It is not uncommon for sociopolitical changes in a country to influence developments in many other areas, such as education or general health policy. Although in the case of the European Union we are not referring to a single country, sociopolitical changes have occurred in all of the European countries involved, and these changes have led to minor or major developments, depending on the country, in education and health.
The establishment of the European Common Market—now called the European Union (EU)—with the Treaty of Rome in 1958 had already outlined the need for harmonization in medical training, along with other domains of civil life in European countries. More specifically, in 1993, Council directive 93/16/ EEC (1) was adopted, ensuring "freedom of migration" for medical doctors and many other professional trades. This directive implied that certificates, diplomas, and other documents proving medical qualifications that were issued by a nation's competent authorities allowed physicians to practice in any EU country.
Until recently, quality assurance of psychiatric training was under autonomous regulation and was country specific (2). This was a serious obstacle to the uniformity of psychiatric training.
The identification and institution of common requirements for specializing in psychiatry (3) became an issue of great priority for the European Union of Medical Specialists, Specialist Section (UEMS Section of Psychiatry) and more specifically for the European Board of Psychiatry (EBP).
The recommendations elaborated by the EBP provided criteria for the approval of national training programs. They specified that the authority responsible for recognizing training institutions and teachers at country level should be a professional authority, or some other authority advised by a professional body. At EU level the monitoring authority for psychiatry would be the European Board of Psychiatry.
Under the EBP requirements, the overall length of training from registration to completion is determined at a minimum of 5 years, 4 of which must be in psychiatry. Training in neurology and/or medicine is compulsory, and training in developmental and adolescent psychiatry is highly recommended. So far, the European Board of Psychiatry has not recognized subspecialties within psychiatry. Requirements for all national training programs in psychiatry introduce a compulsory common trunk of training, which covers all aspects of general adult psychiatry (including inpatient and outpatient psychiatry, emergency psychiatry, old-age psychiatry, and substance abuse, as well as psychotherapy training). Among other things, it specifies the overall length (hours) and content of theoretical training, including structured training (lectures, seminars, etc.) with a duration of 4 years and an average of 4 hours per week. Concerning theoretical courses in psychotherapy, requirements mention that at least psychoanalytic and cognitive-behavioral psychotherapy should be included in the training curricula for 1 hour per week, or 120 hours in total.
Although a small number of modifications have been made to the requirements during the last few years, the 15 EU members and the associated European countries are already involved in a process of transforming their national training programs in order to fulfill the requirements, with progress toward this goal depending on their starting point.
In Greece, until we started to discuss European requirements on psychiatric education, the national strategy on postgraduate psychiatric training was very general in that it specified only duration of training and contained an outline of topics to be covered and objectives to be reached. An established national curriculum with a common trunk of theoretical teaching and a detailed training program that could be applied to all training centers in Greece did not exist. Thus, the question of how convergent with or distant from European requirements we are, or what are the main problems we have to deal with in order to fulfill these requirements, could not be answered readily until at least accumulative data on details of psychiatric training programs of each training center were available. Therefore, we considered that conducting a survey could be useful to record the characteristics of the various training programs and compare them 1) between themselves to find out their variability and 2) with the European requirements set by the European Board of Psychiatry.
Our sample consisted of the 14 institutions presently recognized by the national authority (Ministry of Health) as eligible to provide full-time training in psychiatry, having a training capacity of 202 trainees (actual number of trainees: 119). Eight of the 14 institutions are located in the wider area of the capital (Athens), 4 are in the second-largest city (Salonika), and the rest are in other areas. All 14 institutions can be classified according to the current mental health system into three main categories: university psychiatric departments (n=6), psychiatric departments of general hospitals (n=5), and psychiatric hospitals (n=3).
According to recent legislation (4), which has not yet fully incorporated the EBP recommendations, specialization in psychiatry has a duration of 5 years, 3.5 of which are exclusively in psychiatry. The first 18 months include training in internal medicine (6 months) and neurology (12 months). Training programs recorded in this survey represent the remaining 42 months (3.5 years) of training in psychiatry.
In order to investigate the training provided in relation to European standards, we created a structured questionnaire based on the primary requirements of the EBP. The information we gathered concerned measurable aspects of training (t1), ranging from training positions and clinical supervision to rotational clinical practice and hours of theoretical training.
The questionnaire was divided into five major sections according to the survey topics. Each section was designed to gather detailed information that would adequately represent the topic and offer data comparable to European requirements.
