Psychiatric training in Europe

Abstract

Aims and method

This study aimed to establish the variations in the pre-defined aspects of postgraduate psychiatric training within the member countries of the European Federation of Psychiatric Trainees and illustrate the diversity of training experiences within Europe. Participants were required to complete a structured questionnaire.

Results

There are wide variations in the length, content and structure of postgraduate psychiatric training across Europe. There are differing requirements for, and access to, psychotherapy training. Some countries have no examinations or formal assessments.

Clinical implications

An understanding of the postgraduate training systems across Europe is essential not only for making informed choices about the development of trainees recruited from the European Economic Area but also for enhancing postgraduate training and patient care in all European countries.

There are attempts to harmonise training in psychiatry across Europe but the very different political and social arrangements in European countries present a real challenge to attaining this goal. ¹ Harmonisation of postgraduate specialist training in the European Union (EU) within each medical specialty remains an important aim of the Union Européenne des Médecins Spécialistes (UEMS). ² Towards this aim, several surgical specialties have already established accreditation and examination procedures that are recognised throughout the EU. ³

In 1992, the Psychiatric Trainees' Committee of the Royal College of Psychiatrists facilitated a meeting of European trainees and representatives from nine European countries convened in London. ⁴ At a subsequent meeting in 1993 the European Federation of Psychiatric Trainees (EFPT) was officially formed with the aim of facilitating the exchange of ideas, improving training and developing national trainee organisations for psychiatrists. ⁵ Since its inception, EFPT has held a forum annually in a different European country and its membership now includes national trainee associations from over 20 countries. The EFPT has representation within the UEMS and the two work jointly on developing a European curriculum for postgraduate training in psychiatry. Comparing the developmental processes in postgraduate education in psychiatry in different countries can be invaluable in further development of these initiatives and ideas. ⁶

Competency-based training is only one aspect of postgraduate training in psychiatry and there is limited knowledge about the variation and similarities in psychiatric training across Europe. This is of particular importance in the UK because of increasing professional migration to this country and the right of European Economic Area (EEA) nationals to apply for employment on an equal footing with psychiatrists who have trained in the UK. It is therefore crucial, especially for those involved in recruiting and supporting psychiatrists at all levels, to understand the diversity of training experiences that psychiatrists in different European countries have had access to.

Method

The 16th EFPT forum was held in Gothenburg, Sweden, in 2008 and was attended by 61 psychiatric trainee representatives from 22 national trainee associations across Europe. The diversity of the training experienced by delegates was apparent during the discussions and it was decided to gather more structured information about psychiatric training in Europe. Informed by these discussions a questionnaire was devised to obtain information about the training experience in different member countries of EFPT. It considered length, structure and content of training, psychotherapy and assessments. Delegates from all 22 countries at the EFPT 2008 forum (Box 1) completed the questionnaire. We then held a discussion with each participant, allowing any queries to be answered and accurate information to be obtained.

Box 1 Countries that completed the survey

Austria	Ireland
Belarus	Italy
Bosnia	The Netherlands
Croatia	Norway
Czech Republic	Portugal
Denmark	Romania
Estonia	Slovenia
Finland	Sweden
France	Switzerland
Germany	Turkey
Greece	UK

Results

Length of training

There are wide variations in the length, content and structure of training across Europe. Of the 22 countries surveyed, in 18, trainees spend 6 years training at medical school. In seven of these countries (Austria, Czech Republic, Finland, France, Germany, Romania and Switzerland), trainees do not spend any time working in the equivalent of UK foundation posts before commencing their specialisation in psychiatry. Of the remaining 15 countries where trainees do spend time in these foundation-style posts, 11 have the opportunity to gain experience in psychiatry during this period.

The length of specialist training in psychiatry varies from 4 to 6 years (average 5 years), except in Belarus where it is only 1 year. Training is nationally standardised in 17 of the 22 countries. It is not nationally standardised in Austria, Bosnia, France, Italy and The Netherlands. There is the opportunity for flexible working in only 9 countries.

Content and structure of training

Of the 22 countries, 6 (Belarus, Bosnia, Croatia, Czech Republic, Estonia and France) have a common training path to become a specialist in psychiatry rather than having separate paths for adult psychiatry and child and adolescent psychiatry. Of these, Belarus has no specifications on compulsory elements of training or placements before becoming a specialist in psychiatry. In the other five countries, a mean of 23 months is spent training in adult psychiatry; four countries have compulsory placements in neurology and in child and adolescent psychiatry, with mean durations of more than 6 months. Placements in general medicine of between 3 and 6 months are mandatory in three countries.

The training is separate for adult psychiatry and child and adolescent psychiatry in the remaining 16 countries. Of these, Italy has no specifications on compulsory elements of training or placements before becoming a specialist in psychiatry. The duration of compulsory elements of training in the other 15 countries is shown in online Fig. DS1 and DS2. In adult psychiatry training the mean duration of compulsory time spent in adult placements is 39 months. Nine countries specify a placement in neurology and six in internal medicine; only a minority of countries expect other compulsory placements.

