H-Net, the 3-year European Network for Harmonization of Training in Hematology project led by Professor Eva Hellström-Lindberg, ended in September 2011, but its strongest components continue. The project is an assembly of 22 of the most important hematology organizations in Europe (and beyond) working to improve the mobility of students and professionals by raising their skills to an equally high standard across countries.
The H-Net project included a political element which was designed to implement the strategies of the Lifelong Learning Programme and arrive at a truly harmonized curriculum for European hematologists, thus raising the competence levels of hematologists and, ultimately, improving patient care and public health. This article is a reflection on what the H-Net project has achieved so far in terms of policy to reach this goal. The paper also aims to provide strategies to promote these ambitions after the three years of the project and calls upon you, the reader, to take action and stand up for the education of hematologists in Europe.
Education and training are largely a national prerogative. It is at the level of the Member State where policies about the education of medical specialists are decided upon and implemented. That is not to say that education is entirely out of the remit of the European Union. The Lisbon Treaty, unchanged from the Maastricht Treaty of 1992, states that “the Community shall contribute to the development of quality education by encouraging co-operation between Member States and, if necessary, by supporting and supplementing their action, while fully respecting the responsibility of the Member States for the content of teaching and the organization of education systems and their cultural and linguistic diversity.” H-Net, for example, is a project funded by the European Union (DG Education and Culture) in the context of the Lifelong Learning Programme, which itself aims for structural change through support of policy development, cooperation and mobility. H-Net is a continuation of the previous ECAH project that had similar goals.
Strategies towards harmonization
The European Hematology Network
Several strategies are adopted to support the harmonization of the speciality training of hematology in Europe. The first is the H-Net network itself that includes most national societies of hematology in Europe and provides a platform for debate among national society representatives in regular meetings, as well as co-operation in project work packages. This network intends to continue with an annual meeting of the existing representatives from national societies of hematology in Europe, who are fondly known as Linkers with a long-standing responsibility for feeding national experience into H-Net and implementing results back on a national level. Hence the continuity of discussion and cooperation between European stakeholders is ensured.
The European Curriculum for Hematology
The development of a curriculum for speciality training in hematology is in itself an instrument of harmonization. The European Curriculum for Hematology was first published in 2006 and was updated in 2011. Organized in sections, subsections, and items, the curriculum consists of an itemized list of skills and competences that describe the entire spectrum of hematology. Each item is given a minimum recommended level of skill or competence that a junior hematologist is expected to have achieved in training.
The curriculum is developed by the European Hematology Association through a consensus building process that includes the involvement of several experts in particular aspects of the speciality. They select the items to be included in the curriculum and set the recommended levels of skill and competence. The draft curriculum is then sent to the presidents of most national societies of hematology in Europe for their comments. The comments of the national societies are taken into consideration and acted upon as far as possible, and the experts send a finalized curriculum to the national societies of hematology for their endorsement. Thus, the development of the European Curriculum for Hematology is a tool that harmonizes the education of medical specialists in hematology through a bottom-up or consensus building process. Similar medical curriculum structures are very rare and none have been prospectively evaluated and updated.
In 2010-2011, the curriculum was updated according to the same process. At the time of writing, the national societies of the following 27 countries have endorsed the updated European Curriculum for Hematology: Portugal, Switzerland, Poland, the Czech Republic, Bulgaria, Austria, Denmark, France, Spain, the Netherlands, Sweden, Hungary, Finland, Croatia, Turkey, Belgium, Germany, Estonia, Slovenia, Slovakia, Israel, Macedonia, Ireland, Norway, Greece, Latvia, and Italy. The network will continue to update the European Curriculum for Hematology at regular intervals along the lines outlined in the process described above.
The partial incorporation into national curricula
Several countries have incorporated (or are in the process of incorporating) parts of the European Curriculum for Hematology into their national curricula. These countries include Switzerland, Greece and Austria. Others have declared that they will follow suit. Clearly, adoption of parts of the European Curriculum for Hematology into the national curriculum is the ultimate means to harmonize it. This will often entail extensive lobbying from the national society of hematology and will be facilitated, where possible, by the European Hematology Association.
At the time of writing, the European Curriculum for Hematology has been translated into Greek, Turkish, French, German, and parts of it into Polish. Translations into Bulgarian, Czech, Italian, Norwegian, and Romanian are planned. In many other countries, it is felt that the English language version of the curriculum is sufficient as English language skills are a prerequisite to entering education in medicine. Obviously, translating the European Curriculum for Hematology breaks down language barriers that would otherwise have hampered the dissemination of the curriculum in countries where English is not a second or third language.
Before the H-Net project, the European Curriculum for Hematology was made available to hematology trainees in the form of the so-called CV-Passport. In addition to the itemized list and the recommended skill and competence levels, the CV-Passport also includes pages on which a trainee’s mentor or tutor can ‘sign off’ parts of the curriculum when the defined standard has been reached. Thus, with the CV-Passport in hand, the trainee can move around freely and is encouraged to follow parts of his or her specialized training in different locations, be these within or outside his or her own country. In the context of the H-Net project, the partners have continued to promote the use of the CV-Passport by European trainees through their extensive dissemination of the project. Equally, it is hoped the opposite will happen, i.e. the implementation and use of the CV-Passport by European trainees will increase through its dissemination by the project partners. In addition, the updated version of the CV-Passport has been published in print, is available in a PDF format for downloading, and is also available as an online passport with links to learning resources (http://ehaweb.org/education-science/online-learning-tools/curriculum-cv-passport/).
