EUROPEAN REGULATION OF MEDICAL PROFESSION IN THE REPUBLIC OF CROATIA

Abstract

SUMMARY – Medical profession is regulated in all European Member States. By stipulating the conditions for performance of the profession, the said activity can only be practiced by members of the profession. The European Member States have coordinated the conditions of education and specialist training, thus simplifying all administrative procedures for the recognition of professional qualifications. During the pre-accession negotiations, the Republic of Croatia made the necessary changes to the study curriculum and in the specialist training programs, and listed all the professional titles acquired under the regulations that were in force at the time of the end of the program. Physicians can freely join/become members the Croatian Medical Association, which is an association, while professional chamber membership is mandatory for physicians who work directly with patients and should therefore have approval for independent work. Medical schools, professional societies of the Croatian Medical Association and the Croatian Chamber of Physicians, as well as the Ministry responsible for regulating the profession, all have a role to play in the regulation of the medical profession.

Introduction

Regulated profession is the one regulated by legislative, regulatory and other provisions. Healthcare is an activity of special public interest that is provided as a public service by law-abiding health workers using medical technology and observing professional and medical doctrines. Healthcare activities are also provided by health associates participating in part of health protection. Healthcare is the activity in public interest of the society as a whole, and of patients, i.e. users of medical services, which is why healthcare enjoys a special status in the country. In the Republic of Croatia, there are ten regulated health professions, including medical doctors or physicians. Health professionals work as a team, applying multidisciplinary approach and cooperation among various professions.

The Act on Regulated Professions and Recognition of Foreign Professional Qualifications defines regulated profession as a professional activity or group of professional activities, access to which, the pursuit of which, or one of the modes of pursuit of which is subject, directly of indirectly, by virtue of legislative, regulatory or administrative provisions to the possession of specific professional qualifications; or group of professional activities pursued by members of professional organizations with a professional title.

Regulation of Medical Profession

The terms profession and occupation do not carry quite the same meaning. A profession is considered to be an activity based on specialized theoretical knowledge and intraprofessional norms that encourage members of the profession to behave in a similar way, regardless of external stimuli. A feature of a profession is the possession of a corpus of particular valuable, abstract and validated knowledge that forms the basis for their autonomy. The knowledge possessed by members of the profession is applicable to work done in public interest. One of the key characteristics of a profession is that specialized knowledge and skills are acquired in specifically established educational institutions (1).

An occupation or vocation is a set of work tasks performed by a person possessing appropriate knowledge and skills required for the position.

Medical profession developed in the early days of mankind. The ancient and medieval education systems were divided into artes mechanicae and artes liberales. Artes mechanicae comprised all trades and included architecture and art where jobs were done by dependent people. Artes liberales covered seven liberal arts, which were called liberal because they were worthy of royalty, i.e. worthy of a free person. The seven skills consisted of the core ones – the trivium (grammar, rhetoric and dialectic) and the advanced ones – the quadrivium (arithmetic, geometry, astronomy and music theory). In order to study medicine, a medical doctor was first required to study all of the seven liberal arts. He was then titled dominus. Since dominus was a prince, the title conferred to a medical doctor was Egresius dominus atrum et medicinae doctor. Present-day universities are divided into Arts (engineering) and Science (natural sciences) (2).

