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Emergency medicine (EM) is emerging worldwide. Its development as a recognized specialty is proceeding at difference rates in different countries. Europe is a region with complex political affiliations and is composed of countries both within and outside the European Union (EU). Europe is seeking greater standardization (harmonization) for mutually improved economic development. Medicine in general, and EM in particular, is no exception. In Europe, as in other regions, EM is struggling for acceptance as a valid field of specialization. The European Union of Medical Specialists requires that once two-fifths of countries acknowledge a specialty, all EU countries must address the question. EM had achieved the needed majority by 2011. This article briefly describes the European road to specialty acceptance.
El Desarrollo de la Medicina de Urgencias y Emergencias en Europa
La medicina de Urgencias y Emergencias (MUE) está emergiendo en todo el mundo. Su desarrollo como una especialidad reconocida está ocurriendo en diferentes proporciones en los distintos países. Europa es una región con complejas afiliaciones políticas y está compuesta de países tanto de dentro como de fuera de la Unión Europea. Europa está buscando una mayor estandarización (armonización) para mejorar el desarrollo económico. La medicina en general, y la MUE en particular, no son una excepción. En Europa, como en otras regiones, la MUE está luchando para ser aceptada como un campo válido de especialización. La Unión Europea de Médicos Especialistas exige que, una vez que dos quintas partes de los países reconocen una especialidad, todos los demás países de la Unión Europea deben abordar esta cuestión. En 2011, esta umbral se ha superado para la MUE. Este artículo describe brevemente el camino europeo para aceptar la especialidad.
The definition of emergency medicine (EM) provided by the International Federation for Emergency Medicine (IFEM) reads: “Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.”
The European Society for Emergency Medicine (EuSEM) adds some specific elements pertinent to Europe: “… It (EM) is a specialty in which time is critical. The practice of EM encompasses the pre-hospital and in-hospital triage, resuscitation, initial assessment and management of undifferentiated urgent and emergency cases until discharge or transfer to the care of another physician or health care professional.”
The development of EM in various parts of the world has reflected the political history of each region more than it has reflected the ambitions and competencies of the region's physicians. During the first half of the 20th century, Europe was twice devastated by huge wars. During the second half of the 20th century, great efforts have been expended to reduce the risk of another world war. One part of that effort has been harmonization of standards across Europe.
Since the Great Wars, among the many organizations and agreements set in place to reduce the risk of war were the UN, NATO, WHO, and in Europe, the European Economic Community, which later evolved into the European Union (EU).
Continental Europe is a large region of sovereign nations whose borders have been drawn and redrawn over centuries by religion, war, immigration, political philosophy, and culture. Further confusing the picture, Europe is a continent only by convention; it is a land-mass contiguous with Asia. Of the over 50 countries currently recognized as European, about half (27 as of November 2012) have joined together into “a unique economic and political partnership” known as the EU (table 1).
Croatia—has met criteria. Membership is awaiting ratification.
Iceland—has begun negotiating entry into the EU
Turkey—has begun negotiating entry into the EU
The Former Yugoslav Republic of Macedonia
Among the over 50 countries of Europe, there are many more models for health care delivery than there are in the three countries of North America (Canada, United States, and Mexico), which makes generalization problematic. However, specialty boundaries and practices of older, established specialties such as surgery, pediatrics, and orthopedics differ less from their North American counterparts than do the newer specialties such as EM.
EM has developed along many separate trajectories, buffeted by widely varying political exigencies and different entrenched special interests in each country. EM in Europe has variously been the domain of anesthesiologists and intensivists, trauma surgeons and orthopedists, internists, and sometimes just new trainees. It has been the target of turf battles and infighting. Still, there are broad commonalities and trends that can be highlighted.
The health care aims of the EU include “protecting and promoting health,” including “reducing health inequalities,” harmonizing payment for medical care (via “the European health insurance card”), and developing regional (as opposed to national) centers of medical excellence to permit Europeans to access health services across national borders. Until recently, EM has not been an area of focus. This article strives to provide a view of the state of EM in Europe as of November 2012.