Data were obtained through discussions with the training directors of the specific institutions, usually at the site of each institution. Formal contact preceded every interview in order to obtain permission from the directors of the institutions and acquaint the training directors with the goals of the survey, so that informed consent and collaboration of the training directors and institutions was ensured. Each interview had a mean duration of approximately 90 minutes. Most of the questionnaires were completed during the interview. The hours devoted to theoretical programs were extracted from the published theoretical curriculum offered to trainees. Regarding clinical rotation we did not consider simply availability of the different services, but the established program on clinical rotation as it was applied for all trainees. In some instances, data on teaching in psychotherapies were not available at the time and had to be sent later by mail.
The project was financed by the University of Athens Department of Psychiatry and approved by the Ethics Committee of the Department.
The data were analyzed by using descriptive statistics and one-way analysis of variance (ANOVA) to investigate if training offered by institutions depended somehow on the type of institution. The Kolmogorov-Smirnov test was used to test the normality of the distributions, homogeneity of variances was used to support the ANOVA, and post hoc tests were used when needed.
Training Positions and Number of Trainees
At the time of the survey, 58.9% of the available training positions in the institutions were actually covered by trainees (total number of available positions, 202; covered positions, 119). Trainees' distribution in relation to training institutions is given in t2.
Thirteen of 14 institutions (92.8%) reported that they had at the trainees' disposal a library with medical, neurological, and psychiatric books and journals, as well as the library's Internet and electronic services. They also had rooms for seminars and courses with audio and visual equipment such as projectors, although 2 of the 14 institutions (14.2%) stated that they had no special room for psychotherapeutic sessions.
Rotational clinical training varied among institutions. Reasons were either that in many cases certain mental health services were not provided by the institutions and in these cases a cooperation with other institutions had not been established, or that although such services existed, they were not included in the training program. Availability of psychiatric services to clinical rotational programs is presented in t3.
Psychiatric services available for training by institutions depended on the type of institution. Estimating the number of missing psychiatric services for clinical rotation per institution, we found that university departments were offering wider clinical experience to their residents compared with psychiatric departments in general hospitals (ANOVA, F=4.790, df=2,11, P=0.032; post hoc comparisons, Bonferroni-adjusted P=0.043).
Regarding clinical supervision of the trainees, in three instances—mostly at psychiatric hospitals—training directors stated that no organized clinical supervision was offered to trainees. Structured individual supervision (dealing with subjects such as attitude and growth in the profession) was not available at any institution with the exception of one university psychiatric department.
The number of patients for whom residents are responsible depended on the institution (t2). Psychiatric hospitals differed significantly regarding the number of patients per trainee compared with university departments or with psychiatric departments in general hospitals (ANOVA, F=7.473, df=2,12, P=0.09; post hoc comparisons, Bonferroni-adjusted P=0.014 and P=0.011, respectively).
We asked training directors whether they had a structured theoretical program. All training centers provided us with their analytical theoretical curricula except one university department, which, because of administrative changes, was under reform.
The responses revealed a considerable variance. Of the theoretical training programs, 76.92% (n=10) had a duration of 2 to 3.5 years in psychiatry and 23.07% (n=3) had a duration of 1 year. The duration of the programs and the hours of theoretical training provided by the institutions are presented in t4. A statistically significant relationship was found between the type of institution and the hours of theoretical training provided (one-way ANOVA, F=8.541, df=2,10, P=0.007). In particular, university departments offered more comprehensive theoretical programs. More specifically, university departments differed significantly from psychiatric departments of general hospitals as well as from psychiatric hospitals regarding hours of theoretical training provided (post hoc comparisons, Bonferroni-adjusted P=0.037 and P=0.010, respectively). Estimating the number of hours recommended by the EBP (a curriculum of 4 academic years with 4 hours weekly, resulting in a total of approximately 480 hours, depending on the duration of the academic year in each country), the current index of mean response for the theoretical programs was found to be 0.43 (1=full response). Regarding theoretical issues covered by the programs, less than 20% of the programs provided courses in administrative psychiatry, and no more than 40% provided courses in research methodology (F1).
Training in Psychotherapies
Theoretical training in psychotherapies was provided by all training institutions except two; one of these had no specialized personnel, and the other could not provide courses in psychotherapy during that specific training year for administrative reasons. For the rest, the mean number of types of psychotherapies taught (e.g., psychoanalytic, cognitive) was 3.27. In each case, trainees could have supervision in psychotherapies (mostly on a voluntary basis) either individually (usually) or in a group supervision setting, depending on the institution's capabilities. According to the training directors, all of the psychotherapeutic teaching personnel had received training in psychotherapeutic centers, mostly abroad but in some cases in Greece.
The distribution of theoretical hours in psychotherapies in relation to the type of institution is presented in t5. Psychotherapies taught by the institutions and the hours spent on each psychotherapy are presented in t6. The index of mean response in relation to the EBP requirements for theory in psychotherapies was 1.50 (1= full response).