Today, medicine is a universal occupation, which enables medical doctors to pursue their profession in any country along with appropriate application of the recognition of qualifications. Contemporary medicine is a graduate university course of science that can be continued through scholarly work in medical science(s). Pursuing medical profession is contingent upon successful completion of the university study of medicine. In the Republic of Croatia, with the introduction of the Bologna Process in medical schools in 2005, the undergraduate and graduate university studies have become integrated in the medical curriculum. As a consequence, upon completion of the third year of study, a medical student is not awarded a qualification, but should continue graduate university course, which takes a total of six years. The European Directive 2005/36/EC on the recognition of professional qualifications in particular singles out the doctor of medicine profession by laying down minimum training requirements for university medical study comprising a total of six years of study or 5500 hours. The Directive 2013/55/EC amending Directive 2005/36/EC on the recognition of professional qualifications lays down basic medical training in duration of five years and 5500 hours, with the possibility to express the duration of a program in ECTS credits (3). Concurrently, the EU Member States have harmonized graduate medical studies at medical schools and consequent learning outcomes at medical schools. Learning outcomes are defined at graduate and postgraduate levels, as well as the standards of physicians’ education. Learning outcomes entail everything a student is supposed to learn, understand or be able to competently do in practice after completing the program. In the Republic of Croatia, there are four medical schools at the Universities of Zagreb, Split, Rijeka and Osijek. However, the medical schools had the curriculum of medical studies in duration of six years and 5100 hours, which was a slightly shorter program duration than the one stipulated by the European Directive.

At the time, upon graduation from medical school, the physicians had the obligation to complete one-year internship, after which they had to sit for a Medical Licensing Exam, which comprised the required internship hours as the internship was undergone in full-time employment of 40 hours per week and lasted for 2080 hours over 52 weeks. The Croatian medical schools have changed the curriculum of medical studies in accordance with the European Commission’s advice to exclude non-medical subjects, such as the English language and physical training, from the required study duration of 5500 hours. Concurrently, medical schools have included in the integrated undergraduate and graduate medical studies curriculum clinical science education, which used to be taken separately during the internship year. The new curricula of the integrated undergraduate and graduate study have included the clinical science education, i.e. the practical part of the program. The European Commission approved the four integrated curricula of undergraduate and graduate studies, and medical schools in Zagreb, Rijeka and Split consequently introduced new study programs for students who enrolled in the academic year 2010/2011. The School of Medicine, Josip Juraj Strossmayer University of Osijek introduced the curricula in the academic year 2011/2012. Once a student is granted his/her MD degree, he/she possesses all the theoretical and practical knowledge necessary for autonomous work. The change introduced into the integrated curricula of undergraduate and graduate study was one of the requirements for the accession of the Republic of Croatia to the European Union and the harmonized study programs were introduced in medical schools before full Croatian membership in the European Union. The internship was a transitional period between being a student and becoming a professional where a young physician, aside from his/her clinical skills, was given the opportunity to learn about professionalism, collaboration with other professions and the like. The European Directive does not recognize internship, and sitting for a Medical Licensing Exam is often an obstacle to the free movement of persons and the mobility of health workers when a physician wishes to pursuit medical profession in another country. Practicing clinical skills is fully under the supervision of the university that coordinates both the theoretical and clinical parts of the program (4). The regulation of the medical profession includes the standard of education of physicians, the standard of qualification, and occupational standards. At the point of graduation, a physician acquires knowledge outcomes, i.e. output competence, and the competence and quality of service can only be assessed by fellow professionals.

After completing medical school, physicians focus on specialist medical training. Specialist training for physicians, which has been harmonized with Directive 2005/36/EC on the recognition of professional qualifications, is regulated by the Ordinance on specialist training for doctors of medicine from 2011 in 45 specialties, which are based on the acquisition of competence, i.e. a set of knowledge, skills and attitudes of a trainee specialist (5).

Due to the need to organize a new system of specialist training of medical doctors that would meet the requirements of the Directive 2005/36/EC on the recognition of professional qualifications and standards of the European Association of Medical Specialists (European Union of Medical Specialists, UEMS), unique and immediately oriented specialties were introduced. The Directive lays down the minimum education requirements for physicians, and harmonizes and coordinates the length of specialist training with the appropriate level of education. The Directive recognizes 52 main specialties that are common to the European Union Member States. Admission to specialist training in the European Union is allowed to a physician with a completed and validated university degree in medicine lasting for five years and 5500 hours in the course of which the trainee has acquired the relevant medical knowledge, which precedes the specialization of physicians (3). Specialist training for medical doctors comprises theoretical and practical instruction at a university or an approved teaching hospital (4). The Member States ensure the minimum duration of specialist medical training courses of not less than the duration provided for in the Directive.

