Postgraduate Medical Education System Research Articles

Competency-Based Medical Education at Scale: A Road Map for Transforming National Systems of Postgraduate Medical Education.

In the past decade, the Canadian system of postgraduate medical education has been transformed with the implementation of a new approach to competency based medical education called Competence by Design. The Royal College of Physicians and Surgeons of Canada (Royal College) developed an approach to time-variable competency based medical education and adapted that design for medical, surgical, and diagnostic disciplines. New educational standards and entrustable professional activities consistent with this approach were co-created with 67 specialties and subspecialties, and implementation was scaled up across 17 universities and over 1000 postgraduate training programs. Partner engagement, systematic design of workshops to create discipline specific competency-based standards of education, and agile adaptation were all key ingredients for success. This paper describes the strategies applied by the Royal College, lessons learned regarding transformative change in the complex system of postgraduate medical education, and the current status of the Competence by Design initiative. The approach taken and lessons learned by the Royal College may be useful for other educators who are planning a transformation to CBME or any other major educational reform.

Review of the need for the reforming medical education, Republic of Armenia

Medical education is a fundamental link in the formation of qualified medical personnel. At different periods of development of the health care system, the system of education of health workers was also revised and improved. The article describes the stages of formation and development of the system of postgraduate education of medical workers in Armenia. To assess the current situation and the necessity to update the current system of postgraduate medical education, we conducted a survey in which participated the clinical residents, employees, and heads of departments, medical workers, leading specialists and representatives of the Ministry of Health of the Republic of Armenia.

Collaborative governance of postgraduate medical education: Can it be achieved?

Faced with the need to modernize and improve the postgraduate medical education experience and to maintain the high quality of physicians that Canadians expect, in 2010, four organizations –Association of Faculties of Medicine of Canada (AFMC); Collège des Médecins du Québec (CMQ); College of Family Physicians of Canada (CFPC); and Royal College of Physicians and Surgeons of Canada (RCPSC) formed a consortium to conduct a review of Postgraduate Medical Education (PGME) in Canada. In 2012, the Consortium published the Future of Medical Education in Canada Postgraduate (FMEC PG) project’s 10 recommendations for change in PGME. One of these recommendations was to ‘Establish Effective Collaborative Governance in PGME’. The recommendation stated- ‘Recognizing the complexity of PGME and the health delivery system within which it operates, integrate the multiple bodies (regulatory and certifying colleges, educational and healthcare institutions) that play a role in PGME into a collaborative governance structure in order to achieve efficiency, reduce redundancy, and provide clarity on strategic directions and decisions’ The purpose of this paper is to describe the creation, function and dissolution of a collaborative governance structure within the complex system of PGME and the challenges that were faced in its sustainability. The lessons learned are applicable internationally where integration of multiple organizations is being attempted. A fundamental question remains as to whether a consensus-based decision-making process can ever be achieved among organizations with overlapping mandates and in some cases, hierarchical structures?

Evolution of postgraduate medical education in paediatrics: the Singapore story

Postgraduate paediatric education in Singapore has seen a seismic shift in the past 50–60 years, from a primarily time-based, passive, teacher-centric and apprenticeship model with hierarchical learning culture to a competency-based and learner-centric one. The postgraduate medical education system in paediatrics in Singapore will continue to evolve and adapt with best practices in evidence-based medical education, with the aim to train and develop the next generation of paediatricians who will strive to continually improve child and population health in Singapore.