Importance of Standardization and Role of the Union Européenne Des Médecins Spécialistes (Uems)
One goal of the EU is standardization, or “harmonization.” Standardization is necessary for the free exchange of goods, services, people, and information. Mechanical standardization culminated in the wealth of the Industrial Revolution; standardization of medical training will improve the free exchange of medical knowledge and personnel. In the EU, currency, passports, and some professional qualifications have already been harmonized, to “ensure the free movement of people, goods, and services.” The European Cooperation in Science and Technology (acronym “COST”) is a European intergovernmental framework for improving coordination of research (including medical research) across Europe. COST Action IC 0604 was a project that concluded in 2011 with standardization of digital medical images.[6, 7]
At the post-medical school and specialist level, harmonization is the mission of the European Union of Medical Specialists (EUMS), more commonly known as Union Européenne des Médecins Spécialistes (UEMS).[8, 9] This paper will briefly describe the state of medical standardization of EM in continental Europe as of the end of 2012.
Theoretically, European physicians are free to seek employment in countries other than that in which they qualified. However, medical education is not yet harmonized, and employers are wary of the qualifications of physicians trained abroad.
The Green Paper, in 2011, addressed this issue. One of its stated objectives was to set minimum training requirements for physicians, nurses, midwives, dentists, and pharmacists. Additionally, for a limited number of professions, the Directive allows for automatic recognition of qualifications. For example, a French doctor qualified in France must be recognized as a doctor in all other Member States. However, recognizing specialist competence can be more problematic when the receiving country either does not recognize EM as a specialty or has a significantly different path to specialist competence than does the country in which the physician qualified.
Health Care and Health Care Systems in Europe
World Health Assembly Resolution 60.22 states that emergency care is an essential part of the public health and calls on governments to establish comprehensive emergency health care systems that seamlessly integrate prehospital care with stabilization, triage, immediate care, and in-hospital care. Unfortunately, professional standards, organizational structures, and coordination mechanisms vary widely across EU countries.
In that report, EU national representatives declared that their national law guarantees “free access to in-hospital emergency care for all.” In reality, some countries or regions, or even individual hospitals, invoice patients for emergency care (however, copayment for emergency care is often waived in life-threatening situations or if the patient is admitted).
Conceptually, emergency care contains out-of-hospital emergency medical services (OOH EMS) and in-hospital emergency medical services, which must be seamlessly integrated for a complete EM health care system.[12-15] The relative importance of pre-hospital versus in-hospital emergency care (which reflects the location in which the bulk of care is provided) and the qualifications of the providers of care in those different locations have developed according to dissimilar models in parts of Europe compared to North America. Regardless of which model of emergency care is practiced, increasingly there is recognition that when a patient is met by a physician skilled in EM, the patient does better. There are no convincing Level I studies showing that an emergency physician (EP)-based EMS system, compared to a paramedic-based EMS, leads to a decrease in overall mortality or morbidity; the many methodical, legal, and ethical issues make such studies difficult. In some area of emergency care, such as severe trauma, there is some evidence that the physician-based model is better. The evidence for the superiority of one model over another is, as yet, still mixed.[13-17]
Models of Emergency Care
Prior to the 1990s, there was no one predominant model for the care of the acutely ill and injured in most of continental Europe. Some patients with acute problems were cared for in their practitioner's offices, some were cared for by ambulance-based specialists, and others in emergency rooms, which were variably staffed. In some countries, where physicians rotated in and out of the emergency department (ED), nurses were more likely to consider themselves EM specialists than did the physicians. In larger hospitals, EDs served as the “acute clinics” for each of the hospital-based specialties. Depending on the size of the hospital, the ED might be divided into only medical and surgical sides or might multiply subdivided into pediatrics, gynecology, urology, etc.
