Specialist postgraduate training in Finland Docent Hannu Halila Director, Education and Research Finnish Medical Association Specialist in obstetrics and gynaecology Past President of UEMS (2002 – 2005) NordÖl Helsinki 6 June 2008

SNAPS 2008

Specialitetsstrukturen i Norden SverigeDanmarkFinlandNorgeIsland Grundspecialitet Grenspecialitet

SNAPS 2008 Gula Boken Anm: *) Samtidigt med specialistutbildningen kan det ingå två års ”euroläkare utbildning”, som ger självständiga rättigheter som allmänläkare **) Från augusti 2008: 1 år SverigeDanmarkFinlandNorgeIsland Grund- utbildning 5½6666 AT/turnus1½–21½ **)– *)1½1 Specialist- utbildning min 55–6 5–74½–7½ Summa årmin 1211–12 12½–14½11½–14½

Specialist training in Finland Administered until 1960 by the Finnish Medical Association National Board of Health (under the Ministry of Social Affairs and Health) administered 1960 – 1985 From 1986 a postgraduate training of the medical faculties of universities

Doctors in Finland 2008: of them were of working age and living in Finland.

Population per active physician 2008 (physicians of working age living in the country): Denmark261 Finland295 Iceland268 Norway244 Sweden*)318 *) Only members of the Swedish Medical Association SNAPS Group 2008

Licensed physician Independent rights as general practitioner/ licensed general practitioner General practitioner under the national social security system Licensing of doctors in Finland Licentiate of medicine 6 years Year Licensed physician Pre- registration period 1 year Specific training in general medical practice 2 years Licensed physician under the guidance and supervision of another doctor Specific training in general medical practice 2-3 (-5) years Licensed physician Licentiate of medicine 6 years Proposal from the Finnish Medical Association

Reform of specialist training in Finland in 1999 Until then Finland had 32 main specialities and 60 sub-specialities Number of specialities was cut down to 49 and sub- specialities were ended with a transition period until 2005 Already in the early 1990’s a working group of surgeons suggested independent specialities into surgery.

Medical specialities 1999 (49) Training program 5 years (16) - child neurology- ophthalmology - clinical chemistry- otorhinolaryngology - clinical microbiology- pathology - clinical neurophysiology - phoniatrics - forensic medicine - physical medicine - geriatrics- public health - medical genetics- radiology - oncology- sports medicine

Training program 6 years (33) - adolescent psychiatry - internal medicine - anaesthesiology and intensive care medicine- nefrology - cardiology- neurology - cardiothoracic surgery- neurosurgery - child psychiatry- obstetrics and gynaecology - clinical pharmacology and pharmacotherapy- occupational medicine - clinical haematology- oral and maxillofacial surgery - clinical physiology and nuclear medicine- orthopaedics and pharmacology - dermatology and allergology- paediatrics - endocrinology- paediatric surgery - forensic psychiatry- plastic surgery - gastroenterological surgery- psychiatry - gastroenterology- respiratory medicine and - general practice allergology - hand surgery- rheumatology - infectious diseases- surgery - urology - vascular surgery

Structure of training e.g. in surgery (oral- and maxillofacial surgery and neurosurgery separate): Common trunk 3 years (including 9 months in health centres, common to all specialities) 3 years of specialized training Training and workforce planning policies have been mixed up often in Finland

As a result of the National Health Project from 2003 the training in health centres for all specialities became 9 months instead of 6 months and the so- called fifty-fifty rule was applied: at least 50 % of the training time (5 or 6 years) has to be spent outside of the university hospitals (some exceptions e.g. neurosurgery). After the common trunk the specialized training (3 years) is usually spent in university central hospitals (Helsinki, Kuopio, Oulu, Tampere and Turku)

Theoretical training: 80 hours (20 hours of which training in administration and leadership) A written anonymous national examination usually during the last year of training

Specialist exam in urology September 21, 2007: 1.Active follow up of prostatic carsinoma 2.Surgical treatment of hyperactive bladder 3.In situ carsinoma and premalignant skin leasons of the penis 4.Treatment of the renal pelvic stones 5.Obstruction of the pyelourethal junction

Two ministries administer specialist training in Finland: 1.Ministry of Education is the central body for universities and gives legislation 2.Ministry of Social Affairs and Health has money that is given to hospitals and health centres as compensation for expenses caused by medical education and research.

Evaluation of the education of specialists in medicine and in dentistry Ministers of Health and Social Affairs and Education appointed to rapporteurs to evaluate: How to present training meets the expactations of the service system and the populations health needs whether the objectives and implementation of the education are appropriate from the point of view of the universities organizing education, the organisations of the health service system and the doctors in specialisation training rapporteurs: Professor Anja Tuulonen, Oulu (ophthalmology) and Docent Hannu Puolijoki, Seinäjoki Central Hospital (internal medicine and pulmonary diseases)

Rapporteurs reported problems in diminishing common knowledge in surgery and internal medicine and also problems in organizing on-call work especially outside the university hospitals. Report given to ministers Sarkomaa and Risikko on September 6, 2007

Proposals in surgery New 5 year program in surgery After that possibility to take an other degree (3 years) in cardio-thoracic surgery, gastroenterological surgery, hand surgery, paediatric surgery, plastic surgery, urology and vascular surgery Of the 3 years one year can already be included in the 5 years training in surgery In surgery (and in internal medicine) at least 4,5 years (including the health centre 9 months) should be possible to work in also “central hospitals of big hospital districts”.

Proposals for new specialties: emergency medicine (also additional degree program during the transition period) geriatric psychiatry

Future of the proposals A very rapid and limited consultation process was organized by the Ministry of Education in September 2007 Professors in surgery strongly apposed to the proposals New consultations going on within surgery (and cardiology) Time table for new legislation open, Ministry of Education not willing to pursue proposals, Ministry of Social Affairs and Health more eager.

Special competences As a supplement to the official system of specialisation, the Finnish Medical Association introduced in 1993 a system of special competences. Suggestions for the establishment of new areas of special competence usually come from the specialist societies. There are presently 32 different special competence areas and the number of recognized competences of physicians is over 1700.

Special competences The FMA has changed the rules for special competences so that now new competences are developed only in areas which are common to at least two specialities (e.g. pain management or insurance medicine, but not any more e.g. cardiac anaesthesia).

Future challenges of specialist training in Finland 1.Increasing retirement of specialists from hospitals, specialist training not sufficient to replace them in some specialities 2.Controversies regarding the proposals from 2007 to reform specialist training 3.Training in leadership and administration

Leadership and administration for specialists Until 2007 it was possible to gain a competence in administration from the medical faculties for specialist doctors, not anymore. The Finnish Medical Association strongly supports that in the future (from 2009) all specialist training programmes include 30 credits (20 study weeks) of practical and theoretical training in leadership and administration.

Physician 2003 study About 1500 young doctors responding. 94 % were satisfied with their choice of speciality. 22 % would not study medicine anymore if they were choosing their career.

BMJ December 2005 Choice of speciality according to types of personality

Thank you! Tack! Kiitos!