Journal of the Royal Society of Medicine Volume 72 February 1979
123
Pathology and the EEC: training in pathology in Europe M G Rinsler MD FRCPath Northwick Park Hospital, Harrow HAl 3UJ
The details of the procedures and regulations for postgraduate training in pathology in the EEC countries in Europe have been discussed recently (Rinsler 1977); this paper is concerned with the training of individual pathologists based on interviews with trainees and senior members of laboratories. For each subject examples have been selected which cannot of course be regarded as comprehensive or definitive. Morbid anatomy and histopathology In the Federal German Republic, after two years of clinical internship, the trainee starts his first year in a pathology institute acquiring basic understanding of the discipline. He assists at autopsies, helps with the undergraduate teaching programme and attends seminars for which he prepares short papers. During his second year he helps in the biopsy laboratory learning to describe the macroscopic appearance of surgical material and how to prepare it for histological examination. In at least one pathology institute (Hamburg-Eppendorf) the trainee spends six months with his professor looking at duplicate slides of a large fraction of the department's output. By taking part directly in the description of the histological appearance, its analysis and the diagnostic procedures, he learns the technique of producing histological reports. During his third year the trainee handles a share of the department's output himself and his work is checked by the professor or a senior member of the department. During the fourth and fifth years he spends more time in the post-mortem room and starts on his scientific programme. Most university departments have assistant professors or other senior workers specializing in particular fields and the trainee may be supervised by one of these. This aspect of his work could result in a series of papers or a monograph. German institutes support the publication of monographs, many of a high standard, by their members. During these five years the trainee fulfils the requirements of the regional regulating organization (Arztekammer) which defines the minimum number of autopsies, biopsies and cytology preparations. He also needs to have experience in the preparation of legal reports for insurance, pension and other purposes. The professor signs the trainee's application and the Arztekammer provides the certificate of specialization. The specialist can now work in a local institute of pathology or can continue his career in the university service. Training is usually complete at the age of 32-34 but it is not usual to be appointed as chief of a small institute under the age of 38-40. In France histopathologists are trained in university departments or large regional hospitals. Training for regional posts takes 3 years leading to the Certificat des Etudes Specialistes (CES) by examination. Training for academic posts now also involves a series of examinations (Rinsler 1977). Training for the Certificates in Advanced Studies which are part of the Cycle d'Etudes et de Recherches en Biologie Humaine include (in Paris) general pathological anatomy, special pathological anatomy, systematic microbiology and virology, general immunology, general parasitology, general biochemistry, statistics and computing applied to medicine, and physical biochemistry. In many ways the candidate works in a pattern similar to that described above, but because of the examination pattern there are numerous formal Paper read to Section of Pathology, 14 March 1978. Accepted 30 October 1978 0 1 41-0768/79/020123-03/$O 1.00/0
'."
1979 The Royal Society of Medicine
124
Journal of the Royal Society of Medicine Volume 72 February 1979
classes, courses and seminars organized by university departments to meet these needs. Trainees may have to go to several centres to acquire aspects of their specialty training, for example in neuropathology or gastroenterology. After passing the CES examination specialists are able to practise privately, full-time in hospital as chief assistant, or in research supported by Centre National de Recherche Scientifique (CNRS) and the Institut National de la Sante et de la Recherche Medicale (INSERM). The CES involves written papers, an oral examination and includes performance of an autopsy and examination of a frozen section. In Belgium and Italy training in histopathology is by the apprenticeship system. The Netherlands and Denmark have a training system similar to that of Germany but which includes circulation in hospitals recognized by the Royal Dutch Medical Association and the Danish Medical Association. Medical microbiology In Germany there are university institutes and institutes of hygiene which provide training facilities in medical microbiology. The hygiene institutes correspond to our Public Health Laboratory Service. Most cities have a university institute and in addition there may be regional institutes doing work for smaller hospitals. Trainees spend a minimum of three years learning all the bench methods in the laboratory practice, rotating in the familiar apprenticeship fashion. In many institutes there is an emphasis on immunology and internal medicine and good communication with the clinicians is encouraged. The German Society for Medical Microbiology has a diploma, but this is orientated towards the training of senior university staff and has no legal standing. The certificate provided by the Arztekammer depends on the professor's assessment of the candidate and allows the specialist to practise in regional hospitals. This pattern of training in microbiology is similar in many other countries in EEC with some local variation. In some laboratories there are responsibilities for blood bank immunology. In the Netherlands there is a defined training programme which includes: (1) fifteen months of clinical and experimental microbiology during which the trainee acquires facility in diagnostic bacteriology and the theory of diagnostic microbiology, antibiotics, epidemiology and hospital cross-infection; (2) three months serology; (3) six months research on some practical new application in one of these fields; (4) six months virology; (5) courses in medical mycology, parasitology and statistics each lasting 4-6 weeks. It is possible to specialize in the subspecialties of virology, immunology, parasitology or mycology. Trainees are also recommended to follow and take advantage of advances in bacterial physiology and genetics, cellular and humoral immunity, methods of analysis using readioactive markers. In France there is a CES examination in clinical bacteriology and virology.