The different models for providing emergency medical care across Europe can be bewilderingly different from each other. Some systems are almost entirely prehospital-based, performing triage (sorting) functions, care, and if needed, resuscitation in the field, and then making a disposition. The disposition could range from leaving the patient in his or her home if the reason for the call had been solved, or delivering the patient directly to an operating room, a medical ward, or even a catheterization suite. This model is often called the Franco-German model, although it is also the predominant model in Russia.
The other predominant model for delivering emergent medical care is known as the Anglo-American model. In this model, the EP is co-located with the hospital, with access to the hospital's resources, and after evaluation, resuscitation if needed, and treatment, the patient may be discharged to go home or admitted to an appropriate hospital location.
However, it is important to note that one major difference between two of the competing models could be described as the difference between “the patient comes to the hospital” and “the caregiver comes to the patient.” Both systems acknowledge that there are theoretic advantages to delivering certain patients to non-ED hospital locations. For example, patients with acute ST-segment elevation myocardial infarctions fare best when reperfusion is quickly accomplished.
Models of Prehospital Care
Emergency care begins with activation of the system. Although the United Kingdom has had a universal emergency access number, “9-9-9,” for over 70 years, both in 1991 and again in 2002, Article 26 of the Universal Service Directive defined “1-1-2” as the single-call European emergency number. (The European emergency number 1-1-2 also works in the United Kingdom.) Depending on the country, 1-1-2 calls may be handled by police, fire, or medical command. In spite of the Directive, a study in 2008 demonstrated that only 19.2% of the total European population could cite 1-1-2 as the number to call in case of an emergency.
When a medical response is needed, it is the OOH EMS that delivers medical care at the scene. In 70% of EU countries, OOH EMS systems are physician-based. This does not mean that doctors are dispatched for all cases. Only when the dispatch center believes the situation requires it is a physician sent.[15, 16] For an excellent discussion of OOH EMS care in Europe, its development and further challenges, please see the 2008 report of the World Health Organization.[11, 12]
A Brief History of Em
Emergency medicine has been practiced for as long as there have been people with medical knowledge who could respond to emergencies. However, EM could claim to have had its start as a separate specialty in the United States in 1968 when the American College of Emergency Physicians (ACEP) was founded, or perhaps in Great Britain in 1967, at the first meeting of the College of Emergency Medicine. In 1978, the Canadian Association of Emergency Physicians (CAEP) was founded; the following year the American Board of Medical Specialties approved the American Board of Emergency Medicine (ABEM) as a conjoint medical board. In 1981, the Australian Society of Emergency Medicine was founded; in 1984 it metamorphosed into the Australasian College of Emergency Medicine (ACEM). ABEM became a primary board in 1989. In 1990, the Casualty Surgeons Association (CSA) reinvented itself as the British Association for Accident & Emergency Medicine (BAEM). In 1989, the International Federation for Emergency Medicine (IFEM) was founded by ACEP, ACEM, BAEM, and CAEM together. The mission of IFEM was to be “an international association composed of national EM organizations.” One factor that may have aided the founding of the federation was that each of these nations is primarily English-speaking.
Although the English-speaking European island-nations of Great Britain and Ireland adopted EM as a specialty earlier than did the continental, non–English-speaking European nations, EM is making strides also in continental Europe.
European physicians are not new to emergencies; on the contrary, European physicians have pioneered much of modern trauma care. Wars have always been a cradle of trauma innovation, and Europe has seen more than its fair share of war. Yet, we posit that the same diversity of culture, religion, and geography that sparked so many conflicts over centuries has also hindered the development of a standardized specialty of EM.
Development of Modern Eds in Europe
In the past, a patient presenting to an ED might be met by a physician skilled in resuscitation (a reanimatologist or an intensivist) or by an unsupervised junior trainee. Over time, country by country, a larger percentage of patients are being evaluated by more senior physicians. In the majority of EU countries, trainees in many different specialties may rotate to the ED; their supervision is primarily by non-EM specialists located elsewhere in the hospital. Fortunately, an increasing number of European hospitals now staff EDs with either emergency specialists or aspiring emergency specialists.