An additional and gratifying result from the H-Net project is that many partners are tailoring their educational activities on the basis of the educational strategy report that was developed by the H-Net project. This report is an analysis of a survey that established differences between the recommendation levels of the European Curriculum for Hematology and the actual competence levels in European countries. Thus, a long-term harmonization process of education has been established, through a bottom- up process, by modifying educational opportunities to bring them into line with the minimum recommendations expressed in the European Hematology Curriculum. Future educational opportunities organized by H-Net partners will take into account the recommendations made in the educational strategy report. In addition, new educational strategies may be developed as a consequence of further insights generated by a new survey.
Before harmonization of speciality training in hematology across Europe can be realized, national fragmentation of the speciality should be prevented. In two countries, Bulgaria and Portugal, efforts are being made to converge several hematologic specialities into one. Recently, the Bulgarian Society successfully addressed the Ministry of Health on the problems associated with three recognized specialities in hematology (clinical hematology, transfusion hematology, and pediatric hematology and oncology) of which only one (transfusion hematology) is recognized as a speciality in the Professional Qualifications Directive. In Portugal, the Portuguese Society of Hematology is committed to continuing its efforts to merge clinical hematology and immuno-chemotherapy. National societies of hematology will continue to address the relevant authorities (e.g. Ministry of Health, Medical Council) to merge the different specialities of hematology into one.
The Professional Qualifications Directive
One major policy dossier on the level of the European Union, which is relevant to the harmonization of speciality training of hematologists, is the Professional Qualifications Directive (PQD, or Directive 36, as it is usually called (http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:2005L0036:20110324:EN:PDF.). In the context of the Single Market Act, its purpose is, amongst other things, to facilitate the free movement of professionals across Europe, including medical specialists. The directive prescribes the automatic recognition in host Member States of the training medical doctors have received in another Member State. Annex V of the Directive includes the stipulation that the minimum period of training in general hematology be three years and that the minimum period of training in biological hematology be four years.
Clearly, this is not enough. The European Curriculum for Hematology describes in detail the competences and skills that are associated with the speciality of hematology. Currently, the Directive prescribes a minimum duration of training of three years of hematology. Given the scope of the discipline, this is clearly not enough to allow trainees to gain sufficient training to manage patients with hematologic diseases properly.
On 11 March 2011, H-Net adopted the “Brussels Declaration on the Recognition of Professional Qualifications”. The declaration was a call to the European Commission to increase the minimum period of training and to consider the European Curriculum for Hematology when extending the minimum requirements to actual competences. The declaration was annexed to the response of the European Hematology Association to the Consultation Paper by DG Internal Market and Services on the Professional Qualifications Directive of 7 January 2011 (http://ehaweb.org/news/eha-news/advocacy/).
Since then, the European Commission has presented, in December of 2011, a proposal to the European Parliament and the European Council to revise Directive 36. This proposal is an important step forward as it aims to modernize the system of automatic recognition of qualifications of the medical specialist. It is sensitive to the problem of minimum training requirements as it will empower the Commission to adapt these to scientific progress by way of so-called delegated acts. Several committees in the parliament have deliberated on the issue or will do so in the near future. A first plenary reading of the proposal is scheduled to take place in January of 2013. On the issue of minimum training requirements, it is proposed that the European Parliament adopt an amendment that stipulates that all medical specialist training has a duration of at least five years, which may also be expressed in terms of ECTS (European Credit Transfer and Accumulation System) credits (http://ec.europa.eu/education/lifelong-learning-policy/ects_en.htm).
The European Competitiveness Council will first discuss the proposal on the occasion of their meeting of 10-11 December 2012. Because the Council is composed of the ministers of the EU Member States, we call upon you to contact your minister and ask him or her to support the amendment that the minimum training requirements be set to at least five years.
H-NET as a project finished in 2011. However, the EHA and its project partners strongly believe that harmonization of medical education and training in hematology must continue and is crucial for continued improvements in patient care. Therefore, the EHA has taken the initiative of continuing with activities in this direction and invites partners to participate in these. For more information, visit the EHA website at www.ehaweb.org.
The outcomes of the H-Net project and future plans can be summarized as follows:
- – Finalized and reported to national societies – continuous survey planned
- – CV-Passport version 2 launched in hard copy, PDF and online version – further updates approximately every five years.
Strategy for Targeted Education
- – Identifying appropriate educational tools and length of training
- – National and European strategies based on survey results
- – Successfully piloted and continuing in 2012-2013 and beyond
Policy Conferences and Linkers Meetings
- – Continuing on an annual and ad hoc basis. These should be more numerous while projects are ongoing
- – In harmony with the EHA Advocacy and Political Affairs activities
- Thom Duyvené de Wit is Lobbyist at the European Hematology Association. Eva Hellström-Lindberg is Professor of Hematology at the Karolinska Institute, Karolinska University Hospital in Stockholm, former Project Leader of H-Net and former Chair and now ex-officio Member of the Curriculum Committee of the European Hematology Association. Ulrich Jäger is Professor of Hematology at the Medical University of Vienna, President of the European Hematology Association and Chair of the Advocacy and Political Affairs Committee of the European Hematology Association. Gareth Evans-Jones is Project Manager for Medical Education, EU Projects and CME at the European Hematology Association. Carin R. Smand is Managing Director of the European Hematology Association.
- Financial and other disclosures provided by the author using the ICMJE (www.icmje.org) Uniform Format for Disclosure of Competing Interests are available with the full text of this paper at www.haematologica.org.