In creating the specialist medical training program, the recommendations by the UEMS were taken into account. The UEMS is the European body representing national associations of medical specialists in 43 specialist sections and bodies, which promote European medical specialists by providing a high standard of specialist medical training and quality of health care at the European level. Specialist medical training is a precondition for improvement of the overall healthcare system. Specialist medical training programs with related standards are defined by the UEMS. The UEMS Council adopted the Charter on Training of Medical Specialists in the European Community in 1993. The Charter defines the goals of a specialist medical training and stipulates the structure of European and national bodies that ensure standards for medical specialist training of doctors, criteria for establishments where specialist medical trainings are carried out, requests for mentors and requests for trainees. Chapter 6 of the Charter is dedicated to the specific requirements for the implementation of specific specialty trainings, led by the UEMS specialist sections. The Charter on Visitation of Training centers for medical specialists (1997) and the Statement on the assessment policy in postgraduate specialist medical training for doctors (2006) were also published. Representatives from all Member States participate in the work of UEMS sections.

In the Republic of Croatia, specialist medical training programs have been introduced that fully correspond to specialist medical training for doctors in the European Union Member States. In the current system of European specialist medical trainings, it is possible for specific specialties to have a portion of specialist training that is common to several medical specialties. For example, cardiology and gastroenterology both have the common trunk in internal medicine. In that case, the specialist medical training in duration of five years requires that at least 50 percent of specialist training is dedicated to the specific part of specialty. The Ordinance defines the common trunk as a common part of specialist medical training in internal medicine, surgery and other specialties, which includes improvement of core competence for these specialties (5). Emphasis is placed on the content and duration of specialist medical training. Its content comprises the acquisition of knowledge and skills. As resident physician masters the specialty program, he/she acquires certain competence, and with it certain autonomy and responsibility. The novelties introduced to specialist medical training programs do not affect the manner in which specialist activities were performed to date. The specialists and subspecialists who had undergone their specialist medical training in line with the previous regulations have been included within the system of acquired rights. By means of acquired rights, the EU Member States enable citizens of the EU/EEA contracting states access to a regulated profession based on necessary professional experience acquired. Therefore, the present-day specialists and subspecialists have retained their title in line with the specialist training program they had undergone. The title specialist is conferred in line with the completed specialization and the title subspecialist in line with the completed subspecialization field. Given that these titles fall within the acquired rights system, a medical doctor is still entitled to access the specialist activities.

Competence based training is the ability to perform the required specialization standards. Competence is a set of knowledge (cognitive abilities), skills (functional abilities) and attitudes (social abilities), which determine a trainee’s behavior. General (generic) and special (specific) competence are defined at different stages of the training. General competence can be defined as a set of skills that are common to many professions and are not specific to a single job. Special competence is related to a specific profession. Many national and international medical associations and educational institutions have proposed lists of general competence that ought to be taught and acquired in the course of training and which are related to the profession of medical doctor. The best-known document was published by The Royal College of Physicians and Surgeons of Canada as a revised edition of educational standards entitled CanMEDS 2005 Physician Competency Framework, in which seven roles or domains of medical doctor’s competence are defined. In terms of that document, in addition to being a medical expert, the doctor also has to assume the role of a communicator, collaborator, team player, manager, health agent, student/teacher, and a professional.

