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Training in infectious diseases across Europe in 2021 – a survey on training delivery, content and assessment

  • Author Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Ronja A. Brockhoff
    Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Affiliations
    University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany

    University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany

    German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
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  • Author Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Scott R. Hicks
    Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Affiliations
    Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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  • Jon Salmanton-García
    Affiliations
    University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany

    University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany

    German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
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  • Davorka Dušek
    Affiliations
    Medical School University of Zagreb and Zagreb University Hospital for Infectious Diseases, Zagreb, Croatia
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  • Jean-Paul Stahl
    Affiliations
    Infectious Diseases Department, University and Hospital Grenoble Alpes, Grenoble Cedex, France
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  • Author Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Nick J. Beeching
    Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Affiliations
    Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK

    Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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  • Author Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Oliver A. Cornely
    Correspondence
    Correspondence author: Oliver A Cornely, Department I of Internal Medicine, University Hospital Cologne, 50937 Cologne, Germany.
    Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
    Affiliations
    University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany

    University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany

    German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
    Search for articles by this author
  • Author Footnotes
    † Ronja A Brockhoff and Scott R Hicks contributed equally as junior authors. Nick J Beeching and Oliver A Cornely contributed equally as senior authors.
Open AccessPublished:August 06, 2021DOI:https://doi.org/10.1016/j.cmi.2021.07.033

      Abstract

      Objectives

      To define the status of infectious diseases (ID) as an approved specialty in Europe; to enumerate the number of specialists (in general and in relation to the overall population) and specialist trainees and describe the content, delivery and evaluation of postgraduate training in ID in different countries.

      Methods

      Structured web-based questionnaire surveys in March 2021 of responsible national authorities, specialist societies and individual country representatives to the Section of Infectious Diseases of the European Union for Medical Specialties. Descriptive analysis of quantitative and qualitative responses.

      Results

      In responses received from 33/35 (94.3%) countries, ID is recognized as a specialty in 24 and as a subspecialty of general internal medicine (GIM) in eight, but it is not recognized in Spain. The number of ID specialists per country varies from <5 per million inhabitants to 78 per million inhabitants. Median length of training is 5 years (interquartile range 4.0–6.0 years) with variable amounts of preceding and/or concurrent GIM. Only 21.2% of countries (7/33) provide the minimum recommended training of 6 months in microbiology and 30% cover competencies such as palliative care, team working and leadership, audit, and quality control. Training is monitored by personal logbook or e-portfolio in 75.8% (25/33) and assessed by final examinations in 69.7% (23/33) of countries, but yearly reviews with trainees only occur in 54.5% (18/33) of countries.

      Conclusions

      There are substantial gaps in modernization of ID training in many countries to match current European training requirements. Joint training with clinical microbiology (CM) and in multidisciplinary team working should be extended. Training/monitoring trainers should find greater focus, together with regular feedback to trainees within many national training programmes.