The Glaring Gender Bias in the Operating Room: A Qualitative Study of Factors Influencing Career Selection for First-Year Medical Students

Despite greater female than male-identifying Canadian medical graduates, women continued to be underrepresented in surgical specialties. The aim of this study was to explore the role of lifestyle challenges and gender-specific considerations in career selection for first-year medical students following early exposure to surgery through an immersive surgical program. A single institution, qualitative study consisting of structured focus groups before and after completion of a 2-week surgical program was used to explore medical student perceptions of surgery. The program consisted of shadowing, surgeon-led talks, and surgical skills workshops in all direct-entry surgical specialties within the Department of Surgery at the University of Toronto. Six entry and exit interviews were conducted by 2 authors. Interviews were recorded, transcribed, and coded for thematic analysis. Teaching hospitals affiliated with the University of Toronto, Canada PARTICIPANTS: Thirty first-year medical students with interest in surgery participated in the program and the focus groups. Four prominent themes emerged: gender imbalances in the work environment, the importance of female mentors, gender-specific challenges of parenting, and the importance of flexible work hours for both male and female students. Greater exposure to female surgeons improved the outlook of medical students on work-life balance. Medical students are concerned with the challenges of pregnancy in a surgical profession. Both male and female students consider parenting, supportive partners, and flexibility of work hours in their career selection. This study demonstrates the prevalence of gender bias in surgical specialties, raising gender-specific challenges that impact career selection for first-year medical students. In an effort to address these perceptions, this study supports efforts to implement formalized mentorship programs for women in surgery early in medical education. Furthermore, concerns surrounding childbearing further support the need for well-established parental leave policies in the Canadian postgraduate medical education system.

RESEARCH OF PSYCHOLOGICAL READINESS OF DOCTORS TO ADAPTIVE TRAINING

The aim: To empirically investigate the psychological readiness of physicians for adaptive learning during the acquisition of professional competences in the system of postgraduate medical education. Materials and methods: We surveyed a sample of 148 physicians who began studying the discipline of Psychology of Conflict, which was specially developed by us on the principles of adaptive learning. There were three occupational groups among doctors: surgeons (n = 47), therapists (n = 53) and pediatricians (n = 48).In the work a range of methods are used: content analysis, biblio-semantic, systematic approach, analysis of products of activity, psycho-diagnostic methods. Results: When characterizing the identified and calculated integral indicators, the most pronounced for the entire study sample is the desire for dominance (85%), adaptation and emotional comfort at 75%. The lowest percentage of self-perception - 65%, slightly higher internality (68%). Acceptance of others at 78%. In general, the dominant factor of the 148 physicians was service motived, indicating that this group is truly focused on the benefit of their patients and others. Our researchers perceive their work as a service, as a means of being useful to people, society and humanity as a whole. This is an indicator of high readiness for adaptive learning in the postgraduate medical education system. The results of the method of "Self-regulation style of behavior" by the doctors of the three medical specialties studied by us testify to their readiness for active inclusion in the system of adaptive training in postgraduate medical education. Conclusions: Based on the results of our empirical study, we are able state that the doctors who participated in the study are ready for adaptive training in the system ofpostgraduate medical education. The results of our research can be basis for drafting recommendations for adaptive education, which can be grounded on a competent approach.

Regulatory support of the healthcare system: according to the results of sociological research

Purpose of the study. Forming of recommendations for improving the legal aspects of health care in modern conditions.
 Materials and methods. To achieve the purpose of the research, we used the survey method in the form of a standardized (formalized) interview as the main tool for gathering information.
 Results. A significant proportion of respondents believe that the existing regulatory framework in the field of health care only partially meets modern needs and needs significant changes. Regarding the legal framework governing the field of postgraduate education, according to more than half of respondents, it only partially meets the existing present needs and only a third believe that it meets modern requirements.
 Conclusion. The current legal framework of the health care sector, due to its imperfection, only partially meets the modern needs of the population of Ukraine and requires significant changes. Among the normative legal acts that regulate the activity of health care bodies and interconnection in the «doctor-patient» system, a number of normative acts need to be improved, in particular: Fundamentals of legislation of Ukraine on health care: Law of Ukraine from 19.11.1992 № 2801-XII. The regulatory framework of postgraduate medical education system also needs to be improved, as it greatly contributes to the successful reform of the medical field as a whole.

Medical Education Reform in China: The Shanghai Medical Training Model.

Medical Education Reform in China: The Shanghai Medical Training Model.

