1List of surveyed countries and country respondents: Austria: K Pils, Belgium: JP Bayens, Bulgaria: I Petrov, Cyprus: C Agathangelou, Czek Republic: E Topinkova, Denmark: F Rønholt Hansen, Estonia: K Saks, Finland: T Strandberg, France: A Benetos, Germany: D Lüttje, Greece: G Sparatharakhis, Hungary : B Szekacs, Iceland: P. Johnson, Italy: A Cherubini, Ireland: S. O'Keefe, Lithuania: J Macijauskiene, Luxemburg: JC Leners, Macedonia: M Adzic, Malta: A Fiorini, The Netherlands: L Boelaarts, Norway: M Mowe, Poland: A Skalska, Serbia: M Davidovic, Slovakia: Z Mikes, Slovenia: PS Marija, Spain: P Abizanda, Sweden: A Rundgren, Switzerland: Ph Huber, Turkey: U Ateskan, Ukraine: V Bezrukov, United Kingdom: P. Crome, A Mair and G Mulley.
Europe-Wide Survey of Teaching in Geriatric Medicine
Article first published online: 2 SEP 2008
© 2008, Copyright the Authors. Journal compilation © 2008, The American Geriatrics Society
Journal of the American Geriatrics Society
Volume 56, Issue 8, pages 1536–1542, August 2008
How to Cite
Michel, J.-P., Huber, P., Cruz-Jentoft, A. J. and a representative of each surveyed country (2008), Europe-Wide Survey of Teaching in Geriatric Medicine. Journal of the American Geriatrics Society, 56: 1536–1542. doi: 10.1111/j.1532-5415.2008.01788.x
- Issue published online: 2 SEP 2008
- Article first published online: 2 SEP 2008
- medical education;
- pregraduate teaching;
- life-long training
By 2050, the European population of 720 million will include 187 million (one quarter) octogenarians. Although living longer is a true privilege, care for the graying population suffering from chronic and disabling diseases will raise enormous challenges to healthcare systems and geriatric education. Are European countries ready to cope with these challenges? An extensive 2006 survey of geriatric education in thirty-one of 33 European countries testifies that geriatrics is a recognized medical specialty in 16 countries and a subspecialty in nine of them. Six European countries have an established chair of geriatric medicine in each of their medical schools. Undergraduate teaching activities are organized in 25 of the surveyed countries and postgraduate teaching in 22 countries under the leadership of geriatricians (n=16) or general internists (n=6). A comparison with data collected in the 1990s shows important progresses: the number of established chairs increased by 45%, the undergraduate and postgraduate teaching activities increased respectively by 23% and 19%. However, these changes are very heterogeneously organized from country to country and within each country. In most European countries, there remains a huge need for reinforcing and harmonizing geriatric teaching activities to prepare the next generation of medical doctors to address the projected increase in chronic and disabled older patients. Several different innovative strategies are proposed.
The Council of Europe, the continent's oldest political organization, groups 47 different countries (all European countries except Belarus), of which 27 are now state members of the European Union (Figure 1).1 The total European population of 720 million is likely to remain stable until 2050. Today, 20% of the European population is aged 60 and older (144 million) and 15% aged 80 and older (108 million). By 2050, the proportion of the population aged 80 and older will reach 26% (187 million).1 At present, in the United States, patients aged 65 and older account for 39% of ambulatory visits to general internal medicine physicians.2 This fast growth in the oldest, sickest, and frailest patients, many with multiple comorbidities and in need of specific community or institutional care,3 presents tremendous challenges.
