Training programs throughout Europe in Internal Medicine: Are there ...

EJINME-03093; No of Pages 3 European Journal of Internal Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim

Letters to the Editor Training programs throughout Europe in Internal Medicine: Are there critical differences between northern and southern countries? An international survey Keywords: Internal Medicine Education Differences Quality of life

Dear Editor, The commitment to a holistic vision and the comprehensive care for patients is the cornerstone of Internal Medicine [1]. It is beyond doubt that applying these parameters improves both health care quality and economic features [2]. Although this approach is common among internists, there are many differences in the development of the training program (TP). Several efforts have been made in order to homogenize the residency among a European framework [3–5]. Furthermore, The European Board of Internal Medicine established a unified program and a common exam [6]. There are even data about Young Internist saying that the vast majority of them think positively about a consensus in TP [7]. However, non-consensual frameworks prevail among Young Internists [8]. All of these differences need to be contextualized in the current “Old Europe”, a vast territory with huge economic and sociocultural disparities. Without any pretensions to homogenize, but to describe and compare, we came up with the idea of doing a survey about IM training program. After assisting to the European School of Internal Medicine (ESIM), we prepare a survey to evaluate this heterogeneity. A 69 item questionnaire was constructed and given to trainees from 19 different countries at ESIM the last day of the course. It was our aim to address specific features of the residency, theoretical and practical skills, as well as differentiate between north and south. In this paper we report the results of the survey. We included a quantitative and qualitative description of working time, a list of clinical attachments and technical skills able to perform, research features and Core Competency Program (CCP) details. We traced as well the need for psychological support, quality of life and satisfaction indexes measured with a Visual Analog Scale (VAS). Finally, we divided respondents into two groups, North and South, (Fig. 1) and compared them. 38 of the 39 participants, fully completed the questionnaire, representing a response rate of 97.43%. 38 residents of 19 different countries throughout Europe, as well as Israel, Tunisia and Canada which were in the medium–final period of the training program were included on a SPSS database and statistically analyzed. 25 were women, ranging from 25 to 30 years. The following results were found. The vast majority of residents work an average of 8.39 h per day, doing a mean of 5.2 shifts per month. Shifts

last around 16 h but a huge variability exists, ranging from 9 to 32 h. Residents care for a mean of 12.7 patients when doing the ward. Just 52% of respondents carry out clinics and those who do them, assist an average of 20 patients per week. Talking about specific program features, half of them have core-competency defined programs, 65.8% identify a tutor role and most of them implement mandatory level tests. Hardly any of the interviewees rotate in Radiology, Dermatology or Primary care; while more than two thirds rotate in the Emergency Department, Intensive Care Unit or Cardiology. Practical skills performance such as placement of central venous lines, orotracheal intubation and US scanning is extremely infrequent. 47% of residents will get a second subspecialty when finishing his residency, extending in those cases his training. Up to 28% will complete a doctorate during these years and 57.9% a master. Besides, although most residents have no specific time dedicated to research (68%), 4.6 h a week on average in their spare time is dedicate to this purpose. Quality of life subjective assessment by the residents is 6.6/10, which is very similar to the degree of satisfaction with their specialty (6.7/10). Most of the respondents (83%) want to keep working in their home country but just 63% think they will end up working easily there. In addition to this, more than half (52%) consider necessary psychological support during the residency but only 34% of respondents have some kind of structure dedicated to. Comparative analysis revealed that northern countries work more hours per non-shift day (p 0.021) but average shift hours (p 0.006) as well as total hours per week (p 0.02) are less. The fact that South Group rotates more in neurology (p 0.02) than the North Group and them, more in the Emergency department (p 0.08) was found statistically significant. We also seek for significance on the current skills performed by an Internist and spotted it in the ability of channeling peripheral lines (p 0.02) and the existence of a core-competency program (p 0.049) in the South Group. Talking about research, we found that it is valuated (p 0.02) and promoted with specific funds (p 0.006) in the North Group. In this group, job expectancies in general (p 0.046) and in their particular countries (p 0.018) were significant as well as the achievement of a subspecialty (p 0.011) and psychological support (p 0.015). Finally, we found statistical significance in the perception of quality of life and status in and out of the hospital for the North Group. The survey reveals some similarities and many differences still in IM residency. Considering the main limitation of our work, which is the small number of subjects, and the object, thereof, which is far from the extraction of firm conclusions, we will point out some ideas extracted from it. While there is significant variation between respondents in the length of on-call hours, the normal workday, however, runs more evenly-balanced, with 8.39 h worked in a daily basis, being done in half of them in the ward and both in the ward and clinics in the rest. On call hours but also absolute-worked hours are more in the South Group. Regarding clinical attachments there is a certain homogeneity although some of them have more success than others. Then, the fact that

