Erikoistumisen kirjavat käytännöt yhtenäistyvät

Diverse practices of specialisation becoming more consistent

Specialist training in medicine and dentistry are being reformed. Key objectives include the consistency and transparency of teaching content and competence criteria. Patients will also benefit from the reform, as it will ensure the homogeneity of treatment and an adequate number of doctors in all special fields.

After completing a basic degree, a doctor or dentist may specialise in one of the 50 medical or five dental specialities. Practices in specialisation training have developed gradually and field-specifically over the decades. The reform, which started in 2019, is the first time that these practices are being harmonised.

In the reform led by the Ministry of Social Affairs and Health, the University of Oulu is represented by Mervi Ryytty, a specialist in neurology, and Janne Liimatainen, a specialist in general medicine. Ryytty is acting as the coordinator for the development of the national study attainment system ELSA, which is the responsibility of the University of Oulu. Liimatainen is the development coordinator of the University of Oulu’s largest special field, general medical education.

Reform needs relate firstly to the content and skills requirements of specialist training, says Ryytty.

“In the past, special fields and their professors have developed skills requirements within their own university. Where requirements have not been guided or monitored nationally, they have varied between special fields and even within them. Skills have been mapped out using a national final exam, but otherwise graduation as a specialist has been time-based: once you have worked in the specialist field for a certain period and have the necessary certificates, you become a specialist.”

Learning content and skill requirements may thus have been diverse and personalised, and the training set-up may have been of the master-apprentice type. The job description of the specialising physician has been agreed with the clinic’s chief physician or other person in charge. For example, most of the work may have been done on the acute side although the work of a specialist is more extensive.

“You must be able to manage, for example, follow-up care and chronic situations,” says Liimatainen. “However, the practical knowledge of the specialising physician has not been considered separately but has been dependent on communication between the specialising physician and their supervisor. Many elements, such as patient consultation, may not have been followed.”

Labour needs of each sector taken into account in the selection of specialising physicians

Personalised variation has also been possible in the selection of specialising physicians. In the past, those wishing to specialise have only enrolled in the training programme, after which the professor of each special field has decided who receives the right to study. This has manifested as critical messages from the field when people have not been admitted to their desired field.

The reform has started from the selection procedure. The registration process ended at the end of 2018, and now the selection is made twice a year based on starting points (work experience, scientific merit), an interview (suitability, motivation) and a six-month trial period.

At the same time, it is ensured that an appropriate number of applicants will be directed to each field.

“New rights to study will be granted according to which special fields they are needed in,” Ryytty says. “One area where there is a clear shortage of specialists is psychiatry. There is also a shortage of specialists in general medicine, neurology and diagnostic fields such as radiology and pathology. As for orthopaedics, more people have been trained than there are jobs.”

While the consideration of needs may in principle make it more difficult to be admitted to some fields, the selection procedure is more transparent than previously. “If you do not succeed, you can gain more scientific experience and try again in the next application period.”

In addition, instructors will be provided with pedagogical training. So far, specialists have trained specialising physicians using the capabilities provided by their clinical experience. The University of Oulu has already organised its first pedagogical course for all special fields, and the next ones will be held in the autumn.

ELSA study attainment system to increase transparency

The next phase of the reform concerns learning content and skills requirements. February 2020 saw the entry into force of a decree that makes specialisation competence-based rather than time-based, and now all special fields have developed uniform content and objectives for education.

The requirements that entered into force at the beginning of August have been included in the new study guides. The number of study guides has fallen to a fraction: the five universities providing specialist training previously had their own guides for each special field, but now the study guides are national.

After this phase, a new kind of assessment of the specialising physicians’ skills will begin, says Ryytty. “The graduate specialist assesses the specialising physician’s expertise in individual situations where a patient is encountered. In addition, semi-annual round-ups are prepared to see what has been done and what the skills are.”

At the same time, the self-assessment of the specialising physician is developed. “Specialising physicians must evaluate themselves: how I succeeded, what should be done and how to develop," says Liimatainen. “The instructor comments on this self-assessment, and then the specialising physician is able to express their views on this statement.”

In other words, evaluation will increase. This is facilitated by the national study attainment system ELSA, in which both situation-specific developing evaluations and periodic broader summaries and evaluations are carried out.

“At the start of the specialist studies, the specialising physician will better know how the training is structured and where the work periods will be done.”

“The specialising physician sends an assessment request to the instructor for a specific event, the instructor records their assessment, and the specialising physician makes a self-assessment,” says Ryytty, describing the operation of ELSA.

In addition, the intended learning outcomes of each special field are defined in ELSA, which acts as a study attainment register: where a specialising physician previously collected paper certificates for both clinical work and theoretical studies and finally delivered the whole stack to their university, in the future the deliverables will be stored in ELSA.

As the assessments and skills requirements are clearly recorded in ELSA, the system contributes to the transparency of specialist training. The same applies to the implementation of education and training: each specialising physician will be given a specific training path.

“They will sit down with the professor and think about what the education will contain and where it will take place,” Ryytty says. “At the start of the specialist studies, the specialising physician will better know how the training is structured and where the work periods will be done.”


Ville Lindholm, who is specialising in paediatrics, sees many advantages in Oulu: commuting distances are shorter, living costs lower and work hierarchies flatter than in the southern cities. Photo: Mikko Törmänen

Oulu strives to keep graduating specialists in the north

The minimum duration of specialisation will be harmonised in all special fields to five years instead of five or six years. In addition, the rule that half of the training be carried out in a central hospital and half in a university hospital will be abolished and replaced by a minimum requirement of at least one year in each. This makes it easier for a specialising physician to reconcile education with family life, for example. A year is a more tolerable time for commuting.

Ville Lindholm, who is specialising in paediatrics for the second year at the University of Oulu, has had no difficulty commuting from one specialisation site to another.

“I now work at OYS; formerly I was at the Central Hospital in Kokkola. I’m happy to go back there to do another year. The timing is not yet known, but it can be agreed flexibly according to the situation in your life.”

The smooth cooperation between OYS and central hospitals is one of the ways the University of Oulu strives to attract more specialising physicians and to keep graduating specialists in the north. On average, 22 per cent of specialists graduating from the University of Oulu move south, which means that more specialists need to be trained than are needed locally.

Lindholm sees many advantages in Oulu: commuting distances are shorter, living costs lower and work hierarchies flatter than in the southern cities.

“It’s easy to collaborate and connect with other special fields here. In addition, specialising physicians are appreciated and not pushed around.”

Lindholm also appreciates the functionality of the Esko patient information system. Digitalisation is one of the local strengths, and Janne Liimatainen says Esko is in a class of its own. “In Helsinki, you have to use three or four systems at once.”

Lindholm is working on additional ways to keep graduates in the north. “Hospitals do not really attract so many specialists or invest in their own specialists. There is no competition for workers and no emphasis on one’s own merits.”


Text Jarno Mällinen, photos: Mikko Törmänen



Last updated: 1.9.2020