EUROPE
Special Section: Building a better radiologist

The Oxford English Dictionary defines "harmonious" as forming a pleasing or consistent whole, free from disagreement or ill feeling. In the context of radiology education in Europe, "harmonization" refers to the standardization of training requirements throughout the continent. Achieving this ambitious goal is akin to assembling and directing a multilingual choir composed of people who have been reading from their own hymn books for many years.

Although minimum standards have been accepted and are being implemented across Europe, the programs are still out of sync in many key areas, such as examination structure, entry requirements, availability of equipment, and assessment of training centers.

"There is an awareness that standards are not even across all the countries for a variety of reasons, usually economic. There are also different hierarchical systems in medicine, which may not deliver broad-based training," said Prof. Helen Carty, a professor of pediatric radiology at Royal Liverpool Children's NHS Trust-Alder Hey in the U.K.

The tide appears to be shifting, however. Most of the national societies subscribe to the idea of harmonization and are planning changes to their training and education programs.

"The harmonization of radiology education is a long-term project; it may take many years. We are supposed to be a common labor market and it makes more sense to have a common European standard," said Prof. Holger Pettersson, a professor of radiology at the University of Lund, Sweden, and president of the European Association of Radiology (EAR).

Among the anticipated changes are the following:

• Italy will soon create masters degrees in pediatric and interventional radiology and will establish a national voluntary board exam.
• Austria made its board exam compulsory this year and will create subspecialty programs in pediatric radiology, neuroradiology, and interventional radiology by the end of 2003.
• A voluntary assessment program for training centers sponsored by the EAR will be expanded, and national accreditation systems based on this program could become mandatory within 10 years.

Part of the impetus for harmonization is coming from the EU, which has passed directives requiring countries to ensure that medical professionals can work across borders. But harmonization is also being driven by leaders in the specialty who want to guarantee the same standard of patient care throughout Europe. The goal is to establish minimum rather than optimum standards.

"We have to take cognizance of differences in various countries," said Carty, who will become president of the European Congress of Radiology in 2004. "We cannot say what is right in the U.K. is necessarily right for Portugal, or what is right for Portugal is right for Italy. What you can say, and on this everyone agrees, is that there has to be a basic standard across the European Union so patients get quality care."

Harmonization efforts are necessary for members of the union, but non-EU members are likely to adopt the same training standards with a view toward joining the EU in the future and/or to allow the transfer of personnel throughout Europe. Leaders in Switzerland, for example, which is not an EU member, are active in harmonization activities.

YELLOW BOOK REVISITED

The EAR has already made strides toward standardization. In 1997, it compiled guidelines for training and education in a print publication referred to as the "yellow book," which have led to important changes in university radiology departments throughout Europe. The guidelines are now available online at the EAR Web site (www.ear-online.org).

The guidelines advise five years of training: four years covering the common trunk of general radiology and one year in a subspecialty. The subspecialty training may be applied toward a postgraduate degree.

Minimum numbers of examinations have been established for each modality. Residents are advised, for example, to perform 1500 CT exams, including 200 head and 200 spine studies. Continuing medical education is voluntary, but radiologists are strongly encouraged to complete a minimum of 50 credits per year and 250 credits within five years.

The EAR also provides guidelines for training in a full range of radiological specialties, from breast imaging to urogenital radiology. EAR guidelines are in the process of being revised, according to Prof. Pierre Schnyder, chair of the EAR education committee. Basic elements, such as the number of weeks radiologists spend in each radiology section and the duration of postgraduate training, will not be changed.

"The most important changes relate to requirements, such as an exhaustive list of pathologies to be learned by trainees," Schnyder said.

In line with EAR guidelines, Italy will migrate from a four-year to a five-year training program in 2003, according to Prof. Roberto Passariello, chair of radiology at the University of Rome "La Sapienza" and past president of the EAR. This decision had to be approved by the government bodies responsible for healthcare because it involved a sizable increase in the cost of salaries for residents.

As of November 2002, France will also move to a five-year training system, following seven years of lobbying the government's medical education ministers by the College des Enseignants de Radiologie de France (CERF), the French Radiology Society, and the radiologists' trade union. The change should allow more concentration on subspecialty training, said Prof. Alain Blum, a professor of radiology at University Hospital of Nancy, France.

A number of countries in East and Central Europe, including Poland and Hungary, have already adopted the five-year training model. Russia has traditionally had a short training program (five months) in general radiology, plus on-the-job training. The country's health authorities plan to make the two-year program mandatory this year and to move toward conformity with EAR guidelines by 2005 (see accompanying article).

VOLUNTARY ASSESSMENT

Length of training is just one measure of equality across healthcare systems. One of the newest initiatives in European standardization is assessment of radiology training centers.

Earlier this year, the EAR launched a pilot assessment program for training centers, which runs in conjunction with the European Union of Medical Specialists (UEMS).

The voluntary EAR project, which is closely modeled after the successful U.K. accreditation system, involves site visits to radiology centers for evaluation in a number of areas, including availability of equipment, level of supervision, and the structure of the training program itself. Three centers-in Italy, Slovenia, and Switzerland-have taken part thus far.

Six more programs will be assessed in the next eight months, and the long-term goal is to evaluate one center in each European country every year, said Prof. Iain McCall, chair of the EAR's professional organization committee and radiology section head at the UEMS.

The EAR pilot program involves a two to three-day site visit by physician assessors who inspect the facility. The inspectors work on a voluntary basis, but the center itself pays the cost of their travel and accommodations, which usually totals about Euro 5000 to Euro 6000.