      Keywords

      Introduction

      The current coronavirus disease 2019 (COVID-19) pandemic has reinforced the need for infectious disease (ID) specialists and clinical microbiologists (CM) to collaborate across Europe, meeting the threats of emerging infections and future pandemics [
      • Koehler P.
      • Bassetti M.
      • Chakrabarti A.
      • Chen S.C.A.
      • Colombo A.L.
      • Hoenigl M.
      • et al.
      Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance.
      ,
      • Petersen E.
      • Petrosillo N.
      • Koopmans M.
      ESCMID Emerging Infections Task Force Panel
      Emerging infections-an increasingly important topic: review by the Emerging Infections Task Force.
      ]. Recognition and management of infections acquired during travel or migration is increasingly important [
      • Petersen E.
      • Petrosillo N.
      • Koopmans M.
      ESCMID Emerging Infections Task Force Panel
      Emerging infections-an increasingly important topic: review by the Emerging Infections Task Force.
      ,
      • Schlagenhauf P.
      • Weld L.
      • Goorhuis A.
      • Gautret P.
      • Weber R.
      • von Sonneburg F.
      • et al.
      EuroTravNet. Travel-associated infection presenting in Europe (2008–12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation.
      ,
      • Bloom D.E.
      • Cadarette D.
      Infectious disease threats in the twenty-first century: strengthening the global response.
      ], as are countering antimicrobial resistance, with proven effectiveness of antimicrobial stewardship and specialist advice on patient management [
      • Bloom D.E.
      • Cadarette D.
      Infectious disease threats in the twenty-first century: strengthening the global response.
      ,
      • Schmitt S.
      • McQuillen D.P.
      • Nahass R.
      • Martinelli L.
      • Rubin M.
      • Schwebke K.
      • et al.
      Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs.
      ] and of infection prevention and control [
      • Tsioutis C.
      • Birgand G.
      • Bathoorn E.
      • Deptula A.
      • Ten Horn L.
      • Castro-Sánchez E.
      • et al.
      Education and training programmes for infection prevention and control professionals: mapping the current opportunities and local needs in European countries.
      ,
      • Brouqui P.
      • Puro V.
      • Fusco F.M.
      • Bannister B.
      • Schilling S.
      • Follin P.
      • et al.
      Infection control in the management of highly pathogenic infectious diseases: consensus of the European Network of Infectious Disease.
      ]. There is a wide range of provision of clinical specialists in infection in different countries, with significant overlap of many areas of professional practice [
      • Dickstein Y.
      • Nir-Paz R.
      • Pulcini C.
      • Cookson B.
      • Beovic B.
      • Tacconelli E.
      • et al.
      Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey.
      ]. The need for additional staffing, collaborative clinical work, training and research between ID and CM has been repeatedly emphasized over the past 20 years [
      • Dickstein Y.
      • Nir-Paz R.
      • Pulcini C.
      • Cookson B.
      • Beovic B.
      • Tacconelli E.
      • et al.
      Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey.
      ,
      • Cooke F.J.
      • Choubina P.
      • Holmes A.H.
      Postgraduate training in infectious diseases: investigating the current status in the international community.
      ,
      • McKendrick M.W.
      • European Union of Medical Specialties
      The European Union of Medical Specialties core training curriculum in infectious diseases: overview of national systems and distribution of specialists.
      ,
      • Read R.C.
      • Cornaglia G.
      • Kahlmeter G.
      European society of clinical microbiology and infectious diseases professional affairs workshop group. Professional challenges and opportunities in clinical microbiology and infectious diseases in Europe.
      ].
      In 2018, the Section for Infectious Diseases of the European Union of Medical Specialists (UEMS-ID) published an updated European Training Requirement (ETR) recommending indicative training periods of a minimum of 2 years in general internal medicine (GIM) and 4 years of specialty ID training [
      European Union of Medical Specialists (UEMS)
      Training requirements for the specialty of infectious diseases - European standards of postgraduate medical specialist training.
      ]. The development of the ETR and its predecessors has been summarized elsewhere [
      • McKendrick M.W.
      • European Union of Medical Specialties
      The European Union of Medical Specialties core training curriculum in infectious diseases: overview of national systems and distribution of specialists.
      ,
      • Beeching N.J.
      • Rautelin H.
      • Stahl J.-P.
      • Leegard T.M.
      Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe.
      ]. In addition to curricula with details of professional competencies to be achieved by the trainee and methods of assessing trainees' progress, there is strong emphasis on adequate organization of training, accreditation of specialists as trainers, and approval and monitoring of training programs [
      • Beeching N.J.
      • Rautelin H.
      • Stahl J.-P.
      • Leegard T.M.
      Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe.
      ].
      This article describes the status of ID training across Europe in 2021 including clinical assessment, curricular updates and governmental regulation. It examines early effects of the COVID-19 pandemic on training and its possible impact. Areas for future improvement are outlined, for countries to learn and adopt good practice from one another.

      Materials and methods

      Information was collected from practitioners throughout Europe in March 2021 using electronic questionnaires (see Supplementary material, Tables S1 and S2) sent out to UEMS representatives, national authorities and/or ID specialist societies of the 35 full or associate UEMS member states (Fig. 1). Respondents were then contacted electronically and by telephone up to five times for follow-up queries and validation of data (Fig. 2). The electronic case report forms were based on previous data collection at annual meetings of the UEMS-ID section, revised and then developed with the EFS Survey™ (Questback, Cologne, Germany). For further detail see the Supplementary material (Appendix S1).
      Fig. 1
      Fig. 1Official approval status of infectious diseases in 35 full or associate UEMS member countries in 2021. No data was received for Bulgaria.
      Fig. 2
      Fig. 2Process of data acquisition for questionnaire 1 and 2. The first questionnaire (left side of flowchart) collected information on national authorities responsible for ID training and specialist societies. These were then contacted with the second questionnaire (right side of flowchart) to provide information on ID training delivery.

