Postgrad Med J (1990) 66, 627 - 638 © AEMIE, 1990

Special Article

Medical training in the European CommunityA.H. Crisp*St. George's Hospital Medical School, Cranmer Terrace, London, SW17 ORE, UK.

Summary: The free movement ofdoctors within the European Community demands harmonization ofstandards of medical practice and carries major implications of an undergraduate and postgraduateeducational kind. These have begun to be addressed by the first three Medical Directives and also by aseries of reports produced by the Advisory Committee on Medical Training to the European Community.This Committee was established in 1975 in order to provide informed agreed advice to the Commission.Many tasks remain to be tackled. A system of mutual inspection of the examination processes andstandards in Member States should be established. Control must also be exercised over the numbers ofdoctors produced since educational resources, including numbers of patients available for study, arelimited. Thus, excellent standards ofmedical practice can only be developed and maintained ifthe primacyof clinical skills derived from the study of patients is recognized as essential in this respect. In someMember States at the present time there are many unemployed and therefore presumably deskilleddoctors.

General introduction

A Guide to Working in Europe without Frontierswhich is the goal ofmany for 1992 has recently beenpublished by the Commission of the EuropeanCommunities.' I will begin by paraphrasing itsintroductory statement about our rights asnationals of the Community's Member States. TheEuropean Community (EC), previously the Euro-pean Economic Community (EEC), is governed bylaw wherein we enjoy rights as a national of aMember State. As migrants within it we are entitledto freedom of movement. This is one of the mostimportant basic principles of the Common Market(Article 3 (c) of the EEC Treaty) which is based onequal treatment with nationals of the host country.In other words we cannot be discriminated againston the grounds of nationality (Article 7 of the EECTreaty). The host country must respect all theimplications of this principle. In return we arelegitimately subject to the same obligations asnationals in the host country. We have a duty toprepare for this, mainly through some form oftraining. The Community is making a contribu-tion to this process, particularly through imple-mentation of the European Community actionscheme for the mobility of university students (TheERASMUS Scheme).

Equal treatment by a host country within theCommunity concerns occupational activity, cer-tain social and political rights, freedom of move-ment and the right to transfer funds. We areconcerned here today with occupational activity.There are certain exceptions to the general ruleregarding equal eligibility for employment. Forinstance, posts in thejudiciary, police, armed forcesor diplomatic service and in goverment administra-tion may be reserved for nationals. However,doctors and others in allied professions to medicineare eligible without discrimination on grounds ofnationality. A distinction, however, is made ac-cording to whether you are an employed person(Article 48 of the EEC Treaty) or a self-employedperson (Articles 52 and 59 of the EEC Treaty). Ifyou are employed by others as a medical practi-tioner, then your terms of employment (profes-sional qualifications, pay, conditions governingdismissal and Trade Union membership) are thesame as those for nationals. If you are a self-employed doctor you may also pursue your activityin any Member State, either on a permanent ortemporary basis. However, you must also possessWe are grateful to the Editor of the European Journal ofInternal Medicine, Professor U. Carcassi, for permissionto publish this article from European Journal of InternalMedicine (1990) 1: 180-192.The Fellowship of Postgraduate Medicine is also

grateful to Wyeth Laboratories for financial support forthis publication as a contribution to postgraduatemedical education.

Correspondence: Professor A.H. Crisp., M.D. D.Sc.,F.R.C.P., F.R.C.P. (E)., F.R.C.Psych.*Professor Crisp was Chairman of the AdvisoryCommittee on Medical Education to the EEC,1983-1986.

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

628 A.H. CRISP

the professional qualification attested by a dip-loma, certificate or other evidence of formalqualification awarded by the host state or recog-nized as equivalent by that state and recognized asnecessary for such medical practice.

Article 57 of the original EEC Treaty states in itsfirst paragraph:

In order to make it easier for persons to take up andpursue activities as self-employed persons, the Coun-cil shall, on a proposal from the Commission and incooperation with the European Parliament, actingunanimously during the first stage and by a qualifiedmajority thereafter, issue directives for the mutualrecognition of diplomas, certificates and otherevidence of formal qualifications.Since that time the machinery for such har-

monization has slowly developed. It has not yetfully addressed all professions, e.g. architecture.However, where there are such Community Direc-tives adopted by the Council, then Member Statesrecognize relevant diplomas issued for the purposesof employment by the Member States. While theseprovisions apply both to individuals in paid em-ployment and to the self-employed, they do notconcern all occupations. They also containarrangements which may vary depending on theoccupation in question, e.g. concerning the use ofaparticular title issued on the completion of training.When diplomas are recognized at Community levelat the same time, a minimum required standard ofqualification is established and, for each occupa-tion, recognition depends on the extent to whichstandards have been harmonized. Accordingly,several situations may be encountered.'1. Based on harmonization of training condi-

tions.2. Without harmonization oftraining conditions,

e.g. architecture.3. Combined with work experience (This was

urged by some Member States).So far as medicine is concerned, practice within

other Member States is governed by the recogni-tion of diplomas based on harmonization of train-ing conditions. For instance, for doctors, nurses,dentists, veterinary surgeons, midwives and phar-macists a diploma is recognized provided it wasissued in accordance with the Directives and hasthe same effects as diplomas issued by that MemberState. This effect is achieved through the har-monization of training in the Member States and inthe case of medicine this is through the initialmedical Directives and which have led to reciprocalrecognition of the relevant diplomas issued by thevarious Member States.

