Three important steps to European neurology harmonization: core curriculum, visitation program, European board examination
Correspondence: W. Struhal, Abteilung für Neurologie, AKh Allgemeines Krankenhaus der Stadt Linz, A-4021 Linz, Krankenhausstraße 9, Austria (tel.: +43 (0)732 7806 73 347; fax: +43 (0)732 7806 74 6866; e-mail: firstname.lastname@example.org).
Although the specialties in Europe have some common guidelines, in most European countries neurological training is practiced differently . This is due to several reasons, such as medical tradition, health system and other factors. These differences are within the federalism and autonomy of the European Union (EU), including the European Economic Area member states, but harmonization of residents training is a major goal in Europe. To serve this goal, a core curriculum, definition of the neurology content, European board examinations and a department visitation program were recently installed on the European level by the European Board of Neurology (EBN) , European Union of Medical Specialists (UEMS). The UEMS (www.uems.net) is the association of European medical specialists, and is constituted from national societies and sections (medical specialist sections). The EBN consists of 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.
The EBN made the decision in 2004 to develop an EBN examination, and it took several years of preparation to establish the examination, which will take place in 2012 for the fifth time. In the course of its development several changes have taken place.
The examination is the final loop of training, but the training content, the faculty and also the local conditions determine the quality of a program. For this reason an EBN department visitation program was established, offering a structural visit to training departments, and also reports on the impression based on faculty, trainees and facilities of the teaching unit. The content of training, the visitation of teaching departments and the EBN board examination offer altogether a European quality circle for neurology.
The continuation of training is continuing medical education (CME) in its various dimensions, such as congresses, e- learning, teaching, reviewing, self-assessment and finally recertification. Many of these activities overlap with residents' training, or are relevant for both the residents as well as the qualified neurologist needing CME. A possible development of neurological board exams could be the accessibility of the UEMS/EBN by consultants as an important component of CME, either informally on a personal level or perhaps in the future as a necessary component for revalidation or recertification.
Content of neurology
The content of neurology for residents varies in different European countries . 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 medical fields, which in neurology are mainly neurosurgery, clinical neurophysiology, internal medicine, orthopedic surgery, and physical therapy and rehabilitation. Psychiatry has in many European countries had strong associations with neurology, but overlapping fields are diminishing. 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 . The Core Curriculum of Neurology has also been published  and is now (2013) in the process of revision.
Practical skills are trained mostly in some core competencies of neurology, such as stroke, extrapyramidal diseases, multiple sclerosis and epilepsy . 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. The issue of skills and particular competences will become more important as future stroke therapies with interventions also need the participation of neurologists . Rotation and exchange of trainees are encouraged by the UEMS, and an instrument of announcing available departments [Open Facilities for Training in European Neurology (OFTEN)] has been established [6, 7]. To facilitate this, European Federation of Neurological Societies (EFNS) provides short time bursaries for department exchange (www.efns.org).
European board examination – why and for whom?
Within the EU medical doctors have the right to travel and practice, and a mutual acknowledgment of the diplomas has been established. Despite this fact, many European sections, like urology, anesthesiology 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 as a sign of quality and excellence. Indeed the European scientific and professional societies contribute to elevate and keep the content of the examinations at a high level, and the joint effort has a constant influx on quality on this instrument, and subsequently on training.
Still, the choice of the instrument of the examination is difficult and much debated within the medical disciplines. This concerns the source of questions, the format, examination type and the evaluation of results. A practical example explaining this difference would be that in neurology the examination can essentially rely on questions and content, whereas in surgical fields, a practical evaluation of skills will be needed. At present no universally applicable format of examinations is offered by the UEMS/Council for European Specialist Medical Assessments (CESMA), and the development of questions often depends on the individual section developing these examinations according to their needs.
Elements of the European board examination
Neurology faced the development of an examination tailored to its needs. It was decided that an instrument for the reliable and objective testing of skills would not be feasible, and that 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. Thus, a three-step examination was developed.
Step 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. This may be based on a certain number of years of training, a national examination or an already certified neurologist. This mode of acceptance would ensure that practical training is confirmed by the national society.
Step 2. Assembling a set of 120 multiple-choice questions (MCQs) with a single best answer, which were provided by members of the UEMS/EBN, the large European neurological societies [EFNS and European Neurological Society (ENS)], other neurological societies (Movement Disorder and European Stroke Societies) and recently also e-brain, an e-learning program .
All questions are graded independently by an examination board in a database. The grading is from 0 (reject) to 10 (top score), and only questions that obtained an average score above 5 were accepted by the examination board. The quality of questions and options of answers were then checked by members of the Department of Medical Education, Ege University, Turkey . Examination quality assurance concentrated on question stem, clarity, language, ambiguousness, etc. Recommendations were derived based on this process to either accept or reject individual questions. The final editing of the accepted questions was performed by the chairmen of the examination committee, who also distributed the number of questions allocated to different topics. The final number of questions is 120 for each examination. Over the years a database with MCQs has been collected and, each year, about a third of the questions are replaced by new ones.
Step 3. The examinees receive four case vignettes that have to be answered in a structured way, in an oral examination. This oral examination has met some criticism for several reasons. In principle it could have been presented as a written examination, and also the oral examiners have reported that the answering format was felt to be too rigid. The future UEMS/EBN examination will therefore abandon this oral format and replace the oral examination with extended matching questions (EMQs), in its limited structure of the single best answer out of five format. The major advantage of EMQs over MCQs is that this format not only evaluates lexical knowledge, but also requires synthesis and application of knowledge on a given problem.
