Abstract
Background: In the majority of European countries, postgraduate psychiatry training schemes are developed and evaluated by national bodies in accordance with national legislation. In order to harmonise training in psychiatry across Europe, the European Union of Medical Specialists (UEMS) issued a number of recommendations for effective implementation of training programs in psychiatry.
Aims: To describe the structure and quality assurance mechanisms of postgraduate psychiatric training in Europe.
Method: The European Federation of Psychiatry Trainees (EFPT) conducted a survey, which was completed by the representatives of 29 member national psychiatric associations.
Results: In most countries (N = 19), the duration of the training programme is 5 years or more. Twenty-six countries have adapted a basic training programme that includes the ‘common trunk’ (according to UEMS definition) or a modified version of it. In 25 countries, trainees are evaluated several times during their training with a final exam at the end. In 25 countries, official quality assurance mechanisms exist. However, results demonstrate great variations in their implementation.
Conclusions: Overall, psychiatric training programmes and assessment methods are largely compatible with one another across Europe. Quality assurance mechanisms, however, vary significantly. These should receive adequate attention by national and international educational policy makers.
Introduction
Postgraduate psychiatry training schemes in the majority of European countries are developed and evaluated by national education policy makers. However, during recent decades, the European Union has emphasised the need for harmonisation in medical training across Europe in order to facilitate migration of medical professionals (Council Directive Citation2009). The European Union of Medical Specialties (Union Europeene des Medicine Specialists; UEMS) and its Board of Psychiatry were established to facilitate this process. In 2003, the UEMS made a number of recommendations for effective implementation of training programmes in psychiatry. Recommendations were made for the structure of training programmes, competency-based training standards, standards for training institutions, trainers and supervisors, and quality assurance mechanisms (UEMS Section for Psychiatry Citation1997; ). In a follow-up survey, the UEMS members evaluated the extent of the implementation of their recommendations (UEMS Section for Psychiatry Citation1997) and found that these were met only in part (Lotz-Rambaldi et al. Citation2008). The results from subsequent surveys further confirmed differences amongst training programmes throughout Europe (Karabekiroglu et al. Citation2006; Oakley & Malik Citation2010). According to recent data, substantial problems with the implementation of training curricula exist in many European countries (Nawka et al. Citation2010). Therefore, the European Federation of Psychiatry Trainees (EFPT) conducted a survey examining training in psychiatry across European countries. The aim of this survey was to describe the current structure and evaluation processes of training in Psychiatry in 29 countries, providing valuable comparative information to national and international authorities who oversee training.
Table 1. A selection of requirements for the specialty of psychiatry from the ‘Charter on training of medical specialists in the EU: Requirements for the specialty of psychiatry’ (UEMS Section for Psychiatry 1997)
Materials and methods
Data collection and study participants
The EFPT is the federation of national European psychiatric trainees’ associations from more than 30 member countries, all across Europe, formed in 1993. The EFPT has a permanent seat with full voting rights in the European Board and Section for Psychiatry and the European Board for Child and Adolescent Psychiatry, which permits its active participation both in the development of educational guidelines and the evaluation of psychiatric training institutions in Europe. The EFPT is run by the General Assembly as its highest body and the Board as its executive body.
Every year, the EFPT president organises the annual European Forum, where official trainee representatives from national psychiatric trainee associations (two per country) meet and work on issues of significance to psychiatric training in Europe and report the current situation related to psychiatric training in their country. Each country submits one official report to the EFPT Board. The country reports have a standardised format and are completed by the official representatives of national training associations. Representatives of the EFPT are trainees elected by their national trainee association and are usually the president, officer, or other members of the association who are official delegates at the Forum. On the basis of the country reports submitted to the annual forum by the national trainee associations, specific action plans are developed to meet the needs of the EFPT members.
For the purpose of this study, data were collected by self-reported questionnaires. The questionnaire was distributed as an addition to the official country report form to national trainees’ association representatives participating in the EFPT Annual Forum (Dubrovnik, Croatia, June 2010). The questionnaire was delivered in English and was collected in May 2010. The questionnaire was designed by members of the EFPT for the purpose of this study and was reviewed by the consultant statistical specialist. Although the basic structure remained the same, the statistics’ expert helped us to formulate questions suitable for data analyses. The questionnaire consists of 20 questions, 10 on the structure of training programme and the methods of assessment of trainees and 10 on the methods of quality assurance of the training programmes (Supplementary material). In order to ensure the reliability of the data, the respondents were asked to provide an official reference source (e.g., National Ministry of health) to be contacted in case of ambiguous responses. In two cases where the responses were considered as unreliable, additional data checks were performed by contacting the national training association to verify data provided in the questionnaires.
Data from 29 member countries (27 full members and 2 observers) who participated at the EFPT Forum 2010 were included in the study. Data from two full members were not obtained as the representatives did not participate at the EFPT Forum 2010.
Statistical analysis
Data on psychiatric training programmes, assessment of trainees and quality assurance of psychiatric training were analysed using descriptive statistics. Main outcome measures are given in and . Analyses were carried out by SPSS 11.5 (SSPS inc., Chicago, IL) statistical software package.