In professions that are characterized by distinctive diagnostic and therapeutic procedures and interventions, the program defines the required number of interventions that a trainee must perform and the level of competence he/she must acquire. The ordinance underscores the content and length of specialist medical training. The specialization program stipulates the length of stay in institutions where certain competence is acquired. In line with the UEMS Charter, the program outlines the training requirements to be met by the institution in which specialist training is conducted and the requirements for mentors. The Ordinance on specialist medical training lays down the general requirements for the training institution and each specialist program comprises specific requirements for the institution, which ensure carrying out the specialist training program, e.g., the characteristic structure and organization of the institution, the equipment, the required number of patients, and so on (5). The institution, together with mentors, must provide trainees with a sufficient number of patients whom they can treat autonomously, or a sufficient number of interventions that they can be part of to acquire the skill of independent work. More than 50 percent of the total length of specialization is undergone in teaching institutions, whereas up to 50 percent can be undergone in a health institution or a company registered with health activity within which the targeted portion of continuing medical education of doctors is conducted. The latter institutions are not educational per se but they do conduct a sufficient number of procedures and treat patients and therefore, in line with the criteria, can conduct a lesser portion of continuing medical education.

The new Ordinance stipulates three categories of responsibility in the supervision of the specialization program or mentoring. At the national level, each specialized program is led by the head of specialty training program who coordinates the implementation of the program of specialist development of a particular specialization in the Republic of Croatia and supervises the work of all the chief mentors and a mentor for a particular branch of specialization. Each resident is assigned a chief mentor who is responsible for the prescribed implementation of the overall training programs, and who must supervise a resident’s progress until the required level of competence is acquired. The chief mentor, in consultation with mentors who are specialists in the same specialty or a related specialty branch, supervises the resident’s progress. The mentor is responsible for the prescribed implementation of the specialist training program, for the accuracy of the information/data in the booklet on specialist training for medical doctors in which he/she records the progress of the resident in his/her acquisition of competence, and for the accuracy of data in the logbook of medical doctors undergoing specialist training. The mentor supervises the resident’s progress and regularly assesses the acquired knowledge and skills in line with the provided specialization program. Theoretical specialist knowledge is acquired through postgraduate medical study that is organized for each specialty by medical schools and via organized forms of teaching work with specialists in institutions where specialist training is conducted. Postgraduate medical study is organized as full-time study and to the full extent of training. Each postgraduate study comprises a subject devoted to general competence and specialized subjects specific to a particular profession. Institutions providing specialized medical training enable residents to participate in regular professional meetings, to present a patient’s case at least twice a year, as well as to publish, during the course of specialization, at least one professional paper in the field of specialization.

Professional/Medical Chamber

A chamber is a professional organization that promotes the profession and safeguards its members and public interest. The Croatian Medical Chamber was founded in 1995, and its activities are stipulated by the Medical Profession Act. Its area of expertise is healthcare. The Croatian Medical Chamber was established as an institution, and its highest body is the Assembly comprised of selected Chamber’s representatives. The Assembly adopts the Statute of the Chamber and other general acts, approves the budget, elects and dismisses body members, approves the registration and membership fees of its members, and performs other tasks. The Croatian Medical Chamber has a council and executive committee that conducts executive activities, and the Council is the representative body authorized to pass general acts, establish expert commissions and working groups. The head of the Chamber is the president, whose task is to promote and represent its bodies, convene meetings, and care for its lawful operation. The Croatian Medical Chamber has a supervisory board responsible for internal control of Chamber’s activities, supervising adherence to the Statute and regulations, as well as supervising Chamber’s financial activities. The Croatian Medical Chamber has its Court of Honor, which conducts disciplinary actions or proceedings against Chamber members in the event of a breach of regulations.

The Court of Honor has two instances. The Chamber has specific Standing Boards, committees that consider specific matters within the scope of Chamber’s activities. The Chamber has an expert service, a secretary and treasurer responsible for administrative work. The Chamber is active in the territory of the Republic of Croatia and devolves its activities by establishing branch units. The Croatian Medical Chamber is a professional association that regulates a profession and implementation of regulations via public authorities, but it also carries out expert work, i.e. promotes medical profession, adopts guidelines and plans activities development, cooperates with the competent Ministry of Health by issuing its opinion when regulations, strategies and programs are about to be adopted. The Croatian Medical Chamber is member of the following international organizations: European Union of Medical Specialists (UEMS), European Union of General Practitioners (UEMO), European Association of Senior Hospital Physicians (AEMH), Permanent Working Group of European Junior Doctors (PWG), Standing Committee of European Doctors (CPME), and International Association of Medical Regulatory Authorities (IAMRA) (1).

