An exploratory survey on the state of training in adolescent medicine and health in 36 European countries
The development of adolescent health and medicine as a medical discipline lags behind in Europe compared with other regions of the world. This study aims to evaluate the structure and content of adolescent medicine and health training curricula for medical students, paediatricians, and other primary care physicians in the European region. A questionnaire survey was sent by e-mail to experts in the field from 36 European countries, addressing the content of adolescent health issues. Data was obtained from all 36 countries. At the undergraduate level, seven countries reported some mandatory stand-alone teaching (sessions dealing specifically with adolescents), while seven countries reported optional stand-alone teaching. In only 7 out of 36 countries were issues critical to adolescents covered as stand-alone sessions. At the postgraduate level, 15 countries delivered stand-alone mandatory training sessions to primary, secondary, or tertiary care paediatricians, covering most of the five critical areas listed in the questionnaire. In another 13 countries, such sessions were not mandatory and were inexistent in eight of them. The coverage among school physicians was similar but was much lower among general practitioners.
What is known:
• In most European countries, adolescent medicine is still poorly represented as a discipline.
• Experts have recently published recommendations regarding what form the structure and content of a training curriculum in this field should take.
What is new:
• This paper gives information on the extent and content of training in adolescent medicine and health as currently offered within under- and postgraduate European training curricula, in terms of stand-alone mandatory (versus optional) sessions.
• In many European countries, both medical students and residents are poorly exposed to the basic knowledge and skills pertaining to adolescent health care.
KeywordsAdolescent Adolescent medicine Training Medical education Adolescent health Europe Survey
European Academy of Paediatrics
European Paediatric Association
European training in effective adolescent care and health
Models of Child Health Appraised
United States of America
World Health Organization
Worldwide, the specific health needs of adolescents are increasingly being addressed [13, 16, 18]. As mentioned in a recent publication of the World Health Organization (WHO) , “Investments in adolescent health bring a triple dividend of benefits for adolescents now, for their future adult lives, and for the next generation. Their health and well-being are engines of change in the drive to create healthier, more sustainable societies.” Policymakers and health professionals need to develop the technical capacity for policy, programming, research, and clinical care in all regions of the world. Several documents have recently outlined how high-quality health care can be achieved for adolescents [3, 15, 17, 22], in which the training and competencies of health care providers play a pivotal role [9, 12, 14]. When asked about their training needs in the area of adolescent medicine and health, paediatricians express a wish to acquire a variety of knowledge and skills. For instance, in a survey conducted among French paediatric residents, 81% considered that paediatricians should acquire skills in adolescent medicine and health; they reported major difficulties in providing care for teenagers reluctant to seek health care, or in managing suicidal adolescents . In another survey carried out 15 years ago among Swiss primary care providers in private practice , two-thirds wanted to acquire more skills in managing functional disorders and half expressed a desire to receive training in areas such as communication skills, mental health (including eating disorders), substance use, or coping with dysfunctional families.
Training in the area of adolescent medicine and health needs encompasses more than just the delivery of knowledge; it also involves acquiring specific competencies and skills that allow the trainee to develop a mutually respectful relationship with an adolescent. Furthermore, it involves helping to develop appropriate screening and counselling approaches in reviewing the adolescent’s lifestyle, as well as learning how to deal with family conflicts and address situations posing ethical dilemmas. Finally, it means acquiring the capacity to deal with health issues such as exploratory and risk behaviours, mental health, and sexual and reproductive health as applied to adolescents10. This is why, in the opinion of the authors, it is insufficient to include some information on adolescent medicine within sessions dealing with broader areas; rather, it is important to devote dedicated stand-alone sessions to this field [12, 14]. Medical students and residents should be trained to deal concretely with clinical situations via interactive participative training sessions, bedside teaching and observation, and discussion of videos, and by testing out their skills with simulated patients [7, 12, 14]. In the USA, Canada, and Australia, and to a lesser extent in some South American nations, adolescent health and medicine is considered a medical discipline or sub-discipline, and most medical school and university hospitals provide both lectures and training sessions specifically addressing this population of patients [11, 16]. Compared with these countries, Europe is lagging behind [6, 11]. This study aims to evaluate the structure and content of adolescent training curricula in the European region for medical students, paediatricians, and other physicians who, regularly or occasionally, work as primary care providers, such as family physicians (GPs), gynaecologists, and psychiatrists. Specifically, it assesses the extent to which training in the field is provided as a stand-alone topic or embedded in the programmes of other disciplines, and whether it is mandatory or optional. A second objective is to explore the content of such training programmes in terms of issues that are most relevant to this period of life, such as communication skills, and issues pertaining to mental or sexual and reproductive health.