Haematology This is normally practised as a clinical specialty in university and large regional hospitals. Specialists are usually trained as clinicians with an interest in laboratory work as in a university medical unit, though they may be supported by laboratory orientated specialists. In smaller regional hospitals and private laboratories the laboratory aspects of haematology are undertaken in multidisciplinary laboratories. Clinical pathology In most of the EEC countries there is a need for a multidisciplinary pathologist. It is usual, therefore, in small hospitals and private practice to separate histopathology and combine microbiology, clinical chemistry and some aspects of haematology. Training in clinical pathology (biologie medicale) is spread over a period of three years with a fourth year to meet the EEC requirements. A trainee may have difficulty in acquiring experience in haematology. The Italian Schools in Clinical Pathology are in fact formal courses held in a number of universities. A typical programme would include in the first year lectures on physiology, general pathology, biochemistry applied to medicine, microbiology, hospital cross-infection
Journal of the Royal Society of Medicine Volume 72 February 1979
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and epidemiology, general laboratory techniques and sample collection. In the second year fields would include applied bacteriology, applied biochemistry, applied physico-chemistry, parasitology and relevant techniques, and mycology. In the third year topics such as biological statistics, immunochemistry, virology, clinical microscopy and immunology are covered. Practical course work may be a problem and the postgraduate student may be expected to cover at least some relevant practical studies at his place of work. In his fourth year the student undertakes a project and writes a dissertation. It should be realized that the private practice element is very strong in most EEC countries. The provision of training standards and certification have been related more to this than to university practice which is, of course, dependent mainly on academic achievement. Chemical pathology Chemical pathology is generally not practised as a separate subject outside university departments. In general candidates are encouraged to spend two years in an academic department of biochemistry and to have good postgraduate training in clinical medicine. In many university hospitals the clinical chemistry service is part of the medical department as is the case with haematology. Where there are separate university departments the trainee is expected to learn the methodology at the bench. When he is judged competent he may take charge of a section of the laboratory and undertake a research project. Training in the clinical application of the work depends very much on the head of the department. By and large heads of departments do not have beds and this aspect of the training depends on local cooperation with the clinicians. In addition, the trainee requires to learn how to manage a laboratory service including its finance and to take part in forward planning. Clinical chemistry societies in a number of countries are drawing up common training and examination programmes. Reference Rinsler M G (1977) Journal of Clinical Pathology 30, 788
123
Pathology and the EEC: training in pathology in Europe M G Rinsler MD FRCPath Northwick Park Hospital, Harrow HAl 3UJ
The details of the procedures and regulations for postgraduate training in pathology in the EEC countries in Europe have been discussed recently (Rinsler 1977); this paper is concerned with the training of individual pathologists based on interviews with trainees and senior members of laboratories. For each subject examples have been selected which cannot of course be regarded as comprehensive or definitive. Morbid anatomy and histopathology In the Federal German Republic, after two years of clinical internship, the trainee starts his first year in a pathology institute acquiring basic understanding of the discipline. He assists at autopsies, helps with the undergraduate teaching programme and attends seminars for which he prepares short papers. During his second year he helps in the biopsy laboratory learning to describe the macroscopic appearance of surgical material and how to prepare it for histological examination. In at least one pathology institute (Hamburg-Eppendorf) the trainee spends six months with his professor looking at duplicate slides of a large fraction of the department's output. By taking part directly in the description of the histological appearance, its analysis and the diagnostic procedures, he learns the technique of producing histological reports. During his third year the trainee handles a share of the department's output himself and his work is checked by the professor or a senior member of the department. During the fourth and fifth years he spends more time in the post-mortem room and starts on his scientific programme. Most university departments have assistant professors or other senior workers specializing in particular fields and the trainee may be supervised by one of these. This aspect of his work could result in a series of papers or a monograph. German institutes support the publication of monographs, many of a high standard, by their members. During these five years the trainee fulfils the requirements of the regional regulating organization (Arztekammer) which defines the minimum number of autopsies, biopsies and cytology preparations. He also needs to have experience in the preparation of legal reports for insurance, pension and other purposes. The professor signs the trainee's application and the Arztekammer provides the certificate of specialization. The specialist can now work in a local institute of pathology or can continue his career in the university service. Training is usually complete at the age of 32-34 but it is not usual to be appointed as chief of a small institute under the age of 38-40. In France histopathologists are trained in university departments or large regional hospitals. Training for regional posts takes 3 years leading to the Certificat des Etudes Specialistes (CES) by examination. Training for academic posts now also involves a series of examinations (Rinsler 1977). Training for the Certificates in Advanced Studies which are part of the Cycle d'Etudes et de Recherches en Biologie Humaine include (in Paris) general pathological anatomy, special pathological anatomy, systematic microbiology and virology, general immunology, general parasitology, general biochemistry, statistics and computing applied to medicine, and physical biochemistry. In many ways the candidate works in a pattern similar to that described above, but because of the examination pattern there are numerous formal Paper read to Section of Pathology, 14 March 1978. Accepted 30 October 1978 0 1 41-0768/79/020123-03/$O 1.00/0
'."
