i cal spe cialty of its own right at th

•
Clinical Neuropathology, Volume 30 – No. 1/2011, p 43
Neuropathology on the
verge to become an
independent specialty
in the UK
Society News
European
Confederation of
Neuropathological
Societies
Dear Reader,
A key goal of Euro-CNS is the recognition of Neuropathology as a medical specialty of its own right at the
EU level. Currently, Neuropathology
holds a full specialty status in 4 EU
member states (Austria, Germany,
Ireland, Hungary). According to current EU regulations, Neuropathology
will attain only a specialty status at the
EU level if a national specialty status
exists in at least 2/5 (= minimum 10)
EU member states. In this regard, we
are faced now with an important
move in the UK: Neuropathology
seems to be on the verge to become a
fully independent specialty in Great
Britain. We anticipate that the favorable development in such an important EU country like the UK will stimulate and facilitate the development
of the Neuropathology specialty status also in other member states. In this
context it is important to know the exact causes and mechanisms that have
been paving the way in the UK. We
are grateful to Paul Ince (Sheffield)
who is providing us with detailed insight in the British situation. Among
many decisive factors, broad-based
external support, in particular by representatives of clinical neuroscience
disciplines, seems to be of crucial importance.
Kind regards,
Editorial Team Euro-CNS News
Neuropathology in the United
Kingdom is now embarked on a development that may radically change
the status of the discipline within the
National Health Service (NHS). As in
many countries Neuropathology in
the UK grew from roots in both the
clinical sciences (e.g. neurologists establishing diagnostic laboratories for
neuromuscular diseases) and in Laboratory Medicine (e.g. for neuro-oncology and autopsy diagnosis). Until
the last 20 years the background of
practizing Neuropathology consultants reflected this diversity. In the
1980’s there were as many Neuropathologists who had come into the
discipline from a clinical neuroscience training background (mostly
from Neurology but also from psychiatry and neurosurgery) as there were
from subspecialist pathologists. The
gradual adoption of national clinical
governance structures, even before
that now all pervading conceptual
framework had been recognized, was
associated with a gradual move towards a system of training and qualification that was exclusively administered as a branch of histopathology.
Responsibility for training and accred itation within the NHS is distributed among a number of bodies.
The Royal College of Pathologists
(RCPath) define and manage the
standards for training and service delivery. RCPath prepares the training
curricula for Laboratory Medicine
and runs the program of examinations
and assessment that determine progress throughout the training years.
The Department of Health (DoH), under the authority of the Secretary of
State, authorizes conferment of specialty status (i.e. which medical disciplines are officially a specialism and
which are subspecialties) and employ
specialists in hospitals, although increasingly at “arms-length” through
the adoption of Foundation Trust sta-
Euro-CNS News
tus that devolves the employment of
doctors down to the level of individual hospitals. The Postgraduate Medical Education and Training Board
(PMETB) approves UK postgraduate
medical training programs and curricula and is being merged with the General Medical Council (GMC) who
keep an official list of practitioners
who have successfully completed
training and who confer the Certificate of Completion of Training (CCT)
enabling acceptance onto the Specialist Register. A doctor is not able to be
appointed to a consultant post in the
UK unless they are on this list.
There are two routes to Specialist
registration; the first involves the
completion of an approved training
program in the UK and progress
through to the award of a CCT. The
second, increasingly used because of
the need to permit freedom of movement for all EU medical staff, is called
“Article 14” registration. This process, beyond the scope of this discussion, essentially uses detailed CV information (supported by evidence) to
determine the equivalence of an applicant’s training and experience
compared to a UK trained doctor. The
DoH relies on the Royal Colleges to
scrutinize and advise on Article 14
applications.
Until 2009 Neuropathology trainees followed Histopathology training
through to a point at which they transferred to Neuropathology training
(Figure 1).
A trainee would take the FRCPath
Part 1 examination during ST2 in general histopathology and then transfer
to full-time training in Neuropathology, taking the FRCPath Part 2 Neuropathology examination during ST4/5.
Having completed the examination,
and ST5, the RCPath would recommend that the trainee be awarded a
CCT in Neuropathology.
A problem has arisen because
PMETB reviewed their policy regarding medical subspecialty status in the
UK. Under their new interpretation of
the rules a subspecialist practitioner is
required to have full competency and
Figure 1. FY = Foundation year, the two years in training immediately following graduation from medical school; ST = Specialist Trainee.
