Dr. Johan De Mey
Introduction to the
To understand the Belgian education and health care systems, it is necessary to know something about the structure of the Belgian federal state. The country's federalization process created many new legislatures: aside from the Belgian (Federal) government the administration is further sub-divided by language, with the French-speaking Community accounting for nearly 40% of the total population, the Flemish-speaking Community about 60% and the German-speaking Community less than 1%. This is followed by a further sub-division into Regions: the Walloon Region, the Flemish Region and the Brussels-Capital Region. Education is the responsibility of the Language community; the economy falls under Regional jurisdictions; and the federal government regulates health care. Scientific research is divided across all governmental institutions.
The Belgian Social Security
In Belgium the national social security system covers most basic health care needs for all citizens. The federal government re-imburses medical expenses through RIZIV (the national institute for illness and invalidation insurance). We Belgians are proud of our claim that, at only a 8.7% share of gross domestic product (GDP), the health care system provides good quality health care services for the whole population, with a minimum of delay, whilst encouraging social solidarity. Even with a relatively high doctor/patient ratio 44,9 medical doctors/1000 population and 0,12 radiologists /1000 population (see Table 1), health care costs remain under control. However, ever increasing examples of rising health care costs are coming to light. The growth rate of health care charges in Belgium has been limited by the government to 4.5 %, annualized. However, this rate is still low compared to that of the United States (average of 6.5% growth between 1998 and 2001, against a background of total spending on healthcare of 14% of the GDP, and may exceed 16.2% by 2008).
The Universities and Medical
Following the procedure agreed at the Bologna Declaration, the study of medicine is divided into a bachelor program of 3 years and a masters program of 4 years. This structure was introduced last year in the Flemish community, and will completely replace the existing structure by 2011. The bachelor program forms an introduction to the masters program. During the bachelor program students learn how to think scientifically, studythe difference between normal and pathological conditions of the human body, and follow basic practical courses in patient examination and diagnosis. The masters program qualifies the student as a fully-qualified doctor with allthe necessary theoretical and practical knowledge. During the 7 years study program there is at least one year of clinical practice. In the final year students choose between general practice or hospital medicine (e.g. preparation for specialization in radiology).
The full medical curriculum may be followed in seven universities, which are divided between the Flemish community (Antwerp (UA), Brussel (VUB), Leuven (KUL), Gent (UG)) and Frenchspeaking community (Bruxelles (ULB), Louvainla- Neuve (UCL), Liège (ULG)). Three other universities offer the bachelor program as a ‘stand-alone’: LUC (Limburgs Universair Centrum) in the Flemish community and FUNDP (Namur) and UMH (Mons) in the French community.
Obtaining access to the Bachelor program is easier in the French than in the Flemish community. In the French community, students require only a degree from secondary school (high school education between 12 to 18 years). In the Flemish community, students also need to pass an admission examination with evaluation of basic scientific knowledge and social aptitudes of the candidate. This exam was introduced seven years ago, and since then the number of medical students applying to Flemish universities has declined by more than 50%.
Training in Radiology
The candidate requires a masters degree in medicine and a license to practice in Belgium. Each university selects the candidates and a post-graduate training plan is introduced atRthe Commission of Recognition of Radiology.
The plan is signed by the university and coordinated by the head of the academic radiology department. He or she has to follow a fulltime training course (X-ray, mammography, angiography, interventional radiology, ultrasound, CT and MRI) during 5 years at recognized training centres (91 centres in Belgium in 2002). Some training centres can provide the full training program (24 in Belgium), others offer only the first or second years. During these training years the 'training master' will provide the candidate with a fair salary (between 1500 and 2000 euro/month). The 'training master' will be responsible for dayto- day training, seminars and student supervision. The first two years are completed under the direction of the university. In the Flemish community, four hours of inter-university courses are organized each month in combination with annual inter-university examination. Following 5 years of training, the commission of recognition must assess and approve the candidate, and provide him or her with accreditation as a 'Specialist in Radiology'.
Before 1997 there was no limit in Belgium on the number of medical doctors or specialists. Since that time various regulations have been introduced in order to avoid a national surplus of doctors. The Federal government decided that the total number of new medical doctors should be reduced to meet an annual target set for each community, and that the ratio between specialists and general practitioners should be set as 60/40 (table 2). In the Flemish community the total numbers of last year’s (2003) newlyqualified doctors correlates almost exactly with the new regulations, on account of the ‘numerus clausus’ imposed on the inflow of students. However, concern is growing for the future, and the question is being asked, “Will there be enough medical students to fulfill the needs?” In the French community the problem is different, since, with two and a half times tha number of medical students in the Flemish community they have a lot more flexibility. However, at this moment, due to the new regulations, over half of the students who qualify with a masters degree will not get a license to perform medicine and so access employment.
Within the regulations, some exceptions are made for the female students and the medical needs of an aging population. However, we believe that because of entrance examinations imposed on the Flemish community,
taken together with medical students and doctors who abandon the profession, the ‘brain drain’ to other countries and the reduction in working hours, there will be a shortfall of Flemish doctors in the future. This could be problematic, certainly in some departments of medical imaging, because of a general move to more complex procedures and also to the increased demand for qualified specialists. Medicine as a whole is in evolution and, as the experience of recent years shows, it is becoming very difficult to predict future needs. The full impact of these new regulations will only become completely clear after 12 years and the consequences will also last for a further twelve years. The imaging professions believe that the impact of these controls on patient care has not been fully thought through.
The Postgraduate Courses
Postgraduate courses are mainly organized by the Belgian Royal Society of Radiology or by individual universities. The Belgian Royal Society of Radiology was founded in 1906 and is one of the oldest societies in Europe. The Society is organized into nine organ-specific or specialty-specific sections: Abdominal, Bone and Joints, Cardiovascular and Interventional, Head and Neck, Neuroradiology, Pediatric, Senology, Thoracic and Ultrasound. The principal goals are to promote and support clinical research in the field of radiology, to collect, evaluate and disseminate scientific knowledge and to encourage and support continuous medical education (CME). The four Flemish universities are working together in order to organize a monthly inter-university postgraduate evening course focused on a single topic.
In order to encourage (CME) a radiologist who achieves higher levels of accreditation enjoys additional honoraria per examination. To achieve this accreditation a minimal level of activity must be reached, the radiologist must submit him or herself to local quality control audit and acquire CME 200 points (the equivalent of 20 hours of postgraduate study).
In my experience, most Belgian radiologists work very hard, offer a high degree of clinical skill, and love their work . Certainly in the Flemish community, which I know well, concern is growing about the future. The work rate
is rising and the supply of new trainees is falling because of the plethora of new government regulations.