      Results

       Statistical overview and recent development in terms of ID accreditation

      Full responses were received from 33/35 (94.3%) countries (Table 1). ID is regarded as a specialty in 24 countries, as a subspecialty of GIM in eight and is not recognized in one (Fig. 1). ID was approved as an independent specialty in France in 2011 and in Germany in 2021, and as a subspecialty of GIM in Belgium in 2020. Official approval in Spain has been awaited for over a decade, despite training being well established in several university centres. Paediatric ID is recognized as a separate specialty or subspecialty of paediatric medicine in at least 17/33 (51.5%) countries.
      Table 1Status of infectious disease training and service provision in 33 European countries (full or associate members of UEMS)
      ID specialists (n)Trainees/year (n)ID trainers (n)Training centres (n)Workforce planningTraining in ID (total)Training in GIMPaediatric IDFormal exam
      Countries in which ID is a specialtyTotal in 2020
      Current numbers are estimates supported by statistics of the previous year.
      Total/million inhabitants [
      The World Data Bank
      Popular indicators.
      ]
      Total in 2020
      Current numbers are estimates supported by statistics of the previous year.
      In 2020
      Current numbers are estimates supported by statistics of the previous year.
      Total in 2020
      Current numbers are estimates supported by statistics of the previous year.
      National policyOfficial curriculumDuration (years)Duration (years)Specialty statusForm of exam
       Armenia551810152Yes3Subspecialtyo, w
       Croatia1303230104Yes52 CT
      Training in GIM precedes ID training.
      SpecialtyC
       Czech Republic35033104527Yes53 CTc, o
       Denmark1402491105YesYes51.75 CT
       Estonia40313106YesYes40.5 CTSubspecialtyo, w
       Finland50955563 CT∗Subspecialtyw
       France70010458030YesYes51 CT
       Germany
      In May 2021, ID was recognized as a specialty in Germany. The implementation of an official training curriculum with regards to the decree is anticipated.
      767 [
      • Ärztinnen/Ärzte mit Bundesärztekammer
      Zusatz-Weiterbildungen nach Tätigkeitsarten.
      ]
      966 [
      • Liste der Landesärztekammern Bundesärztekammer
      ]
      155 [
      • Liste der Landesärztekammern Bundesärztekammer
      ]
      124
      Only 31 of 124 training centres are accredited by the German Society for Infectious Diseases and therefore comparable to European standards.
      [
      • Liste der Landesärztekammern Bundesärztekammer
      ]
      Yes [
      Bundesärztekammer (Arbeitsgemeinschaft der deutschen Ärztekammern)
      ]
      1 [
      Bundesärztekammer (Arbeitsgemeinschaft der deutschen Ärztekammern)
      ]
      5
      Training in GIM precedes ID training.
      [
      Bundesärztekammer (Arbeitsgemeinschaft der deutschen Ärztekammern)
      ]
      o [
      Bundesärztekammer (Arbeitsgemeinschaft der deutschen Ärztekammern)
      ]
       Hungary2002083013YesYes50.5 CTc, o
       Ireland1946187YesYes73 CT
      Training in GIM precedes ID training.
       + 2 or 2 CT
      Training in GIM precedes ID training.
      only
       Italy1500259710025YesYes40.3 CTo, w
       Latvia10053UNKUNK2YesYes5UNK
      Training in GIM precedes ID training.
      Specialtyc, o, w
       Lithuania123442
      In Lithuania, a decrease in numbers of trainees terminating ID training has been observed due to structural problems caused by the COVID-19 pandemic.
      122YesYes42 CT
      Training in GIM precedes ID training.
      Subspecialtyc, o, w
       Luxembourg
      In Luxembourg, ID specialists are trained abroad (predominantly in Belgium; also, France and Spain). Trainees spend one year of training in Luxembourg. After that, training is continued abroad.
      610111NoNo
       Malta
      In Malta, ID is considered a specialty in terms of training, but as a subspecialty within the working system of the Department of Medicine. Employment requires specialization in both, GIM and ID.
      714181YesYes62
      Training in GIM precedes ID training.
       +3 CT
      Subspecialtyw
       Poland1131301304576Yes50.7 CTo, w
       Portugal30029189012YesYes51 CTc, o
       Romania70036503006YesYes52 CTc, o, w
       Slovakia801553NoYes51 CT
      Training in GIM precedes ID training.
      o, w
       Slovenia1055040245YesYes61.1 CTSpecialtyc, o
       Sweden800782003030Yes51 CT
       Switzerland3003515405Yes63 CT
      Training in GIM precedes ID training.
      Subspecialtyc, o, w
       Turkey13001612030090Yes50.5Subspecialtyo, w
       UK27347020040YesYes73 CT
      Training in GIM precedes ID training.
       + 2 or 2 CT
      Training in GIM precedes ID training.
      only
      Subspecialtyw
      Countries in which ID is a subspecialty
       Austria712742
      In Austria, there is a total of 42 training centres. Training is only performed in eight of those centres because numbers of trainers are limited.
      Yes62.25 CTo, w
       Belgium
      Numbers for Belgium are based on estimates. ID was recognized as subspecialty for the first time in May 2020.
      1009204010Yes43.5
      Training in GIM precedes ID training.
       Cyprus
      In Cyprus, there are no official training centres. Based on a bilateral agreement between Cyprus and Greece. Cypriot, Greek and EU citizens can perform their ID residency in Cypriot hospitals, if accredited by the Greek Ministry of Health.
      108Yes25
      Training in GIM precedes ID training.
      Subspecialtyo, w
       Greece70710206Yes25
      Training in GIM precedes ID training.
      Subspecialtyo, w
       Iceland
      In Iceland, there are no training institutions. ID training is performed abroad (Sweden, UK, USA).
      205033 CT
      Training in GIM precedes ID training.
      Subspecialty
       Israel235261223518Yes24 CT
      Training in GIM precedes ID training.
      Subspecialtyo, w
       Netherlands150920107Yes24
      Training in GIM precedes ID training.
      Specialty
       Norway17533141004YesYes64 CT
      Countries in which ID is not a specialty
       Spain
      ID is not recognized as a specialty in Spain. Training delivery and duration are highly variable depending on local regulations and training institutions. Trainees participate in different courses/rotations.
      400950UNK30NoUNK
      Abbreviations c, clinical examination; CT, common trunk; GIM, general internal medicine; ID, infectious diseases; o, oral examination; UNK, unknown; w, written examination; –, not applicable.
      Data collected from representatives of the Infectious Disease Section of the UEMS and national health authorities in 2021. No response was received from Bulgaria or Serbia. Numbers are estimates based on statistics of the previous year.
      Training in GIM precedes ID training.
      a In May 2021, ID was recognized as a specialty in Germany. The implementation of an official training curriculum with regards to the decree is anticipated.
      b In Luxembourg, ID specialists are trained abroad (predominantly in Belgium; also, France and Spain). Trainees spend one year of training in Luxembourg. After that, training is continued abroad.
      c In Malta, ID is considered a specialty in terms of training, but as a subspecialty within the working system of the Department of Medicine. Employment requires specialization in both, GIM and ID.
      d Numbers for Belgium are based on estimates. ID was recognized as subspecialty for the first time in May 2020.
      e In Cyprus, there are no official training centres. Based on a bilateral agreement between Cyprus and Greece. Cypriot, Greek and EU citizens can perform their ID residency in Cypriot hospitals, if accredited by the Greek Ministry of Health.
      f In Iceland, there are no training institutions. ID training is performed abroad (Sweden, UK, USA).
      g ID is not recognized as a specialty in Spain. Training delivery and duration are highly variable depending on local regulations and training institutions. Trainees participate in different courses/rotations.
      h Current numbers are estimates supported by statistics of the previous year.
      i Only 31 of 124 training centres are accredited by the German Society for Infectious Diseases and therefore comparable to European standards.
      j In Lithuania, a decrease in numbers of trainees terminating ID training has been observed due to structural problems caused by the COVID-19 pandemic.
      k In Austria, there is a total of 42 training centres. Training is only performed in eight of those centres because numbers of trainers are limited.
      The population-adjusted number of adult ID specialists varies from fewer than five per million inhabitants in Austria, Ireland and the UK to more than 40 per million in Iceland, Latvia and Lithuania, with 78 per million in Sweden (Table 1). Numbers tend to be higher in countries where ID is an independent specialty. There were similar wide variations in the number of trainees. Central workforce planning, i.e. matching trainee numbers to the anticipated need for future specialists, was recorded in 13/24 (54.2%) countries where ID is a specialty compared with 1/8 (12.5%) where it is a subspecialty.

