A European Training Charter as a common achievement of the UEMS division of Neuroradiology, UEMS Sections of Neurology, Neurosurgery, Radiology and Cardiology has been approved by the UEMS Council
by Wolfgang Grisold, Olof Flodmark and Bernd Richling
The UEMS (www.uems.net) has approved a training document for training in Interventional neuroradiology at their Council meeting in Naples in October, 2011. This document (http://neuro.uemsradiology.eu/education.aspx) enables neurologist to enter training in interventional neuroradiology in Europe. The document has been sent out to all European UEMS members states, and gives the recommendation towards training and access into interventional neuroradiology.
This development comes timely as interventional procedures in stroke become increasingly important. Stroke, as the most common neurological disease has had a decade of improvement with the implementation of stroke units and iv thrombolysis and is now on the verge of doing even better by neurointervention. However, the manpower needed, is limited in most European countries, and neurologists have so far been unable to enter training in interventional neuroradiology.
To fulfill the needs of interventions in neurological diseases, the joint work of several specialists is necessary other than neuroradiologists; neurologists, neurosurgeons, interventional radiologists, and to a lesser degree cardiologists. Furthermore the content and text of a Training Charter in Interventional Neuroradiology accepted by all these groups, had to be developed as a joint project by these specialties.
The general objectives and goals of the training are outlined in Article 3.1.1. which states that “Having finished the training program, the specialist physician with particular qualification in INR, will be able to perform endovascular procedures as described in Art 4 in a team with other interventional neuroradiologists.” It is the common opinion that INR should ideally be practiced in teams where exchange of experience, knowledge and research is possible. It is the mission of this paper to make sure that those practicing INR possess real competence to safely perform endovascular procedures and thus be able to coexist with interventional neuroradiologists on equal terms, in fact become respected as interventional neuroradiologists, but with a different background. An interventional neuroradiologist with a clinical background as a neurosurgeon or neurologist may in fact be an important addition to a team of interventional neuroradiologists and provide a solid platform for a healthy practice of INR.
The EU directive 2005/36/CE regulates professional licensing of all professions and includes rules for Specialization of doctors. This directive lists all recognized medical specialties and having a specialty named in that list leads to automatic acceptance of a doctor’s specialty qualifications in all European community countries. However, the listed specialties do no longer reflect developments within medicine. Thus it has become necessary to find a solution to diversify medical specialties and still satisfy both politicians and the profession. The UEMS has proposed an amendment to this directive introducing the concept of “particular qualification” when this directive is due for revision in 2012. A “particular qualification” is not meant to be a new specialty but will represent a recognized body of knowledge that exists over and above more than one specialty. . The Division of Neuroradiology decided to use the concept of “particular qualification” as a roadmap to produce a training charter – Chapter 6 – in INR.
A task force, under Chairmanship of the President of UEMS Division of Neuroradiology (Prof O Flodmark), was formed by mandated representatives from the Sections of Neurology (Prof W Grisold) and Neurosurgery (Prof. B Richling) and from the Division of Neuroradiology (Prof L Pierot) as well as representation from the Sections of Cardiology (Prof H Mudra) and Radiology (Prof. P Pattynama). The text to the Chapter 6 in INR was finalized in December 2010. Final approval of the document was given by the UEMS Council 2011-10-08. Thus the Charter of training in INR has now an official status as an UEMS recommendation and is part of the EU legislative apparatus through the Directive 2005/36/CE.
The next steps will be the implementation on the national level,.”Identification, visitation and subsequent recognition of a training program is a procedure, supervised by the UEMS and coordinated by the UEMS Division of Neuroradiology. This procedure is a joint responsibility of neuroradiology, radiology, neurosurgery and neurology.” (Article 1.3.2). The full training in INR is 4 years full time training and includes 24 months of a core of INR and 12 months each of clinical neuroscience and diagnostic neuroradiology for a medical specialist entering into this training program. It is also important to realize that this is not a new specialty but requires that the trainee has established a basic recognized specialty (e.g. neurology) before the training in INR can commence. It is recognised that many trainees will enter this program with previous experiences and skills for which credit will be possible.
A European board examination in INR will be established, following the suggestions and directives of the UEMS / CESMA (Council for European Specialist Assessment). Visitations and accreditations of training centers will require cooperation between scientific societies, i.e. ESNR, ENS, EFNS and the UEMS.