The first medical directives

Medical practice was one of the first professions tobe addressed. Working parties comprising relevantgroups of professionals from the Member States atthat time were assembled and they advised on theform ofthe first two medical Directives. These werepromulgated in June 1975. The first of theseDirectives (75/362/EEC) concerned the mutualrecognition of diplomas, certificates and otherevidence of formal qualifications in medicine andincluded measures to facilitate the effective exerciseof the right of establishment and freedom toprovide services. It addressed itself to both underg-raduate and postgraduate education and thepivotal articles are Article 2 and Article 4 respec-tively. Article 2 states:

Each Member State shall recognize the diplomas,certificates and other evidence of formalqualifications awarded to nationals ofMember Statesby other Member States in accordance with Article 1of Directive No 75/363/EEC and which are listed inArticle 3, by giving such qualifications, as far as theright to take up and pursue the self-employedactivities of a doctor is concerned, the same effect inits territory as those which the Member State itselfawards.

Article 4 states:

DIPLOMAS, CERTIFICATES AND OTHEREVIDENCE OF FORMAL QUALIFICATIONSIN SPECIALIZED MEDICINE COMMON TOALL MEMBER STATES

Each Member State shall recognize the diplomas,certificates and other evidence of formal quali-fications in specialized medicine awarded to nationalsof Member States by the other Member States inaccordance with Articles 2, 3, and 4 and 8 of DirectiveNo 75/363/EEC and which are listed in Article 5, bygiving such qualifications the same effect in itsterritory as those which the Member State itselfawards.

This Directive goes on to list the areas ofspecialty practice in the various Member Statesand, over the years since 1975, it has been updatedto include the new Member States, ofGreece, Spainand Portugal. It refers to all specialties which arepractised in two or more Member States (Article 6).Such mutual recognition of diplomas is restrictedto those Member States wherein the specialty isrecognized.The Directive goes on to acknowledge the need

to accommodate existing circumstances (Article 9).For instance, recognition is given by certificate tothose nationals whose qualifications in medicinedid not satisfy all the new minimum trainingrequirements laid down in the medical Directive75/363/EEC but who could produce a certificate

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

INTERNAL MEDICINE & MEDICAL MANPOWER 629

indicating that they had effectively and lawfullybeen engaged in the activities in question for at leastthree consecutive years during the previous fiveyears.

Other Articles in 75/362/EEC govern the use ofacademic titles (Article 10) and the provision ofproof of good character (Article 11).The other medical Directive (75/363/EEC)

specifically addresses the matter of harmonizationofstandards both at undergraduate level and at thelevel of specialist training.The key introductory paragraph here recognizes

that medical practice is in the main specialized (atthis stage general practice was not regarded as aspecialty). It therefore begins by also recognizingthe need for co-ordination of the requirements forpostgraduate training in specialized medicine. Itrecognizes that certain minimum criteria should belaid down concerning the right to take upspecialized training, e.g. satisfactory completion ofundergraduate and pre-registration medical educa-tion, minimum training periods, methods by whichsuch training is given and the places where it is to becarried out as well as the necessary supervision.The matter of undergraduate education is add-

ressed in Articles 1 and 2. There is a bare outline ofthe necessary and basic content of such trainingand a statement that it shall comprise at least asix-year course or 5500 hours of theoretical andpractical instruction given in a university or underthe supervision of a university. Article 3 concernsitself with part-time training. Over the years thishas caused difficulties because in the UK we have aformal system for part-time training at a specialistlevel, mainly for married women. However, thathas been sorted out. Articles 4 and 5 then impor-tantly address the question of minimum length ofspecialized postgraduate training courses both forsuch specialist practice occurring in all MemberStates and for such practice recognized only withinsome of the Member States. As originally laid outthese are as follows:

All Member States (Article 4)Member States shall ensure that the minimum lengthof the specialized training courses mentioned belowmay not be less than the following:-general surgery- neuro-surgery-internal medicine five years-urology-orthopaedics

-gynaecology and obstetrics-paediatrics four years-pneumo-phthisiology

-anaesthesiology and reanimation-ophthalmology three years- otorhinolaryngology

Some Member States (Article 5)Member States which have laid down provisions bylaw, regulation and administrative action in this fieldshall ensure that the minimum length of the special-ized training courses mentioned below may not be lessthan the following:-plastic surgery-thoracic surgery-vascular surgery five years-neuro-psychiatry-paediatric surgery-gastroenterological surgery

-cardiology-gastroenterology-neurology-rheumatology-psychiatry-clinical biology-radiology four years-diagnostic radiology-radiotherapy-tropical medicine-pharmacology-child psychiatry-microbiology-bacteriology-pathological anatomy

-occupational medicine-biological chemistry-immunology-dermatology-venereology four years- geriatrics-renal diseases-contagious diseases-community medicine-biological haematology-general haematology-endocrinology-physiotherapy three years-stomotalogy-dermato-venereology-allergology

The Advisory Committee on Medical Training(ACMT), the first 10 yearsThese first two medical Directives were seminal.Similar Directives for nursing and dentistry veryquickly followed. The working groups of doctorsfrom the Member States who had helped draft the1975 Medical Directives had expressed the viewthat the Commission would require an establishedAdvisory Committee on Medical Training there-after. In this way the present Advisory Committeewas born in 1976. Others in allied fields were thenalso established. In many ways veterinary medicinecan be taken as a paradigm over the subsequentyears. The subject, being much smaller thanmedicine, has proved more manageable and a great

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

630 A.H. CRISP

deal of progress has been made. An illustration ofthis arises later in this paper. The Advisory Com-mittee on Medical Training (ACMT) settled downto consider development and updating of the firsttwo Medical Directives. Ten years after the pub-lication of the first two Medical Directives theCommittee undertook a formal review of its workof the previous nine years and the proceedings ofthe conference wherein this was undertaken andalso made a systematic attempt to forecast thenature of medical practice in the twenty-first cent-ury have been published.3The Conference was reminded5 that ACMT first

met in April 1976 and, over the next nine years, hadadopted a number of reports relating to the twoMedical Directives. The principal ones are:

1. The general tendencies in basic medical education(1978).

The recommendations of this report were:-The need to control and restrict numbers ofmedicalstudents

-The essential integration during basic studies ofpractical with theoretical training

-The advantage ofreplacement ofseparate courses inindependent disciplines by integrated education

-The necessity for freedom for universities toexperiment with curricula and teaching methods,with provision for the exchange of results

-The need to promote self-education and optionalcourses

-The periodic re-examination of curricula

2. Opinion on the part-time training of specialists(1978)

3. Report and recommendations on the generalproblems of specialist training (1978)

This contained the following recommendations:-A competent authority should be set up in eachMember State to lay down training standards,enforce their application, validate them byawarding qualifications and ensure coordinationbetween the various disciplines

-Specific training for specialists should begin aftersuccessful completion of basic training

-Number of candidates should be matched to thecapacity of the training establishments

-Selection methods should be considered-Full-time training should be remunerated-Specific training should start in the form ofextendedgeneral training of a common-trunk curriculum

-Care should be taken not to create new specialtiesunnecessarily

4. Recommendation on the clinical training ofdoctors(1979)

These were that:-The core of essential knowledge and experiencewhich the student should acquire by the end of hisstudies should be defined by the competentauthorities

-Assessment and control methods should be devisedto determine whether these aims and objectives have

been achieved and, if necessary, to see how thetraining programmes should be modified

-The relationship between theoretical teaching andclinical experience should be kept under continualreview

-Clinical training should cover the main disciplinesand lead to a high level qualification and clinicalcompetence

-Preclinical and clinical disciplines should be integ-rated into training

-New discoveries should be incorporated intocourses and outdated material replaced, andstudents should be encouraged to pursue privatestudy and take part in the improvement of thecurriculum

-Student numbers must be brought into line with theavailable teaching and clinical facilities

-Each student's motivation and personal characteris-tics should be assessed; methods of assessment andselection might vary from one country to another

-Teacher training must be tailored to teachingmethods and techniques, and ways devised forassessment of the teaching

-Optimum use must be made of teaching potentialand an acceptable ratio sought between the numberof students receiving clinical training and thenumber of teaching staff

-There should be early contact between students andpatients

-Hospital medical staff and technical equipmentshould be of a high standard

-Not only teaching hospitals but also regional andlocal hospitals should be used for training

-Students should be brought into contact with themedical and social aspects of medicine in all placesconsidered able to provide this kind of teaching.

5. Report and opinion on specific trainingfor generalpractice (1979)

The Committee recommended that:-Specific instruction in general medical practice begiven after basic training

-Member States should promote such specific train-ing

-General practice should be recognized as a specificdiscipline

-Periodic reports to the Commission be submitted bymember states on progress in this area

6. Opinion on the mutual recognition of trainingperiods completed in another Member State aspartof specialist training courses (1981)

The Committee proposed the following:- It should be possible to undergo part ofthe specialisttraining in one or more Member States

-Prior agreement of the authorities of the country oforigin is necessary, subject to production of adocument attesting to the training programme, thenature of the establishment and its organisationalstructure and the agreement ofthe authorities ofthehost country

-On his return, the trainee will produce a certificatefrom the supervising specialist, attesting to hisactivities

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

INTERNAL MEDICINE & MEDICAL MANPOWER 631

-Channels of communication should be developed,specialty by specialty, between the competentauthorities in the Member States for the purpose ofexchanging lists of recognized training posts andanswering specific enquiries

7. Report andrecommendations on theproblem ofthebalance between the number of medical studentsand the resources neededfor their training (March1981)

The recommendations are as follows:-Measures should be taken in Member States toensure and maintain comparably high levels ofmedical training

-Staffing norms should be introduced-Student numbers and training facilities should bematched

-Account should be taken of the student's overallknowledge of and aptitude for the practice ofmedicine

-The ideal student/teacher ratio should be sought-Assessments should be carried out at the end ofstudies to ensure uniform levels oftraining through-out the Member States

8. Opinion on the aims of basic medical training(1981)

This listed the abilities required for the practice ofmedicine.

9. Second report and recommendations on thetraining of specialists (1983)

These recommendations were as follows:-The number of trainee specialists must be regulatedon the basis of future needs for specialists and theavailable training resources, so as to ensure that thetraining is of a high standard

-To this end, use must be made of the practicaltraining potential of posts in non-university hos-pitals and sometimes in non-hospital institutions

-Training should normally be full-time, with excep-tions for part-time training. It should includetheoretical training at the highest level and practicalexperience in appropriately remunerated serviceposts. Trainees should gradually be assigned anincreasing measure of responsibility commensuratewith their growing skills and experience.

-Training should include a common trunk in relatedspecialties, the duration and content ofwhich wouldbe adapted to the intended ultimate specialisation

-All specialist training should be supervised by acompetent authority approved to grant, or, whereappropriate, withdraw approval of training estab-lishments, account being taken of the hospitalfacilities, the activity of the unit and thequalifications and experience of the trainers andtheir colleagues

-The competent authority should ensure that thetraining given is of a high standard by priorapproval of the training programme and super-vision of trainees' performance by means ofa reportbook, suitable examinations or assessments

-Whereas the minimum periods of training for thespecialties referred to in the 1975 directive arealready exceeded in most Member States, and

whereas the duration of training courses shouldcorrespond to the training content which is reallynecessary in the present state of medical science, itshould be for the competent national authorities todecide for themselves on the nature and timetable ofany measures that may be necessary for the purposeof altering the duration of training courses in theirrespective countries

The report also contains a proposal on changes to theduration of training in the case of certain disciplines.10. Report on occupational medicine (1985)

This specialty was identified as having developedrapidly but with radically different training program-mes across Member States. The report recommendedaccepting it as a specialty and contains a number ofproposals for harmonizing the training for it.