Medical doctors are obliged to join the Croatian Medical Chamber. The Chamber keeps the Register of Medical Practitioners, and once a medical doctor is registered with the Chamber he/she is issued the license for independent practice (Medical License). The Medical Chamber membership is obligatory for all medical doctors with the acquired university degree and specialist training required for performing medical activities, and who intend to directly/immediately carry out healthcare activities for patients. The Chamber provides the possibility of membership for retired doctors, doctors living abroad, etc. The membership in the Chamber differs from the approval for independent work/practice, as membership per se is not proof of fitness for independent work. In the Republic of Croatia, the Chamber issues approval for independent work (Medical License) for the period of six years, during which a doctor is continuing medical education or performs permanent education, for which a doctor is awarded points required for the Medical License renewal. By means of continuing medical education and permanent education, a doctor renews his/her knowledge and follows contemporary progress of the chosen profession.

The field of medicine is constantly evolving, and that progress is shaping the profession’s standard. By being up to date with novelties in medical or technical progress of profession, a doctor does not only improve his/her knowledge, but enhances the healthcare service. The authorization to practice independently (license), acquired on the basis of continuous professional development, is a prerequisite for the pursuit of a profession aimed at ensuring quality standards for healthcare services. A physician can lose his/her license for independent work when it should be renewed if he/she does not meet the conditions for its renewal, or if he/she commits a violation stated by the special act of the Chamber and if the competent authority makes a decision on temporary or permanent revocation of licenses for independent work (1). However, upon its accession to the European Union, the Republic of Croatia has become part of the single European Union internal market, which means that persons with a valid license of a Member State can find employment in another Member State. There are systems of European chambers, e.g., in Finland, where a physician who meets the requirements to practice medicine is granted his/her license for indefinite period of time. A medical license can be lost/revoked in case of committing an act (of unprofessional conduct), and when a physician retires. Compulsory membership is present in chambers of the continental system, for example, Austria, Germany, Italy and Slovenia. There are also European chambers of Anglo-Saxon states in which membership is voluntary, but the licensure or registration of physicians is compulsory. Moreover, the Croatian Medical Chamber keeps the Register of Medical Practitioners comprising their members’ data. The Register is divided depending on the type of membership (physicians with licenses for independent work, interns, etc.) and there are special registers for foreign citizens who have obtained temporary licenses for independent work. These registers and the information contained therein are publicly accessible, which honors the principle of transparency requiring that all published data are made clear and readily comprehensible. The Croatian Medical Chamber is a public institution with legal characteristics that carries out administrative procedures and that was founded pursuant to law. The total number of members is roughly 19,882. The Croatian Medical Chamber allows the possibility of membership for foreign citizens, but European Union citizens are not obliged to register with the Chamber. However, the practice of all registered physicians is subject to expert supervision by the Chamber.

Besides the Croatian Medical Chamber, physicians can associate on a voluntary basis in the Croatian Medical Association that manages professional societies, publishes professional journals, fosters advancement of medical profession and observance of medical ethics on the part of physicians. The registration of physicians is done by the Croatian Institute of Public Health, which keeps the statistics on professions, hospitals, etc.

The Croatian Medical Chamber also performs supervision over physicians’ professional work pursuant to the requirements laid down in the Medical Profession Act and in specific regulations issued by the Chamber. The Chamber supervises the work of its members in relation to their professional qualifications, professional work, continuing medical education, observance of medical ethics, etc. The Chamber sets up the Committee for Professional Issues and Professional Supervision. There is a difference between regular supervision and the one in which the Chamber acts upon filed complaint. The Croatian Medical Chamber has the code of medical ethics that defines the principles and standards of conduct for its members in performing their work (1).