In child and adolescent psychiatry training the mean duration of compulsory time spent in child and adolescent placements is 38 months and in adult placements 13 months.

In 14 countries trainees have some choice of placements during their training. The total time spent in these placements is between 3 and 15 months (mean duration nearly 12 months). In addition to placements in the six psychiatric specialties (general adult, old age, forensic, psychotherapy, learning disability, and child and adolescent psychiatry) and three adult endorsements (liaison, rehabilitation and addictions psychiatry) in the UK, trainees in Europe have access to neurology placements in five countries, internal medicine placements in seven countries and specific research placements in nine countries.

In the Czech Republic and Bosnia it is only possible to work as a specialist in adult psychiatry but in the other 20 countries it is also possible to work as a child and adolescent psychiatrist. Specialists in old age psychiatry and forensic psychiatry exist in 12 countries, psychotherapy in 10 countries and learning disability psychiatry in 4 countries.

Psychotherapy

Psychotherapy training is compulsory in 12 countries. With regard to access to training in different modalities of psychotherapy, 20 countries have training in psychodynamic psychotherapy, 21 in cognitive-behavioural therapy, 17 in family therapy, 16 in systemic therapy, 12 in interpersonal therapy and 7 in dialectical behavioural therapy. Additionally, psychotherapy case requirements for trainees vary greatly in terms of number of patients to be treated and the duration of therapy for individual patients, which ranges from 3 to 24 months. In 10 countries, trainees have to pay for their own supervision of the psychotherapy they administer, even though in 3 of these countries (Estonia, Germany and Italy) it is a compulsory part of their training. In 4 countries it is compulsory to have personal therapy. In 19 countries, trainees have to pay for personal therapy and in 3 of these countries (Austria, Switzerland and Germany) it is a compulsory part of their training.

Examinations and assessments

In 18 of the countries surveyed, trainees have to complete examinations before finishing training in psychiatry and becoming a specialist. There are no examinations in Denmark, France, Norway and Sweden. In most countries there is one examination but in Bosnia there are 30 throughout the course of the training. A variety of methods of examination are used (Table 1). Currently, seven countries are undertaking workplace-based assessments (Table 1).

Table 1 Examination and workplace-based assessment methods

Countrya	Multiple choice questions	Short answer	Essay	Short clinical cases	Long case	Oral exam	Multisource feedback	Observation of a patient assessment	Non-clinical skills	Case-based discussion
Austria			x		x					x
Belarus		x
Bosnia						x
Croatia					x	x
Czech Republic	x	x	x		x
Estonia				x		x	x
Finland			x
Germany						x
Greece	x	x				x
Ireland	x			x			x	x	x	x
Italy			x			x
The Netherlands	x						x	x	x	x
Portugal					x	x
Romania			x	x	x
Slovenia				x	x
Switzerland	x						x	x	x	x
Turkey		x	x		x
UK	x			x			x	x	x	x

Only in 10 countries do supervisors complete a regular report on the trainee's progress; in seven of those it is necessary to demonstrate satisfactory progress at each report in order to continue to the next stage of training. In 17 countries, trainees are required to keep a logbook or portfolio of evidence of their achievements.

Discussion

Knowledge of the differing training in psychiatry in Europe is of increasing importance in the UK due to migration of doctors. As more doctors move across borders it is important to consider equivalence of training, qualifications and experience across Europe. As highlighted by this survey, the discrepancies between the UK and other countries are apparent, for example there are no examinations or formal assessments in France and no compulsory placements in Italy. There are moves to standardise training across Europe but at present five of the countries surveyed do not even have nationally standardised training schemes. As UEMS develops a European competency-based curriculum and associated assessments, the challenge of harmonising training across Europe remains very real. The varying training systems in place inevitably result in diverse attitudes to training and assessment in different countries dependent on the culture of learning and apprenticeship.

In general, the overall length of undergraduate and postgraduate training in the countries involved in the survey was similar to that in the UK, with the majority spending 6 years at medical school and 4-6 years in specialist training. In half of the countries, doctors are able to undertake psychiatry placements in the equivalent of the UK foundation programme. Almost all countries specify mandatory placements during psychiatric training, for example a certain number of months spent in adult psychiatry placements. Of particular interest is that unlike the UK, placements in neurology and general medicine are quite common during specialist training. Psychotherapy training is very varied and is only compulsory in half the countries surveyed. Some trainees have to pay for supervision of psychotherapy patients and personal therapy, even though it may be a compulsory component of their training.

Conclusion

This survey provides useful information regarding postgraduate training in psychiatry across Europe. This is particularly relevant not only for individuals involved in recruiting and supporting psychiatrists who have trained in Europe, but also for statutory organisations like the UK General Medical Council who decide on issues such as equivalence of training. Additionally, an improved understanding of European postgraduate psychiatric training structures is the starting point in enhancing the quality of training across Europe.