels of clinical and operative experience with trainees as their hours are reduced by EWTD. The key in avoiding this pitfall is close consultant supervision. Likewise with the potential risk of consultants not seeing the same number of specialist cases is manageable by working in teams. This latter position is often viewed as unattractive by many older surgeons, but those who have, for example, pioneered the laparoscopic work over the past decade will realise that it has great benefits. Planning and agreeing management of difficult cases with a colleague should be nothing less than a positive experience and is also protective in the event of legal issues arising.

In essence, therefore, for the present EWTD gives as good a reference point as any in terms of manpower needs. It does not however account for circumstances in which there are already more surgeons than the Directive requires, nor does it account for circumstances in which general surgeons are carrying out work on children in a way that some national services would find unacceptable. This must now be addressed by what is known as Clinical Governance issues in the United Kingdom and should now be developed by UEMS and the European Commission as a recommended standard of practice in each specialty.

Team working and standards of practice are well developed in some European States and not in others, however all are subject to the current legislation (directive 93/16/EEC, amended 2001/19/EC) which states that twenty-one of the twenty-five member states have agreed that when medical training has been completed in any of the countries which are party to the agreement, that it is “automatically and unconditionally” recognised in the other twenty countries. Note that the directive refers to “training” and not “qualifications”. The interpretation of this legislation has been confirmed to me as a co-chairman of the European Examination Board in Paediatric Surgery by the Department of Health in the United Kingdom and the European Commission. We all know that this piece of legislation is not uniformly applied in practice but it is nevertheless something to build on as it comes forward for review on or before January 2008. The aim of the European Parliament and the Commission is to harmonise professional standards and facilitate the free movement of the workforce. Whilst there has been some objection to this philosophy expressed to this during the course of recent referenda, it is without question a desirable goal in the field of health care. The simple fact is that we all need healthcare, we need to be assured of good medical care when we travel, and the more nations that provide a standard that is high quality, and that we can recognise as such, is to everyone's advantage.

European legislation has created some benefit for our profession and a means on which to improve matters further. The issue of training will take a long time to standardise, however the issue of standardising qualifications is already within our grasp. Several specialities including paediatric surgery have established a European qualification. None of these hold any legal status because of the legislation referred to above. It is now essential to establish an inter specialty forum under the auspices of UEMS to develop standards for each of these examinations which will be of a high level and accepted by all within the European Union as an end of training qualification. Such qualification is of clear benefit to the trainees, their employers and to members of the public and should give immediate entry to the European Specialist Register. This would then form the basis for appointment as a consultant anywhere in Europe although clearly other factors such as super specialty training, research, publications etc. would be the final determinant when such posts are awarded.

These issues of manpower, training and education will provide problems for as long as medicine is practised. We are however well placed to address them all to a significant degree.

Standardising our system of qualification is not difficult provided that there is the desire to do it. Ideally one would standardise the curriculum, then standardise the training and finally adopt the standard examination. Europe being what Europe is, the examination process will have to come first. Indeed it already exists. We should use it to move the process forward.