During this, the first nine-year period of office ofthe Committee, other new specialties such asfasciomaxillary surgery and nuclear medicine hadalso come to be recognized and listed in theDirectives.

In his subsequent summary review of the impactof the two Directives and the Committee's reportsup until 1985 Sorensen6 drew attention to theconcept of the common trunk of specialist trainingthat had by then been recommended several timesby the Committee and also the Committee's con-cern that there be required special postgraduatetraining for general medical practice as soon aspossible. He doubted whether the overall impact ofthe Directives and the Committee's work was yetsubstantial and he identified some ofthe resistancesto change. His emphasis on the need to protect andsometimes to reinforce the present common trunkofmedical training, especially at postgraduate level,resonates with the increasing emphasis placed onthis idea by other medical educationalists in theUSA2 and in the UK.4 I would add that theseReports reflect a constantly recurring concern ofthe Committee with the need not only to recom-mend but also to ensure that uniformly highstandards of medical practice operate throughoutthe Community and also the Committee'sawareness that such high standards are closelylinked to control of the numbers of doctors inpractice which in its turn is linked to the numbers ofpeople initially admitted to medical studies.The remainder of the 1985 Conference was

devoted to an attempt to identify the direction thatmedical education should now take to preparestudents and young doctors for practice in the nextcentury. Some considered that this was an impossi-ble task but it was evident that students startingtheir studies now would not become independentpractitioners before the turn ofthe century and thattherefore there was a real need to set them optimaland focused educational goals.7 Summarizing this

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

632 A.H. CRISP

part of the proceedings Castermans8 concludedthat the following priority educational needs andbeen identified:

1. Solid clinical training accompanied by arejuvenated curriculum including new knowledgeand designed to train minds rather than pumpthem full of facts.

2. Enlightened training of the future doctor toassume all his responsibility either on his own orin a team by confronting him specifically withethical problems such as he will be constantlyencountering

3. Supplementary training in general medical prac-tice and in specialized medicine, the characteris-tics of which will coincide closely with the recom-mendations of our Committee

4. Generalization of continuing education as aprerequisite for maintaining the quality ofmedical care.

I believe this list to be central to the maintenanceand development of medical practice in the yearsahead. To the first point I would add that suchskills are importantly underwritten by a knowledgeofanatomy9 and the skills for communication withall kinds of patients and colleagues within andacross ethnic boundaries.8'0The second point has preoccupied the Commit-

tee ever since, there being those on it who believethat recognition of the measures necessary toensure the maintenance of defined ethical stan-dards are the only realistic ones that can beundertaken in respect of the future. All else, theysay, is unpredictable, subject to such events as theunexpected emergence of new disease, new tech-nologies and new knowledge.The third point, stressing the importance of

ensuring high standards in general medical practice,emphasizes the centrality ofprimary care as well as,indirectly, the importance of the common trunk ofpostgraduate training for everyone.The fourth point concerns the neglected area of

the need to maintain high standards of practiceother than by the debarring of those practitionerswho palpably fail in this.

In 1985 the Committee also attempted formallyto identify its priorities for the next decade (coin-cidental with this it found itself needing to defendits continued existence but persuaded the Commis-sion that there was still work to be done!).A working party of the Committee duly

reported" that the new priorities should be asfollows:

PROPOSED FUTURE TASKSA. To strengthen the Committee's review procedures

(To date much reliance has been placed uponnational groups within the Committee reportingback upon developments in their own countries;for instance, as regards changes in medical

training and practice, or as regards the impact ofreports and recommendations published by theAdvisory Committee. The variation between -and, in the case ofsome Member States, the totalof absence of- the national reports required bythe Committee for the 1985 review underlinedthe inconsistency of this system. If the Commit-tee is to be correctly informed on mattersfundamental to its task, its review proceduresneed to be strengthened).

B. To develop the techniques ofevaluation (includingselection) as part of the internal educationalprocesses within schools.

(The Committee is currently considering a report- III/D/1643/4/83 - which deals with methods ofassessment in basic training. This work needs tobe built upon, because the issues go much widerthan the scope of that report. Assessment inspecialist training is another issue. But there arealso the questions of initial selection for entryinto medical studies and of selection of trainers.There is also the question of assessment of theoutcome of medical training - the impact of themedical education process upon the recipients ofit.)

C. To develop continuing medical education

(The attention this topic attracted at the Sym-posium reflects the increasing interest beingshown in it in many countries, inside and outsidethe EC. With the rapid developments in medicalscience, it is linked with the ethical/moral obliga-tion on doctors to keep themselves abreast ofideas and knowledge throughout their profes-sional lives.)

D. To have a continuing awareness of new areas ofdevelopment in medical practice and the need tomonitor recent developments, e.g. occupationalmedicine, specific training in general medicalpractice(Such developments, especially major ones likethose in general practice, can have implicationsfor training given elsewhere; for instance, ontraining that immediately precedes or followsthe innovation. The impact may vary betweenMember States and could thus lead to adivergence of standards of training in the Com-munity.)

