- serving Europe’s ageing population

Older people make greater than average use of Europe’s health services. About 7500 - 10,000 geriatricians provide services to the EU’s growing population of older people.

The European Commission has shown an interest in specialist services for older people and has recognised geriatric medicine as a specialty 1, 2. However, among the member states there are large differences in structure, health care services and training facilities 3. The Geriatric Medicine Section of the European Union of Medical Specialists (GMS-UEMS) has collected information from its members about the differences in geriatric medicine and other medical organisations within the member states of the European Union.

Recognition of the specialty
Geriatric medicine has been recognised in Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Spain, Sweden and the UK. It has not yet been recognised in Greece and Portugal, although it is hoped that the specialty will be recognised in these countries in the future. However the debate over recognition has a political impact and needs the co-operation of the medical professions.

All aspects of care for geriatric patients, including rehabilitation and the care in residential and nursing homes, are covered by the same specialist in Finland, Italy and Spain, although not all geriatric patients may see a geriatrician. Other countries have different specialties covering the different parts of this spectrum of care. This highlights the unevenness of the approach to health-related problems in older people within the member countries. Problems which are met at home, in the residential and nursing homes, or in the hospital setting, pose the question of whether a uniform system across Europe is preferable to a culturally, socially and economically sensitive local system.

Continuing medical education
CME is provided in all countries, however, only in Austria, Belgium, the Netherlands and the UK is it on a formal basis. A system for accreditation has been organised in these countries along with France and Ireland. It might be expected that in order to guarantee the quality of health care, there would be an obligation in the future to establish formal programmes for continuing medical education (CME) and continuing professional development, with a similar system of accreditation in all member countries.

Training
In most countries the training varies between 4 and 7.5 years. Austria is the exception, with a training programme of 8 weekends over a period of two years, with most of the trainees being general practitioners. In Belgium, France and Germany the training in geriatric medicine is in addition to the completion of specialist training in internal medicine. In nearly all countries the trainees have to spend at least two years in general or internal medicine. Here, Italy is the exception, as training in internal medicine is not required, although it is under discussion as to whether this will be changed. The differences in training have an impact for the exchange of medical specialists across the European Union. A free exchange has been agreed for all European Union member states, however, the differences in the training especially in Austria and Italy could lead to problems.

The UEMS recommends a period of four years specialist training in geriatric medicine. However a problem arises in the difference of opinion about the content of the specialty. In Austria and Italy most geriatricians are dealing with patients outside the hospital. In other countries most of the time is spent on inpatients, albeit sometimes with consultations at home and in nursing homes. The GMS accepted the general principle of needing four years specialist training for geriatric medicine but this is in addition to two years of internal medicine. The curriculum for this training has been published in the brochure ‘Training in geriatric medicine in the European Union’ 5. Included are the knowledge of basic care and provision of appropriate services in geriatric medicine, assessment and training, rehabilitation services, discharge planning, assessment for long term care and research. The brochure also describes the requirements needed for the recognition of training institutions and teachers.

The use of a logbook is recommended in most countries and provides useful information about the facilities of the training centre and departments where the trainee has been trained. Only in Germany, Italy and the Netherlands is a logbook not used. The GMS advises a combination of clinical and theoretical training as the best method 5. Most countries have this combination, but Denmark, Finland and Germany suffice with clinical training alone. The value of a final examination is a matter for debate. At present only five countries have introduced an examination to mark the end of training. The need for, and the benefits of, a European examination at the end of training in geriatric medicine require discussion. Some medical specialties have an examination but on a voluntary basis and it is seen as providing a European standard especially for those specialists who potentially want an academic or international position.

The United Kingdom and Italy have by far the greatest number of specialists and corresponding professional societies for geriatric medicine.

Geriatrics Fora within Europe
The European Association of Gerontology (IAG)
The objective of the IAG is to promote gerontological research in biological, medical, behavioural and social policy, and practice fields. It has a close relationship with the United Nations programme on Ageing. The IAG has five regional divisions: Europe, Africa, North America, Latin America and the Caribbean, and Asia/Oceania, and different sections have been established for social sciences, biological sciences and medicine. A world congress is organised every four years, the next being in Rio de Janeiro, Brazil, in August 2005. Regional congresses are organised in the intervening years

European Academy for Medicine of Ageing (EAMA)
In 1995 the EAMA started a programme for teaching and training the teachers in geriatric medicine. It was thought to be the best way of stimulating education in geriatric medicine for both medical students and specialist training. Each course is divided into four one-week sessions spread over two years. Geriatric medical issues, over a wide range, are covered during the four weeks, and include a large variety of medical problems, ethics, preparing and judging an article and aspects of management and education.

The executive board selects about 35 candidates on their functional abilities and their positions within educational or training institutions. The training consists of lectures by the students, and chairing and reporting the results of discussions in small groups. Highly renowned scientists are invited as teachers and participate in the discussions with the ‘students’ after the presentations. An individual evaluation is given by a tutor after all ‘students’ activities’. Five courses of four one-week sessions have been completed. The excellent feedback has encouraged the EAMA to continue this training 6, 7.

Geriatric Medicine Section of the UEMS
The statutory purpose of the UEMS is the harmonisation and improvement of the quality of medical specialist practice across the European Union. Education is a key element in this field, with the aim of studying, promoting and defending the free movement of specialists in the European Union. The UEMS collaborates with the Standing Committee of Doctors in Europe and with the European Union of General Practitioners and encourages information exchange between medical specialists 4. Special attention is given to the quality of specialists’ training and continuing medical education 8, 9. Medical specialties that have been recognised by at least eight European Union member states can be accepted as a section by the UEMS, and 36 sections have so far been established.