ОРГАНІЗАЦІЙНІ ПРИНЦИПИ ПРОФЕСІЙНОЇ ПІДГОТОВКИ МЕДИЧНИХ ПРЕДСТАВНИКІВ У ФЕДЕРАТИВНІЙ РЕСПУБЛІЦІ НІМЕЧЧИНИ

A topical issue concerning the modern domestic professional education, i.e., the training and certification of specialists in the postgraduate period for the pharmaceutical industry, was examined in the article. Foreign and domestic scientific literature on the problem of professional training of medical representatives of pharmaceutical companies was analyzed and the constructive experience of Germany was studied as well. The main formats (formal, non-formal and informal education) of professional training that meet the requirements of the German legal framework were also taken into account. It was found out, that the main organizational function during the training of medical representatives in the country is performed by associations such as civil society institutions among them – the National Association of Pharmaceutical Sales Representatives. Their websites contain the terms for obtaining this profession, the program, training support – manual, tests, the testing procedure, issuing of a certificate and recommendations for the establishment of expert commissions. It was found out that the professional training of medical representatives is carried out on the principles of lifelong learning and dual training (without being interrupted from the production process) and with preference that is given to distance learning and testing in order to obtain a certificate. According to German law, certification of a medical representative after passing an exam (testing) is a prerequisite for his/her employment.The results of the research represented by the author actualize the need to include a medical representative as a profession in the National Classification of Professions, development of the master’s educational and professional program for the specialty “Medical Representative” or an appropriate specialization. It was proved that the introduction of foreign experience in the training of medical representatives directly in medical establishments of higher education, in the system of postgraduate medical education with the involvement of professional associations in the field of pharmacy, which is fully consistent with Ukrainian legislation on public-private partnership, is very actual at present.

МЕТОДИЧНІ АСПЕКТИ РОЗВИТКУ МІЖКУЛЬТУРНОЇ КОМПЕТЕНТНОСТІ ЛІКАРІВ-ТЕРАПЕВТІВ У ЗАКЛАДАХ ПІСЛЯДИПЛОМНОЇ ОСВІТИ

Актуальність: розвиток міжкультурної компетентності набуває важливого значення у системі післядипломної медичної освіти, оскільки успішність міжособистісної комунікації фахівців системи охорони здоров’я, зокрема лікарів-терапевтів, значною мірою залежить від рівня міжкультурної компетентності. Дана проблема є надзвичайно актуальною в умовах поширення епідемій, пандемій, техногенних та екологічних катастроф. 
 Мета дослідження полягає у аналізі навчальних програм, що мають одним із завдань розвиток міжкультурної компетентності лікарів та виокремленні основних методичних засад щодо розвитку цієї компетентності у післядипломній медичній освіті.
 Методи: теоретичні (аналіз, синтез, узагальнення). 
 Результати: проведено аналіз навчальних програм, спрямованих на розвиток міжкультурної компетентності лікарів. Встановлено, що для розвитку цієї компетентності серед лікарів-терапевтів необхідним є впровадження тем до основних курсів у системі післядипломної медичної освіти, що зумовлять вивчення та вирішення проблем розуміння та усвідомлення міжкультурних особливостей професійного оточення. 
 Висновки: основними методичними засадами щодо розвитку міжкультурної компетентності лікарів-терапевтів у закладах післядипломної освіти є виокремлення актуальних тем у межах міжкультурної проблематики для їх включення до дисциплін, що пропонуються лікарям у системі післядипломної освіти; застосування форм навчання, що сприяють активізації, мотивації та підвищенню інтересу до навчання у лікарів; забезпечення неперервного навчання лікарів-терапевтів без відриву від основної роботи.