       ID specialist training—numbers, institutions, overall structure and areas of training

      Specialist training is delivered in all countries except Luxembourg and Iceland. The ratio of trainers to the total number of specialists varies from <5% (30:800) in Sweden to almost 100% in Austria, Denmark, Ireland, Israel and Malta; there was similar variation in the number of available training centres. In some countries, access to training centres was limited because of insufficient numbers of trainers (Austria) or limited accreditation of training centres, as in Germany (Table 1) [
      Deutsche Gesellschaft für Infektiologie
      Weiterbildungsstellen “Infektiologie” Deutschland.
      ]. Funding and control of centres and trainees varies between countries and trainee salaries may not be centrally funded. Trainees receive some sort of salary everywhere but access to fully funded training rotations may be limited. For example, in Armenia, trainees must pay tuition fees if they are not accepted on a state-allocated residency.
      Combinations of training patterns and their indicative length vary across Europe (Table 1). In countries where ID is a separate specialty, specialist training takes a median of 5 years (IQR 5–6 years; range 1–7 years), with a median of 1.8 years (IQR 1–3 years; range 0.3–5 years) initial ‘common trunk’ GIM training followed by ID training. However, some countries require concurrent or sequential accreditation in GIM for appointment as a specialist. Similar requirements are being introduced in 2021 in Ireland and in the UK for trainees who are not undergoing joint training in ID and medical microbiology (MM) or virology. In Estonia, the content of GIM training is being increased in 2022. Only three countries (Estonia, Turkey and the UK) provide concurrent specialist training in ID and MM/virology. This is being introduced in 2021 in Ireland and revised in the UK, where ID training will be combined for 7 years total with either GIM (3 years common trunk GIM training) or with MM/virology (2 years common trunk GIM training) [
      • Beeching N.J.
      • Rautelin H.
      • Stahl J.-P.
      • Leegard T.M.
      Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe.
      ,
      Joint Royal Colleges of Physicians Training Board
      Infectious diseases and tropical medicine.
      ]. In countries where ID is a subspecialty or not officially recognized, trainees usually complete 2.3–5 years of GIM training (median 4 years; IQR 3.3–4.5 years) before entering a median 2.5 years (IQR 2–5 years) of ID specialty training (range 2–6 years).
      Overall, 54.5% of countries (18/33) provide training across all three main activities: direct inpatient care, consults and outpatient clinics (Table 2). Time allocation to these areas varies widely and may overlap throughout all training (the majority) or be performed in rotation. In Israel, there are no specific ID wards, and emphasis is on consult activity and infection prevention and control activity. There is greater focus on training and provision of dedicated inpatient care in southeast Europe. Although 29/33 (87.9%) countries include a training attachment in an MM laboratory, the duration varies from 1 to 12 months and only 7/33 (21.2%) allocate ≥6 months of training as recommended in the 2018 ETR [
      European Union of Medical Specialists (UEMS)
      Training requirements for the specialty of infectious diseases - European standards of postgraduate medical specialist training.
      ].
      Table 2Infectious Diseases training delivery in 33 European countries in 2021 in comparison with the UEMS European Training Requirements (ETR) for the Infectious Diseases Specialty (2018) [
      European Union of Medical Specialists (UEMS)
      Training requirements for the specialty of infectious diseases - European standards of postgraduate medical specialist training.
      ].
      Table thumbnail fx1a

       ID specialist training—curricular contents

      The main ‘traditional’ components of the ETR curriculum are delivered in most countries, with varying degrees of emphasis (Table 2). In Armenia, the Czech Republic, Hungary and Lithuania, care of non-HIV immuno-compromised patients and sexually transmitted infections are excluded. Some respondents mentioned the need for more extensive and practical training in microbiology. The questions on tropical and travel medicine were not answered consistently but these areas were included in 31/33 (93.9%) countries. It was unclear how many countries provide specific training and accreditation in ‘tropical medicine’ similar to that provided in the UK [
      • Beeching N.J.
      • Rautelin H.
      • Stahl J.-P.
      • Leegard T.M.
      Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe.
      ,
      Joint Royal Colleges of Physicians Training Board
      Infectious diseases and tropical medicine.
      ,
      • Beeching N.J.
      • Borysiewicz L.K.
      Training in infectious diseases and tropical medicine in Britain.
      ].
      Newer aspects of the training curriculum are only delivered in 30% of countries, with training in palliative care in 11, quality improvement/audit in 13 and leadership/team management in 12. However, a new curriculum was approved in Slovenia in 2021, meeting the ETR criteria and foreseeing additional training in bedside ultrasound. Apart from Croatia, the Czech Republic and Slovakia, research methodology is part of the curriculum and encouraged in all countries and in 39.4% of countries, trainees may take time out of clinical training to focus on research. The revised Finnish curriculum foresees a 6-month funded rotation into clinical research, whereas French trainees defend a thesis before the end of the penultimate year.