1979 The Royal Society of Medicine
124
Journal of the Royal Society of Medicine Volume 72 February 1979
classes, courses and seminars organized by university departments to meet these needs. Trainees may have to go to several centres to acquire aspects of their specialty training, for example in neuropathology or gastroenterology. After passing the CES examination specialists are able to practise privately, full-time in hospital as chief assistant, or in research supported by Centre National de Recherche Scientifique (CNRS) and the Institut National de la Sante et de la Recherche Medicale (INSERM). The CES involves written papers, an oral examination and includes performance of an autopsy and examination of a frozen section. In Belgium and Italy training in histopathology is by the apprenticeship system. The Netherlands and Denmark have a training system similar to that of Germany but which includes circulation in hospitals recognized by the Royal Dutch Medical Association and the Danish Medical Association. Medical microbiology In Germany there are university institutes and institutes of hygiene which provide training facilities in medical microbiology. The hygiene institutes correspond to our Public Health Laboratory Service. Most cities have a university institute and in addition there may be regional institutes doing work for smaller hospitals. Trainees spend a minimum of three years learning all the bench methods in the laboratory practice, rotating in the familiar apprenticeship fashion. In many institutes there is an emphasis on immunology and internal medicine and good communication with the clinicians is encouraged. The German Society for Medical Microbiology has a diploma, but this is orientated towards the training of senior university staff and has no legal standing. The certificate provided by the Arztekammer depends on the professor's assessment of the candidate and allows the specialist to practise in regional hospitals. This pattern of training in microbiology is similar in many other countries in EEC with some local variation. In some laboratories there are responsibilities for blood bank immunology. In the Netherlands there is a defined training programme which includes: (1) fifteen months of clinical and experimental microbiology during which the trainee acquires facility in diagnostic bacteriology and the theory of diagnostic microbiology, antibiotics, epidemiology and hospital cross-infection; (2) three months serology; (3) six months research on some practical new application in one of these fields; (4) six months virology; (5) courses in medical mycology, parasitology and statistics each lasting 4-6 weeks. It is possible to specialize in the subspecialties of virology, immunology, parasitology or mycology. Trainees are also recommended to follow and take advantage of advances in bacterial physiology and genetics, cellular and humoral immunity, methods of analysis using readioactive markers. In France there is a CES examination in clinical bacteriology and virology.
Haematology This is normally practised as a clinical specialty in university and large regional hospitals. Specialists are usually trained as clinicians with an interest in laboratory work as in a university medical unit, though they may be supported by laboratory orientated specialists. In smaller regional hospitals and private laboratories the laboratory aspects of haematology are undertaken in multidisciplinary laboratories. Clinical pathology In most of the EEC countries there is a need for a multidisciplinary pathologist. It is usual, therefore, in small hospitals and private practice to separate histopathology and combine microbiology, clinical chemistry and some aspects of haematology. Training in clinical pathology (biologie medicale) is spread over a period of three years with a fourth year to meet the EEC requirements. A trainee may have difficulty in acquiring experience in haematology. The Italian Schools in Clinical Pathology are in fact formal courses held in a number of universities. A typical programme would include in the first year lectures on physiology, general pathology, biochemistry applied to medicine, microbiology, hospital cross-infection
Journal of the Royal Society of Medicine Volume 72 February 1979
125
and epidemiology, general laboratory techniques and sample collection. In the second year fields would include applied bacteriology, applied biochemistry, applied physico-chemistry, parasitology and relevant techniques, and mycology. In the third year topics such as biological statistics, immunochemistry, virology, clinical microscopy and immunology are covered. Practical course work may be a problem and the postgraduate student may be expected to cover at least some relevant practical studies at his place of work. In his fourth year the student undertakes a project and writes a dissertation. It should be realized that the private practice element is very strong in most EEC countries. The provision of training standards and certification have been related more to this than to university practice which is, of course, dependent mainly on academic achievement. Chemical pathology Chemical pathology is generally not practised as a separate subject outside university departments. In general candidates are encouraged to spend two years in an academic department of biochemistry and to have good postgraduate training in clinical medicine. In many university hospitals the clinical chemistry service is part of the medical department as is the case with haematology. Where there are separate university departments the trainee is expected to learn the methodology at the bench. When he is judged competent he may take charge of a section of the laboratory and undertake a research project. Training in the clinical application of the work depends very much on the head of the department. By and large heads of departments do not have beds and this aspect of the training depends on local cooperation with the clinicians. In addition, the trainee requires to learn how to manage a laboratory service including its finance and to take part in forward planning. Clinical chemistry societies in a number of countries are drawing up common training and examination programmes. Reference Rinsler M G (1977) Journal of Clinical Pathology 30, 788