Unlike the European board exam, which has proven divisive, support for assessment programs appears to be strong, and they are likely to become compulsory in the future, Schnyder said.

"Within five to 10 years, they will probably be mandatory," he said. "Insurers don't want to pay for their patients to be treated in incompetent centers."

The EAR does not intend to run the program itself, however. It would like to enable national societies to form their own, possibly legally binding, accreditation programs.

Adapting the U.K. system for the estimated 1500 training centers across Europe may prove a daunting task.

"The EAR program is in its infancy," Carty said. "You can imagine the number of training programs delivered in different ways in different countries. You can't say the British model will automatically become the European model, but I am sure there will be similarities. Harmonization in Europe is about acknowledging that countries don't have to do everything on their own. You take the best practice and adapt it."

Access to equipment varies depending on the financial resources of a given country, Schnyder said, and national societies may need to adapt equipment standards to their own local conditions.

SUBSPECIALTY GAP

Even if standards for the basics of radiology can be worked out, subspecialties pose additional problems.

"There is a much wider array of interesting technologies, and they have to be mastered. Everybody strives to do that. But fields are changing so rapidly, it is like shooting at a moving target. That is why all countries have introduced some form of continuing education program," said Prof. Dr. Gustav von Schulthess, director of nuclear medicine at University Hospital Zurich in Switzerland.

Radiologists are also concerned that they will lose procedures to nonradiologists unless more emphasis is placed on subspecialty training.

Radiologists in Austria have been lobbying the medical board, which is responsible for radiology education, to create official subspecialization programs in pediatric radiology, neuroradiology, and interventional radiology. These programs could be approved and developed by late 2003.

Italy is planning to introduce two-year masters programs in pediatric, neuroradiology, and interventional radiology next year. Educators would like to maintain the "unity of radiology" while encouraging formal subspecialty training, Passariello said.

In France, the new five-year radiology training program calls for one year of training to be spent outside radiology, to enable residents to gain experience in a clinical discipline that will aid them in developing a radiological subspecialty.

"It is a good opportunity for a resident who wants to become a musculoskeletal radiologist to spend some time in a rheumatology department. Residents who want to become neuroradiologists can spend time in neurology," Blum said.

French radiology professors published a list of specific training requirements in June, which should help standardize education across the country and ensure that residents receive sufficient training in all of the modalities.

There is concern in France that radiologists are not being trained sufficiently in some areas of cardiac imaging. Cardiologists are beginning to take over those procedures and could move into vascular imaging as well. But although professors would like to educate residents in this procedure, as well as others, shortages of equipment and radiologists hamper training. The French Ministry of Health must grant authorization for the purchase of MR scanners in both the public and private sectors, and for increases in the base of medical practitioners. The field of diagnostic imaging is attractive to medical school graduates, and radiology societies have been lobbying to increase the numbers in training, but the government prefers to address more serious shortages in other fields, such as gynecologic surgery, Blum said.

Due to their full caseloads, private-practice radiologists have let certain studies, including some in cardiac imaging, slip into the control of other specialists.

"We have to deal with a large increase in activity in all fields of radiology, and residents have to learn studies most useful in private practice. In general, they don't recognize the importance of making an investment in cardiac imaging," Blum said.

STAFFING CRISIS

Officials in other European countries, such as Germany, also report concerns about radiologist shortages. Staffing problems will become worse as the elderly population increases, placing greater demand on healthcare systems. While changing the training system to bring in more radiologists is no easy task, it is being considered seriously as a solution to the immediate threat.

The U.K.'s Royal College of Radiologists released a report in January called Clinical Radiology: A Workforce in Crisis. It asked for an increase in the number of radiologists from 1586 to 3300 to cope with the growing workload associated with new and time-consuming procedures. The report concluded that the current workload is "excessive to the point where it threatens the quality of care."

Based on 1999 data provided by Eurostat, the statistical arm of the European Commission, the report noted that the number of radiologists per million is far lower in the U.K. than in other European countries (see chart page 29). Eurostat data also showed that imaging utilization in the same year was lower in the U.K. than elsewhere, leading the Royal College to conclude that U.K. patients may be undertreated (see chart page 27).

Because of the staff shortage, the goal of training is to get radiologists out in the workforce as soon as possible. Any delay, such as for further subspecialty training, occurs at a cost to the national government, according to Carty. Radiologists are less likely to fight for the right to perform procedures because they are already overworked, she said. Consequently, some studies traditionally done by radiologists are now performed by consultants in other fields.

"In the U.K., coronary angiography is almost always done by cardiologists, but it is a radiological technique. We are so busy, we don't have time to take on studies we can trust other consultants to do," she said.

Carty believes greater flexibility in training is needed. Residents might be given the option to complete a shorter training program in a subspecialty rather than complete the full four years in general radiology plus one year in a specialized area.

"I could see education evolving as time goes on. I trained in radiology from 1971 to 1974, when there was only rudimentary interventional radiology and nuclear medicine. There was no ultrasound, no CT, no MR, no subspecialization in the field," she said. "Education has evolved to accommodate those changes, so I don't see why it won't evolve for the next changes."

But the downside to this strategy would be that physicians would limit themselves professionally in the long term. It also runs counter to tradition.

"It is often said that radiologists know a little about an awful lot, but not perhaps a lot in depth about a particular little area. That is our great value: the ability to have little bits of information and to cross-reference it. That is where broad-based training has led us and why we are so respected in the hospital environment," Carty said.