Some years ago, a thorough reform of higher education in Europe was started, known as the “Bologna process,” aimed at establishing the European Higher Education Area by 2010 to uphold and harmonize academic degree standards.4,5 However, this process has not been fully applied to medical studies,6 which are generally not yet fitted to meet to the challenge of our aging populations. Specifically, medical graduates need to acquire adequate knowledge, skills, and attitudes to manage people with chronic and disabling diseases.7
A small group of professors of medical gerontology performed a first European geriatric education survey in 1991 and published it in 1994.8 It developed three main strategic goals to anticipate the impending needs of society and to promote geriatric medicine throughout Europe: establish the basis of a consensus on the content of an undergraduate core curriculum in geriatrics, promote the creation of a chair of geriatric medicine in each European medical school, and provide continuing education and life-long training in academic geriatric medicine for all those with responsibilities for older patients.8
Fifteen years later (2006/07), an updated survey is needed to evaluate whether the previous goals were achieved, to ascertain the actual situation, and to forecast the education and training needs of medical practitioners to address the increasing demands of elderly and aging European citizens.
Three European organizations (European Union Geriatric Medicine Society (EUGMS),9 the European Region of the International Association of Gerontology and Geriatrics (ER-IAGG),10 and the European Union of Medical Specialists—Geriatric Section (UEMS-GS))11 with similar and complementary goals in the field of aging and geriatric medicine combined their resources to perform this survey on training in geriatrics throughout Europe.
Each national geriatrics society from the different European countries was asked to designate a respondent who would agree to complete the questionnaire prepared by the authors of the current report. If no geriatrics society existed in a particular country, the network members of the above-mentioned European organizations sought a relevant correspondent. All identified respondents were asked to gather accurate and current information from all medical schools of their own countries to respond to a semistructured questionnaire presented in five parts:
- 1General information: official recognition of geriatric medicine as a medical specialty or a subspecialty, number of medical schools, and number of established chairs in geriatrics in their country.
- 2Undergraduate teaching in geriatrics: number of medical schools organizing training in geriatrics, academic recognition of this teaching, qualification of the teachers involved in the program, existence of a core curriculum in geriatrics, and mechanisms to expose medical students to geriatric patients.
- 3Postgraduate training in geriatrics: the same set of questions as for undergraduate teaching, and opportunities available to follow a residency program in geriatrics.
- 4Continuing medical education (CME) in geriatrics: main accountability of such programs, format, and validation.
- 5Additional information, comments, and suggestions.
The EUGMS, ER-IAGG, and UEMS-GS questionnaire was sent to the identified representatives of 33 of the 47 European countries in the Council of Europe (Figure 1). In spite of tremendous efforts, it was not possible to identify a reporting representative for geriatric medicine in 14 countries, mainly because of the absence of a functional geriatrics society in these countries.
Table 1 summarizes the data from 31 of the 33 countries surveyed (94% response rate) in 2006. Data from Portugal and Romania are missing. Among the 31 responding countries, geriatrics is recognized as an independent specialty in 16 and as a medical subspecialty of general or internal medicine in nine others. Six countries do not recognize geriatric medicine. Geriatric nurses are recognized in 13 of the 16 European countries where geriatric medicine is considered a medical specialty.
|Country||Recognition of Geriatrics||Medical Schools n||Medical Schools with a Chair of Geriatrics n||Undergraduate Teaching in Geriatrics||Postgraduate Teaching in Geriatrics; If So, Leaders||Continuing Medical Education Mandatory?*|
|1991||2006||1991||2006||Available||Mean Number of Hours||Clerkships in Geriatrics Available|
|Countries surveyed in 1991 and 2006 (n=21)|
|Germany||Specialty||36||43||3||7||Yes||25||?||Internists and geriatricians||Yes|
|Iceland||Subspecialty||1||1||1||1||Yes*||40||Yes*||Internists and geriatricians||No|
|Switzerland||Subspecialty||5||5||2||3||Yes||Varying||Yes||Internists and geriatricians||Yes*|
|Countries surveyed only in 2006 (n=10)|
|Serbia and Montenegro||Subspecialty||—||2||—||1||Yes||60||Yes*||Internists and geriatricians||No|
|Turkey||Subspecialty||—||11||—||6||Yes||9||Yes*||Internists and geriatricians||No|
|Ukraine||Subspecialty||—||14||—||3||Yes||Varying||Yes*||Internists and geriatricians||Yes|
An established chair of geriatrics exists in all medical schools (100%) of six European countries (Belgium, Finland, France, Iceland, Norway, and Sweden) (Table 1). There is an established chair of geriatrics in 71% of the Italian medical schools, 60% of the Swiss, 50% of the Dutch, 39% of the English, 36% of the Spanish, 33% of the Danish, and 16% of the German (Table 1). No chair of geriatric medicine exists in eight countries (Austria, Greece, Estonia, Macedonia, Moldavia, Slovenia, Luxembourg, and Malta). There are no medical schools in Luxembourg, but in Macedonia, where there is no chair of geriatrics, the discipline is recognized as an official independent specialty.