To view the full text of the Training Charter, please go to: http://neuro.uemsradiology.eu/education.aspx
Wolfgang Grisold is Professor of Neurology in Vienna, Austria and member of the UEMS section of neurology
Olof Flodmark is Professor of Neuroradiology in Stockholm, Sweden and President of the UEMS Division of Neuroradiology
Bernd Richling is Professor of Neurosurgery in Salzburg, Austria and member of the UEMS Section of Neurosurgery
Comment by Gian Luigi Lenzi
The UEMS, Section of Radiology, Division of Neuroradiology, has published a „Consensus“ Document, to define the rules to be followed by a young MD to achieve the qualification in Interventional Neuroradiology. This Consensus refers to the previous European Society of Radiology (ESR) Education Committee charter for training, revised and published in February 2011. It is important to underline that the ESR charter encourages “a structured clinical radiological training period of a minimum of five years throughout all European countries.” In the ESR charter, the space devoted to the cultural aspects of the neurology appear to be quite limited, but this has to be accepted in a radiological core curriculum. Pg 30 indicates the Core knowledge and the Core skills on the Neuroradiology branch. Pgs 92 and 93 develop better these aspects, indicating also that “Arrangements should be made within the training scheme for secondment to neurology and neurosurgery departments.”
The UEMS Consensus indicates that „The aim of specific training in neuroradiology is to prepare a specialist for a career in which his/her clinical and research time will be devoted to diagnosis and treatment of diseases of the areas cited above….. A neuroradiologist will also be expected to adopt and develop new imaging and interventional methods, to disseminate neuroradiological knowledge and, from a basis of strong clinical background, be able to discuss with the referring clinicians the diagnosis and treatment.“.
It appears that this Consensus has been prompted by the increasing relevance of interventional procedures in stroke and by the fact that „the manpower needed is limited in most European countries and neurologists have so far been unable to enter training in interventional neuroradiology“. And it says that „It is the mission of this paper to make sure that those practicing INR possess real competence to safely perform endovascular procedures …“. To that , a full training of 4 years is proposed, including 12 months each of clinical neuroscience and diagnostic neuroradiology.
That is, the problems are: a) stroke and SU; b) request for INR qualified MD; c) lack of this manpower. And the answer is: INR training of 4 years with final UEMS board examination.
I feel that the problem, from the point of view of neurology, is more complex, and it refers to the Urgent Neurology, or ICU-Neurology , and also to the proposed „Strokology Postgraduate School“. For the sake of brevity, I will restrain my comments to the proposed INR document. What is requested to an MD to enter the INR training program?
From the Consensus document, it appears that a young Neurologist may enter directly this INR program after the „basic recognized specialty“, so the need of receive „… a neurological competence through 12 months of clinical neuroscience“ may be credited.
It is better that we neurologists became well aware that in many EEC Countries, Neuroradiology is no more an indipendent cultural Postgraduate School, having been readsorbed by the Radiology, and that the young Neurologist is requested to go through five years of radiology before being allowed access to the imaging technologies. That is, Neurologists cannot go directly to this INR training whatsoever.
Therefore, summing up all the degrees that the neurologist-INR-to be is requested to achieve, there are 5 to 6 years for a MD, then 1 year of practical experience or waiting list for entering a postgraduate neurological school, then this 30-32 year old Neurologist is requested to enter a Radiological Post-graduate School ( 5 years ), to be later admitted to the INR training program. He/She will be older then 40 when graduated INR specialist.
Perhaps this is what the UEMS-EEC regulatory Authorities want to achieve, due to the delicate aspects of the procedures. But I am afraid that all this will demotivate Neurologists to proceed on this qualification, and neurological culture in INR will be lost. The practical aspects of this de-neurologization of INR could be that the management of the Stroke Units, so far mainly attributed to Neurologists, may change direction and…. Directions.
So, the dilemma is this: it is more important , for a INR specialist with particular competence to work in a SU, a full training in Radiology or a full training in Neurology ?
Let us see what is happening in some countries.
In the USA, neurologists do all neurological aspects of ICU, from intensive therapy to INR. To that, after 4 years residency in Neurology, they have to do a 2 year NeuroICU fellowship. At the end of this training, there is a board examination in Vascular Neurology or NeuroICU. In total, after the MD, six years of charter.
For Europe, the panorama is scattered. In France, each University is free to organize the NeuroICU-SU training as it want. In Portugal, acute neurology is part of the residency program, and definitely the SU are part of the Neurology. All the residents in Neurology do at least 12-24 hours of emergency service per week. In UK and CH strokes go into specialist units with facilities for thrombolysis and intensive monitoring. The same for Norway, where most Neurological Depts have SU. In Italy, INR is reserved to radiologists. Neurologists who want to achieve this competence, have to enter the Radiology Postgraduate school.
In conclusion, the UEMS training program for INR appears to me heavily biased toward the radiology, with little consideration of the relevance of clinical competence in vascular neurology, and constructed relying more on paper certificates than on field experience. I acknowledge that a system based on „credits“ would imply a deep structural change in the EEC PostGraduate medical education.