This survey is part of the 4-year-long EU-funded MOCHA research programme (“Models of Child Health Appraised”), initiated by leading experts from Imperial College in London. This research programme aims to assess various aspects of primary care delivered to children and adolescents in EU countries, including topics such as quality assessment, economic factors, structure of health care delivery, training, and ethical aspects . The overall project was undertaken by several specialist groups of researchers working in collaboration.
List of the 36 countries involved, showing the sources of their answers
Bosnia and Herzegovina*
Number of countries that offer mandatory or optional training sessions within the postgraduate training of physicians in specific disciplines
Primary care paediatricians mandatory 11
(Nonexistent in some countries) optional 3
Not as a stand-alone 11
Not applicable 11
Primary care physicians (GPs) mandatory 3
(Not applicable in some countries) optional 10
Not as a stand-alone 20
Not applicable 3
Secondary care paediatricians mandatory 8
(Not applicable in some countries) optional 12
Not as a stand-alone 14
Not applicable 2
Gynaecologists mandatory 3
Not as a stand-alone 15
Psychiatrists mandatory 9
(Not applicable in some countries) optional 16
Not as a stand-alone 11
School physicians mandatory 10
(Not applicable in some countries) optional 1
Not as a stand-alone 5
Not applicable 20
Number of countries providing formal training in different areas within the postgraduate training curriculum of paediatricians and GPs (either as a stand-alone or embedded in other disciplines)
• Communication skills: in 20 countries
• Ethics in 22 countries
• Screening of lifestyles in 21 countries
• Sexual and reproductive health in 26 countries
• Mental health in 25 countries
• Communication skills: in 21 countries
• Ethics in 29 countries
• Screening of lifestyles in 25 countries
• Sexual and reproductive health in 22 countries
• Mental health in 29 countries
General practitioners/family physicians:
• Communication skills: in 16 countries
• Ethics in 18 countries
• Screening of lifestyles in 16 countries
• Sexual and reproductive health in 17 countries
• Mental health in 23 countries
For the majority of participating countries, data were received from more than one source (Table 1), i.e. for seven countries from three sources, for another 20 countries from two sources, and from nine countries from one source only. In some instances (not more than four to eight occasions, depending on the nature of the question), data available from different sources were only partially consistent. In cases where answers were inconsistent, the answer included in the final analysis was the one confirming that a training activity did indeed take place. This approach was based on the assumption that people who answered “yes” to the question knew of the existence/content of a training programme, while those who answered “no” may simply have not been aware of it. A complete set of answers (i.e. answers via either one or all of the three different sources) was received in 2017 or 2018 from all 36 European countries. Most questionnaires were adequately completed, with very few questions left unanswered (< 5%).
Training in adolescent health and medicine for medical students
Training in adolescent health and medicine for residents
Table 3 gives an overview of the adolescent health topics included within the postgraduate training of paediatricians and general practitioners (GPs). Mental health was the area covered most and in around three-fifths of the surveyed countries; the areas of communication skills, ethics, screening of lifestyles, and sexual and reproductive health were also included. The countries in which most of these topics were covered are Croatia, Finland, Iceland, Lithuania, Moldova, Norway, Slovenia, Sweden, Switzerland, Turkey, and the UK. In addition, several countries had established one or several specialised units where paediatric or internal medicine residents could acquire specific competencies from tutors trained in adolescent medicine. These were Croatia, Finland, France, Greece, Italy, Moldova, Portugal, Slovenia, Spain, Sweden, Switzerland, Turkey, and the UK.