The 6-year undergraduate medical education, which occurs after 12 to 13 years of primary education, is organized in most European countries, although big differences can be found between countries in organization and content of the curricula. Typically, medical students will start with a 3-year preclinical curriculum in which the emphasis is on the acquisition of basic sciences, followed by a 3-year clinical curriculum more oriented toward the acquisition of clinical disciplines. Undergraduate teaching in geriatrics is implemented in 25 of the 31 surveyed European countries (81%) but to widely differing extents. Undergraduate teaching in geriatrics in all medical schools of a country occurs in only seven countries (Table 1). Such undergraduate teaching is mandatory in nine countries but does not exist in six other countries. The content of the teaching in geriatrics is based on the European Union core curriculum recommendations in only two countries. In most countries, each medical school determines the undergraduate curriculum independently.
The mean number of undergraduate teaching hours devoted to geriatrics varies considerably, with a maximum of 100 hours of teaching in Norway to less than 10 hours in Ireland, Luxembourg, and Turkey (Table 1). In most cases, teaching in geriatrics takes place during the clinical years (fourth to sixth year) of the undergraduate medical curriculum. The teaching methodology is “problem-based learning” in nearly 50% of the cases. Clinical rotations in geriatrics (clerkships) are organized in 16 countries (60%). These clerkships are mandatory in 11 countries and elective in five.
Geriatricians specifically organize postgraduate training in geriatrics in 16 of 31 countries and in collaboration with internal medicine in six other countries (Germany, Iceland, Serbia, Switzerland, Turkey, and Ukraine). In nine countries providing postgraduate training in geriatrics, physicians must fulfill specific qualifications to be admitted. The content of the postgraduate curriculum is defined in 16 countries. A final mandatory examination is taken at the end of postgraduate training in 13 countries, and a mandatory curriculum for maintaining certification is implemented in eight countries.
CME in geriatrics is organized in 18 European countries but is mandatory for maintaining certification in geriatrics in only 10 of them (Table 1). CME and continuing professional development are not harmonized in different European countries. Recently, the European Accreditation Council for Continuing Medical Education (EACCME) was created to facilitate the transfer of CME credits obtained by individual specialists in CME activities that meet common quality requirements in European countries, in different specialties, in the European credit system, and in comparable systems outside Europe. The EACCME and the American Medical Association have been recognizing each other's CME credits since 2000. The EACCME depends on the UEMS, and each section (including the Geriatric Section) assesses geriatric content of activities.12
The questionnaire includes space for additional information and comments. Three frequently encountered responses to this part of the questionnaire are important to report:
- •The need for better training in geriatric medicine for family physicians was stressed, because in Europe, as in other parts of the world, general practitioners care for the great majority of community-dwelling frail and older patients.
- •A desirable objective, expressed by respondents from many countries, was that practitioners of internal and organ specialized medicine should recognize geriatric medicine as a specialty.
- •The European Academy for Medicine of Ageing, which “teaches the future teachers in geriatrics,” is a highly valued organization, according to 30 of 31 respondents.
