Occupational physicians' education and training across European Union countries

Int Arch Occup Environ Health (1999) 72: 338±342 Ó Springer-Verlag 1999 REPORTS ON NATIONAL HEALTH REGULATIONS G. Franco Occupational physicians' education and training across European Union countries Received: 3 January 1999 / Accepted: 14 January 1999 Abstract The framework directive on improvements in the safety and health of workers is being implemented into the national legislation of European Union countries, and occupational physicians are requested to play a key role in undertaking preventive measures. Since there is no common speci c requirement for the training and education of these health professionals, this report aims to provide a comparative picture of the educational process across European Union training bodies. Each curriculum provides theoretical knowledge and practical experience, but deep di erences exist among di erent countries. Core knowledge is mainly based on the traditional disciplines (such as occupational hygiene, occupational toxicology, ergonomics, epidemiology and biostatistics, relevant legislation, and preventive medicine). General learning objectives should include assessment of the workplace environment, communication and education, legislation, occupational diseases, and relationships between health and work. Core experience, often based on task-based learning, emphasizes the need for assessment of a range of working environments; for surveillance, including the biological monitoring, of workers at risk; for assessment of disability, impairment, and tness for work; for the clinical ability to recognize occupational diseases; for the formulation of di erential diagnosis; and for management of workers developing disease in the course of their employment. New curricular elements (such as management, economics, quality assurance, and marketing) are being introduced in some institutions with the aim of stressing the renewed role of the occupational physician in meeting society and employers' needs. The need to educate and train a professional gure whose competence should allow the delivery of high-quality occupational health services G. Franco Cattedra di Medicina del Lavoro, Dipartimento di Medicina Interna, Largo del Pozzo, 71, I-44100 Modena, Italy e-mail: franco@unimo.it Fax: +39-059-270866 across European Union countries compels the harmonization of the formative process of occupational physicians. Key words European Union á Occupational physicians á Educational curriculum á Training Role of the occupational physician in protecting workers' health and preventing risks In recent decades, several actions have been undertaken to improve working conditions. At the European Union level, framework directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of workers is being implemented into the national legislation of all European countries. Although the directive does not provide any guidance about the required competencies of the multidisciplinary team of professionals involved in the prevention of working risks and in the protection of workers' health, the activity of the occupational physician (OP) must comply with the renewed rules. Article 8 of the directive does not mention any professional gure as being responsible for health surveillance. However, according to article 14, in spite of some di erences existing in each national legislation, OPs (or even physicians not specializing in this eld) are required to practice health surveillance, whereas their participation in other activities of primary importance in the whole preventive process is less focused. These factors are leading to a rapidly changing role and function for OPs under the pressure of legislative duties and market forces, although several nuances exist in di erent countries. Competencies of the occupational physician Although it could easily be assumed that every OP should act as a doctor with high levels of competence to deal with the delivery of high-quality occupational

339 health services, there is no speci c education and training requirement for occupational health professionals. These are not even the subject of any European Commission proposal [5], and every decision about the educational and training process is left to each country's sovereignty. Whereas the American College of Occupational and Environmental Medicine provides a detailed description of actions the doctor should be able to undertake and of jobs the doctor should be familiar with in the United States [2] and a similar document exists for OPs' activity in Australia [24], at the European Union level there is much debate about this topic, although it represents an exigency for all people involved in the preventive process. Numerous actions were undertaken in the past few years by associations grouping training bodies (such as the European Association of Schools of Occupational Medicine) and grouping professional bodies (such as the European Network of Societies of Occupational Medicine and the Occupational Medicine Section of the Union of European Medical Specialties). These actions aimed to de ne the competencies (de ned as the condition of being capable, of having the ability and/or the state of being legally competent or quali ed) [20] OPs must be capable of adequately performing their job. A recent survey has shown that there is a reasonable level of agreement by experts in the educational eld about the knowledge and experience required to become a specialist OP [20]. Some di erences can be explained mainly by the di erent OPs' roles, thus re ecting the di erent activities performed by doctors in di erent countries. Appropriate competencies should be the outcome of the educational process centered on theoretical knowledge and experiences. These competencies should be (a) speci c to allow an easy linkage with the training activity, (b) parallel to the role the OP covers in practice, and (c) validated as being appropriate for training in the specialty [10]. This paper aims to compare OPs' educational process as provided by the