Finally, and this has been the voluntary element of the examination, the trainees can orally present a case, an own scientific work or any other neurology-related topic, and thus earn extra points. This option was welcomed by the majority of the attendees, and the personal contact between the examinees and members of the examination committee in this way has been appreciated.
The passing limit of the MCQ questions and of the case presentations has been set to 75% in the first series of examinations. From 2012 a passing limit was determined by an evaluation panel the day before the examination, based on the Nedelsky method. This represents an additional effort to optimize the procedures according to educational standards (Table 1).
Table 1. Quality assessment of MCQs and case vignettes
| Steps of the UEMS/EBN question assessment || Quality assurance || |
|Questions prepared by scientific panels, board members, specialist societies, e-brain||Several independent groups, according to recommendations|| |
|Questions reviewed by examination committee of UEMS/EBN||Independent viewing and rating by 10 members||Only questions above a defined passing limit are further processed|
|Selected questions reevaluated by Department of Medical Education, Ege University||Independent reviewing for: stem, wording, clearness|| |
|Recommendation of Ege University incorporated||Recommendation: accept, change, reject||Editing|
|Final editing|| || |
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 . The rooms for the examinations, which take place during European neurological congresses, have been provided by the EFNS (http://www.efns.org/) and ENS (www.ENS.org), respectively. This has served the purpose that the exam 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. The examination requires a large room for the MCQs, and several smaller rooms for the staff, preparation rooms and rooms for the oral examination. In addition to the examiners, also secretarial staff from the Vienna Medical Academy were present, and in addition handled the computer analysis of the MCQs.
In recent years the development of European board examinations as a sign of quality and towards a move to harmonization was encouraged. An UEMS group called CESMA  has been established, and has regular meetings to work on the format and quality of European board examinations. A member of the Ege University Department of Medical Education helped with practical and atmospherical issues, and also performed a feedback analysis from candidates after the examination . This contained several questions in regard to difficulty, content and conditions of the examination. 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 Ege University and Vienna Medical Academy, and economical aspects.
When it comes to funding the UEMS/EBN received initially two grants from the ENS and EFNS as a contribution to develop the EBN examination. All the 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, but which do not cover the organizational expenses. The largest part of the development was done by volunteers, who wrote questions, helped to prepare the examination, and also practically participated in several tasks. Other fixed costs, like those for the database, the administrative assistance and also travel costs have to be covered. However, the rooming and facilities for the examinations provided by the ENS and EFNS have saved a considerable part of the real costs for the examination.
Still, at present, despite the individual fees, the incomes are not covering the expenses, and the development of the new EMQs needs a new financial effort, not only for administration, but also for traveling cost for persons participating in the meetings to develop the questions.
Different aspects of feedback on the EBN examination
In addition to feedback issues mentioned above, we have also learned that the examination was commented on, and published considering several aspects . The use of English language and fee (price) has met criticism.
Acceptance and frequency
At this time the participation to the UEMS/EBN is steadily growing, but the expectations have not been fulfilled to satisfy the great efforts and resources that have been invested in this project.
Several reasons have been debated: (i) the examination is just a sign of excellence and has no legal consequences; (ii) lack of formal support from most European national societies; (iii) language issues; (iv) uncertainty about the difficulty by candidates; (v) amount of examination fee that can be more easily settled by candidates from Western European countries, but may be too expensive for those from Eastern European countries.
At present the UEMS/EBN examination is accepted as equal to the national in Austria and Belgium only.
Future aspects – including non-Europeans
An issue of controversy has been the exclusivity of admission to the examination only for applicants from Europe. This has been changed with the successful participation of approved applicants from Turkey, and will be even more liberal in 2013 when the UEMS/EBN examination will be open for applicants from around the world. The non-European participants will receive a diploma stating that they have passed the European board examination, while the successful European participants will continue to be titled ‘Fellow of the European Board of Neurology’ as they have been previously. A possible future cooperation with the Royal College of Physicians (UK), who offers a similar examination, has been initiated.
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. The establishment of a quality circle, which not only evaluates trainees but also the quality of a training center, is therefore a further important step.
Several countries (like Norway) have implemented department visits on a national basis. This concept, also adapted from the UEMS, means a voluntary visit of a training center, both by a representative of the UEMS as well as of the national 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.
All faculty members, residents, the head of the training program and also the hospital staff receive questionnaires that are standardized and collected prior to the visit. The exception is the residents, who need to complete the questionnaires on site.
At random, four members of the faculty and four residents are selected for a standardized oral interview by the head of the UEMS/EBN visitation committee and a representative of the national society.
The final report analyses the different aspects of teaching and training, and gives recommendations that can be used by the department or the hospital. The objective of the visitation is directed towards assessing and eventually improving the quality of training. Details of this reviewing process can be downloaded from the UEMS/EBN website .
Increasingly subspecialties in neurology have developed. In the USA about 25 subspecialties in all fields have been identified and are recognized by the United Council for Neurological Subspecialties (UCNS) , which also provides an examination and certification system that is open worldwide. However, so far recognition of this qualifications within the UEMS has been not been agreed on.
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.
The overarching vision for the training in European neurology is a harmonized training in neurology in Europe. This does not only include the contribution from the scientific societies, but one needs to have a universal core curriculum, optimal training facilities, and also instruments of assessment of quality at several levels as training departments and European board examinations.
Disclosure of conflict of interest
The authors declare no financial or other conflict of interests.