In all EU countries, EDs are a legally required component of hospitals. Each ED must have its own department director, as well as dedicated medical and nurse teams. The creation of EDs is a trend that started in the 1990s and represents the most important change in recent years in the structure of hospitals and provision of health care in Europe. In France, for example, a reform mandated in 1993 that such hospitals provide an ED with a sufficient number of consultants trained in EM to function 24 hours a day, 7 days a week.[24-29]
The Manifesto for Em in Europe
The Manifesto for EM in Europe was published in 1998, by EuSEM, to be used as a starting point for dialogue with governments. The Manifesto proclaims that the provision of high-quality emergency care is best provided by physicians with specialized training in EM. While recognizing that other physicians (not specialists in EM) will still be involved in the care of patients with emergent conditions, the Manifesto recommends that both the head of the department and the senior medical staff should be emergency specialists. The Manifesto further asserts that “Emergency medicine is a specialty in its own right.” It recommends that the right to practice EM as a specialist should be granted by a board of accreditation. The Manifesto also proposed a European certification in EM based on standards that would be comparable throughout Europe. A Pan-European exit examination was discussed in this document. Fourteen years after the publication of the Manifesto by the Council of EuSEM, a European Curriculum of EM has been published and approved by the Council of UEMS. The creation of a European Diploma in EM is in process, and finally, the primary specialty exists in 15 EU countries.
In a report prepared for the European Parliament, Unger reported the strategic vision of a new, comprehensive European Healthcare Market (EHCM). “The European Institute of Medicine sees this as a great opportunity to consolidate the different National models and inherited systems in an EHCM, and consequently to stimulate clinical leadership to achieve sustainable reforms.” The goals of this strategic vision are broad and include providing health care for all Europeans, transforming health care from national state monopolies to an open European market, reducing barriers to professional mobility and thereby better use of resources, and identifying mutual potentials for cost control. Unger did not specifically address standardization of medical training, but without assurances that training is equivalent, the free movement of health care professionals will continue to be hindered.
Standardizing Medical Education
At the risk of oversimplification, the European model of medical education consists of professional training entered directly from secondary school; the training lasts 6 years and produces physicians ready for specialty training. The “Bologna Process” or “Bologna Accords” are a series of agreements among countries to harmonize European higher education. Not an EU initiative, the Bologna Process includes 47 countries, of which 27 are EU members. The 1999 Bologna Agreement for medicine suggested dividing these usual 6 years of education after secondary school into three cycles: bachelor, master, and doctorate. As of 2012, only 32 of 442 medical schools in the Bologna signatory countries had successfully harmonized their medical education.
The 2008 Charme (Challenges of Harmonizing Medical Education in Europe) report noted that the proposed three-cycle medical education structure has been adopted at different speeds and with different levels of enthusiasm across Europe. Given the difficulties in harmonizing the overall structure of medical education, it is not surprising that at the undergraduate (medical school) level, EM is a mandatory subject in only 16 EU countries.[11, 12] There is no current standardized medical school exit examination, but the United Kingdom is exploring using the USMLE as an exit examination, as is Switzerland and the Netherlands. Italy has its own standard exit examination.
Recognition of Specialties
The formal recognition of specialties among members of the EU is regulated by EU Directive 93/16, updated in 2005 as directive 2005/36/EC. Specialty recognition is a two-step process. As a first principle, each sovereign nation regulates its medical system as it sees fit. However, when two-fifths of EU countries recognize a given specialty, that specialty must be addressed by the EU as a whole. Currently, UEMS recognizes over 50 medical disciplines, of which 39 are specialist sections, and others are multidisciplinary joint committees (MJCs). These groups are charged with “defining European standards of medical education and training” and creating “a European Board of [specialty].”