In addition, in several countries there was some discrepancy between the format of training and its content. For instance, while Switzerland, Turkey, and Estonia offered a wide variety of topics to students, residents in paediatric and internal medicine (GPs), and to in-practice doctors, none of these was covered as stand-alone mandatory sessions. On the other hand, countries like Germany and Greece had implemented stand-alone training sessions in adolescent medicine and health but included only a limited number of topics in their curricula. Only a few countries such as Moldova or Finland provided training to paediatricians with mandatory stand-alone sessions covering all or most of the important topics.
Training in adolescent health and medicine as part of continuing medical education
The percentage of countries organizing continuing medical education sessions in the field is fairly similar to that pertaining to postgraduate training. Fifteen countries offered such sessions in all or most of the topics considered important: Armenia, Austria, Bosnia and Herzegovina, Bulgaria, Croatia, Finland, France, Lithuania, Moldova, Romania, Slovenia, Spain, Sweden, Switzerland, and Turkey. The other countries (N = 11) did not offer a single session in the specific areas of adolescent health and medicine. Of interest is the fact that 17 countries (Austria, Croatia, Czech Republic, Denmark, Finland, France, Greece, Israel, Italy, Norway, Portugal, Slovenia, Spain, Sweden, Switzerland, Turkey, and the UK) had established an Association for Adolescent Medicine and Health, which may ultimately lead to a better range of offers at the CME level. The questionnaire did not allow assessment of the objectives and activities of these Associations.
Paediatricians and primary care providers (such as GPs) should acquire specific basic competencies in order to respond to the health care needs of adolescents [9, 12, 16]. In the USA, there are currently 26 accredited centres that offer CME programmes, residency to younger paediatricians or family doctors, as well as 2- or 3-year fellowships. Some of these centres have been in operation for more than 30 years. In addition, several academic institutions provide training programmes dealing with adolescent health for dieticians, psychologists, nursing students, or social workers. Australia also offers 4-year fellowship programmes in the field of “AYA” medicine (Adolescent and Young Adults). Both countries have created an official certified sub-specialisation in adolescent medicine. Some South America nations (Argentina, Chile, and Brazil) have their own academic centres. These academic centres have included areas in their educational programmes such as the acquisition of sound communication skills, expertise in dealing with sexual and reproductive health or substance misuse, and how to care for adolescents with chronic conditions; all these initiatives have an impact on the delivery of health care. While it is difficult to assess the impact of such training on the care of adolescents, a recent survey conducted in the USA shows that 43–81% of adolescents received provision of preventive services over the course of a year . In contrast, such an achievement cannot be expected in the European region, given the lack of specific education in adolescent medicine and health within many training institutions [15, 21, 24]. Indeed, only seven out of the 36 surveyed European countries include mandatory stand-alone sessions in the undergraduate training of medical students, while in another seven countries, such sessions exist but are only optional. In several countries, residents in paediatrics receive training sessions covering important topics such as communication skills and ethics, screening of lifestyles, mental health, or sexual and reproductive health. However, in many instances, such training sessions are neither mandatory nor provided as stand-alone sessions. Moreover, it is likely that this type of education is not available in all regions of the countries in which they exist. The results regarding the training of general practitioners are of even greater concern: only three countries (< 10%) offer mandatory courses in the field.
A similar survey run on behalf of the EPA (European Paediatric Association—UNEPSA)  showed that in 2008, undergraduate education in adolescent medicine was offered in half of the countries surveyed (N = 14), and training in the field was provided in 18 out of 29 countries in the context of paediatric residency programmes. This earlier survey did not distinguish between mandatory and optional education and did not either investigate stand-alone teaching and learning. Given this situation, which seems not to have improved in the last 10 years, it comes as no surprise that, according to a recent UK survey, many adolescents feel dissatisfied with the provision of the health care they receive .