http://dx.doi.org/10.1016/j.ejim.2015.12.013 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Sada PR, et al, Training programs throughout Europe in Internal Medicine: Are there critical differences between northern and southern countries? An international survey, Eur J Intern Med (2015), http://dx.doi.org/10.1016/j.ejim.2015.12.013

2

Letters to the Editor

Fig. 1. North and south graph showing the distribution of respondents.

little more than half of the respondents identified the figure of a tutor and only 50% knew their CCP, is the key point of this lack of homogeneity. Because of that, the great variability in the willingness to investigate which results in disparate data regarding the performance of third degree studies and the acquisition of practical skills is understandable. Taking into account the geographical differences, an increased research trend in the North Group and a practical skills trend in the South Group seem clear. Respondents indicate a good perception of quality of life and status as an internist, which was remarkable in the North Group. This does not prevent half of respondents from saying “Yes” to psychological support at some point in the residency. Comparatively, it is more used in the north, where the concept of quality of life and image as a specialist in IM are significantly better. In spite of the efforts of some working groups, it seems still clear that a huge range of approaches to the training program exist. Our study highlights a palpable polarization on the way trainees receive their training, being clearly more pleased in the north. Who knows if being able to do research, spend less time on the bed of the patient and have psychological support will have a role on that. We feel that the key

point to this disparity is the lack of homogeneous CCP. Although many efforts have been made on this direction, there is still further work to do. Conflict of interest There is no conflict of interest. References [1] Wachter RM, Bell D. Renaissance of hospital generalists. BMJ 2012;344, e652. [2] Tanriover MD, Rigby S, Van Hulsteijn LH, Ferreira F, Oliveira N, Schumm-Draeger PM, et al. What is the role of general internists in the tertiary or academic setting? Eur J Intern Med 2015 Jan;26(1):9–11. [3] Borleffs JCC, ten Cate O. Competency-based training for internal medicine. Neth J Med 62(10):344–6 [4] The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physician. Ann Intern Medicine Mar. 6 2007;146(5):355–60 [5] Palsson R1, Kellett J, Lindgren S, Merino J, Semple C, Sereni D. Core competencies of the European internist: a discussion paper. Eur J Intern Med Mar. 2007;18(2):104–8. [6] Semple C, Gans R, Palsson R. European Board guidance for training centres in Internal Medicine. Eur J Intern Med Apr. 2010;21(2):e1–6.


Letters to the Editor [7] Roux X, Puyade M, Aumaitre O. Training in internal medicine: the young internists' point of view. Rev Med Interne Nov. 2012;32(11):714–6. [8] Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med 2007; 146:392–3.

Pablo Ruiz Sada⁎ Itziar Garmendia Antía Miriam López Martínez HCU Basurto, Av Montevideo s/n, Bilbao 48013, Spain ⁎Corresponding author. E–mail addresses: [email protected] (P.R. Sada), [email protected] (L.G. Antía), [email protected] (M.L. Martínez). 9 December 2015 Available online xxxx


3