E. Specific subjectsThe following individual subjects were also con-sidered to merit special attention, either asisolated topics or within wider programmes ofstudy such as those listed above

-overloading of the undergraduate curriculum-undergraduate teachers being too specialized-the need for doctors to develop problem-solving skills

-the continued importance of practical skills-teaching the social and behavioural sciences-the continuing refinement of the core cur-riculum

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

INTERNAL MEDICINE & MEDICAL MANPOWER 633

-the teaching and understanding ofethical issues-the development ofmanagement skills (includ-ing an awareness of economic constraints)

-the involvement of the doctor more widely inhealth care systems

The working party concluded its Report with thefollowing important footnote:

THE AD HOC WORKING GROUP WISHES TOCONVEY TO THE MAIN COMMITTEE ITSSPECIAL CONCERN ABOUT THE HAZARDSTO TRAINING STANDARDS POSED BYEXCESSIVE NUMBERS OF STUDENTS. THISPROBLEM IS PARTICULARLY ACUTE INTHOSE COUNTRIES WITHOUT NUMERUSCLAUSUS.In June 1985 the Commission produced a White

Paper addressing the matter of the completion ofthe European internal market. The document dwelton the need for the complete removal of physical,technical and fiscal barriers and set 1992 as thetarget. It construed the freedom to provide serviceswithin the Community as being dealt with withinthe rubric of removal of technical barriers. Parag-raph 88 of the White Paper states:

The Commission considers it crucial that theobstacles that still exist within the Community to freemovement for the self-employed and employees beremoved by 1992. It considers that Communitycitizens should be free to engage in their professionsthroughout the Community, if they so wish, withoutthe obligation to adhere to formalities which, in thefinal analysis, could serve to discourage such move-ment.

Since the publication of the White Paper theMember States have met and enshrined many suchobjectives within the Single European Treaty(1988).

ACMT since 1985

As a result of the Committee's advice a thirdMedical Directive (86/457/EEC) was eventuallyproduced on the 15th September 1986. Therationale for this was contained in a series ofimportant introductory paragraphs, the three mainones of which are as follows:

Whereas the point has now been reached where it isalmost universally recognized that there is a need forspecific training for the general medical practitionerto enable him better to fulfil his function; whereas thisfunction, which depends to a great extent on thedoctor's personal knowledge of his patient's environ-ment, consists of giving advice on the prevention ofillness and on the protection of the patient's generalhealth, besides giving appropriate treatment;Whereas this need for specific training in generalmedical practice has emerged mainly as a result of thedevelopment of medical science, which has increas-

ingly widened the gap between medical research andteaching on the one hand and general medical practiceon the other, so that important aspects of generalmedical practice can no longer be taught in a satisfac-tory manner within the framework of the MemberStates' current basic medical training.Whereas, apart from the benefit to patients, it is alsorecognized that improved training for the specificfunction of general medical practitioner would con-tribute to an improvement in health care, particularlyby developing a more selective approach to theconsultation of specialists, use of laboratories andother highly specialized establishments and equip-ment.

The Directive goes on under Article 2 to identifythe minimum requirements for training in generalpractice:

1. The specific training in general medical practicereferred to in Article I must meet the followingminimum requirements:(a) entry (into training) shall be conditional upon

the successful completion of at least six years'study within the framework of the trainingcourse referred to in Article I of Directive73/363/EEC;

(b) it (training) shall be a full-time course lastingat least two years, and shall be supervised bythe competent authorities or bodies;

(c) it (training) shall be practically rather thantheoretically based; the practical instructionshall be given, on the one hand, for at least sixmonths in an approved hospital or clinic withsuitable equipment and services and, on theother hand, for at least six months in anapproved general medical practice or in anapproved centre where doctors provideprimary care; it shall be carried out in contactwith other health establisments or structuresconcerned with general medical practice;however, without prejudice to the aforesaidminimum periods, the practical instructionmay be given for a maximum period of sixmonths in other approved health establish-ments or structures concerned with generalmedical practice;

(d) it (training) shall entail the personal participa-tion ofthe trainee in the professional activitiesand responsibilities ofthe persons with whomhe works.

As with the second Medical Directive there is aqualifying paragraph within Article 7 which allowsthe certification of doctors as being trained withinthe spirit of the Directive if they have beenestablished in practice for some years and withoutthe need now for them to undertake such a formalretraining.With this achieved (though many on the Com-

mittee believed that a three-year period of post-graduate training for general practice would havebeen appropriate) the Committee decided to under-

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

634 A.H. CRISP

take two new main tasks. One working party wasset up to examine and report on the quality oftraining in the Community in relation to thenumbers of medical students. A second workingparty was set up to report on what could beforeseen as being the future role of the doctor. TheCommittee's attention was also drawn by theCommission to the Community's concerns aboutpreventive approaches to disease with particularreference to cancer and for the need for doctors tobe conversant with this area. Another workingparty was therefore also set up to examine thismatter and has since reported (III/D/2111/87-EN).

Future role of the doctor

The working party convened to consider the futurerole of the doctor in medical practice has not yetreported. It has available to it the views of the 1985working party" (III/D/1570/85-EN) on the matterwhich were that the doctor would continue to havea core role based on consultation skills coupledwith a management role and with the need tomaintain his or her standards of knowledge andskill within the framework of proper professionalattitudes. In detail these roles and attributes wereidentified as follows:

A. CORE ROLE

1. To occupy a central role in terms ofunderstand-ing the structure and function ofthe human bodyand mind in its interaction with the social andphysical environment in health and illness, andwith the function of alleviating distress andillness when possible.

2. Recognition of the central importance to thistask of the totality of consultation skills, includ-ing clinical skills, the skill ofhistory taking and ofcommunication in general; and also an under-standing of health-related behaviour, the socialsituation of the patients and the societal supportsystems available.

3. Recognition that one's role is also important inrelation to the treatment and management ofchronic disability, including rehabilitation; alsoin the care of the terminally ill.

