By Wolfgang Grisold, Walter Struhal and Svein Ivar Mellgren
European neurology is in the process of increasing harmonization. This is a consequence of the right of European neurologists to practice freely in Europe. This implies practically and scientifically based needs to approach the issue with care and preparation. Presently the UEMS/EBN (European Union of Medical Specialists-Section of Neurology/European Board of Neurology) provides a core curriculum for neurologic training, a definition of the neurology speciality, a training center visitation program and a European Board examination.
The UEMS (www.uems.net) is the union of European medical specialists, and is constituted of representatives from national societies and sections. The European Board of Neurology has representatives from European UEMS members and has biannual meetings. The website of the UEMS/EBN contains information of present activities, including that on examination and visitation of departments. One of the main activities of the UEMS is education. The UEMS/EBN also has provided a core curriculum, a definition of neurology within the UEMS, in addition to the department visitiation program and board examination, and is active in the accreditation of CME activities.
Content of Neurology
The content of neurology training for residents varies in different European countries of Europe.1 This is not only depending on national traditions, but mainly on the way neurology is practiced and how health system structures are used. In addition, local and national health systems have different professional relations with related overlapping medical fields. Pediatric neurology is in most countries attached to pediatrics. The definition of European minimal standards of content and structures of neurology are available in the UEMS/EBN chapter 6.2 The Core Curriculum of Neurology has also been published previously3 and is now (2013) in the process of revision.
Practical skills are trained mostly within the core competencies of neurology such as stroke, extrapyramidal diseases, multiple sclerosis and epilepsy.4 Some disciplines, such as clinical neurophysiology, may not be part of the neurology curriculum in several countries, but are still practiced by neurologists or specially trained neurophysiologists (in some countries with a separate specialty in clinical neurophysiology). Skills and particular competences will become more important as future stroke therapies with interventions also need the participation of neurologists.5 Rotation and exchange of trainees are also encouraged by the UEMS.
European Board Examinations
Many European sections, like urology, anesthesiology, ophthalmology and others have developed a European board examination, which in some countries in part or as a whole has replaced the national examination. The attendees of these examinations have to prove that their knowledge is at a European level, and can use the examinations a sign of quality and excellence. The UEMS-SN/EBN decided to develop a European Board examination in 2004, and after several years of development the first examination took place in Milan 2009 during the ENS congress.
The choice of the instruments of the examination is difficult and much debated within the medical disciplines. This concerns the source of questions, the format of the examination, the examination format and the evaluation of results. At present, no universally applicable format of examinations is offered by the UEMS/Council for European Specialist Medical Assessments (CESMA),6 and the development of questions often depends on the individual section constructing these examinations according to their needs and requests.
Elements of the European board examination
It was decided that an instrument for reliable and objective testing of skills and practical issues would not be feasible within the neurology examination format, and therefore only candidates were accepted from EU/European Economic Area (EEA) countries, who had already been trained, or were declared qualified for the examination by their national society. These European candidates are conferred the title “Fellow of the UEMS/EBN.” By 2013 also applicants from non-European countries were admitted to the examination provided they could present proof of similar qualifications.
In more detail, for the European Fellow of Neurology, a three-step approach was designed:
1: The national certification of trainees by their national society is considered as part of the examination. This certificate proves the person to be qualified for the examination. It may be based on a certain number of years of training, a national examination or status as an already certified neurologist. This mode of acceptance would ensure that practical training is confirmed by the national society. This step can practically only be accepted for UEMS states. Also for non-European states, certification of training, or national speciality, or board acceptance need to be provided at application for the UEMS/EBN examination
2: A set of 120 multiple-choice questions (MCQs) with one single best answer has been the main part of the examination. The MCQs were provided by members of the UEMS/EBN, the large European neurological societies (EFNS (European Federation of Neurological Soceties) and ENS (European Neurological Society (ENS), other neurological societies (Movement Disorder Society, European Stroke Society)) and recently also e-brain.
Before the examination all questions were graded independently by an examination board in a specific database. Only questions that obtained an average score over 5 (range 0-10) were accepted. The quality of questions and options of answers were then assessed by members of the Department of Medical Education, Ege University, Turkey, chaired by Prof. Ayhan Caliskan.7 This examination quality assurance concentrated on question stem, clarity, language, ambiguousness, and flaws. The final editing of the accepted questions was performed by the chairmen of the examination committee, who also distributed the number of MCQs to different topics.
3: Until 2013, the examinees also had to sit at an oral examination which consisted of four case vignettes with structured questions/answers. The oral examination was replaced from 2013 (examination in Barcelona) by EMQ (extending matching questions). The major advantage of EMQs over MCQs is that this format not only evaluates knowledge, but also clinical reasoning. The EMQ case scenarios have been developed and written by experts in various topics on a given problem. 100 scenarios were prepared for Barcelona.
The passing limit of the MCQ questions, oral examination, and of the case presentations has been set to 75 percent in the first series of examinations. From 2012 onward, a passing limit was determined by an evaluation panel the day before the examination, based on the Nedelsky and Angoff methods. This represents an additional effort to optimize the procedures according to educational standards.