The response rate for this extensive survey on geriatric education in European countries in which a reliable correspondent was found was good (31 of the 33 European countries (94%)), even if the response rate decreases to 66% when considering the 47 countries that are members of The Council of Europe. This response rate is comparable with those of recent surveys. In the United Kingdom, 23 of 31 medical schools (74%) responded to a World Health Organization/Royal College of Physicians questionnaire;13 in the United States, a cross-sectional survey of geriatric medicine fellowship programs had a response rate of 76% (96 of 126 program directors),14 and a survey of geriatric training in internal medicine residency programs approved by the Accreditation Council for Graduate Medical Education had a response rate of 60% (235 of 389 internal medicine residency directors);15 whereas in Canada, only a 48% response rate (253 of 530 geriatricians and medical trainees) to the Geriatric Recruitment Issues Study was achieved.16 The good response rate of the present study is probably linked to the enormous support from the three major European geriatrics bodies (EUGMS, ER-IAGG, and UEMS-GS) and the involvement of the various national geriatrics societies. However, 16 European countries are not included in the present survey. Two countries did not answer: Portugal, which has five medical schools, and Romania, which has 13 medical schools. Moreover, it was not possible to identify a correspondent in 14 European countries (among them, the Russian Federation, which has 33 medical schools).
Numerous European political changes resulting in the creation of new countries complicate comparison of the present results with those from the survey performed 15 years earlier,8 but it is clear that the three goals identified in the previous survey are only partly achieved:
(i) The UEMS-GS suggested, completed, and endorsed a unified European Geriatric Undergraduate Core Curriculum under the leadership of the European Community,17 but only two countries were found to explicitly base their undergraduate teaching on this consensus core curriculum. However, it seems likely that the majority of teachers in geriatrics who organize their undergraduate teaching courses in their various medical schools use this core curriculum.
(ii) The goal of creating an established chair of geriatric medicine in each European medical school is not yet realized, but considering only the countries represented in both surveys (n=21), it appears that the number of chairs in geriatric medicine increased from 88 to 136 (54.5% increase), which is outstanding progress in only 15 years. Among the countries that clearly enhanced their geriatric involvement during this period of time, the achievement of France is outstanding. Political educational input obliged the 32 French medical schools to create a chair of geriatrics, following the assumption that only academic geriatricians could teach geriatrics at the undergraduate level (mandatory course). In contrast, the number of chairs in geriatric medicine markedly decreased in the United Kingdom following new imposed academic standards18,19 and the re-attribution of chairs of geriatrics to academics not working in geriatrics.
There are 152 established chairs of geriatric medicine in the 288 medical schools of the 31 European countries included in this survey. However, as previously stressed, the present survey does not cover 65 medical schools of 16 other European countries, which in practice have no teaching activity in geriatrics.
(iii) The third recommendation concerned the setting up of a higher-qualification postgraduate course to “teach the future teachers in geriatric medicine” called the European Academy for Medicine of Ageing. This qualification is now mandatory to obtain a professorship in geriatrics in a few European countries, including France.20
The 1991 survey showed that 14 of 21 different countries (67%) had undergraduate teaching in geriatrics.8 Considering the same 21 countries in 2006, there are now 19 (90%) delivering geriatric undergraduate teaching. Of the 10 additional countries included in the 2006 survey, six (60%) have undergraduate teaching in geriatrics. This teaching is mandatory in Lithuania and the Slovak Republic.
