Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

The Long Way Towards a Really United Europe: The Role of UEMS - Section Pediatric Surgery

image4701Editorial

Gian Battista Parigi 

President of the UEMS Section and Board of Paediatric Surgery

Director, Specialisation School in Paediatric Surgery, University of Pavia, Italy 

 

The Past 

At 2:41 in the morning of the 7th May 1945, in Reims, France, General Alfred Jodl signed the surrender act ending the bloodiest war (some 55 millions casualties!) Europe ever saw in its very much troubled history. Less than twelve years later, the 25th March 1957, representatives of six of the Countries engaged in the war signed the Treaties of Rome, an agreement defined as European Economic Community (EEC), thus starting an unifying process hopefully bound to a fascinating evolution.

One more year later, the 20th July 1958, the Union of European Medical Specialists (UEMS) was founded in Brussels, with the scope to harmonise and to improve the quality of medical specialist practice in the member Countries, as well as to raise to the highest possible standard the quality of care delivered and the level of training of the future medical specialists in the EEC countries (Belgium, France, Germany, Luxembourg, Italy, Netherlands).

In the following years the EEC, after the 1st November 1993 named European Union (EU) according to the Treaty of Maastricht, progressively enlarged to include Denmark, Ireland and the United Kingdom (1/1/1973), Greece (1/1/1981), Spain and Portugal (1/1/1986), Austria, Finland and Sweden (1/1/1995), Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia (1/5/2004) and eventually Bulgaria and Romania (1/1/2007), raising the total number of EU Countries to 27, hosting a population just a bit short than half a billion inhabitants.

In the meanwhile UEMS, preceding the European unification process, opened to the EFTA-non EU Countries (Iceland, Norway and Switzerland), as well as to the Countries in the "waiting list" to enter EU, thus becoming Associate Members in the General Council of the UEMS before achieving the status of Full Member. Most of Associate Members become, in recent years, Full Members; today, on top of Countries in the waiting list to enter EU, Associate Membership has been offered also to Countries outside the geographical boundaries of Europe, raising the total number to 5 (Azerbaijan, Croatia, Georgia, Israel, Turkey).

Since 1962, when the process of building Europe was still at its beginning, the UEMS created Monospecialist Committees (MC) for each of the main disciplines recognised and practised in at least three of the member Countries. Objectives of these MC were to defend at international level the title of Specialist and his professional status in society; to study, promote and defend the quality of the comparatively high level of specialist care given to the patients; to contribute to the creation and maintenance of solidarity amongst the European Specialists, particularly the specialists in the same field; to study, promote and defend before the international authorities, the free movement and the moral and material interests of European Specialists.

In 1973, with the inspired vision of Peter Paul Rickham, author of the “Rotterdam resolution” promoting the case of a still new specialty, of Andrew W. Wilkinson of the BAPS and of François Moyson, well introduced in the UEMS circles in Brussels, the idea of a MC in Paediatric Surgery (PS) was put forward: after two years of lobbying, in the 1975 meeting in Copenhagen the Council of Directors of the UEMS established such a Committee. The first meeting was held the 18th February 1978 in Brussels, where representatives of 8 out of the then 9 Countries of the EEC met under the chairmanship of Andrew W. Wilkinson, with Jacques Borde as Vice President and Jan C. Molenaar as Secretary. It was then agreed that training in PS should include at least 3 years of General Surgery and at least 3 years of PS , of which at least 2 at senior level.

The Committee was still a baby when a death in the cradle was threatened: in the UEMS Council of November 1979 the Chairman of the MC in Surgery proposed to refuse the recognition of minor specialties within medicine and surgery, to be simply established as “areas of competence”. After a firm pleading of Mr. Wilkinson, Paediatric Surgery was definitely confirmed within the UEMS as an independent specialty, thus saving our peculiarity and emphasising the role that our organisation would have played in the future on behalf of PS.

Monospecialist Committees, since 1990 defined as Specialist Sections, increased in time to a total number of 38 and enlarged their field of interest creating in the early 1990s the European Boards, working groups of the Sections aiming to guarantee optimal care in the field of the speciality concerned by bringing the training of medical specialists to the highest possible level, as well as dealing with CME / CPD issues, the assurance of quality in specialist medicine and the defence of the autonomy of practice of medical specialities and specialists. Among them, in 1993 was established the European Board of Paediatric Surgery (EBPS).

The present

A visit to the homepage of the European Commission website (www.europa.eu) gives an appealing idea on the way still facing Europe before a complete unification: welcome message is offered in 23 different languages, written in three different alphabets (Roman, Greek, Cyrillic).