Table 2. Training programmes and assessment of competencies of adult psychiatric trainees across Europe
Table 3. Overview of the basic quality control mechanisms of psychiatry training programmes across Europe
Results
Psychiatry training programmes and assessment of trainees across Europe
Duration of the training programmes varies from 1.5 to 6 years. Ten of the 29 surveyed European countries have adapted a basic training programme that includes the so called ‘common trunk’ as recommended by the UEMS (). However, standard training schemes of the majority of countries (in 16 countries) have a modified version of the ‘common trunk’ that include general adult psychiatry, substance abuse, child and adolescent psychiatry (CAP) in in-patient, outpatient and emergency psychiatry settings; however, old age psychiatry, forensic psychiatry and liaison and consultation psychiatry are frequently missed. Two countries have substantially shorter duration of training and different training scheme; and for one country, data were not available (see ). In five countries, there are several officially recognised training schemas: in three countries there are two officially recognised training programmes and in two countries there are modifications of one officially recognised training schema. CAP training is a separate specialty from adult psychiatry in most of the countries (N = 19).
In nearly all of the European countries (N = 25), trainees undergo several methods of assessment during their training. Assessments are carried out on an annual basis (N = 8) or after each new placement (N = 17) usually by a combination of at least three distinct assessments (observation of the patient assessment, case presentation, non clinical skills and oral and written exam; N = 14). These assessments are carried out by supervisors (N = 23) or as workplace-based assessments (N = 8). In the majority of countries (N = 24), assessment results are formally recorded in trainees’ logbooks. In the majority of countries (N = 19), poor outcomes of assessments during training results in the repetition of the recent placement. In four countries, no assessments during training are performed. In most of the countries (N = 25), there is a final exam at the end of training, which may be written (N = 2), oral (N = 3), oral in combination with written (N = 5) or clinical case (N = 7) or a combination of several methods (N = 8). This exam is organised by supervisors (N = 11), an independent specialist board (N = 9) or by multiple evaluators (N = 5; ).
Quality assurance of psychiatric training across Europe
Overall, in 3 of 29 countries, no official quality assurance mechanisms exist; and for one country, data were not available. In the remaining 25 countries, national educational or healthcare authorities are in charge of developing and implementing psychiatric training programmes. Trainees participate in the process of programme development in 11 countries. In 16 countries (64% of the countries with official quality assurance mechanisms), the same national authority is in charge for both the programme development and quality assurance, whereas in two countries (8%), one additional independent national organisation is responsible for quality assurance. In the remaining four countries (15% of the countries with official quality assurance mechanisms), different national organisations are in charge of the programme development and quality assurance, respectively. For three countries, data were not available. Negative evaluations of training placements can lead to serious consequences for training institutions, which can involve loss of accreditation status in 10 countries. However, it should be noted that although in some of the countries official quality assurance mechanisms exists, in 3 of 25 of these countries no audits of psychiatry training programmes of any kind are performed.
In the remaining 22 countries, regular audits of psychiatry training programmes are performed. In those countries, the principal quality assurance mechanisms comprise commissioned reports or questionnaire reviews of placements, trainers/supervisors and working conditions filled out by training deliverers (in six countries) or by trainees (in six countries) or in situ evaluations by a national authority responsible for quality assurance of training implementation (in six countries). In two countries, multiple quality assurance mechanisms exist (evaluations by trainees and in situ evaluations by a national authority responsible for quality assurance of training implementation); and for two countries, data were not available. Evaluation results are available to a national authority responsible for quality assurance of training implementation only in seven countries, to training providers, such as heads of departments or hospital directors in seven countries, trainees in two countries and or even open to public in four countries; and for three countries, data were not available. Trainees participate in the process of programme evaluation in 14 countries ().
Discussion
Training programmes and assessment of trainees across Europe
The majority of European countries have adapted the basic training programme that includes the common trunk or a slightly modified version of it, in line with the UEMS recommendations (). Thus, we consider training programmes in Europe to be broadly compatible with one another and that significant progress has been made towards harmonisation of psychiatric trainees’ curricula in Europe. These findings are consistent with those from previous studies (Lotz-Rambaldi et al. Citation2008; Oakley & Malik Citation2010). It should be noted, however, that some countries do not yet offer important subspecialties in old age or liaison psychiatry. Considering the increasing evidence of an ageing population in Europe (Lyketsos et al. Citation2006), reduced training opportunities in these areas may have a significant impact on trainees’ clinical practice.
Postgraduate psychiatry training schemes in the majority of European countries are developed and evaluated by national authorities in accordance with the national legislation. Such legislation may or may not take the recommendations of the UEMS and other international bodies into account. Although the reporting of differences in the educational programmes between European training centres may ultimately be beneficial for the overall quality of education, as poorer performing countries can aspire to the standards of countries that perform better, a minimum of educational requirements should be compulsory for all European psychiatric training centres. For example, according to our results, two former Eastern European countries continue to struggle to provide a number of training opportunities. This may be due to socio-political reasons, as these countries have recently undergone significant regime changes. Therefore, for a number of countries, adapting their psychiatric training programme to the existing international recommendations might be useful to assure minimum standards are met.