There are limitations to this survey. The most important one is that the respondents were usually not specialists in the field of adolescent health and medicine and came from different professional backgrounds. As a result, they may have not been able to obtain complete information about the state of training in this field, despite their efforts to gather as accurate information as possible. In addition, the respondents often mentioned that the distribution and organization of training curricula differed from one region or institution to another, but that it was not possible to measure to what extent this was the case. In some cases, the answers provided by respondents from different sources were not consistent. As we chose to keep the most positive answers, our findings may provide too optimistic a view of the situation within some countries. However, this problem does not jeopardize our conclusion as the situation may even be worse than the one we describe. Finally, the size of the questionnaires forced us to limit the number of topics included, as well as limit other details such as the number of hours delivered, or the types of teaching methods used. This survey must therefore be considered a first attempt to review the situation in Europe. In addition, for the same reason (questionnaire size), we were unable to include questions concerning the training of other professionals such as psychologists or social workers, despite the importance of an interprofessional approach in adolescent care, especially when dealing with complex situations such as long-term chronic conditions.
What can be done to improve the situation? In our opinion, in the future, all European countries should endorse policies regarding adolescent-friendly primary care and the development of training sessions at under- and postgraduate level, as recommended recently by the Lancet commission, the World Health Organization, and various authors [2, 5, 9, 14, 16, 20, 21]. Apart from the development of policies, several bodies could contribute to the training of health professionals. A first step would be to introduce a few specific stand-alone mandatory training sessions pertaining to adolescent medicine and health in all medical faculties—and additionally in schools of nursing/midwifery . The emphasis should be not only on specific knowledge regarding issues such as sexual and reproductive health, mental health, or substance use but also on attitudes to adopt when caring for adolescents, and skills such as communication skills. In this regard, an important step would be the systematic inclusion of topics related to adolescent medicine and health in the summative examinations using competency-based assessment approaches.
Most importantly, physicians planning to become paediatricians or GPs, as well as future gynaecologists and psychiatrists, should be the target of training initiatives at postgraduate level. In countries providing health care or preventive/screening activities within the school health setting, junior physicians could be exposed systematically, under supervision, to the specific needs of this young population. This also applies to outreach centres dealing with the vulnerable or dropout adolescent population. Ideally, the presence of a special ward or an adolescent outpatient clinic such as those created in London, Lisbon, or Lausanne allows for an effective sensitization of in-training residents. Academic institutions and university hospitals should ensure that one or several members of their paediatric staff develop an interest and specific competencies in the area of adolescent medicine and health, become credible mentors, and establish training programmes in the field. A typical content for such a curriculum—which should be created in collaboration with other disciplines—was recently proposed under the auspices of the European Academy of Paediatrics 11. Another useful tool is the EuTEACH programme (www.euteach.com), which provides a set of online training modules with slides and videos free of charge [9, 14]. In conclusion, a better coverage of adolescent health and medicine in the training curricula of medical students, residents in paediatrics, and other primary care disciplines is necessary. To achieve this, the voice and input of paediatric associations and academic institutions is needed.
This survey results from a collaboration between three networks of scientists and collaborators, the MOCHA network (Models of Child Health Appraised), the network of representatives of the EAP (European Academy of Paediatrics), and the one of Young EAPs. The authors are extremely grateful to all the colleagues of these three networks for having carefully filled in the questionnaires that had been sent to them. They also want to thank warmly some members of the MOCHA WP3 who participated in discussions regarding the content of the survey, namely Prof. Paul Kocken (Netherlands Organization for Applied Scientific Research) and Menno Reijneveld (University Medical Center Groningen). They express their full appreciation to Profs. Mitch Blair and Michael Rigby and to Mrs. Denise Alexander (Imperial College, London) for their continuing support in the research. They finally deeply acknowledge the input of Artur Mazur, Adamos Hadjipanayis, Stefano del Torso, Tom Stiris, and Rob Ross-Russel, members of the adolescent working group of the European Academy of Paediatrics, who have encouraged the authors to undertake this survey and, while endorsing its purpose, have encouraged their colleagues to respond.
All authors provided critical feedback and helped shape the research, analysis and manuscript. PAM - project design and main conceptual ideas. LS, ŁD - collection and assembly of data. PAM, DJ, LS, JV, AV, ŁD - data analysis and interpretation, writing the article.
Mrs. Danielle Jansen: European Commission through the Horizon 2020 Framework (Grant Nb. 634201).
Prof. Pierre-André Michaud: State Secretariat for Education Research and Innovation (SEFRI), Switzerland (Grant number 15.0152).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies which involved the authors using human or animal participants.
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