ASSESSMENT OF THE OPINION OF INTERNS ON PROBLEMS AND PROSPECTS OF PROFESSIONAL ACTIVITIES IN THE FRAMEWORK OF THE HEALTH CARE SYSTEM REFORM

An integral part of the reform of the health care system of Ukraine is the change in medical education, which particularly implies a qualitative change in postgraduate education. The aim of the study is to form recommendations for improving the system of postgraduate medical education in the context of general health care reform. The study is aimed at examining aspects of the activities of interns who have completed their internship training. The main method of collecting socio-psychological information was the survey method in the form of standardized (formalized) interviews. 399 individuals took part in the survey. According to the results of the research, it is found that in general physicians who have completed internship training face such problems of personal character and life goals as a certain living and psychological instability, desire for professional growth, awareness of their strengths and weaknesses in professional skills. The results of the survey indicate that, according to interns, health care facilities only slightly meet the modern requirements. It concerns both the material and technical base and the organization of work of a medical establishment. The analysis of the responses also indicates that the administration of a health care institution does not take into account the specifics of working with young specialists, their insufficient involvement in the treatment of patients in the medical establishment: interviewing patients, physical examination of patients, appointment of diagnostic methods, involvement in decision making, primary examination of patients, clinical examination of patients in hospitals. It should be noted that the staff of medical establishments are characterized by a sufficiently high degree of goodwill. The vast majority of respondents indicated a low level of conflict in health care institutions. Of particular note is the general tendency to reduce the prestige of the medical profession in the Ukrainian society. This indicates the need to develop measures aimed at forming a positive public opinion on the importance and usefulness of the profession of a physician in society.

Surgical leadership in Poland: ideas and challenges.

The Polish system of undergraduate and postgraduate medical education, including specialization courses in surgery, provided only general guidelines concerning the issue of creating a leader or preparing for leadership. The process of building the position of a leader has had a rather spontaneous character thus far; it has been based on the individual, natural predispositions of a candidate for the position of a leader. There are no formal guidelines for this in Poland. It is required that graduates of medical studies or residents should acquire the so-called professional and social skills before they complete their specialization training. In the light of the ongoing debate, it seems worthwhile to give a thought on the role of a leader and to undertake harmonized actions to work out a common stance on understanding the issue of leadership and teach leadership skills as a part of a harmonized, methodologically correct system of education, so that the best ways of preparing residents to perform the role of a leader in surgical and other medical surroundings could be realized.

Comparison of stomatology education systems between two medical universities in China and Russia

By comparing the similarities and differences in the higher education system and degree levels of stomatology, especially in the undergraduate-level courses, between I. M. Sechenov First Moscow State Medical University and Harbin Medical University, we found that: the class hours for undergraduates majoring in stomatology in Russia are three times as many as those in China, and the former's class hours for PBL accounts for 80% of its total class hours, which can greatly develop the medical students' competence of life-long learning and innovation. Russia focuses more on the early exposure to oral medical and clinical education. Moreover, they make stomatology penetrate the whole education process. The system of combing postgraduate medical education with residency training in Russia has been developed early and relatively mature, which can provide example for Chinese standardized training of oral residents. The study for the current education system of stomatology in Russia is of great significance in strengthening the cooperation between China and Russia on stomatology education and promoting the reform of Chinese stomatology education. Key words: Russia; China; Stomatology; Education system; Comparison

A Review of Echocardiography Training for Internal Medicine Residents: Proposed Goals, Methods, and Metrics

Focused cardiac ultrasound (FCU) is a useful bedside tool that is often utilized by internal medicine residents. Multiple studies have shown that FCU adds valuable information beyond the history and physical. No formal recommendations exist regarding which physiologic parameters should be included in FCU, how those parameters should be assessed, or how to adequately train residents in its use. This review highlights the available literature on FCU training for medicine residents and provides in-depth analysis of the existing programs. There is significant variability among FCU training of internal medicine residents. A standard FCU training protocol should be considered to incorporate this powerful modality throughout the American Post-Graduate Medical Education System. This review offers recommendations for standard training.