In the majority of countries, trainees’ competencies are assessed several times during the training by their supervisors and at the end of the training. However, our data highlight the wide range of assessment strategies across European countries, as was already documented by a previous survey (Oakley & Malik Citation2010). Although our results indicate that in the majority of European countries assessment methods are comparable, in a few countries assessment structures for psychiatric trainees differ substantially. To avoid these discrepancies and to ensure equivalence of training standards between European countries, the efforts to guarantee the harmonisation of assessment procedures should be discussed and coordinated on a European level. In 2009, the UEMS issued a framework for competencies in psychiatry with a wide range of recommended procedures for the assessments of the knowledge, competences and performance of psychiatry trainees. However, at the moment, none of the countries in our survey have fully implemented these standards (UEMS Board for Psychiatry Citation2009).
Quality assurance of psychiatric training across Europe
According to our data, trainees report that quality control mechanisms in a number of countries are very scarce and vary significantly among countries. In three countries, no officially recognised quality control mechanisms exist. In 3 of 25 of the countries where official quality assurance mechanisms do exist, no audits of psychiatry training programmes of any kind are performed. It is unclear how the evaluation of training programmes is executed in these countries. It can be supposed that as a consequence, the implementation of training curricula reforms may be unsatisfactory in these countries. This has been reported by one of the countries (Kuzman et al. Citation2009).
In 6 of 20 countries where regular audits of training programmes are performed, trainees do not participate in the review process. In addition, in the majority of countries, evaluation results are available to the official bodies responsible for quality assurance or to training deliverers who themselves are evaluated, and rarely to trainees, which may appear as a ‘closed circle’. Furthermore, it is noteworthy that negative evaluations of training placements can lead to consequences such as the loss of accreditation status (as reported in some countries surveyed). As a result, it seems that some countries adhere to the training regulations ‘on paper’ but are reluctant to evaluate implementation of the programmes in situ. For example, recent data have highlighted variations in quality of training in practice across Europe (Nawka et al. Citation2010). Strachan (Citation2007) has pointed out that those psychiatric national associations that regularly engage in external audit processes more often identify discrepancies between what is described on paper and what occurs in practice. In explaining these findings, it should be noted that in most countries, the same national authorities are responsible for the development and implementation of psychiatry training schemes. Consequently, it seems that many countries lack an independent review body to oversee implementation of training. In addition to the reorganisation of the structure of training programmes in order to meet international standards (such as the ones provided by the UEMS), proper implementation is crucial to assure the quality of education. International organisations such as UEMS or EFPT could assist in the coordination of quality control and auditing of training standards and serve as an additional and independent evaluation body. This possibility already exists in the UEMS recommendations (UEMS Section for Psychiatry Citation1997), but there are relatively few countries where independent audits of training are performed (Strachan Citation2007). It is noteworthy that in countries where regular audit of training programmes exists, differences between training standards and implementation were reported less frequently regardless of the evaluation strategy (Kuzman et al. Citation2012). As such, more effective strategies for the implementation of the existing quality control mechanisms should be developed on an international level.
Overall, one could argue that the most efficient quality assurance mechanisms comprise multisource evaluations, are conducted in a transparent way with publicly available evaluation results, and are under the responsibility of an independent national body. In addition, an effective quality assurance programme should incorporate legal mechanisms that assure that the results of evaluation of training make a tangible difference in practice. On the basis of these assumptions, the most comprehensive and effective quality assurance mechanisms seem to exist in Denmark, Switzerland and UK.
This study has several limitations. The first is that the data reported are largely descriptive. The study does not explore the practical consequence of the differences in training programmes or quality control mechanisms for the implementation of the training. However, in a recent publication (Kuzman et al. Citation2012), we indicated problems in the implementation in practice of psychiatric training curricula associated with the absence of quality control mechanisms. A second limitation of the study methodology is that data of countries where multiple officially recognised training programmes exist is only based on responses concerning a majority of accredited training institutions.
Conclusion
This report offers a unique and comprehensive overview of the structure and quality control mechanisms in psychiatric training in 29 European countries. The results suggest that in the majority of European countries, the structures of training and assessment methods are largely comparable with one another and compatible with the existing recommendations at the European level, whereas the quality assurance mechanisms of training vary significantly among countries.
The discrepancies in psychiatry training standards and quality control mechanisms should receive adequate attention from responsible national authorities and from those bodies engaged in the harmonisation process of training in psychiatry on a European level. Although to date, clear efforts have been made to establish comprehensive guidelines on the content of training, quality control mechanisms have rarely received sufficient attention. The development of effective and standardised quality control mechanisms is one of the most important steps towards the optimisation of psychiatric training in Europe. If we are to expect harmonisation of European standards from the novel shift in training policies in European psychiatry, the competency-based training (Oakley et al. Citation2008), it will be critically important to ensure its proper implementation.
Acknowledgements
We thank Zarko Bajic and Biometrika Healthcare Research team for statistical advice for the development of the questionnaire.
Declaration of interest: All authors are members of the EFPT. The authors received no source of funding for work described. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributors
All authors were members of the EFPT board.
Supplementary Material
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