Examining more in depth the differences between European Countries, beyond the linguistic ones, and focusing our interest on data specifically within the domain of PS, it appears immediately clear the striking difference in infant mortality ratio among the western and eastern part of the continent. Although this differentiation is now considered “politically incorrect” and seen somewhat with impatience in the hallways of the European Commission, it is nevertheless a crude fact that average infant mortality rate in the former 15 EU countries is 4,38 x 1000 infants, while in the new 12 Countries average ratio more than doubles to 9,28 x 1000, with a worrying two-digits figure in Bulgaria and Romania (18,5 and 23,7 x 1000 respectively).The chances for a Swedish newborn to survive his first year of life are 9-fold greater than those of his Romanian mate: as a paediatric surgeon - front-line troops in the battle against neonatal mortality - we can't simply limit ourselves to emphisize the difference we must work to reduce and ultimatelly cancel this difference.

Again speaking about differences, the very same definition of PS, again we are facing a long way before harmonisation within Europe. In some countries, namely Denmark, Netherlands and Belgium PS is not even recognized as an independent specialty and the UEMS Section of PS already took up a position on this issue towards the relevant National Authorities. The Section intervened also to support Bulgarian and Norwegian colleagues struggling for "independence" against State or corporate regulations aiming to reduce medical specialities to a minimum - and consequently not recognising the uniqueness of expertise of a paediatric surgeon, comparing him to a surgeon "tout court".

Paying now attention to the problem of manpower in PS, again we are facing a long way before harmonisation within Europe: on one side we have Ireland, credited with only 4 Consultant Paediatric Surgeons, on the other one Italy that boasts 440 staff surgeons, but whose only 60 are Chief of Department. Empirical evaluation adopted by the BAPS indicates as optimal the numbers of 1 consultant Paediatric Surgeon every 500.000 inhabitants, of 1 Paediatric Surgical Centre every 2.500.000 inhabitants and the optimal ratio trainee to consultant of 1:1. Substantial differences among European Countries are evident, with huge overcrowding of medical doctors in some Countries and a lack of trainees in others: thus, Greece has roughly a 40% of unemployed trained paediatric surgeons, Italy some 20%, Germany some 15%, Spain some 10%. On the other hand, in UK training programs restrictions and the demographic shift determines a shortage of paediatric surgeons, while in Portugal mean age of our Colleagues is over 40 years thus prompting the need of young colleagues.

This striking variability among European Countries, once more highlighted by differences in training policies and number of training centres, prompted the Section of PS of the UEMS to set up a "peer review system" aiming to harmonise performances and training in PS throughout Europe at the highest standard reasonably attainable. This system is working on the basis of Site visit of training centres, European Register of Paediatric Surgeons and European examination, CME / CPD fostering policies.

Site visit of training centres - In 1997 the EBPS appointed visiting commissions to check the level of training in relevant PS Centres throughout Europe. Since then, 21 training Centres have been awarded the European Certificate (for the updated list, see www.uemspaedsurg.org). These site visits are performed in two days, the first spent visiting the Institution with all the facilities, laboratories, library, etc and the second day spent interviewing the trainees, inspecting their logbooks as well as obtaining details regarding their views on gaining employment after the completion of their training.

An accreditation from the Board, although not yet officially endorsed by the European authorities, it is now recognised as a mark of excellence within the paediatric surgical community: a clue about the esteem in which the Certificate is hold comes from the request of Centres outside the geographical boundaries of Europe to be visited by the EBPS Committee. First of these “intercontinental” Site Visits has been successfully hold in Dubai in April 2008, and the Certificate awarded during the EUPSA Congress in Istanbul.

European Register of Paediatric Surgeons and European examination - The EBPS set up an European Register of Paediatric Surgeons, involving the Certification of Paediatric Surgeons from European Countries. This task is accomplished through a process addressed both to established Paediatric Surgeons (the so-called “grandfather clause”), trained before 1993, and to younger Paediatric Surgeons trained after 1993. These Colleagues must undergo a full process of European Examination, again with the clear aim of setting a standard of excellence, a bench mark which most paediatric surgeons should strive to achieve (details about the Examination can be found at www.paediatricsurgeryexam.org ).The EBPS Register has not yet legal status but ensures a high standard of candidates who have completed their paediatric surgical training: the more than 1100 Colleagues registered become Fellows of the European Board of Paediatric Surgery (FEBPS). Although devoid of any legal value, this fellowship is a mark of excellence that should ideally distinguish all and only those Paediatric Surgeons whose level of professional value meets the demanding standards set by the European Board.

Wishing to offer also to Colleagues non EU-citizens the possibility to challenge themselves with the European Examination, since 2006 the Board decided to open the application to candidates from all over the world: successful ones will be awarded the European Board Certification (EBC), being the Fellowship for legal reasons reserved to EU citizens.