       Measures of training assessment for trainees, trainers and institutions

      Trainee progress is monitored by personal logbook or e-portfolio in 25 countries (75.8%). Workplace-based assessments are used in 17 (51.1%) and knowledge-based assessments in 20 countries (60.6%) (Table 2). In some countries, regular assessments are formative and may be trainee-led, whereas in Portugal trainees must pass activity reviews and yearly examinations. Regular formal reviews of training are conducted in at least 18 countries (54.5%), with a penultimate year assessment in 4. At least 69.7% of countries require final examinations, usually written, with additional oral and/or clinical bedside components in some (Table 2).
      Approval of centres and trainees is performed by bodies such as Ministries of Health, national medical bodies or colleges, specialist societies or individual universities. Supervisors are usually required to have been an accredited specialist for at least 3–5 years, and training centre approval requires the presence of sufficient clinical activity and/or ID bed base, and enough specialists (typically at least two). Renewal of approval of centres, typically in a 5-year cycle, is required in some countries. Some respondents suggested the need for more structured and frequent quality control of mentors/trainers.

       Influence of the COVID-19 pandemic

      There has been an increase in ID trainees in six countries and further increase is expected in 13. Due to the ongoing COVID-19 pandemic, the Lithuanian government increased funding of ID residency positions. The University of Tartu (Estonia) is applying for additional residency positions and is considering increasing epidemiology studies within the curriculum. Some respondents thought that the pandemic would improve the external perception of ID as a specialty, but others were concerned about loss of trainees due to physician exhaustion and ‘burn out’.