Mutual Recognition of Professional Qualifications for Medical Doctors in the European Union

Based on the Regulated Professions and Recognition of Foreign Professional Qualifications Act, the recognition of qualifications has been carried out since the day the Republic of Croatia became full member of the European Union. With the Regulated Professions and Recognition of Foreign Professional Qualifications Act, the Republic of Croatia has accepted the acquis communautaire in the area of recognition of qualifications, or more precisely, it has incorporated it into its legal and educational system provisions of the Directive 2005/36/EC on Recognition of Professional Qualifications (hereinafter: the Directive) (3). The Directive sets out the three systems of recognition of qualifications in the internal market: the general system for the recognition of professional qualifications, the recognition of professional experience, and coordination of minimum training conditions for regulated professions. Concurrently, the Republic of Croatia has incorporated into its legislation minimum training conditions laid down in Articles 10 to 49 of the Directive, which in turn has led to amendments of study and educational programs (curricula) and continuing medical education programs. The new study and educational programs have been amended in accordance with the accepted norms that are valid within the territory of the European Economic Area (3).

Persons who obtained the said titles, i.e. professional titles based on completed training programs valid prior to the above-mentioned dates, are entitled to acquired rights. Comparison of curriculum with the minimum requirements laid down in the Directive was done and differences were corroborated during the 2008 and 2012 peer missions. The Treaty concerning the accession of the Republic of Croatia to the European Union specifies professional titles acquired in the Republic of Croatia. Council Directive 2013/25/EU of 13 May 2013 adapting certain directives in the field of right of establishment and freedom to provide services by reason of the accession of the Republic of Croatia to the European Union was published with Croatian qualifications. Croatian physicians and specialist medical doctors are automatically recognized in other Member States and are equal to their European colleagues. With this, the obligation to guarantee that persons who are in the Republic of Croatia awarded academic and professional titles have met minimum training requirements prescribed in the European Economic Area was honored. Professional chambers are first instance bodies for the recognition of foreign professional qualifications, and the Ministry of Health is the appeal body that deals with second instance.

The basic rule in the European Union on which the freedom to provide services is founded stipulates that a service provider in a Member State is allowed to provide his/her services in another Member State under the same conditions applying to national natural or legal person. With this, an equal treatment is ensured for foreigners and nationals alike. The exercise of the right to free provision of services is based on the regulations on the recognition of professional qualifications acquired in a Member State other than the one in which a person intends to provide his/her services. Member States are making the recognition of professional qualification procedures easier. The European Union Treaty in Chapter 3 prohibits restrictions on the freedom to provide services within the Community for nationals of Member States, and prohibits restrictions on the freedom to establishment for nationals of one Member State in the territory of another Member State. The Directive set forth the standards for length and minimum requirements of training, which enabled automatic recognition of qualifications. The purpose is to make the Union’s Labor Market more flexible, to liberalize the provision of services, to facilitate the recognition of professional qualifications, and to simplify administrative procedures. With regard to provision of services, one is able to provide temporary services; it is possible to temporarily provide services based on professional qualification of that Member State. The general system of recognition of qualifications introduces various/varying levels of professional formal education according to professional qualifications. A Member State will allow the pursuit of activities under the same conditions as applied to its nationals to persons who obtained their professional qualifications in another Member State and whose education level is at least of a lower level. Persons who have undergone the recognition procedure have the right to use the professional title in the language of that Member State. The general system of the recognition of medical doctors’ qualifications is applied subsidiary, when the physician does not have acquired rights or if he/she obtained his/her professional qualifications outside the EEA contracting state. When carrying out the recognition of professional qualifications obtained outside the European Union, the competent body honors the minimum training requirements defined by the Directive. The general system for recognition is applicable where there is a significant difference in the content or level of education. A person can then choose a compensation measure between an exam or adaptation period during which it is possible to acquire additional education or further professional training. Furthermore, the general system of recognition is applied with specialties that are not listed under 5.1.3. Annex V of the Directive.