The main goals of the GMS are to provide a European view on geriatric medical services to the UEMS, to provide recommendations on training requirements in geriatric medicine and to encourage discussion of issues affecting older people across European Union countries. The GMS has developed guidelines for specialist training 5 and has prepared a chapter on geriatric medicine for the European Manual of Internal Medicine 10, which is aimed at all trainees in specialties that incorporate a period of training in internal medicine. The GMS is now preparing guidelines for the accreditation of specialist training in geriatric medicine. The requirements for the specialty are laid down in the Charter on Training of Medical Specialist in the European Union 8. National authorities are responsible for the selection and approval of training institutions and teachers in accordance with their national rules, European Union legislation and the recommendations from the GMS. The guidelines include site visits as an instrument of quality control 11.

European Union Geriatric Medicine Society (EUGMS)
Between 1999 and 2001 there were discussions between the national geriatric medicine societies of the European Union member states, when the general feeling was that there was a need for an umbrella medical society for geriatric medicine in the European Union. These discussions led to the launching of the EUGMS in August 2001. The mission of the EUGMS is to develop geriatric medicine in the member states of the European Union as an independent specialty caring for all older people with age-related disease. It will develop evidence-based guidelines for preventive and treatment strategies for older people within the European Union.

Unification of Diversity
The expected demographic change in the world will have a high impact on social and economical aspects of life. Part of the expected consequences of these increasing numbers are the associated health-related problems. Between the European Union countries there are great differences in geriatric medicine, regarding the structure, content, services, undergraduate and postgraduate training, and continuing medical education. The national governments are autonomous in their health care systems, yet it is accepted that there is free migration and exchange of medical specialists. Consequently the national geriatric medicine societies agreed to form the EUGMS. However, this society is not the only player in this field. The ER-IAG, the GMS and the EAMA also try to enhance the services for health-related problems in older people. The last thing that is needed is overlap and unnecessary competition between these players. In the current situation of limited resources, with co-operation, the position of geriatric medicine will strengthen. Competition will be fruitful as long as it stimulates creativity and additional resources.

The first step of co-operation was for the EUGMS to invite the ER-IAG, the GMS and the EAMA, to accept positions within the Society, in order to shape its overall position and to share the activities. The IAG’s ‘Research Agenda of Ageing for the 21st Century’ 12 and the ‘Valencia Forum’ 13 papers show that the IAG gives a high priority to social, economic, behavioural and biological aspects of care. Special attention is given to preventive health measures and health promotion activities. The ER-IAG promotes the development of CME and guidelines for common health problems, although here there may be an overlap with the activities of the EUGMS. The agenda for the congresses and symposia must be carefully drawn up and co-operation is needed in the development of guidelines for medical practice. It is to be welcomed that a representative of the ER-IAG is on the EUGMS board. The training of the teachers is well developed to a high standard by the EAMA, and there is no reason to change this. The EAMA accepted a position on the board of the EUGMS to emphasise the interaction between the two organisations, and the GMS has also become a board member. The tasks for the GMS are quality control, and development of guidelines and recommendations for education and training in geriatric medicine. Through this co-operation it is to be expected that there will be acceptance of the GMS guidelines by the EUGMS.

The health care system and the position of geriatric medicine in the United States of America are different from the European Union. Geriatric medicine in the USA has been developed, in the main, as a primary care specialty, with a number of linked nursing home facilities. Within the European Union some countries focus on primary and nursing home care, but in most countries the focus is on hospital services for older people. Research into ageing is well developed in the USA and putting this new research into clinical practice should have a positive effect on the quality of services for older patients around the world.

The IAG allows for exchange between the European and North American regions, but now the American Geriatrics Society (AGS) has a European counterpart in the EUGMS. The ‘1st Congress of the EUGMS’, in 2001, was also the ‘2nd Transatlantic Meeting’ between members of the AGS and the EUGMS.

The ER-IAG, the EUGMS and GMS all have aspirations to influence the political climate and national governments regarding geriatric medicine and the development of health services for older people. In the structure of the EUMS a link can be made between the GMS, the European Commission and the ministers of health care in the European Union member countries. Influencing the national governments via this route can take a long time, but joint recommendations of the three European Union organisations will have a much quicker and higher impact than advice given by these organisations alone.
Geriatric medicine is a growing specialty in the European Union. To meet society’s needs, to guarantee the quality of services, and to allow the free movement of specialists between the member states, is a process, that takes time and energy, but is worth doing. The ingredients for a successful future are available now.

Extracted from a paper entitled
Geriatric Medicine in the European Union: Unification of Diversity written by
Ian R Hastie and Sijmen A Duursma
on behalf of the Geriatric Medicine Section of the European Union of Medical Specialties (UEMS)

The article is a summary of an article published in Aging, Clinical and Experimental Research. The full article may be read in: Hastie I, Duursma S. Geriatric Medicine in the European Union: Unification of Diversity. Aging, Clinical and Experimental Research 2003; 15,4,4: 347-351

Acknowledgements
Thanks go to the members of the GMS of the UEMS, to Prof F. Guillén Llera, Prof. A. Capurso and Prof J.F. Macías Núñez of the IAG and Prof J.P. Michel of the EAMA for providing information on their organisations.

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