pertinent institutions in European Union countries so as to provide elements of understanding how di erent training bodies prepare a doctor to be capable of playing a key role in meeting society's and employers' needs. Education and training of the occupational physician Background European directives require mutual recognition of specialty training to support the principles of the free movement of goods and labour throughout Europe. Free exchange of people and services within the medical sector has been achieved by mutual recognition of basic and specialist medical quali cations brought into e ect by European directive 93/16. The directive speci es that each member state shall recognize diplomas, certi cates, and other evidence of formal quali cation by giving such quali cation the same e ect in its territory as those that the member itself awards. In 1986 an ad-hoc report of the Advisory Committee on Medical Training of the Commission of the European Communities [1] stressed that occupational medicine must be recognized as a specialty on the basis of the speci c skill, knowledge, and methods required for its practice and recommended that mutual recognition of the specialist quali cation be given on the basis of the following criteria: (a) the content of the course should provide clinical experience, theoretical knowledge, and practical experience, and (b) the duration of the course should be no less than 3 years. Presently, according to the above-mentioned directive, the requirements needed for recognition of the formal quali cation are (a) it shall entail the basic medical training completion of 6 years' study; (b) it shall include both theoretical and practical instruction; (c) it shall be a full-time course supervised by the competent authorities or bodies; (d) it shall be arranged in an academic center, in a teaching hospital, or in another appropriate health establishment; and (e) it shall involve the active participation of the physician training to be a specialist in the subject. Training institutions The training institutions are mainly organs that formally depend on academic institutions such as the schools of medicine of universities, e.g., in Belgium [14], Finland [15], France [4], Germany [19, 29], and Italy [7]. Other government-recognized institutions are authorized to provide training to OPs in Germany [29], Norway [18], and Sweden [27], sometimes with the participation of the university in the Netherlands [17]. In some instances a special body controls the standards, content, and format of training, as in the case of the Faculty of Occupational Medicine of the Royal College of Physicians in the United Kingdom [12]. Selection of access The selection process of candidates to a post of training is usually competitive and is based on an examination [4, 6, 12]. Duration Occupational medicine, like the majority of other medical specialties, requires a 4-year period of full-time training in most countries (Belgium [14], Denmark [23], Finland [15], France [4], Germany [29], Italy [6], UK [12, 13]), except in Norway, where a 5-year period is required [18], and in Austria, where a 6-year period is under discussion [28]. In Denmark [23], Finland [15], and the United Kingdom [13] the 4-year course must be preceded by a general training period of up to 24 months. In Sweden, applicants are required to be specialists in internal or general medicine [27].

340 A di erent level of education in occupational health, requiring a reduced level of practical training, is provided in Germany [19, 29], whereas in Belgium a certi- cation in occupational medicine can be obtained in a 2-year period [14]. A basic level of training in occupational medicine at the generalist level (Diploma in Occupational Medicine) has recently been introduced in the United Kingdom. It requires attendance of a theoretical course (for at least 55 h) and is o ered by a number of academic and training centers [13]. This diploma, in the absence of any legal requirement for any workplace to have an OP, allows physicians providing services at workplaces and not aiming to obtain the specialization in occupational medicine to be trained for a basic level of competence. Common trunk No school foresees a common trunk with other specialties. It should be noted, however, that basic medical training is considered to provide a su cient level of clinical competence in most countries, whereas others require a period of practicing general medicine or other clinical specialties before the application to the school; this period ranges from 18 [23] to 24 months [12, 15]. Curriculum Core knowledge Curricula are mainly based on the traditional disciplines (such as occupational hygiene, occupational toxicology, ergonomics, epidemiology and biostatistics, relevant legislation, and preventive medicine) [4, 6, 13±15, 23, 28, 29] rather than on learning objectives as in the Netherlands [17], but considerable e ort is being made to further the best integration between courses so as to focus learning on the objectives rather than explore foggy disciplinary areas [6]. In the Netherlands [17], Sweden [27], and the United Kingdom [12], special emphasis is given to management training. In Sweden, considerable attention is given to other topics such as health economics, quality assurance, and marketing, leading to a professional capable of facing the speci c competitive and highly professional working context and of interacting with other actors and stakeholders [27]. Recently a consensus was obtained about the speci c information a doctor should have about assessment of the workplace environment, communication and education, legislation, occupational diseases, and relationships between health and work [16]. Core experience Recently a consensus was obtained about the experience an OP should have [25]. In the eld of occupational hazard to health, emphasis was placed on the assessment of a range of working environments; on the surveillance, including the biological monitoring, of workers at risk; on assessment of disability, impairment, and tness for work