Specialty training system in Poland in 2011-2018 according to the Centre of Postgraduate Medical Education register data

Results: The analysis of data from the register of physicians undergoing specialty training indicates that the number of physicians who trained to be specialists and the percentage of women in the group increased in the years 2011-2018. In the period in question, the percentage of doctors in training within a residency, the number of specialty training providers the number of training places and the use of training places enabling them to pursue specialisation rose as well. The situation differed between 10 specialties analysed.


Introduction
Physicians in Poland are obliged to continuously complement and enhance their knowledge and professional skills (1). Moreover, a doctor in Poland has the right and obligation to fulfil continuing professional development, primarily through various forms of post-graduate education (2). Specialty training is the most common way of improving professional competences among physicians in Poland. The Polish system of specialty training is strongly regulated. Currently, doctors may pursue a specialisation in 77 fields and dentists in 9 domains (3). The total minimum duration of specialty training ranges from 4 to 6 years in case of medical specialization and 3-6 years for dental specialties (3). The education system for medical specialists is subject to constant changes both at the formal and legal levels, as well as at the qualitative and quantitative ones. The changes are mainly due to the continuous development of the specialty organisation and result from the advances in medical sciences.
Nowadays, the condition for beginning specialty training is to complete six year medical studies, 13 -month post-graduate internship, and obtain a positive result of qualification proceedings where the result of the Medical Final Examination plays a decisive role (3). A physician undergoing specialisation performs the full range of duties appropriate for a specialist doctor in a given field. Besides, they can practise medicine freely outside the place of specialty training (2). Completion of the entire specialisation programme is a necessary condition for taking the State Specialization Examination. Passing this examination is equivalent to obtaining the title of a specialist doctor in a specific field of medicine.
A doctor in Poland may undergo specialty training within a residency or a non-residency mode (3). A resident doctor performs work in a specific field of medicine under an employment contract concluded with a hospital or department conducting training for medical specialists. The number of resident physicians enrolled in specialisation programmes in a given domain depends on the number of training residency places granted by the Ministry of Health. The number of granted training residency places is announced by the Minister of Health twice a year based on the analysis of staffing needs from the suggestions of national consultants in individual medicine domains (4). A resident doctor receives remuneration from public funds (5,6). Apart from residency, specialty training may be carried out under the non-residency employment in the form of a contract with a training hospital, which finances it from its own resources. Supervision over each physician undergoing specialisation is exercised by a specialty training tutor, who is a specialist doctor in the given domain. Public funds finance all specialty training courses and specialty practical internships required by the specialty training curriculum. It does not include, for example, commuting to and from courses and internships, or accommodation during this period. Doctors bear the costs mentioned above at their own expense (5).
Only hospitals and departments that fulfil specific conditions and have been accredited can conduct specialty training. Inclusion in the list of bodies authorised to provide specialty training in a given field is confirmed with accreditation (2).

Objective of the paper
The study aimed to determine the quantitative changes occurring in the system of specialty training of physicians in general and concerning the ten most numerous fields of medicine in the years 2011-2018. The analysis will be used to assess the directions of development of medical specialty training in Poland in the last eight years.

Material and methods
The data from the register of physicians undergoing specialty training conducted by the Centre of Postgraduate Medical Education (in Polish Centrum Medyczne Kształcenia Podyplomowego, CMKP) from 2011 to 2018 was the material for analysis. The data accessibility dictated the choice of the analysis period. Data from previous years are incomplete and were collected in a different standard. Due to the lack of data availability, no comparison with the pre-2011 situation is possible. The analysis covers ten most numerous medical fields in which doctors received specialty training in 2018. These domains include internal medicine, paediatrics, family medicine, anaesthesiology and intensive care, cardiology, radiology and diagnostic imaging, obstetrics and gynaecology, orthopaedic surgery and traumatology, general surgery, and psychiatry.
The analysis concerned the data on the number of: physicians working on completing specialisation in individual domains, including the number of women and men, doctors undergoing specialisation within residency, training places and entities providing specialty training programmes, as well as the age of doctors.
The register data were quantitatively analysed using the Statistica 12 Software (TIBCO Software Inc., Palo Alto, CA, the USA).
The average age of a physician under specialisation in 2018 was 32.9 years. Compared to 2011, the average age slightly declined (Table 1). Among the analysed fields, the lowest average age of physicians was observed in paediatrics -30.4 years and in internal medicine -30.5 years. On the other hand, the highest average age of physicians was noted in cardiology 32.7 years and family medicine 33.5 years (Table 2).
Practitioners enrolled in specialisation programmes in 2018 in Poland are mostly women (63%). In the years 2011-2018, the percentage of female doctors undergoing specialty training showed an upward trend (+2.6 pp from 2011). In the ten specialisations in question, the highest percentage of women in 2018 was in paediatrics (89.9%), obstetrics and gynaecology (69.4%), family medicine (68.6%), and psychiatry (63.5%). In turn, the lowest percentage of women was found in the so-called surgical specialties, i.e. orthopaedic surgery and traumatology (12.8%) and general surgery (37.7%), in which men dominated in numbers ( Table 2). In the period from 2011 to 2018, the percentage of women increased in six out of ten analysed fields (general surgery (11.9 pp), obstetrics and gynaecology (8.9 pp), cardiology (5.4 pp), orthopaedic surgery and traumatology (5.1 pp), anaesthesiology and intensive care (1.4 pp), and internal medicine (0.3 pp). While a decrease was noted in 4 other areas: paediatrics (-0.5 pp), psychiatry (-2.2 pp), family medicine (-2.6 pp), and radiology and diagnostic imaging (-3.5 pp).
In 2018, most physicians (71.7%) participated in specialty training within the residency. It was 16.7 percentage points (pp) more than in 2011. Among the ten domains analysed in 2018, the largest share of residents was in paediatrics (94.6%), general surgery (88.4%), anaesthesiology and intensive care (88.3%), internal medicine (88.3%) and obstetrics and gynaecology (86.2%). The lowest percentage of residents was recorded in cardiology (68.5%). In the period 2011-2018, the percentage of physicians undergoing specialty training within residency increased in all ten analysed areas. The highest rise in the percentage of doctors undergoing specialisation as residents was recorded in the following areas: obstetrics and gynaecology (28.8 pp), cardiology (24.6 pp), and psychiatry (18.1 pp).