      Discussion

      This paper provides important insights into the status of ID training programmes across Europe, relying primarily on reports and opinions from senior physicians in each country. Previous reviews have shown variations in format and duration of training, supervision and examinations between countries, and 20% of countries lacked formal training programmes in 2005 [
      • Cooke F.J.
      • Choubina P.
      • Holmes A.H.
      Postgraduate training in infectious diseases: investigating the current status in the international community.
      ,
      • McKendrick M.W.
      • European Union of Medical Specialties
      The European Union of Medical Specialties core training curriculum in infectious diseases: overview of national systems and distribution of specialists.
      ,
      • Read R.C.
      • Cornaglia G.
      • Kahlmeter G.
      European society of clinical microbiology and infectious diseases professional affairs workshop group. Professional challenges and opportunities in clinical microbiology and infectious diseases in Europe.
      ]. The situation has now improved with only one country in 35 awaiting specialty recognition, but there is still substantial variability in the numbers of ID specialists per million inhabitants and in the central regulation of the number of future specialists in training. As highlighted previously [
      • Cooke F.J.
      • Choubina P.
      • Holmes A.H.
      Postgraduate training in infectious diseases: investigating the current status in the international community.
      ,
      • McKendrick M.W.
      • European Union of Medical Specialties
      The European Union of Medical Specialties core training curriculum in infectious diseases: overview of national systems and distribution of specialists.
      ,
      • Read R.C.
      • Cornaglia G.
      • Kahlmeter G.
      European society of clinical microbiology and infectious diseases professional affairs workshop group. Professional challenges and opportunities in clinical microbiology and infectious diseases in Europe.
      ], a recent internet-based survey of ESCMID members and affiliates found that only 58% of hospitals had a specialized ID ward and that there was an average of one ID or CM physician per 100 hospital beds [
      • Dickstein Y.
      • Nir-Paz R.
      • Pulcini C.
      • Cookson B.
      • Beovic B.
      • Tacconelli E.
      • et al.
      Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey.
      ]. Although practice varies across Europe, all trainees have to achieve general competence in both inpatient care and outpatient and consult practice to become a specialist. Any further subspecialization occurs informally or formally after specialist accreditation [
      • Bonura E.M.
      • Armstrong W.S.
      Increasing subspecialization in the field of infectious diseases: evaluating challenges and strategies to move forward.
      ].
      Investigation of the number of specialist trainees in each country proved difficult, emphasizing the need for central national databases to track numbers of trainees and their progress. However, in some countries the approval of training centres, funding of training and control of training content and delivery are functions of different ministries/national authorities.
      The length of training varies from 1 to 7 years. There is an increasing trend towards double training in ID and GIM, in keeping with the general trend seen in UEMS across all specialties allied to GIM. Very few countries provide dual training in ID with MM or virology and such programmes tend to have shorter GIM components. Only 21.2% of countries provide the minimum 6 months of microbiology training recommended in the ETR [
      European Union of Medical Specialists (UEMS)
      Training requirements for the specialty of infectious diseases - European standards of postgraduate medical specialist training.
      ], which seems disappointing given the emphasis on the need for improved training in antimicrobial stewardship, infection control and joint ID/MM training recommended more than 15 years ago [
      • Cooke F.J.
      • Choubina P.
      • Holmes A.H.
      Postgraduate training in infectious diseases: investigating the current status in the international community.
      ]. Familiarity with laboratory practice improves interpretation of results and reports and also underpins better antimicrobial stewardship. Detailed surveys of training needs have led to the introduction of new European standards of practice and training programmes in antimicrobial stewardship and infection prevention and control [
      • Dickstein Y.
      • Nir-Paz R.
      • Pulcini C.
      • Cookson B.
      • Beovic B.
      • Tacconelli E.
      • et al.
      Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey.
      ,
      • Zingg W.
      • Mutters N.T.
      • Harbarth S.
      • Friedrich A.W.
      Education in infection control: a need for European certification.
      ,
      • Maraolo A.E.
      • Ong D.S.Y.
      • Cimen C.
      • Howard P.
      • Kofteridis D.P.
      • Schouten J.
      • et al.
      Organization and training at national level of antimicrobial stewardship and infection control activities in Europe: an ESCMID cross-sectional survey.
      ,
      • Yusuf E.
      • Ong D.S.
      • Martin-Quiros A.
      • Skevaki C.
      • Cortez J.
      • Dedic K.
      • et al.