4. Contributing to the prevention of illness and tothe promotion of health.

B. MANAGEMENT ROLE

5. The ability to work within a team, and as a teamleader.

6. The development and deployment of administ-rative and planning abilities.

C. CONTINUING EDUCATION

7. The ability to assess one's own performancecritically and to permit its assessment by others.

8. Keeping oneself up-to-date and highly capablein relation to new knowledge and skills andcontributing to the promulgation of knowledge.

D. ATTITUDES/ETHICS9. The development and maintenance of proper

attitudes appropriate to a high level of profes-sional performance.

10. The ability to recognize and think clearlythrough ethical problems in such a way as toenable the patient and the doctor to reachinformed decisions.

E. SPECIALIZED ROLES11. i.e. Subsequent to core training, and in the

relevant clinical, administrative or laboratoryfields.

The present concerns of this working party havebeen referred to earlier and have to do with theemphasis that should be placed on the role of thedoctor in respect of ethical issues and whether ornot the main statement should be restricted to hisresponsibility for relieving distress and preservinglife under all circumstances.

Numerus clausus and medical manpower

The working party concerned with the numerusclausus issue reported in 1988 (III/D/331/3/87-EN)within a document entitled Report on quality oftraining. It had begun by identifying the presentnumbers of students admitted to medical schooleach year and the number of doctors graduatingeach year from the Member States. These findingsare displayed below in Tables I and II respectively.The working party noted a number of trends

within the data as follows:1. The United Kingdom, where the situation is

stable, with a small number of students admittedand qualified doctors emerging per annum (app-proximately 1/15,000 of the population perannum). The second characteristic is the very lowrate of failure over the training period. Thisobservation confirms the finding in report III/D/234/4/80 that medical training in that countryholds a privileged position. Even if it is notproved that the severe restrictions on access tomedical studies in the United Kingdom wereoriginally introduced for docimological reasons,it has to be said that they and the stability theyproduce have enabled training resources to beadapted as efficiently as possible to the numbersselected.

2. A second trend is represented by three MemberStates: France, the Netherlands and Portugal,which have adopted policies ofincreasing restric-tions on access to medical studies and are nowapproaching the same ratio of one newlyqualified doctor per annum to 15,000inhabitants; ifthese meaures are kept France and

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

INTERNAL MEDICINE & MEDICAL MANPOWER 635

Table I Number of students admitted to the 1st year of medicine

No. ofinhabit-ants (inmillions) Number of students

1972 1978 1984 1985 1986 1987

*Belgium 9.9 4705 (2093) 3274 (2645) 2791 (3529) 2773 (3552) 2533 (3604) - -

Denmark 5.1 1611 (3140) 855 (5918) 653 (7840) 569 (8998) 539 (9449) 526 (9733)W Germany 61.8 5728 (10791) 10326 (5988) 11962 (5169) 11531 - 11531 - 11614 -

Greece 10.0 - - - - 1384 (7225) 1530 (6509) 1188 (8383) -

Spain 37.7 13547 (2783) 11454 (3291) 6362 - - - 6000 (6283) 4950 (7616)**France 56.5 8652 (6095) 7913 (6664) 5000 (10966) 4754 (11863) 4550(12395) 4400 (12818)Ireland 3.2 507 (6167) 492 (6544) 471 (6623) 446 (6995) 431 (7238) -

*Italy 57.1 30805 (1812) 26738 (2087) 14904 (3830) 12305 (4649) 10943 (5235) 9418 (6073)*Luxembourg 0.4 51 - 74 - 54 - - - - - - -

Holland 14.6 1690 (8082) 1900 (7189) 1457 (9972) 1474 (9857) 1463 (9931) 1432 -

Portugal 10.3 2013 (4290) 1185 (8109) 641(15801) 383 (26446) 342 (29616) 239 (42380)UK 55.8 3488 (15992) 3877 (14387) 3966 (14065) 3938 (14164) 3967 (14061) - -

Derived from EEC Advisory Committee on Medical Training Report III/D/331/3/89-EN, *No selection at admissionto the 1st year ofmedicine. **Selection operates in 2nd year. Figures in brackets = number ofinhabitants per student ordoctor.

Table II Number of doctors graduated

No. ofinhabit-ants (inmillions) Number of doctors

1979 1984 1985 1986 1987

Belgium 9.9 1499 (6571) 1519 (6484) 1432 (6783) 1366 (7210) - -Denmark 5.1 668 (7575) 707 (7242) 663 (7722) 560 (9142) 559 (9159)W Germany 61.8 7333 (9631) 9470 (6529) 9534 10618 9936Greece 10.0 1108 (9025) 1504 (6642) 849 (11731) 1154 (8630) -Spain 37.7 7497 (5028) 10346 (3644) - - - -

France 56.5 8687 (6071) 8577 (6392) ? - 16350 for the two years 86 and 87Ireland 3.2 481 (6486) 477 (6541) 481 (6486) 477 (6540)Italy 57.1 14264 (4010) 14044 (4072) 13079 (4373) 13053 (4382)Luxembourg 0.4 39 - 24Holland 14.6 1461 (9945) 1485 (9693) 1474 (9857) 1746 (8321) - -

Portugal 10.3 1439 (6678) 904 (11205) 859 (11791) 884 (11458) -

UK 55.8 3387 (16469) 3498 (15946) 3483 (16014) 3610 (15451) - -

Derived from EEC Advisory Committee on Medical Training Report III/D/331/3/87-EN

Portugal should reach this level in a few years andcould go beyond it.

