Aliment Pharmacol Ther 2003; 18 (Suppl. 3): 90–92.
doi: 10.1046/j.0953-0673.2003.01724.x
Gastroenterology and hepatology services in Europe V. LA MY* & D. McN AMARA *University Hospital Brugmann ULB/VUB, Charleroi, Belgium; Department of Gastroenterology, Dublin and Meath Hospitals, Dublin, Ireland
INTRODUCTION
Since 1996 data have been collected on manpower (availability and work practices) and training in gastroenterology and hepatology across Europe. The Section of Gastroenterology of the European Union of Medical Specialists (UEMS) and the European Board of Gastroenterology (EBG) performed initial surveys. Additional data collection was performed with the help of the manpower committee of the EBG and the Association des Socie´te´s Nationales et Me´diterrane´ennes de Gastroente´rologie (ASNEMGE). The objectives set out by the manpower committee were to obtain accurate information on manpower levels throughout Europe and to define current work practices. This information was considered of paramount importance to the global development of gastroenterological services, as it would highlight regional variations in practice. This information could then be used to assist in designing a framework for future manpower planning, both locally and across Europe. In addition, collected data would enable the EBG to make informed suggestions for manpower and training provision while bearing in mind foreseeable, necessary changes to gastroenterological practices. Data were gathered from national representatives of professional associations and societies by means of a questionnaire. The initial 1996 questionnaire contained four distinct sections: specialist training, current practice, current manpower, and future proposed developments. A second questionnaire was circulated in 2001, which was designed to update information on specialist training and to compare the situation in 1996–2001.
Correspondence: Dr V. Lamy, Department of Gastroenterologie, and Hepatology, CHU de Charleroi, 92 boulevard P. Janson, B-6000 Charleroi, Belgium. E-mail:
[email protected]
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A final survey on training and an update of the manpower situation, with the addition of costs for gastroenterology services, was performed early in 2003. This survey specifically addressed the situation in accession countries, especially in central Europe, and included Russia. All European countries surveyed responded to the questionnaire. The answers were analysed by the committee, and if there were any queries or unclear responses, additional attempts were made to clarify matters directly with the society’s representative. CURRENT MANPOWER
Gastroenterology and Hepatology is a medical specialty recognized in all European countries except in Germany where it is a subspecialty of Internal Medicine. It is linked to other specialties such as surgery, radiology, pathology and internal medicine. It covers a wide clinical field and concerns all the diseases of the digestive tract and liver, including over 800 medical conditions. Gastrointestinal diseases account for a significant proportion of European annual mortality (the gastrointestinal tract is the most frequent site of cancer), while also contributing to significant morbidity as a consequence of common, chronic illness. Gastroenterology and hepatology is both a clinical specialty and a medical technology, owing to digestive endoscopy, which enables gastroenterologists to work with substantial diagnostic and therapeutic autonomy. Considerable manpower variation exists across Europe (Table 1). It is also apparent from the survey that in almost all countries additional groups, other than gastroenterologists, supply a proportion of gastroenterological services. These include general surgeons (14/17 states; 82%), internists (12/17 states; 70%) and in some countries general practitioners (6/17; 35% states). Competition from other specialities exists in six of the 17 (35%) countries that responded. Ó 2003 Blackwell Publishing Ltd
GASTROENTEROLOGY AND HEPATOLOGY SERVICES IN EUROPE Table 1. Current European gastroenterology manpower
Country
Population (millions)
No. physicians
No. gastroenterologists
Austria Belgium Denmark Finland France Germany Greece Ireland Italy Luxembourg Netherlands Portugal Spain Sweden United Kingdom Norway Switzerland
8.121 10.262 5.349 5.181 59.521 82.193 10.565 3.820 57.844 0.441 15.983 10.023 39.490 8.883 59.832 4.503 7.206
30 115 40 131 15 102 15 794 177 138 282 737 43 030 8469 335 786 1095 48 987 31 087 171 494 24 600 102 631 13 547 22 718
262 390 121 53 2953 2007 356 25 N/A 19 138 340 1616 169 390 171 211
Table 2. Current practice across Europe Gastroenterology activity
No. countries = 17
Gastroscopy Colonoscopy ERCP Ultrasound Endotherapy Laparoscopy Proctology All emergency endoscopy Direct and referred access Referred access only
17 (100%) 17 (100%) 14 (82%) 7 (41%) 15 (88%) 5 (29%) 14 (82%) 5 (29%) 10 (59%) 7 (41%)
ERCP, endoscopic retrograde cholangiopancreatography.
As expected, digestive endoscopy represents a significant component of the gastroenterology work load. Gastroenterologists almost universally perform specialist procedures, through out Europe (Table 2). Most countries reported that gastroenterology consultations could be accessed either directly by patients or through referral by general practitioners. Depending on the capacity of the local healthcare system, the mean waiting times for both public or private consultations and admissions could range from days and weeks to months across Europe. The countries reporting the longest wait for a public consultation and hospital admission were Portugal and Norway, and Portugal, respectively. Ireland had the longest mean delay for both private consultations and admissions; 3 months and 1 month, respectively.