Clinical Neuropathology, Volume 30 – No. 1/2011, p 44
registration in the main
specialty and then should
develop additional competencies in the subspecialty. For
Neuropathology this would mean that
trainees in the future would have to
train fully, and take the FRCPath examinations, in Histopathology (as in
the diagram) and then undergo further
training. The extra training would also
involve taking the FRCPath part 2 examination in Neuropathology, and
would add a minimum of 2 extra years
after ST5. This extra time might be
more for many candidates who did
not progress through the first period
of training up to general histopathology level in the minimum time (e.g. if
any examination or assessments were
failed and needed to be repeated). The
effect on recruitment, and the future
of neuropathology as an academic
discipline in the UK, would have been
disastrous.
The only solution that was offered
was to revisit the possibility that
Neuropathology should become a
specialty in its own right. This possibility was initially problematic because the DoH had applied a moratorium on the creation of any new medical specialties. However we have now
been allowed to apply to become a
specialty. The process has involved
two stages led by Dr John Xuereb. In
Stage 1 we presented an evidencebased case of support for the need to
create a specialty of Neuropathology.
This case was based on accumulating
a large number of supportive letters
from those Hospitals Trusts which
had Neuroscience departments, national bodies (Royal Colleges and Societies) representing our various clinical neuroscience colleagues, national
patient representative organizations
concerned with a range of neurological
diseases, and some key national bodies
involved in the support and development of clinical neuroscience research.
We also presented the argument that
Neuropathology, in practice, already
existed as if it were a specialty in the
UK but was anomalously governed
as if it were a subspecialty.
The Stage 1 application was favorably received and we have
now developed
the Stage 2 application.
This
required
Euro-CNS News
writing a full curriculum in association with the RCPath, together with
all the associated elements of training
and assessment needed to implement
a new training program in our highly
regulated system. If the proposal is
accepted, by DoH, for the first time
there will be a national recruitment
process to Neuropathology training
with a single centralized admissions
system run through the RCPath. This
will allow us to regulate the number
of trainees in the hope of avoiding significant issues of under or over-supply of specialists in the future. The
training will inevitably still involve
some integration into existing Histopathology training programs to deliver key training in generic competencies. The new arrangements will
also potentially allow us to uncouple
from a completely ‘run-through’ training model so that we will be able to accept entry of trainee clinical neuroscientists from other disciplines (e.g.
Neurology and Neurosurgery) in a
way that has been impossible for the
last 15 years.
The clinically active members of
the BNS unanimously welcome this
development and have supported the
process of applying for specialty status whole-heartedly. We hope our application is ultimately successful.
Whilst it does not solve the general
problem of specialty status throughout Europe we hope that this UK development will be an effective lever in
the general goal of Euro-CNS to see
Neuropathology established as widely
as possible as an independent specialty,
linked to Histopathology and sharing
many technological approaches, but
with a distinct identity as a branch of
the clinical neurosciences.
•
By Paul Ince,
Sheffield
European Fellows in
Neuropathology 2010
Following successful examination on
18 and 19 January 2010 in Amsterdam,
Professor Astudillo-Gonzalez from
Hospital Universitario Central de
Asturias in Oviedo, Spain, and Dr.
Nicolas Schröder from Charité Universitätsmedizin in Berlin, Germany,
have been elected to the European Fellowship in Neuropathology (EFN). The
EFN examination constitutes an as-
sessment of candidates’ knowledge of
diagnostic neuropathology and their
ability to apply that knowledge in the
clinical practice. Thus, it provides external quality assurance that a trainee
in neuropathology practice has
reached the standard appropriate for
practice as an unsupervised specialist
in diagnostic neuropathology. For
more details please visit the EuroCNS website: www.euro-cns.org.
ä
Mini teaching corner
Figure 1. Hippocampal neuron with intracytoplasmic star-like inclusion from an individual with neuronal intermediate filament
inclusion disease (HE ´ 600). Inclusions
are argyrophilic and immunoreactive for
neurofilaments and alpha-internexin. FUS
is being tested.
Contributet by the Neurological Tissue Bank,
University of Barcelona – Hospital Clinic.
Contact Us
Editor-in-Chief of Clinical
Neuropathology:
Johannes Andreas Hainfellner,
e-mail: johannes.hainfellner@
meduniwien.ac.at
Editorial Team Euro-CNS News:
Ilja Huang,
e-mail: [email protected]
Ellen Gelpi,
e-mail: [email protected]
Website: www.euro-cns.org