|Home | About | Journals | Submit | Contact Us | Français|
Pathology without frontiers
Pathology in Europe is still mainly directed at a national level by the national pathology societies. The main goal of these societies is to guarantee an optimum practice of the specialty, both professionally and economically, in their own country. The interest or involvement in the same aspects of the specialty in other countries was and is very limited, taking the long history of European unification into consideration.
The main international organisation that binds anatomic pathologists in Europe is the European Society of Pathology. This Society is the main organiser of international European congresses that are held biannually (with a smaller intercongress in between). Moreover, it adds also to postgraduate education by its European School of Pathology and by EuroCellPath. The latter organisation addresses mainly the molecular aspects of pathology. Through these activities, the European Society of Pathology contributes to augmentation of knowledge in Europe in its widest geographical sense. However, it does not play an active role in the process of harmonisation of training and practice in Europe.
With the Treaty of Rome in 1957, a free exchange of diplomas, including the medical ones, in the then European Economic Community (EEC) was realised. In 1958, representatives of the medical specialist organisations of the six involved countries convened to discuss the consequences of the free movement of doctors that could result from this decision. Europe at that time had a great diversity in specialties with only partial overlap in different countries. They, therefore, founded the European Union of Medical Specialists (UEMS) and tackled a number of problems such as manpower planning, subspecialisation, marking out of specialities, the quality of the specialty training and the consequences of free movement of medical specialists.
In 1962 the UEMS founded within its organisation specialist sections for the most important specialties practised at that time in the EEC. Presently there are 39 specialist sections. Pathology was originally part of the specialist section of laboratory medicine, representing anatomic pathology, chemical pathology and microbiology. In 1988, separate sections of anatomic pathology, pathobiology and microbiology were created, recognising the different interests of the involved groups. In 1992, the UEMS asked the different specialist sections to erect European Boards for their respective specialties. According to the UEMS, the goal of these boards was: “to ensure the highest standards of care in the field of the specialty, by ensuring that the training of the specialist doctor is raised to the highest possible level”. In addition, it was said that the European Boards “shall provide fresh impetus for achieving high quality medicine and completing free movement of specialist doctors”. The boards were to have the same name as the homologous section, and the board and section could be one organisation. This was done for pathology, where we now have one body functioning, both as the specialist section of pathology and as the European Board of Pathology, since the activities required of the boards were already topics of discussion in the section. Every country in the European Union (EU) and most other countries in Europe that will be a EU member in the future, or are closely affiliated with the European Community, has two representatives in each of the different specialist sections.
Each section/board usually convenes once a year to discuss topics such as harmonisation of practice (a difficult topic: who is mandated to do what relative to the national bodies), uniform training structures, international accreditation bodies, continuing medical education and examination. Although much progress has been made in the different sections in these fields, the attained agreements have not consistently resulted in parallel actions in the EU member countries. A section/board can agree on a training duration of 5 years, but a government can block that for several reasons (national manpower planning, financial consequences, etc), and decision making within the boards is not always unanimous. The opposing parties do not usually feel bound to comply with the agreements. For example, the section/board of pathology in a majority vote agreed on a voluntary exit examination in 1996, but many countries never sent their candidates to the examination because they had an opposing view. Often, individual country representatives defend their view and continue with their current practice despite a majority decision. As a result, despite a generally positive attitude, there is still, even in pathology, much variation in training duration, content, defined competences at the end of training, certification and quality assurance. This results in qualitative and quantitative differences between the medical specialists from different EU countries, although their specialist certificates are considered to be equal and mutually exchangeable. According to a 1998 report of the Dutch Registration Committee for Medical Specialists, the differences in quality of training are, therefore, a cause of concern.
Pathology as a medical specialty in the EU (and in the rest of the world), has a generally accepted identity in terms of content and modalities of practice, despite a wide variety in content and educational approach of training programmes. During the past 17 years, the specialist section (European Board) of pathology has tried to change this situation through proposals concerning different aspects of the harmonisation of training, and through the introduction of a voluntary exit examination at the end of training. In addition proposals regarding continuing medical education and other quality aspects were made. However, despite the honourable intentions behind these proposals, they did not result in substantial changes in the training programmes. This is partially due to the fact that the UEMS is a very slowly functioning political organisation with enormous differences in vision and conflicts of interest between individual specialties and between different countries. The UEMS aims for uniform regulations for all specialties, and does not support particular initiatives made by individual specialties. The UEMS opposes uniform European specialty examinations (although 10 specialties have already developed a widely accepted European Boards examination) and does not want them to eventually replace the existing national examinations. Through such and other decisions, the UEMS blocks new developments that are in fact the logical consequences of the imposed mutual recognition of medical specialists in the EU.