UEMS is an organ of the EU, unlike the Bologna Process, so its directives affect only EU countries. UEMS also recognizes the barriers to the free movement of specialist doctors within the EU.[39, 40] The role of UEMS is to set the basis for European standards in medical training, to advocate for competence-based training and assessment, to develop a mechanism of evaluation of medical specialists' competence at the European level, and to organize European examination.
Specialty board examinations in Europe do not have the same strength as in the United States. Although most (if not all recognized) specialties have a board and an examination, the examination is voluntary. There is no mandatory recertification, and many countries do not require documentation of continuing medical education (or, as IFEM calls it, continuing professional development).
Recognition of EM as a Specialty
The European island-nations of England, Scotland, Ireland, and Iceland recognized accident & EM (A&E) much earlier than did continental Europe. As early as 1967, Mr. William Rutherford was appointed as the “surgeon in charge of the Accident & Emergency Department” of the Royal Victoria Hospital in Belfast, effectively becoming the first A&E consultant in Ireland. By 1972, there were 30 A&E consultant posts in the UK. In 1992, EM was officially recognized as a specialty in Iceland. In spite of these bright beginnings in the European island-nations, it took until 2012 before the required two-fifths of EU countries recognized that EM is an area of specialization (Figure 1). Not all countries that recognize EM have training programs or certification standards yet.
Within UEMS, EM has been represented by a Multidsciplinary Joint Committee, or MJC. Similar to the conjoint board that was the first incarnation of ABEM, the EM-MJC is composed of surgeons, anesthesiologists, and others, as well as EPs representing the EuSEM. The mission of the EM-MJC is to assure the highest quality of emergency care for all patients and to promote a comparable standard of clinical care in EDs across Europe. The EM-MJC holds that the delivery of such care is done best by specialists trained in EM.
By 2012, three-fifths of EU countries have recognized EM as a specialty, making EM an official specialty throughout all EU countries (this is, however, not binding on non-EU European countries). As of November 2012, the UEMS webpage lists the specialty as “emergency medicine” rather than as “accident & emergency medicine” as it had previously. The Doctors' Directive, updated in 2006, still listed the specialty as “accident & emergency medicine.”
At the meeting of the Council of UEMS in October 2011, the Section of Emergency Medicine was created by the majority of voting members. This means that EM is clearly recognized as a primary specialty in Europe. All members of this Section are EPs, each proposed by his or her national society, and each EU country has representation. The recognition of EM in Europe as a whole has been the culmination of many years of work and encourages all EU countries to create the primary specialty of EM with a 5-year training period, as recommended by the Council of UEMS.
Specialty Training in EM
The 2006 update to the Doctors' Directive mandated that the minimum post–medical school specialty training for EM should be 5 years. Although it may seem longer, the total length of training in Europe is roughly comparable to that in the United States. The 6 years of “undergraduate medical school” in Europe is roughly comparable to 4 years of college plus the traditional 2 preclinical years of U.S. medical school; the 2 clinical years in the traditional U.S. medical school training are included in the generally longer European postgraduate (or specialty) training. In a JAMA “Viewpoint” article, Emmanuel and Fuchs argued that the United States should move closer to the European model by incorporating at least one of the clinical years into residency training. However, contrary to the European trend of longer specialist training, Emmanuel and Fuchs also recommended shortening specialist training to 2 years.
This does not mean that each European country currently endorses 5 years of postgraduate training for EM specialization. The status of EM in each country is different. In some countries (United Kingdom, Ireland, Romania, Italy, Hungary, Finland, Sweden, Malta, Slovenia, Luxembourg, Belgium, Slovenia, Czech Republic, Iceland, and Poland), EM is a primary specialty with specialty-specific training programs. In others (including France, Austria, Denmark, Switzerland, and previously Sweden), EM is a supraspecialty, similar to the critical care qualifications in the United States, which can be accessed after completing one of several recognized primary specialties. This path adds many additional years of training before certification. Short study courses ranging from a few months to 2 years are sufficient to work in an ED in yet other countries. Many European countries do not offer formal EM training at all. Among countries that have granted primary specialty status to EM, the length of training and exit qualifications differ widely. The situation is changing rapidly.
