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EJMINT Editorial, 2012: 1204000018 (23rd January 2012)

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A new European Training Charter in Interventional Neuroradiology - INR
Olof Flodmark, Remy Demuth, Bernd Richling, et al
EJMINT Editorial, 2012: 1204000018 (23rd January 2012)

A new European Training Charter in Interventional Neuroradiology - INR

EJMINT Editorial, 2012: 1204000018 (23rd January 2012)
Olof Flodmark, Remy Demuth, Bernd Richling, Wolfgang Grisold, Laurent Pierot
Keywords: , ,

The importance of UEMS is well known to many medical specialists in Europe. UEMS (Union Européenne des Médecins Spécialistes/European Union of Medical Specialists) today represents 35 national organisations, some 1.6M medical specialists, and is involved in professional issues important to European specialists. UEMS, as an officially recognised and permanent consulting organisation to the European Institutions, has a significant influence on how these issues are formulated in Directives and Laws introduced in the European Parliament. UEMS is the one and only representation of medical specialists for the European Commission and Parliament. Most decisions regarding medical specialists are prepared in cooperation with UEMS. The full members of UEMS are the National Medical Associations; each specialty is represented by a Section or a Division. To have a UEMS Section or Division means that your specialty is recognised in Europe. The Division of Neuroradiology is the face and voice of European Neuroradiology in Brussels and thus in Europe. The Division truly represents all European neuroradiologists as a "Union" and is representing neuroradiologists in professional and legal issues. Scientific issues, however, are managed by the Scientific societies, while educational and training are shared interests.

The definition of a specialty in UEMS is defined by its training requirements. Thus, producing a Training Charter became the first issue for the newly established Division of Neuroradiology, supported by the Section of Radiology. Diagnostic or Clinical Neuroradiology is the core of neuroradiology while Interventional Neuroradiology includes techniques and procedures also practised by other specialists. Although most interventional neuroradiological endovascular procedures in Europe are performed by neuroradiologists, a significant number are performed by neurosurgeons and interventional radiologists and, to a lesser degree, cardiologists and neurologists. It is therefore obvious that all these disciplines must have an influence when defining the body of knowledge, skills and professional issues in Interventional Neuroradiology – INR.

It is often claimed by neuroradiologists that Interventional Neuroradiology was once developed by neuroradiologists and thus should remain within Neuroradiology. Such turf-battles are never productive and patients never win in these situations. It is preferable for the benefit of the patient that a given interventional procedure is performed by the most competent clinician. Every INR specialist has to be trained, albeit tailored to the needs of the trainee based on previous experience, to possess knowledge and skills. The aim of INR training must be to ensure that those practicing INR indeed possess a real competence to perform endovascular procedures safely and thus become respected as interventional neuroradiologists but with a background different from that of the neuroradiologist. An interventional neuroradiologist with a clinical background as a neurosurgeon or neurologist, for example, may also bring new energy into a team of interventional neuroradiologists and provide a solid platform from which a healthy practice of INR can truly claim full responsibility for the patient from establishing diagnosis, setting indications and therapeutic strategy to actual performance and post-procedural care and follow-up.

It is extremely important to have an INR common training programme for all interested specialists. If this is not the case, the end result will be that no rules regarding training or qualification will exist or be recognised by those practicing INR. It would make the field wide open for anyone to practice INR regardless of training or competence.

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"Particular Qualification"

The legislative apparatus of the European Union has several levels, EU rules, directives and communications. The middle level, EU Directives, represents guidelines to be incorporated in national law aiming to achieve similar national law systems throughout Europe. The EU Directive 2005/36/CE regulates professional licensing of all professions, including physician specialisation. This directive lists all recognised medical specialties; having a specialty named in this list leads to automatic acceptance of a doctor's specialty qualifications in all European Community countries. However, the list of specialties is outdated and no longer reflects medical developments. When this directive is due for revision in 2012, UEMS has chosen to correct this anomaly by proposing an amendment to the directive introducing the concept of "particular qualification". A "particular qualification" is not a new specialty, but it is meant to represent a recognised body of knowledge that exists over and above more than one specialty. INR fits very well into this concept as several recognised specialties have a vested interest. Assuming that the Division of Neuroradiology had made an attempt to write a Training Charter in INR without cooperating with other interested specialties, the UEMS Council would not have accepted such an attempt.

The Division of Neuroradiology, in conjunction with the Section of Neurosurgery, decided to take advantage of and use the concept of "particular qualification" as a roadmap to produce a Training Charter in INR. Invitations to participate in the work went out through the UEMS main office in Brussels to all UEMS sections and divisions. Thus, any specialty with even the slightest interest in INR was invited to participate in the work of forming a Training Charter. The obvious purpose in this methodology is that no section or division would be able to claim not being informed about the ongoing work.

The task force was formed by appointed representatives from the Sections of Neurology (W Grisold), Neurosurgery (B Richling) and the Division of Neuroradiology (L Pierot). Representation from the Sections of Cardiology (H Mudra) and Radiology (P Pattynama) joined the final meeting of the task force, which was chaired by the President of the Division of Neuroradiology (O Flodmark). The INR Training Charter purpose is to define the training needed to perform only endovascular procedures safely. Training needed for interventional percutaneous spinal procedures will be the topic of a separate charter.