On the other hand, one should not blame only the UEMS for lack of progress. The national pathology societies and other bodies responsible for resident training also often do not support proposals for harmonisation of pathology training and certification, certainly when they are not actively involved in developing the proposal. Their main goal is still to improve the quality of the training programmes and practise conditions for which they are directly responsible. As a consequence, the efforts of the pathology section of the UEMS have resulted in many good initiatives for pathology in the EU; however, the tangible results at this moment are rather disappointing.
Over time the feeling has emerged that real international changes would require initiatives other than those of the UEMS to be developed within the group of professionals directly responsible for the training of medical specialists: the academic pathology chairs and residency programme directors. A homologous association of professionals exists in the USA and Canada which is the main forum for developments in training and teaching. After ample consultations, in September 2005, the “European Association of Pathology Chairs and Residency Programme Directors” was founded. Its members are academic pathology chairs and residency programme directors, whereas non‐academic programme directors who direct a complete training programme are admitted as extraordinary members.
Statutes and bylaws describe the purpose of its existence thus: “The mission of the Association is to promote within Europe the highest standard of pathology training and certification, and to share good practice. The Association will aspire to and encourage the development and harmonization of pathology curricula, assessments and examinations. This in turn will underpin a sound and uniform pathology practice within the European countries. The Association shall act as the medium for exchanging resources and networking opportunities for (academic) chairs and residency program directors of schools of medicine and pathology departments in the field of undergraduate and postgraduate education, research and training, throughout the European countries”.
The Association has a council consisting of a president (Dr Jan G van den Tweel, The Netherlands), a secretary (Dr Massimo Pignatelli, UK), and a membership secretary/treasurer (Dr Javier Pardo, Spain). Dr Konrad Mueller Hermelink (Germany) holds the function of past president. In addition, there are two councillors, one nominated by the European Society of Pathology (Dr Fred Bosman, Switzerland) and the other by the UEMS (Dr Veli‐Pekka Lehto, Finland). The association has five committees that deal with the major goals of the Association; their chairs are ex‐officio council members. The following committees have been set up:
The harmonisation committee is, among others, involved in formulating general and specialty‐specific end‐term competencies, and weights them against the duration of the training period and the minimum case load requirements.
The committee on competence testing and examination examines the possibilities of an annual European progress test and consults national societies regarding the need for and feasibility of a European exit examination.
The subspecialisation committee addresses the classical dilemma between general and subspecialty competence and its recognition in pathology.
The main task of the research committee is to advise the membership about relevant research developments that may have a diagnostic impact in pathology in the future.
The main task of the committee on undergraduate teaching is to advise on new teaching methods in the medical curriculum, to bring pathology closer to the students and bright students closer to pathology.
Both the EAPCP and the specialist section of pathology of the UEMS might claim the final responsibility for pathology training. However, these bodies have widely overlapping goals. What differs between them is the potential to make them work. Many of the initiatives of the specialist section have not resulted in concrete action. The EAPCP, with its membership composed of those directly responsible for the training programmes, is able to get things going by copying the proposals that have been made, and also by reconsidering them in the context of the developing needs in individual countries and in the EU. Defining a good training programme is more than defining content and setting the duration. High‐quality and stimulating undergraduate education is essential for the recruitment of enthusiastic trainees, and implementation of research in the training is essential for tomorrow's pathologists to remain up to date. Good subspecialists (or whatever one wants to call them) are essential for optimal training and patient care. Competence testing (in whatever form) is the only way to check if harmonisation of the different European training programmes results in a homogeneous profile of the end‐product. Here is another opportunity for the UEMS: the European Board of Pathology is the ideal structure to organise and supervise (sub)specialty examinations.
The European Association of Pathology chairs and programme directors, the European Board of Pathology and the European Society of Pathology each have their own role in shaping the practice of our discipline, which remains crucial for the practice of medicine.
It is clear for everybody involved in these developments that these changes cannot be realised in one day . Time only will tell whether this initiative to create the new association has the support necessary to realise the complex goal that it pursues. However, the overall positive reactions justify the hope that it constitutes an important step towards uniformity in pathology training and practice in Europe.