3. A third trend emerges in Belgium, Denmark,Germany, Greece and Ireland, where the numberof students and newly qualified doctors perannum remains high (between 1:6,000 and1:9,000 in the case of the latter). A confirmedtendency to a slow reduction of numbers can beseen.

4. A special situation is known in Spain whereduring 15 years the number admitted has beenreduced to 1/3 of what it used to be. These

measures are too recent to have an importantimpact until now on student population inclinical studies and number of graduates. Persis-ting on this course should place Spain into thesecond group.

5. Italy represents the last trend. In spite of aspontaneous reduction in the number of entriesinto medical training almost no reduction in thenumber of graduates can be seen. The number ofinhabitants per newly qualified doctor is clearlymuch lower than in other Member States andnothing suggests that the situation will improve

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

636 A.H. CRISP

here. The Advisory Committee is concernedabout the continuing Italian situation with itsvulnerable level ofmedical training. It seems veryunlikely that this Member State can envisage anyincrease in the resources as the number ofpatients as well as the budgetary resources arelimited everywhere. During discussion of thisreport, the Committee was informed that Italyhad just taken measures designed to reduce thenumber of students.

The Committee was concerned about a numberof factors including the loss of traditional andvaluable small group and bedside apprenticeshipteaching opportunities and the unavailability ofpatients for very large numbers ofmedical studentsneeding to learn their consultation skills (forinstance, in the UK we are familiar with requestsfrom medical students from some other MemberStates wishing to undertake extended clinical elec-tives in the UK and wherein it would seem thatthere are sometimes not sufficient opportunities forthem in their own country) and also the likelynumbers of unemployed doctors under such cir-cumstances whose consultation skills woulddiminish through lack of practice. The workingparty's recommendations were as follows:

The most realistic method of matching trainingresources to the number of students admitted tomedical studies, and thus of ensuring a comparablyhigh level of the latter, is to tighten controls on thenumbers admitted. The desirable situation achievedor being achieved by four Member States is given asan example, with reference to the total population ofthe country in question as an approximate estimate oftraining resources. The ratio in these Member Statesis about one qualified doctor to 15,000 inhabitants perannum.

The conclusions of the 'report and recommendations'adopted in 1981 are still applicable, and the presentconclusions should be regarded as supplementing thereport (doc. III/D/230/4/80).The restrictions on the number of students admittedshould be accompanied by a selection process whichsifts out those most likely to become doctors, takingthe wide range of medical activities into account.The Advisory Committee would request the Commis-sion to ensure that the national laws adopted incompliance with Directive 86/457/EEC are imple-mented in each Member State in accordance with thetime limits laid down therein.It would draw attention to the adverse effects of animbalance which could develop as between thenumber of places for training in general medicalpractice and the numbers of applicants for suchtraining. This could give rise to groups of doctorshaving no access to training, that is, being preventedfrom pursuing their professions. This matter mayrequire further consideration in the light of moreexperience of the operation of Directive 86/457/EEC.

Motivation must be the driving force behind thechoice of this specific branch. Its pursuit musttherefore be as attractive as that of specializedmedicine.The Committee recommends that the definition oftraining places and the appointment and training ofsupervisors of training in general medical practiceshould satisfy criteria that are just as strict as thoseapplied to specialist training; they should be placedunder the responsibility of bodies that includerepresentatives from the faculties of medicine, theprofessions concerned and the competent authority.It recommends that the checks on knowledge shouldbe identical in quality to those on specialized trainingand guarantee a comparably high level of training inall the Member States.This report and these recommendations were adoptedunanimously by the Committee on 5 October 1988with 23 (1) votes in favour; 13 (2) members wereabsent and not represented.This report and these recommendations are addressedto the Commission and the Member States and will beforwarded to them after having been confirmed in allCommunity language versions by the Committee bywritten procedure.

It will be seen that the working party was address-ing the problem of numerus clausus from thestandpoint of quality of training and quality ofcare. A number of the recommendations focus onthe problem within general practice. Up until the1986 Directive on the need for training for generalpractice, it was likely that the majority of excessdoctors had settled into such general practicewithout further training. In the future this wouldnot be possible.

This cautionary tale about the Committee'sconcerns with manpower would not be completewithout acknowledging the recent article in theNew England Journal of Medicine'2 and the atten-dant leading article in that journal.'3 There thealternative case is cogently argued, that there willbe a shortage ofdoctors in 20 years' time. However,perhaps the best indicator that we have is that ofmanpower planning in the UK where the majorityof the population receives care within the NationalHealth Service. As previously indicated the steadynumber ofgraduates ofabout 4000 per annum for apopulation of about 55 million is clearly about theright number needed to staff that service. Thereshould undoubtedly be more consultants in thatsystem and they will be especially needed in thefuture now that there are fewer overseas doctors toman the on-call service but this unlikely to lead to aneed for a greater number ofmedical students. Themajor task, as always, is to ensure that people oftheright calibre and motivation are recruited in thefirst instance so that wastage is minimal.

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

INTERNAL MEDICINE & MEDICAL MANPOWER 637

Future tasks

There are clearly many future tasks for theAdvisory Committee to address and some of themhave been spelled out above (ACMT ReportIII/D/1570/85-EN, Annexe 3). An important one ishow to establish in an acceptable way the mutualassessment of each other's standards of educationso that we can truly learn from and help each other.A system of external examining has been standardpractice in the UK for many years'4 but is not awidespread formal custom elsewhere and I find it isstrongly resisted by the representatives of someMember States on the ACMT. The AdvisoryCommittee on Veterinary Training to the EEC hasissued a relevant report (III/D/1656/7/83-EN) inMay 1985, Report and Recommendations to ensurea comparably high standard of Veterinary Trainingin the Community. It makes excellent reading. Itargues the cases, as would be true for medicine, for(A) a relatively rich staff/student ratio and (B) aprocedure of mutual evaluation as the basis forhigh standards. Specifically, its recommendationsare:

1. The adoption of 5:1 as the target figure for theoverall student:teaching staff ratio for veterinaryschools. The ratio for paraclinical and clinicalstudies would be narrower and that for prec-linical studies wider.