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The level of commitment to teaching and either basic science or clinical research was variable. The proportion of time dedicated to teaching varied from 1% in Spain to 9% in the UK. The allotted time for research was 10–90%, depending largely on the contractual commitments of a given position, clinical or academic. The survey found that the overall number of gastroenterologists in relation to the needs of the population was inadequate in almost half (8/17; 47%) of the countries questioned, while the geographical distribution, i.e. general accessibility to specialists, was centralized in the majority of countries. As expected, there is little unemployment in the field of gastroenterology anywhere in Europe (reported as none by 12/17 respondents; 70.5%), although many newly qualified specialists may have to wait several years to obtain a permanent position, reportedly more than 5 years in 4/17 (23.5%) countries. There was a wide distribution in the percentage employed in private practice. TRENDS AND FUTURE DEVELOPMENTS IN GAST ROENTEROLOGY
In general, the majority of nations surveyed thought that the current trend towards increasing efficiency in medical practice was set to continue, with fewer admissions to hospital for specialist gastroenterology care and an increase in outpatient management, including day-case procedures (Table 3). While recognizing that gastroenterology practice is likely to change in the future, there was broad consensus that both the global and scientific impact of the specialism is also set to increase, ensuring continued interest in training in the speciality. In 1996, despite the range of conditions managed by gastroenterologists, 13/17 respondents considered population-based eradication or vaccination programmes for Helicobacter pylori to be likely major future
Table 3. Future developments in gastroenterology
Development
No. countries in agreement
Decrease in specialist hospital beds Increase in out-patient consultations Increase in day case procedures Decrease in hospital admissions
8 13 16 10
Ó 2003 Blackwell Publishing Ltd, Aliment Pharmacol Ther 18 (Suppl. 3), 90–92
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V. LAMY & D. McNAMARA
developments. Similarly, 11/17 countries recognized the future impact of advances in tumour biology and treatments for gastrointestinal cancers, while nine societies thought a vaccine for hepatitis C and new treatments for liver disease in general would be significant initiatives. GASTROENTEROLOGY TRAINING IN EUROPE
A total of 25 countries provided information in the 2001 survey on training. This included all EU member states and EFTA countries. As expected, there was a considerable degree of heterogeneity in how regions structure their national training schemes. Most schemes included a common trunk of general internal medicine training, although the duration ranged from 2 to 6 years. However, the median overall length of gastroenterology training was 5–6 years (range 4–9), which is in accordance with the proposals of the EUMS European Diploma of Gastroenterology. (See http:// www.gastrohep.com and click on EUMS logo or visit http://www.uems.net and click on Section of Gastroenterology.) Although training schemes exist, it was clear that the specifics of each programme varied widely. In half of the countries surveyed, the regulatory authority overseeing training schemes was governmental. Remaining authorities included universities or professional bodies. Qualification may or may not require formal examination. The majority of programmes involve some means of continual assessment. In 75% of regions, a logbook is employed. The most significant limitation to training was access to approved training posts, considered insufficient in the majority of states. In addition, training abroad remains a favoured and popular means of improving a trainee’s skills, although again the duration varies significantly.
Table 4. Gastroenterology reimbursements by country ( ) Procedure
Belgium
France
Ireland
Slovenia
Gastroscopy Theraputic gastroscopy PEG insertion Sigmoidoscopy Colonoscopy Theraputic colonoscopy ERCP Abdominal ultrasound Outpatient consultation
106.17 169.63 N/A 24.13 141.36 254.45 251.34 41.37 24.20
96.00 N/A 153.60 57.60 153.60 153.60 288.00 57.60 23.00
119.03 119.03 253.71 72.90 293.10 293.10 501.67 N/A 130.00
104.00 211.00 306.00 46.00 160.00 483.00 644.00 40.00 18.00
PEG, percutaneous endoscopic gastrostomy; ERCP, endoscopic retrograde cholangiopancreatography.
GASTROENTEROLOGY REIMBURSEMENT
Calculation of the average reimbursements for gastroenterology services across Europe is ongoing. Costs have been provided for Belgium, France, Slovenia and Ireland while limited information was submitted from Estonia (Table 4). It is envisaged that additional costs will be submitted from the remainder of the countries included in the 2003 survey, which will enable comparison throughout the EU and with other healthcare regions such as the USA. It is also apparent that costs may vary with in countries, depending on the type of facility providing the service and whether private healthcare exists. CONCLUSION
The willingness of national professional associations and scientific gastroenterology and hepatology societies to partake in these surveys has provided invaluable information on important manpower and training issues facing European gastroenterology. These data will form the framework for future recommendations on planning European service provision and training.
Ó 2003 Blackwell Publishing Ltd, Aliment Pharmacol Ther 18 (Suppl. 3), 90–92