Despite these positive findings, the promotion of geriatric education still needs to be strongly pursued. Twenty-five of the 31 surveyed countries (81%) offer undergraduate teaching in geriatrics; in only nine of these 25 countries (36%) is this teaching mandatory. The recommended “European Union core curriculum” is strictly applied in few places. Moreover, there is consistency neither in the volume of this undergraduate teaching in geriatrics nor in the geriatric and internal medicine background of the teachers. This raises the controversial question of whether to integrate undergraduate teaching in geriatrics with other areas of medicine or provide specific and specialized training in geriatrics to meet the needs of older people.13 It would be advantageous for academic geriatricians who can provide a more-holistic perspective to performed these teaching activities, but because of the lack of geriatricians, a faculty development program for clinician educators is unlikely to be effective in the short and medium term.21
Too many European countries fail to give medical students sufficient exposure to geriatric medicine, which was also the case for U.S. medical students 2 decades ago.22 In 2000, the Spanish Geriatric Society found that 43% of Spanish medical schools did not include any geriatric teaching or training in their undergraduate curricula.23 In Leeds (UK) Medical School, which developed robust methods of geriatric assessment and incorporated geriatric sessions in the final medical examination, only 30% to 50% of the students were exposed to geriatric patients during their 5 years of studies.24,25 In the United States, a survey conducted in 2000 showed that 93% of the 125 accredited medical schools taught geriatrics with various teaching formats. In spite of this, 38.6% of the graduating medical students felt that this amount of teaching in geriatrics was inadequate.26 Also, experience in the management of geriatric care in the community during medical students' training will allow greater understanding of the importance of home care and of continuity of care between home and hospital. Interdisciplinary teamwork, including excellent communication links, will be appreciated as facilitating factors enhancing the quality of care for older patients.
Undergraduate teaching of geriatrics needs to be consolidated in all European medical schools, and exposure of medical students to geriatric patients must be greatly increased.
In 1991, postgraduate education was organized to include training in geriatric medicine in 12 of 21 countries (57%),8 whereas in 2006, this was the case in 16 countries (76%). Across the 31 countries included in the 2006 survey, postgraduate training in geriatrics was organized in 22 countries (71%). Geriatricians are specifically in control of postgraduate education in 16 countries, whereas specialists in internal medicine and geriatrics are involved in six countries. In the future, the collaboration between geriatrics and internal medicine in teaching needs to be considered, as does the importance of cross-specialty training.25 In the United Kingdom, of the curricula of all 27 adult medical specialties taught, 13 lacked any specific mention of older people, including gastroenterology, nephrology, and respiratory diseases.25 The John A. Hartford Foundation, which supports initiatives to improve the availability of effective care for older people in the United States, has funded 12 geriatric educational retreats in the last 6 years with the goal of integrating geriatric medicine into subspecialties of internal medicine, and these retreats have had successful, positive outcomes.27 Such initiatives must be urgently promoted in Europe.
Of the 21 countries included in both surveys, CME in geriatrics existed in 12 countries in 1991 (57%) and in 14 countries in 2006 (67%). Considering the 31 countries included in the 2006 survey, CME is organized in only 18 of them (58%). The fact that CME is now mandatory in 10 of the 18 countries involved in this type of activity, which is excellent progress, compensates for this unchanged rate of countries involved in CME. Following the recommendations of U.S. colleagues,22 CME activities are regularly organized in Europe using problem-based learning in small groups. Use of tool kits is not frequently encountered but is likely to be promoted in the future following the excellent results reported for such methods of teaching.28
The main goal of the European Academy for Medicine of Ageing CME course is to provide academic reinforcement in different European countries by enhancing and updating geriatric scientific knowledge and facilitating research networking.21
New innovative European initiatives must be developed, particularly making greater use of e-learning. A survey of 130 U.S. medical geriatric educational programs showed that 79% of the respondents were users of existing programs and that 56% are developing Internet-based teaching materials.29 Given the shortage of professionals trained to care for older people, overcrowded medical curricula, the transfer of teaching venues to community settings, and the switch to competency-based educational models, it is time to increase the use of e-learning in Europe,30 but users need to be aware that e-learning materials have often not been subjected to a rigorous peer review process.31 Telemedicine mentoring of students could be another innovative way to increase the availability of educational geriatric programs.32
This present survey has four limitations. The first is linked to the large number of countries constituting the Council of Europe (n=47). Moreover, European political evolution has altered national boundaries and even the number of countries. Therefore, a strict comparison between the 1991 and 2006 surveys is not possible. The second limitation is the number of responding countries: 31 of the 47 (66%) countries of The Council of Europe. Data were not available for 16 European countries, mainly because it was not possible to identify any correspondent to fill in the questionnaire in 14 countries. The response rate is still satisfying, considering that 31 of the 33 countries (94%) with an identified correspondent returned the questionnaire and that all the main European countries are represented, except for the newly constituted Russian Federation. Because numerous small European countries, which did not answer the survey, do not have any medical school, it is important to stress that the present survey includes 288 of the 353 European medical schools (82%). The third limitation is related to terminology; differences in languages, healthcare systems, and university structures make some of the 2006 survey outcomes somewhat equivocal. Respondents from a few countries had difficulties in answering some questions because of these differences in terminology. The fourth limitation is related to the ever-changing organization of the world of medical education; although this survey reflects the situation in 2006, aspects in some countries will have inevitably already changed since the survey was completed.