2. The adoption of a range between 2:1 and 2:5:1 asthe support staff: teaching staff ratio.

3. The determination of the minimum number ofteachers (or their full-time equivalents) necessaryto cover all subjects listed in the annex toDirective 78/1027/EEC.

4. The determination, where possible, of a financialweighting for the annual cost of veterinarysciences compared with non-laboratory-basedcourses.

5. The adoption of a procedure ofevaluation basedon a self-evaluation by each school backed by anadvisory visit along the lines of the frameworkillustrated in the report.

6. Proceeding to a trial of this procedure, financedby the Community.

It is relatively easy in veterinary medicinebecause, as has already been said, it is a muchsmaller subject than medicine itself but, as I havealso indicated earlier, the veterinarians may beshowing us the way ahead. Consequently in their1985 Report the Advisory Committee onVeterinary Training is about to conclude a pilotstudy of reciprocal visits of its members betweenMember States and which I understand has beenfound to be constructive and widely welcomed evenby those Schools of Veterinary Medicine whichwere regarded during the visits as displaying poor

standards in certain respects. It could be that a pilotsystem involving exchange of examiners betweenmedical schools in Member States who wished toengage in this process could be financed by ERAS-MUS, at least in the form of a pilot study.

Is movement occurring?

Finally, this whole concern has to do with the freemovement ofprofessionals within Europe. I cannottell you how that movement is occurring through-out the Community but you may be interested tosee the figures in respect of graduates from otherMember States who are now registered to practicein the UK. These data are outlined in Tables III andIV from which you can see that the numbersregistering are increasing rapidly. The concepttherefore seems to be becoming a reality forMedicine. With the three Medical Directives wellestablished and buttressed by an increasing numberof reports and recommendations from the ACMTit would seem that our subject has anticipated the

Table III Numbers of doctors who had qualified in aMember State other than the UK who have been granted

full registration in the UK

Year No. of Doctors

1977 851978 1091979 1241980 1341981 1841982 2641983 3271984 3021985 3321986 4451987 9951988 1309

Table IV These doctors held qualifications granted inthe following Member States

Country No. of doctors

Belgium 301Denmark 83France 189Germany 1029Greece 851Ireland 659Italy 690Netherlands 549Portugal 46Spain 213

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from

638 A.H. CRISP

1992 threshold such that there will not need to beany further major Medical Directives in order toachieve the Community's new goals at that point.

The requirements for 1992 set out in paragraph 88of the Commission's 1985 White Paper havealready largely been met.

References

1. Seche, J.-C. A Guide to working in a Europe without Frontiers.Commission of the European Communities, Luxembourg.1988.

2. Association of American Medical Colleges GPEP Report. A3-year review of the general professional education of thephysician and college preparation for medicine. 1984.

3. Commission of the European Communities. Medical Train-ing in the European Community. Springer-Verlag, Berlin,1987.

4. Education Committee, General Medical Council. Recom-mendation on the Training of Specialists - issued in pur-suance of Section 15 of the Medical Act 1978, October 1987,General Medical Council, London.

5. Pouyard, P. The impact of the directives and of the work ofthe Advisory Committee on Medical Training in theEuropean Community. In: Medical Training in the EuropeanCommunity. Commission of the European Communities.Springer-Verlag, Berlin, 1987, pp. 5-11.

6. Sorensen, B. The impact of the directives and of the work ofthe Advisory Committee on Medical Training in theEuropean Community. In: Medical Training in the EuropeanCommunity. Commission of the European Communities.Springer-Verlag, Berlin, 1987, pp. 12-16.

7. Crisp, A.H. Marrying medical education to the medical needsof the European Economic Community in the twenty-firstcentury (Introductory Address, 19 June 1985). In: MedicalTraining in the European Community. Commission of theEuropean Communities. Springer-Verlag, Berlin. 1987,pp. 17-18.

8. Castermans, A. Summary and Conclusions. In: MedicalTraining in the European Community. Commission of theEuropean Communities. Springer-Verlag, Berlin, 1987,pp. 72-75.

9. Crisp, A.H. The relevance of anatomy and morbid anatomyfor medical practice and hence for postgraduate and continu-ing medical education of doctors. Postgrad Med J 1989, 65:221-223.

10. Crisp, A.H. & Edwards, W.J. Communication in medicalpractice across ethnic boundaries. Postgrad Med J 1989, 65:150-155.

11. Advisory Committee on Medical Training. Report of ad hocworking group on the future programme and workingmethods of the Advisory Committee. Commission of theEuropean Communities. III/D/1570/85-EN, 1985.

12. Schwartz, W.B., Sloan, F.A. & Mendelson, D.N. Why willthere be little or no physician surplus between now and theyear 2000? N Engl J Med 1988, 318: 892-897.

13. Schloss, E.P. Beyond GMENAC - another physician shor-tage from 2010 to 2030? N Engl J Med 1988, 318: 920-922.

14. Committee of Vice Chancellors and Principals. AcademicStandards in Universities. Universities' methods and proce-dures for maintaining and monitoring academic standards inthe content of their courses and in the quality of theirteaching. July 1986.

15. General Medical Council. Annual Report for 1988. GeneralMedicine Council, London. March 1989.

copyright. on 28 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.66.778.627 on 1 A

ugust 1990. Dow

nloaded from