Specialty Training Examination (Board Examination)
Once trained, some European countries test their physicians' competence; others do not. Where there are boards, recertification is rare. The Council for European Specialist Medical Assessment (CESMA) is an advisory body of the UEMS. It provides recommendations on examinations for medical specialists.
By the middle of the past decade, 21 EU countries reported that they offered elective or mandatory board certification or similar accreditation for physicians. In October 2009, the Rules of Procedure were amended to read: “VI.8. Each Section may create its own European Board … to guarantee the highest standards of care … by ensuring that the training is raised to the highest possible level.” At that time, EM had not yet been recognized by the requisite two-fifths of EU countries and was represented by an MJC. Fortunately, this did not hinder the MJC from moving forward. “VI.10. Although not a Section in its own right, each MJC must follow the same rules of procedure as though they were a Section ….” Therefore, even before reaching the goal of more than two-fifths of EU countries recognizing EM, the EM-MJC focused on developing a European Core Curriculum, and through it, recommended standards for training in EM. Finally, under the authority of the UEMS Rules of Procedures, in October 2010, the EM-MJC's proposal to establish a European Board of Emergency Medicine was approved by the Council of UEMS.
The objective of the European Board of Emergency Medicine is to recommend a unified curriculum and to promote common standards for EM training and practice throughout Europe. As of yet, there is no unified exit examination or board examination in EM.
The European Curriculum for EM
The European Curriculum for EM was developed by the EuSEM Task Force on Curriculum and was loosely based on the American core curriculum. It was approved in 2009 and is posted on the EuSEM webpage. The curriculum is intended for a 5-year course of experience and is described in a 37-page document developed conjointly by representatives of over 17 countries, which outlines the expected competencies of an EP and outlines the structure of training of European emergency specialists. It concludes with a recommendation for European accreditation of training programs and a standardized specialist examination, a recommendation that has yet to be implemented.
Role of the EuSEM
Founded in May 1994, the EuSEM is a professional and political organization founded to advance the specialty of EM care in Europe. EuSEM is both a federation of national societies and an organization open to individual membership. Currently, EuSEM has over 17,000 affiliate members and represents 27 countries (Turkey is represented by two separate national organizations). Congruently with UEMS, EuSEM supports harmonizing specialist training and criteria for the recognition of medical specialists, and in particular EM, throughout Europe via education, its journal The European Journal of Emergency Medicine, and its annual conferences. EuSEM has been a tireless advocate of the development and professionalization of EM standards in all of Europe, both within and outside of the EU (table 2).
Table 2. EuSEM: Federation of 27 European EM Societies, With Year of Establishment of the National Society
EuSEM = European Society for Emergency Medicine.
Turkey (note that Turkey has 2 national EM societies)
Emergency medicine in Europe is developing, diverse, and emerging. The importance of EM is recognized by the EU and is now in the EU list of specialties. Fifteen EU countries recognize EM as a primary specialty, others as a conjoint or supraspecialty. As of yet, not all European countries recognize EM as a specialty, but each year brings further advances. Europe is now moving closer to harmonization of training, qualifications, and evaluations of emergency physicians, thanks to the hard work of many concerned parties. The parties who have moved the continent include specialty organizations in countries with and without recognized EM specialists; supranational organizations including IFEM, EuSEM; and many other governmental bodies. Standardizing qualifications of emergency physicians across Europe would offer European emergency physicians the same freedom of job opportunities currently enjoyed by physicians in more traditional specialties and would further EM as a truly global specialty.
The authors express their deep gratitude to the following persons, on whose work this article has been based, and without whom the struggle for emergency medicine specialty acceptance would not have progressed as it has: David Williams, past president of EuSEM; Gunnar Öhlén, past president of EuSEM; and Roberta Petrino, chair of the EuSEM Education Committee and the European Curriculum on Emergency Medicine Working Group.