      A large survey among European trainees in clinical microbiology and infectious disease on training systems and training adequacy: identifying the gaps and suggesting improvements.
      ]. These could be incorporated more explicitly in the next iteration of the ETRs of both ID and CM as a benchmark of modernizing training programme content [
      • Beeching N.J.
      • Rautelin H.
      • Stahl J.-P.
      • Leegard T.M.
      Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe.
      ]. New areas of the ID curriculum such as palliative care, team leadership and quality improvement have yet to be implemented in many countries. However, these are important because of the increasing emphasis on multidisciplinary team working as part of everyday ID practice.
      In all countries that responded, trainees were paid some form of salary during specialist training, although previous studies have found great variability of yearly gross salary across Europe [
      • Tacconelli E.
      • Poljak M.
      • Cacace M.
      • Caiati G.
      • Benzonana N.
      • Nagy E.
      • et al.
      Science without meritocracy. Discrimination among European specialists in infectious diseases and clinical microbiology: a questionnaire survey.
      ]. This will have a financial impact on clinicians and may deter some from training in those countries, and physicians may choose to emigrate to find better working conditions.
      A standardized training programme detailing each rotation should be given to trainees before commencing training, which should be provided from accredited training centres with independent reviews of educational supervisors. This should ensure that time is allowed for adequate experience in each area and that training meets the desired European standard. However, free text comments revealed confusion about accreditation of specialists as trainers on the basis of clinical seniority, rather than specific training in supervision and mentoring of postgraduate trainees. It is a great concern that only half of countries conduct annual reviews of trainee progress and that even fewer conduct a more global review to identify unmet training needs just before the last year of training. These shortcomings echo the findings of previous ESCMID surveys, in which only 34% of trainees received regular constructive feedback from their supervisor and there were notable differences in supervision of trainees in different European regions [
      • Palacios-Baena Z.R.
      • Zapf T.C.
      • Ong D.S.Y.
      • Maraolo A.E.
      • Ronnberg C.
      • Cimen C.
      • et al.
      How are trainees in clinical microbiology and infectious diseases supervised in Europe? An international cross-sectional questionnaire survey by the Trainee Association of ESCMID.
      ]. Only 36% of ID/CM European trainees were assigned an official mentor during their training and of these, only 60% received constructive feedback on their work [
      • Ong D.S.Y.
      • Zapf T.C.
      • Cevik M.
      • Palacios-Baena Z.R.
      • Barac A.
      • Cimen C.
      • et al.
      Current mentorship practices in the training of the next generation of clinical microbiology and infectious disease specialists: an international cross-sectional survey.
      ]. More than one-quarter did not consider their relationships with mentors to be confidential and 22% felt they could not talk with their mentor if treated unfairly at work [
      • Ong D.S.Y.
      • Zapf T.C.
      • Cevik M.
      • Palacios-Baena Z.R.
      • Barac A.
      • Cimen C.
      • et al.
      Current mentorship practices in the training of the next generation of clinical microbiology and infectious disease specialists: an international cross-sectional survey.
      ]. Trainee feedback is an important factor in developing and improving curricula and training programmes [
      • Yusuf E.
      • Ong D.S.
      • Martin-Quiros A.
      • Skevaki C.
      • Cortez J.
      • Dedic K.
      • et al.
      A large survey among European trainees in clinical microbiology and infectious disease on training systems and training adequacy: identifying the gaps and suggesting improvements.
      ,
      • Palacios-Baena Z.R.
      • Zapf T.C.
      • Ong D.S.Y.
      • Maraolo A.E.
      • Ronnberg C.
      • Cimen C.
      • et al.
      How are trainees in clinical microbiology and infectious diseases supervised in Europe? An international cross-sectional questionnaire survey by the Trainee Association of ESCMID.
      ]. Our findings support the need for improvement in postgraduate education in ID in many European countries. Further innovative approaches to delivering such training could also be considered [
      • Cervantes J.
      The future of infectious diseases education.
      ].
      Research opportunities vary among countries depending on priorities and prior experience. Extra time is needed, often out of training, and funding may or not be available from training fellowships, charities or governmental organizations. Protected time spent in a research rotation allows trainees to further define their skills in terms of international comparison and finding new niches within their chosen specialty.
      This study was limited by the personal response of each clinician completing the questionnaire on behalf of their country and slight ambiguity of interpretation of a few questions. Efforts have been made to validate the data, but it was not possible for all countries.