The INR Training Charter [1]1. European Society of Radiology; Revised European Training Charter for Clinical Radiology; European Society of Radiology. Available at http://neuro.uemsradiology.eu/education.aspx1. Revised European Training Charter for Clinical Radiology; European Society of Radiology. [http://neuro.uemsradiology.eu/education.aspx] text was finalised in December 2010. It was discussed and approved in chronological order by the UEMS Division of Neuroradiology and Sections of Cardiology, Radiology, Neurology and Neurosurgery. On 8 October 2011 The UEMS Council gave final approval to the document. Consequently, the INR Training Charter is now an official UEMS recommendation and is part of the EU legislative apparatus through the Directive 2005/36/CE. Although the concept of "particular qualification" is not yet included in this directive, the sanction by the UEMS Council is vital and the declared intention has a strong influence on how specialists wishing to train in INR should act in order to end training with the appropriate qualification.

The concept of "exclusion by inclusion" is a key concept in this Charter. The basic principle is that all specialist doctors are welcome to train and become interventional neuroradiologists. This goal has been achieved by defining the common body of knowledge, skills and attitudes required for INR work. Transformed into a curriculum, it represents an agreed plan for training that if completed in full, will lead to recognition and "qualification" as an INR specialist. Those who do not wish to complete the full curriculum will not be recognised in Europe as INR specialists. The Charter also includes requirements applied to the Director of Training and the Training Centre.

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Highlights from the Charter of Training in INR

The full text is available from: http://neuro.uemsradiology.eu/education.aspx

The responsible UEMS institutions in Article 1.3.2 are defined as follows: "Identification, visitation and subsequent recognition of a training programme is a procedure, supervised by the UEMS and coordinated by the UEMS Division of Neuroradiology. This procedure is a joint responsibility of neuroradiology, radiology, neurosurgery and neurology."

The general objectives and goals of the training are outlined in Article 3.1.1: "Having finished the training programme, the specialist physician with particular qualification in INR, will be able to perform endovascular procedures as described in Art 4 in a team with other interventional neuroradiologists." It is common opinion that INR should ideally be practiced in teams where exchange of experience, knowledge and research is possible: "Thus solitary practice of INR is not recommended."

The length of the training programme is outlined in Article 2.2: "The education and training needed to become a specialist physician with particular qualification in Interventional neuroradiology is 4 years corresponding to full time study in an INR training programme. The 4 years consist of a core of INR of 24 months, clinical neuroscience for 12 months and diagnostic neuroradiology for 12 months."

It is recognised that many trainees will enter this programme with previous experiences and skills. Therefore, Article 2.2 continues: "Depending on previous training, the training time may be reduced as credit is given for previous training and clinical skills. The assessment of previous training and clinical skills and evaluation of remaining training time is the responsibility of the Director and each of the co-directors of the programme after a thorough and careful assessment of documented and proven training and experience."

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How does this Training Charter affect you?

This INR Training Charter is the result of a work done by five specialties working together to achieve a common goal: a clear definition of the entity "Interventional Neuroradiology" [2]2. UEMS; UEMS recommendations for acquiring "Particular qualification" in Endovascular Interventional Neuroradiology – INR; 08/10/2011; PDF Version2. UEMS recommendations for acquiring “Particular qualification” in Endovascular Interventional Neuroradiology – INR; UEMS 2011-10-08. [PDF Version]. This is the very first time that a number of UEMS recognised specialties have agreed on a common Training Charter. Mutual respect and recognition has prevailed between the specialties and this document is the result of cooperation and compromises with mutual acceptance and agreement among peers. Although "particular qualification" still has to be established in the EU legislation, the joint work by all concerned specialties gives a very strong signal about how this training should be and will be conducted; it is reasonable to assume that this will be part of the future directive replacing Directive 2005/36/CE in 2012.

With this background, it will be very difficult for a medical specialist who wishes to practice INR not to train according to this Training Charter. Any European specialist starting INR training from now on is strongly advised to train according to this Charter; moreover, any European specialist presently in INR training should supplement his/her training to be in agreement with this Charter. Further, it is reasonable to assume that any European specialist claiming expertise in INR whom has not established practice in INR before October 2011, and whom finds him- or herself involved in a malpractice suit, may stand a significant risk of being accused of not being properly trained in INR if not trained according to this new Charter. However, the Charter has no retroactive effect and it is recognised that there are a number of specialists in Europe already performing all or some of the INR activities detailed in this Training Charter. These specialists have acquired the right to continue their practice.

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Although the body of knowledge and the training programme of INR is now established and published, two significant pieces of the framework are still missing: rules for visitation of the INR training centres and the development and introduction of a European examination in INR. Both fields need to cooperate across scientific societies and with the UEMS Institution. Both procedures require the assistance of a level of competence available only within the scientific societies while the regulatory framework must be in agreement with UEMS standards in order to maintain international credibility and recognition by both national and European authorities.


  1. European Society of Radiology; Revised European Training Charter for Clinical Radiology; European Society of Radiology. Available at http://neuro.uemsradiology.eu/education.aspx
  2. UEMS; UEMS recommendations for acquiring "Particular qualification" in Endovascular Interventional Neuroradiology – INR; 08/10/2011; PDF Version