Comparison of this present European survey with the 1991 survey testifies to major progress in geriatric education, which is more frequently recognized as a specialty within medical schools that have established chairs. Undergraduate and postgraduate teaching activities are increasing, improving geriatric knowledge and facilitating medical students' exposure to the oldest and most disabled of patients. CME is becoming mandatory in many European countries for validating practice within the specialty, but efforts to promote a stronger profile for geriatrics have to be rapidly increased, as does cross-specialty training and the use of new educational technologies to meet the medical challenges of a longer life.
We are extremely grateful to the designated respondents from all the countries of Europe for their full responses and cooperation with this survey.
We acknowledge Mrs. Margaret Piggott for her helpful editorial review of the manuscript.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this manuscript.
Jean-Pierre Michel: study concept, preparation of the questionnaire, sending the questionnaire to each country contact person, gathering the answers, analysis, and writing of the manuscript.
Philippe Huber and Alfonso Cruz Jentoft: preparation of the questionnaire, completing the list of contact persons, contributing to the data analysis, and contributing to writing the final version of the manuscript.
Sponsor's Role: No sponsor.
- 1Census Bureau International Data Base [on-line]. Available at http://www.census.gov/ipc/www/idb.html Accessed February 20, 2008.
- 2FedStats: National Center for Health Statistics. Trendtables on 65 and older population. 2004 [on-line]. Available at http://www.fedstats.giv/key_stats/index Accessed February 20, 2008.
- 4Bologna Process [on-line]. Available at http://www.ond.vlaanderen.be/hogeronderwijs/bologna/ Accessed February 20, 2008.
- 5Bologna Process: Towards the European higher education [on-line]. Available at http://www.ec.europa.eu/education/policies/educ/bologna/bologna_en.html Accessed February 20, 2008.
- 9European Union Geriatric Medicine Society [on-line]. Available at http://www.EUGMS.org Accessed February 20, 2008.
- 10International Association Gerontology Geriatrics [on-line]. Available at http://www.iagg.com.br Accessed February 20, 2008.
- 11Union Europe–ene des M–decins Specialistes [on-line]. Available at http://www.uems.net/ Accessed February 20, 2008.
- 12The AMA Council on Medical Education [on-line]. Available at http://www.ama-assn.org/ama/pub/category/14348.html Accessed February 20, 2008.
- 15Are internal medicine residency programs adequately preparing physicians to care for the baby boomers? A national survey from the association of directors of geriatric academic programs status of geriatrics workforce study. J Am Geriatr Soc 2006;54:1603–1609., , et al.
- 17Union Europeéen des Médecins Specialistes—Section gériatrique [on-line]. Available at http://www.uemsgeriatricmedicine.org Accessed February 20, 2008.
- 20Back to the future: The European Academy for Medicine of Ageing revisited. Gerontology 2002;48:56–58., , et al.
- 23Geriatric medical education: An unclosed loop. Rev Fac Cien Med Univ Nac Cordoba 2006;63:71–75., , et al.
- 26Improving Geriatrics in Medical Schools. Contemporary Issues in Medical Education. Association of American Medical Colleges. 2000 September/October; 3(5). Available at http://www.aamc.org/data/aib/cime/vol3no5.pdf Accessed April 9, 2008.
- 29The use of the internet in geriatrics education: Results of a national survey of medical geriatrics academic programs. Gerontol Geriatr Educ 2007;27:85–95., , et al.