What is a possible solution: that the UEMS and the ESR clearly indicate that the access to the INR training program is reserved for no less than 50% of the positions to neurologists, and that this stament enter in the EU legislation, i.e. Directive 2005/36/CE or the following ones.
Gian Luigi Lenzi is Professor of Neurology at the University La Sapienza in Rome, Italy, Vice-President of the EFNS and Editor of Neuropenews
As Co-Editor of FORUM I am happy to post Professor Grisold’s reply to professor Lenzi:
Comment: Wolfgang Grisold (Austria)
Dr Lenzi`s comments are well appreciated, but this paper is not at all concerned “with acute neurology” (whatever is defined as such) but on the access of neurologists into interventional neuroradiology. Interventional neuroradiology (INR) is a subsection of radiology, and has proposed a common entry pathway for other fields into interventional neuroradiology. As stated in this paper, all fields entering this program, will need training in a qualified center, and according to their training will need different times of training (Conceivably neurosurgeons are much more exposed to practical neuroradiological issues than neurologists and will need less training time).
The training curriculum which was drafted by neuroradiology, neurosurgery and neurology, was carefully developed and finally also approved by radiology and cardiology. Dr Lenzis comparison with the other European countries is interesting, but in most European countries neurologist do not have access into INR as a qualified training. Finally, the paper contains a description of an INR training center, and an UEMS board examination, which is a proper way to assess quality.
The UEMS general assembly (uems.net) has approved this document, and sent it to their member states as a recommendation. From the point of neurology, in my opinion, it opens a new avenue for neurologists in INR.
I agree with Dr Lenzi, that there are always better solutions, once an achievement has been reached, but from the perspective of the European Board of Neurology we consider this achievement a success.
Due to increasing knowledge and permanent arrival of new diagnostics and therapeutic possibilities contemporary medical sciences are becoming very narrowly specialized. Soon it will be impossible for a single person to be specialist in all diseases even within one traditionally defined specialty. On the other hand medicine becomes so multidisciplinary that it requires knowledge and expertise in different fields. This fully applies to interventional neuroradiology. This field should not be restricted for radiologists but also allow in those who actually attend patients on a day to day basis, i.e. neurosurgeons and neurologists.
Being a ‘general’ neurologist with a special interest in cerebrovascular diseases and also training in interventional neuroradiology (for which I need to specialize in general radiology). I have welcomed the introduction of the new UEMS recommendations for acquiring particular qualification in INR with the greatest enthusiasm and relief. Thanks to this programme it will be possible to extend the spectrum of treatment options for neurologists in managing patients with cerebrovascular disease without the need of completing a full 5 year course of training in general radiology (as Professor Lenzi rightfully notes – this will help us have younger fully qualified specialists).
Of course close collaboration within all 3 specialties will be needed to develop a well structured training programme. Obviously because of different backgrounds it will be required to create parallel programmes (e.g. more ‘hands-on’ and radiological training for the neurologist, more clinical training for the radiologist). If the duration of the training can be shortened depending on the physicians background this needs to be remembered and carefully planned.
Another matter is unification of European-wide guidelines with national local practice and regulations. In order to regulate this it is required that national radiological, neurological and neurosurgical societies work together as working groups or preferably as new common scientific societies to develop compatible guidelines for both training centers and trainees. This will help identify units eligible to lead such a training. On the other end also trainees will be taught in unified manner in order to prepare for independent practice and eventual UE or national board examinations.
Dr Adam Kobayashi
EFNS Stroke Scientist Panel Secretary
Head of Interventional Stroke Treatment Centre and Research Fellow 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
Comment by Professor Massimo Filippi
Neuroimaging Research Unit, Institute of Experimental Neruology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
The possibility of an Interventional Neuroradiology Training (INR) available for neurologists and neurosurgeons is surely a very interesting perspective. Indeed, it would likely be a significant improvement for treatment of acute cerebrovascular conditions like interventional cardiology is for coronary heart disease. However, I agree with Prof. Lenzi when he points out the importance of competence in vascular neurology to treat these conditions. Another point that is worth discussing is whether the INR training should be considered as a separate qualification to be taken after a post graduate course in Neurology or Neurosurgery. I think it would not be very attractive for a neurologist or neurosurgeon to take an additional four year training to perform interventional neuroradiology techniques. On the contrary, it would probably be more attractive to include INR training as a subspecialty in neurological or neurosurgical schools as already happens for cardiologists. The criteria to access to INR training should also be identical in every EU country for the reasons that Prof. Lenzi explained.