CME fostering policies - There is a strong tradition of continuing medical education (CME) in the medical profession and the most powerful motivating factors are positive ones: doctors’ awareness of their responsibility for safe medical performance, recognition of peers and collective emphasis on the quality of medical practice. CME is regarded as one of the most effective form of Quality Improvement now available and the new keyword in the field of medical updating, fostered by UEMS since 1993 with the publication of the European Charter on CME, followed in 1998 by the EBPS guidelines for CME (see www.uemspaedsurg.org/CME.htm) and in 1999 by the establishment of EACCME, the European Accreditation Council for CME, operational since 2000. Main aim of this body is "… to harmonise and improve the quality of specialist medical care in Europe… by improving quality of CME and accessibility to CME for the medical specialists in Europe" by means of transfer of CME credits (the units of evaluation of CME) in case of migration of a specialist within Europe, between European countries, between different specialities and between the European credit system and comparable systems outside Europe (such as the ABMS - American Board of Medical Specialities).

The future

The 10th April 2008 UEMS celebrated in Brussels its 50th anniversary with the International Meeting on “A new vision for a modern specialist medical care”. In this occasion the President Zlatko Fras presented the strategy document detailing the future policy of our Organisation. Within the next 5 years, aim of the UEMS is to become internationally more well-known, more visible, institutionally stable and respected, a central and leading European organisation for setting standards and consultation in the fields of specialist postgraduate medical training, CME/CPD, as well as the “Quality Agenda” in specialist medical practice. Within this keyword are comprised the three items of Quality Improvement - a continuous striving to provide better practice; Quality Assurance - a process applied to the confirmation or continuing fitness to practice (audit, performance review) and Quality Control - a wholly distinct area, related to medical regulation, in which doctors who have been identified as having difficulties with their practice are assessed and appropriate action is instituted.

Within these broad areas the UEMS Section and Board of PS has identified some particular activities to develop beside those already in place, to be carried on and improved. In particular the UEMS as a whole and our Section in particular have joined the project fostered by the Guidelines International Network (www.g-i-n.net), an international organisation representing 37 countries from Africa, America, Asia, Europe and Oceania and a number of international organisations such as the WHO and the UEMS. GIN seeks to improve the quality of health care by promoting systematic development of clinical practice guidelines and their application into practice, through supporting international collaboration. There is already a wealth of work done on this issue by many Centres of PS throughout Europe: the Section intends to act as a catalyser for the European paediatric surgical community in order to collect, elaborate, validate and popularise clinical guidelines on the most common paediatric surgical pathologies.

Last but not least, during the IX European Congress of Paediatric Surgery held in Istanbul in June 2008 has been officially presented the first edition of the European Syllabus of Paediatric Surgery, to stand as an authoritative reference document - although not yet legally binding - on which are detailed the contents of PS, what is essential and what not essential, which fields are mandatory and which just optional, setting out the optimal standards for training in Paediatric Surgery throughout Europe. The document is the final result of a long process, started in January 2006 and driven by an “ad hoc” Committee, created in full synergy with the European Paediatric Surgeons’ Association (EUPSA), that after two years of work involving all the National Scientific Societies of Europe and four major revisions finally approved the document in January 2008.

The Syllabus defines the contents of training, the professional skills and attitudes requested to become a Paediatric Surgeon, the relationships between paediatric surgery and other related specialties, the details on training programs (access, duration, structure, minimal requirements, monitoring and examination, quality assurance) and training Institutions (recognition, requirements, quality assurance), the characteristics and requirements of trainers and trainees, the relationship among European rules and National Training Programs. The Syllabus as well can be found in the homepage at www.paediatricsurgeryexam.org.

The visionaries that in 1957 signed the Treaties of Rome, conceiving among other daydreams a unified currency in a continent freshly out of a dreadful war, could have reasonably been considered a bit crazy if not positively needing an urgent admission in a psychiatric asylum. Now the euro is a matter of fact in eleven European Countries, and the process is open for the other members to join the club. “Si licet in parvis grandis exemplibus uti” (if we are allowed in trivial issues to utilise illustrious examples), people in UEMS – and the paediatric surgeons first among them - share more or less the same vision for the future of medical specialist care in EU: to obtain in all European Countries a harmonised standard of care, at the highest level attainable, in the day to day care offered to our children. Role of the UEMS Section and Board of Paediatric Surgery is then the continuous strive to increase the standard of paediatric surgical care throughout Europe, because if today Europe is united formally, substantially there is still a long way to do.

"Vision without action is a daydream.

Action without vision is a nightmare."