Training places and entities providing specialty training programmes
In 2018, there were 43660 training places and 6833 entities providing specialty training programmes. In the period 2011-2018, the total number of the abovementioned units increased. In comparison to 2011, in 2018, there was one fifth (20.2%) more training places and one third (33.8%) more entities conducting specialty training. The rise in the number of training places was observed in all analysed areas except for internal diseases (-1.1%). The highest growth in the number of places was recorded in the following areas: paediatrics (+33.9%), psychiatry (+32.8%), and obstetrics and gynaecology (+32.4%). The number of specialty training providers rose in all ten analysed fields, with the highest increases in family medicine (+994.7%), psychiatry (+210.5%), and paediatrics (+30.7%).
In the period under study, the use of specialty training places, as expressed by the indicator of the number of training places to the number of physicians undergoing specialty training remained at a constant level of approx. 1.6.
Among the ten analysed areas of medicine, the highest rate of utilisation of training places in 2018 was identified in radiology and diagnostic imaging (1.1), obstetrics and gynaecology (1.3), and paediatrics (1.3). In turn, the lowest usage of training places was recorded in psychiatry (2.0), family medicine (2.5) and internal medicine (3.0).

Discussion
According to the best knowledge of the authors, the examination of the current situation in the field of the medical specialty training system in the light of the CMKP register data is the first such analysis. It concerned only ten out of 77 areas in which doctors can specialize. There is a need for further analyses, which would cover more areas of specialty training. Medical specialty training differs between countries. These differences relate to, i.e. admission policies, duration, registration and licensing procedures (10). Regardless of this, it is important to describe the situation in particular countries to enable a wider comparison between them. Such comparison is important to gain awareness of existing differences which strengthen transparency and may lead to improve quality of specialty training in medicine.

Physicians enrolled in specialisation programmes
In the years 2011-2018, the number of physicians under specialty training increased significantly (14.9%). The growth in the number of physicians specialising in individual fields was mainly due to the Ministry of Health's decisions on the amount of granted residential places (4). Efforts should be made to ensure that the decisions on the allocation of resident posts correspond as much as possible to the real demand for specialists in individual domains. The financial capacity of the Ministry of Health in this respect is also significant. Expenditures for this purpose are steadily increasing (6).
In 2017, the average age of physicians-in-specialty training was 33.3 years, which was lower than for the whole group of doctors (50.2 years), and for specialist doctors (54.2 years). In 2017, the average age of a person acquiring the first specialisation was 34.6 years, while in the case of the second or subsequent specialisation, these people were 42.0 years old on average (7).
The share of women among physicians undergoing specialty training was 63%. Although it was higher than in the whole population of physicians (57.7%), it was similar to the share of women among physicians (60.9%) who obtained the right to practice their profession in 2017 (7). An increasing share of women among physicians is also noted in other countries (8).
The most common mode of specialty training was the residency contract. In the analysed period, the number of practitioners specialising within residency grew steadily. This direction of changes can be assessed positively, as it ensures a subjectively higher quality of education and meets the doctors' expectations (9).

Training places and entities providing specialty training programmes
The growing number of training providers and the related increasing amount of training places in the analysed period 2011-2018 offers doctors the access to each of the analysed ten specialisation domains and enables all potentially interested physicians to commence a specialisation process in the chosen domain. However, it is the number of places of residency granted by the Ministry of Health in a given field and the number of non-residency ones allowed in training institutions that limits the possibility to begin to specialise. The question arises whether all hospitals and departments which have been accredited to conduct specialty training programmes offer the same high level of education. An alternative to the highly decentralised model of education is the model based on the so-called teaching hospitals, i.e. units which provide future and current health care workers with medical education and training, and which are involved in medical research.
During the period studied, the utilisation of specialty training places expressed by the indicator of the number of training places to the number of physicians undergoing specialty training remained at a constant level, clearly exceeding the number of physicians working on completing specialisation. Such a significant disparity may indicate the need for in-depth analysis to make better use of the system's potential.

Conclusions
Based on the analyses conducted for the years 2011-2018, it should be stated that the system of post-graduate education of physicians in Poland has been continually developing and increasingly making use of its potential. In the examined period: y the number of physicians undergoing specialty training was growing, y the percentage of women in the group of specialised doctors rose, y the percentage of people specialising in residency increased, y the number of entities conducting specialty training and the number of training places grew, y the use of training places for specialty training programmes increased. It must be emphasised that the system of medical specialty training should be analysed on an ongoing basis. The Centre of Postgraduate Medical Education register provides useful data for monitoring the current situation.