      Conclusion

      The COVID-19 pandemic has gathered international attention to ID as a specialty and was cited by several countries as a stimulus to train more ID specialists. It has highlighted the need for more ID specialists across Europe and the importance of unity and collaboration among countries and between the infection specialties in managing such. The specialty should strive to improve training in areas such as antimicrobial stewardship and infection prevention and control. In many countries, improvement and modernization of the framework for delivery of postgraduate training is needed to enhance the training experience and maintain enthusiasm among our excellent trainees. Ideally, ID trainees will benefit from a harmonized curriculum offering equivalent standards of training and professional opportunity across the continent with equitable working conditions encouraging free movement of specialists between European countries.

      Collaborators

      Jonas Ahl, Arvydas Ambrozaitis, Alpay Azap, Bojana Beović, Francesco Castelli, José Miguel Cisneros, Costas Constantinou, Christian van Delden, Eoghan de Barra, Paul de Munter, Olga Džupová, Gerd Fätkenheuer, Robert Flisiak, Simin Aysel Florescu, Claudia Fsadni, Ville Holmberg, Søren Jensen-Fangel, Philipp Koehler, Már Kristjánsson, Andreas Lind, Athanasios Michos, Alastair Miller, Zsofia Muller, Joaquim Oliveira, Mical Paul, Ertan Sal, Marija Santini, Narina Sargsyants, L'ubomir Soják, Pilleriin Soodla, Therese Staub, Florian Thalhammer, Annelies Verbon, Renaud Verdon, Zbigniew Wegrzyn

      Author contributions

      DD developed the first draft of surveys 1 and 2. Subsequent drafts were further developed and finalized by RAB, JS-G, NJB and OAC. RAB, RSH, JS-G, JPS, NJB and OAC collected data, and analysed and interpreted the findings. All authors contributed to all sections relevant to their experience and helped finalize the text and content. RAB and SRH, as junior authors, and NJB and OAC, as senior authors, contributed equally to this manuscript.

      Transparency declaration

      OAC reports grants or contracts from Amplyx, Basilea, BMBF, Cidara, DZIF, EU-DG RTD (101037867), F2G, Gilead, Matinas, MedPace, MSD, Mundipharma, Octapharma, Pfizer, Scynexis; Consulting fees from Amplyx, Biocon, Biosys, Cidara, Da Volterra, Gilead, Matinas, MedPace, Menarini, Molecular Partners, MSG-ERC, Noxxon, Octapharma, PSI, Scynexis, Seres; Honoraria for lectures from Abbott, Al-Jazeera Pharmaceuticals, Astellas, Grupo Biotoscana/United Medical/Knight, Hikma, MedScape, MedUpdate, Merck/MSD, Mylan, Pfizer; Payment for expert testimony from Cidara; Participation on a Data Safety Monitoring Board or Advisory Board from Actelion, Allecra, Cidara, Entasis, IQVIA, Jannsen, MedPace, Paratek, PSI, Shionogi; A pending patent currently reviewed at the German Patent and Trade Mark Office; Other interests from DGHO, DGI, ECMM, ISHAM, MSG-ERC, Wiley.

      Acknowledgements

      This article is dedicated to the memory of our colleague Davorka Dušek who contributed so much to her patients and to the professional infection community across Europe, but sadly passed away during the development of the survey. We thank all those who contributed their time and expertise in responding to the questionnaires, and colleagues across the UEMS Section and Board of ID for past and current insights into the specialty in individual countries.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

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