MEDICAL AND SOCIAL CHARACTERISTICS OF PHYSICIANS ATTENDING POSTGRADUATE TRAINING COURSES (SOCIAL SURVEY)

The paper studies professional, social and psychological aspects concerned with a practical activity of physicians referred to attend postgraduate training courses at Danylo Halytsky Lviv National Medical University. Aim. To develop the recommendations on the improvement in the system of postgraduate medical education under the conditions of general reform in the health care system. The research was done by the survey method in the form of standardized (formalized) interview that was applied as the main approach to the process of collecting social and psychological information.The survey included 823 physicians referred to attend postgraduate training courses at Danylo Halytsky Lviv National Medical University. The working experience of postgraduate course attendants was the following: up to 5 years – 25.39±1.52 %, 5–10 years – 21.39±1.43 %, 11–15 years – 11.79±1.12 %, 16–20 years – 9.96±1.04 %, 21–30 years – 16.89±1.31 %, more than 30 years – 14.58±1.23 %. The majority of questioned medical workers (74.24±1.52 %) feel calm and happy at their working place. However, the received data indicates that 23.09±1.47 % of the responders feel disturbance and 1.94±0.48 % experience fear at work. The analysis of the research results allowed differentiating five sharp problems which are very topical and significant at the medical institution where the physicians have been performing their practice. They can be ranged in the following way: the job compensation (42.93±2.09 %), absence of modern medical equipment (26.65±1.87 %), organization of the working process (22.90±1.78 %), reorganization (7.69±1.13 %), extra documentation (7.33±1.10 %). The carried out survey permitted to determine the psychological atmosphere at medical institutions there the course attendants have been practicing. The conflicts are not a characteristic feature of medical institutions, since almost half of the responders indicated the absence of conflicts with higher managers (52.86±1.74 %), direct managers (43.01±1.73 %), subordinate personnel (43.38±1.73 %). This index is somewhat lower concerning the colleagues and patients. It amounts for 36.33±1.68 % and 33.17±1.64 % respectively. The physicians practicing in medicine and prevention as well as dentistry branches are most disturbed by the lack of financial sources. More than a half of responders (73.86±2.70 %) indicated it by their answers. Other responses included the absence of perspectives – 68.18±2.87 %, extreme, stressful living conditions – 25.38±2.68 %, personal present health status – 20.08±2.47 %, personal lack of confidence – 9.47±1.80 % (the number of responses was not restricted). The carried out work has showed the necessity of introducing the specialized course “State medical policy”. It should be aimed at delivering the information on the status, perspectives, reforming changes and the expected outcomes resulting from these factors in the branch of medicine. In order to decrease the negative influence of the professional burnout, it is recommended to plan the specialized training classes that are directed on the prevention of the listed above phenomena.

TYPICAL FORMS OF LIVER PATHOLOGY IN CHILDREN

This lecture for the system of postgraduate medical education analyzes causes, types, key links of pathogenesis, and manifestations of the main typical forms of liver pathology — liver failure, hepatic coma, jaundice, cholemia, acholia, cholelithiasis, and their complications in children. To control the retention of the lecture material, case problems and multiple-choice tests are given.

MEDICAL PSYCHOLOGICAL MOODS OF THE DOCTORS STARTING THE TRAINING AT THE QUALIFICATION IMPROVEMENT COURSES (BASED ON THE RESULTS OF THE SOCIOLOGICAL STUDY)