in a range of occupations; and on the clinical ability to recognize occupational diseases, formulate di erential diagnosis, and manage workers developing disease in the course of their employment. The OP should also have developed a variety of communicating tools (written reports, counseling) by participating in committees and meetings involving all elements of industrial organization. Other topics have been considered of primary importance: experience in conducting a formal scienti c investigation, in advising the implementation of occupational health and safety legislation, and in participating in health promotion programs, including the prevention of environmental hazards. Practical experience is based on the attendance of internal medicine units [18, 23, 29], specialties units [6, 15, 23, 28, 29], and occupational health units [4, 6, 15, 17, 18, 22, 23, 29]. Teaching-learning methods Theoretical training Theoretical training is mainly based on lectures [4, 7, 13, 15, 17], but attendance of conferences and seminars is provided for and the presentation of papers in scienti c meetings is encouraged [4]. During the 4-year period in Germany a 3-month theoretical course must be completed in an academy of occupational medicine [29]. Distance learning is widening its borders in the United Kingdom [13]. The participation of students in research activities is considered highly desirable [12] or compulsory [17]. Therefore, specialists should be educated toward an independent, unbiased understanding of scienti c methods, allowing them to develop a critical attitude [21]. Training on the job Task-based learning is built around the task, which can stimulate further reading by students. It has been claimed that task-based (on-the-job) learning is focused around the tasks undertaken by trainees, thereby relating education and service [11]. It results from the process of understanding the concepts and mechanisms underlying those tasks. The training occurs indi erently in several medical services such as clinical hospital departments [4, 6, 14, 15, 18, 23, 28, 29], academic institutes of occupational medicine or occupational health [6, 13, 14, 17, 18, 28, 29], occupational health hospital departments [4, 6, 13, 15, 18, 23], occupational health services in industry [4, 6, 13, 15, 17, 29], occupational health services in state administrations [4, 13, 15], and the armed forces [13].

341 The attendance of trainees for a variety of posts can point out possible weaknesses of the educational process, because it reduces the opportunity for medical schools to control the content and the quality of the training. However, this feature provides students with a good opportunity to learn from real-life situations [15]. Furthermore, performance of most of the activities inside occupational health services competing to sell their services, as in the Netherlands [17], could lead to increased research on the quality of instruments adopted by OPs. Assessment There is a variety of formal and informal procedures for assessment as to whether the goal has been achieved. These procedures include continuous assessment during the training, periodic assessment, and nal examination [3]. The emphasis placed on the assessment of knowledge and the assessment of practical skills varies between training institutions and organizations responsible for certifying the nal result. The trainee is usually required to complete a logbook of experience detailing not only clinical work but also all other features characterizing the specialty [12]. A formal appraisal is carried out periodically (four times a year in Finland; at least annually in the UK and Italy) and consists of a variety of di erent tests [12] or of a national written examination [15]. No formal assessment is required in the Netherlands, leading to a potential reduction in the motivation of trainees [17]. In some countries the examination is performed by a committee (sometimes including non-resident members) [4]. The completion of specialist training may require the submission of a dissertation on a research project or a review of a consistent topic in Belgium [14], Denmark [23], France [4], Italy [6], and the United Kingdom [13] or in the presentation of a thesis before a government or professional body as in France [4]. Conclusion A revolution in health care is occurring as a result of changes in the practice of medicine and in society [26]. Many of these factors are in uencing to an even greater extent the role of the OP, who is challenged by the rapid changes in working methods and working life. Changing patterns of diseases, new jobs and new technologies, workers' empowerment, and emphasis on e ectiveness and e ciency are factors in uencing the role of the OP. The educational process should face these challenges, be responsive to the rapid changes in the working world and e ective in relation to health needs, and provide an increasingly broad spectrum of educational opportunities for the OP who is already specialized or as a part of the continuing educational process. Training should provide adequate skills to tackle the new demands created by this rapidly changing situation such that OPs can develop competencies according to their clients' needs [9, 15]. Some countries (Netherlands, Sweden, UK) are more involved in the innovative process as testi ed by the introduction in the curricula of new elements (such as management, economics, quality assurance, marketing). In other areas the formative process is linked to more traditional curricula, leading to a more traditional role for the OP. In the future, any educational process should take into account two main points, namely, assessment of the needs and evaluation of the outcome, for it relies upon client-need satisfaction [9]. In a rapidly changing world there is an increasing need to foresee any health improvement request, and it is therefore necessary to improve and hasten the analysis of health needs. This will allow prompt and exible action to satisfy these needs. 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