We hope that the information acquired from this survey will help us to understand the potentialities of the training programs and their weaknesses as compared with the EBP program requirements.
Our findings indicate that the training provided shows great variability among institutions. This variability in certain aspects seems to depend on the type of institution. To understand this finding we should mention some facts concerning current trends of psychiatry in Greece. Mental health care reform continued throughout the last decade, tending to tip the scales toward community-based psychiatry rather than hospital-based psychiatry. According to the National Health System Law, mental health care is to be provided by mental health centers, psychiatric departments in general hospitals, and psychiatric hospitals, linked together to form sectors of mental health care provision.
This reform process, however, does not move fast enough, and although a variety of mental health services exist (community mental health centers, day hospitals, outpatient services), affiliated mostly to psychiatric hospitals and university departments, conjunction between psychiatric departments of the general hospitals and the rest of the facilities has not been accomplished yet. Inadequate clinical rotation of trainees in psychiatric departments of general hospitals is probably due to this disjunction. In addition, theoretical training has proved to be too difficult a task to be carried out by each of the training programs, especially non-university institutions.
The extensive psychotherapeutic training provided reflects the availability of specialized personnel in the hospitals, as well as the great degree of importance attributed to psychotherapies by the training programs. This brings us to the other dimension of our findings. Functional inadequacies or differences in orientation of the training programs cannot explain all of the deviation observed in clinical rotation, supervision, and even availability of seminars. In some instances, existing affiliated services for some reason were not included in the rotation program, and there were training centers where supervision and didactic sessions were minimal. Lack of a detailed national training plan is perhaps responsible for this variability. National policy on postgraduate psychiatric education has traditionally been based on the number of beds and on the authority of the director of the institution rather than on the quality of the training program itself. Evaluation of the training programs was not carried out by the national authority responsible for recognizing training centers (the Ministry of Health), leaving this task exclusively to the training centers themselves. This lack allowed factors such as hospitals' clinical needs to play a major role in training policy. In other words, the trainees were used as hospital staff and more emphasis was given to routine clinical work than to training. Consequently, training status was given to hospitals without taking into consideration the training efficacy of the institutions.
Clearly, changes must be carried out and quality assurance criteria for training centers must be established. Changes must also include workforce planning based on national needs, and eventually the recognition of fewer training programs on the basis of national needs and proven efficacy in training. Affiliated services and facilities, as well as efficient organizational structure to carry out a residential training program of the candidate institution, must be considered fundamental. Additionally, the strengthening of the role of universities in each wider training area might prove beneficial. This would result in richer and qualitatively better theoretical programs for all trainees.
Recently a change in legislation has been proposed by the Hellenic Psychiatric Association. The proposal is in accordance with the EBP recommendations, ensuring and specifying training standards and recommending evaluation of the programs by auditors.
Evaluation of training programs by auditors is of great importance. The EBP requirements do mention quality assurance, but evaluation of the programs is internal, leaving this matter primarily to national authorities. European authorities have not as yet expanded their responsibility to recognition and accreditation of training programs, although unofficially the European Board has already carried out some evaluations (e.g., of Hungarian institutions).
Although we are not aware of similar surveys from other European countries, information drawn from European meetings (5,6) indicates that differences and deviations in the quality of psychiatric training exist not only among European countries, but also among training programs within the countries. We believe that there is a challenge in confronting this problem, and the way passes through the identification of the problem. On this basis, it is time to move on and gather information based on evidence at the European level. It is apparent that the training standards adopted by the EBP represent a general consensus of what European countries consider as basically important in psychiatric training today—the European "gold standards." The practical impact and the challenge for some countries are of vital importance, and this is the case not only for countries scheduled to become country members of the EU, but also for countries that already have attained this status. Central planning for psychiatric training in Europe not only serves harmonization between European countries, laying the foundations for common health and education planning, but, seen in a larger frame as it deserves to be, creates conditions for active communication and international collaboration on psychiatric training.
In the United States, for several decades now the Accreditation Council for Graduate Medical Education has been the authority responsible for recognizing training institutions and identifying program requirements (7). There are similarities but also differences between U.S. and EU requirements for psychiatric training, and both systems have strong and weak points. We feel that there is a lot of room for collaboration and exchange of experiences in this area. Recent advances in neurosciences and psychiatry in general dictate a reappraisal of the priorities in psychiatric education (8,9), which should be viewed in an international context but also taking into account priorities determined by national strategies on mental health. Additionally, programs for the establishment of a postgraduate curriculum in psychiatry should be encouraged and should be expanded to accommodate universal training needs. In this context, the program of the World Psychiatric Association for the construction of a core curriculum for postgraduate psychiatric education is commendable.