Finally, the trainees need to orally present a case, and they thus earn extra points. This is a strictly oral presentation lasting 5 minutes, which is judged by two jurors according to a scheme.
Practical and Financial Issues
In the creation of the EBN examination, several practical questions had to be solved. The organization, including a database of questions, communication and practical aspects of the examination were handled by a professional company, the Vienna Medical University-affiliated Vienna Medical Academy.8 The examinations have taken place during the European neurological congresses and the societies (EFNS and ENS) have provided the necessary rooms. This has served the purpose that the examination could be combined with a congress visit. The cooperation with the societies has demonstrated their interest and engagement in the UEMS/ENB and the European board examination. In addition to sufficient rooming also secretarial staff from the ViennaMedicalAcademy have been present, and in addition handled the computer analysis of the MCQs and EMQs. As a routine, a full report of the recent examination is presented to the board of UEMS/EBN with regard to participation, questions, feedback of participants, the examination committee, assistance from the EgeUniversity and ViennaMedicalAcademy, and economical aspects.
In recent years, the development of European board examinations as a sign of quality and toward a move to harmonization has been encouraged. The UEMS group called CESMA (Council for European Specialist Medical Assessments)6 has been established, and has regular meetings to work on the format and quality of European board examinations.
Funding
The UEMS/EBN received initially two grants from the ENS and EFNS as a contribution to develop the EBN examination. All other costs have been covered from the resources of the UEMS/EBN, which has its income mostly from member fees (national societies) and by fees paid by the candidates, which do not cover by far the organizational expenses.
The largest academic input and development was done by volunteers of the UEMS/EBN and many European specialist, who wrote questions, helped to prepare the examination, and also practically participated in several tasks.
Department Visits
Several countries (like Norway) have implemented department visits on a national basis. This concept, also adapted from the UEMS, means a voluntary visit at a training center, both by a representative of the UEMS as well as of the national medical representation. It is a structured approach to evaluate departments in the sense of equipment, staff and resources, and is based on a questionnaire with assessment of teachers, residents, head of department and also representatives of the hospital staff. The final report analyses the different aspects of teaching and training, and gives recommendations that can be used and should be implemented by the department or hospital.
Subspecialities
Subspecialties develop in neurology worldwide. In the US, about 25 subspecialties fields have been identified and are recognized by the United Council for Neurological Subspecialties (UCNS), 9 which also provides an examination and certification system that is open worldwide. Within European neurology, no formal subspecialities have been identified. A possible step in this direction might be the attempt to create a multidisciplinary approach towards interventional neuroradiolgy by the division of neuroradiology of the UEMS.
Future Aspects
Since the publication of this paper, the EMQs and also the participation of non-European participants have been successfully implemented. A possible future cooperation with the Royal College of Physicians (UK), which offers similar examination, is under consideration.
Neurological training is based on a curriculum, on training content, methods, and also finally an assessment and certification. One could argue that structuring an exit examination at the end of training may be counterproductive, as it is too late to correct training or detect deficiencies in the individual trainee. The establishment of a quality circle, which not only evaluates trainees but also the quality of training center, is therefore a further important step in European neurology.
The implicit aspects are that a European examination increases harmonization, and the hope is that many European medical associations partly or as a whole will replace their board examination with this European examination in the future.
Paper published in Eur J Neurol. 2013 Aug;20(8):e101-4. Conflict of Interests: none
Grisold is a neurologist in Austria, chair of UEMS/EBN examination committee and trustee of the WFN. Mellgren is a neurologist in Norway, co-chair of the UEMS/EBN examination committee, Norwegian delegate and vice president of UEMS/EBN. Struhal is a neurologist in Austria, active in education in the YNT and EAYNT. He is a member of the education committee of the WFN.
References
1. Grisold W, Galvin R, Lisnic V et al. One Europe, one neurologist? Eur J Neurol 2007; 14(3):241-247.
2. UEMS European Board of Neurology http://www.uems-neuroboard.org/ebn. 2012. Ref Type: Internet Communication
3. Pontes C. Recommended core curriculum for a specialist training program in neurology. Eur J Neurol 2005; 12(10):743-746.
4. Struhal W, Sellner J, Lisnic V, Vecsei L, Muller E, Grisold W. Neurology residency training in Europe–the current situation. Eur J Neurol 2011; 18(4):e36-e40.
5. Flodmark O, Grisold W, Richling B, Mudra H, Demuth R, Pierot L. Training of Future Interventional Neuroradiologists: The European Approach. Stroke 2012.
6. CESMA Statutes http://www.totbid.org.tr/upload/CESMA%20draft%20statutes.pdf. 2012. Ref Type: Internet Communication
7. Caliscan A. – http://ege.academia.edu/ayhan. 2012. Ref Type: Internet Communication
8. V. M. A. http://www.medacad.org/vma/. 2012. Ref Type: Internet Communication
9. UCNS http://www.ucns.org. 2012. Ref Type: Internet Communication