The quality of medical care depends on the training of specialists, carried out, in particular, through continuous medical education. Aim. To form the recommendations for improving the postgraduate medical education system in the context of the overall reform of the health care system. Materials and methods. The survey involved 823 doctors who were starting the training at the qualification improvement courses (27.40 % – males and 70.60 % – females) aged from 24 to 50+. In order to realize the purpose of the study we used, as the main method of social psychological information collecting, the method of questioning in the form of standardized (formalized) interview. Results. Doctors of all specialties used knowledge acquired during previous courses, although with certain differences. Significant difference was found in satisfaction with the level of obtained practical skills during previous courses: 81.04±1.66 % of surgeons, therapeutic, pediatric, dental specialists were very satisfied or rather satisfied, when this indicator in case of doctors of the medico-prophylactic and pharmaceutical specialties was only 39.02±3.00 %. Regarding the level of theoretical knowledge, 85.51±1.49 % of surgeons, therapeutic, pediatric and dental specialists were very satisfied or satisfied with the theoretical part of qualification improvement courses and 57.20±3.05 % of doctors of the medico-prophylactic and pharmaceutical specialties were not satisfied or completely dissatisfied. 85.15±1.50 % of doctors of surgical, therapeutic, pediatric and dental specialties completely or partly used the ideas offered during the previous courses, when 31.82 ±2.87 % of the doctors of the medico-prophylactic and pharmaceutical specialties did not use anything in their practice. 72.42±1.56 % of doctors of all specialties consider that they have not yet reached their own career maximum. Almost half of doctors of all specialties wanted to receive more theoretical and practical knowledge during the courses, although 40.15±3.02 % of doctors of the medico-prophylactic and pharmaceutical specialties were interested in obtaining large volumes of information from their foreign counterparts, while only 4.29±0.86 % of doctors of surgical, therapeutic, pediatric and dental specialties were interested in gaining such information. Conclusion. The survey indicates the need to change and update the content of the qualification improvement courses work programs, as well as the creation of new ones, which is a prerequisite for the reorganization of the postgraduate medical education system. It is reasonable to create curricula and programs according to the specialties of doctors and basing on the previous survey results concerning queries and expectations.

The Development and Implementation of New Assessment Tools for the Surgical Clerkship Rotation.

This article was migrated. The article was marked as recommended. Innovation: We developed two new rubrics with explicit behavioural anchors to assess students in the Queen's undergraduate medical education (UGME) surgery clerkship rotation. These rotation rubrics, complemented by a new ambulatory clinic encounter card, improved the quality, consistency, and timeliness of feedback for clerks from faculty preceptors. This innovation was introduced during a comprehensive workplace-based assessment re-design being undertaken in the Department of Surgery as part of the transition to a post-graduate competency-based medical education (CBME) system for post-graduate education (PGME). The core UGME working group, comprised of a faculty surgeon, assessment consultant, and a surgical resident, selected terminology and designed the tool visual structure to be similar to the new post-graduate assessment tools, since most preceptors supervise learners in both programs. This consistency enhanced buy-in from faculty and ensured a smooth transition to the use of the new UGME tools. Development: The new assessment process was developed and piloted in three phases: (1) development of an assessment system based on rubrics with explicit behavioural descriptors as the key assessment tools; (2) implementation of a pilot study to establish the acceptability and feasibility of the use of these rubrics, with iterative revisions based on stakeholder feedback; and (3) development of a validity argument for the use of these assessment tools. The latter is scheduled for 2018. Outcomes: The use of these rotation behaviour-anchored rubrics and corresponding ambulatory clinic encounter card has greatly improved the mid- and final-rotation feedback provided to students on the Surgery Clerkship. The concrete, descriptive information provided by the rubrics allows the course director to provide specific feedback during rotation exit meetings. The course director has the ability to clearly articulate to students the areas where they have met (or exceeded) the expected level of competency, as well as areas which require additional attention.

Disagreements in surgical decision making for advanced cancer patients secondary to deficiencies in palliative care education.

34 Background: Surgical decision making in advanced cancer patients requires careful thought and deliberation balancing the high risks with the potential palliative benefits. We sought to compare palliative care education and decision-making for palliative surgery among physicians who commonly treat advanced cancer patients. Methods: Practicing surgeons, medical oncologists, palliative care physicians and critical care intensivists from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a palliative care education survey and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. Results: Of the 299 physicians surveyed, 102 responded with a response rate of 34.1%. Respondents reflected the demographics of the total cohort. Physicians reported minimal hours of palliative care education during residency (median 0, IQR 0-8), fellowship (median 0, IQR 0-20), and continuing medical education (CME, median 8, IQR 0-20). Surgeons reported the fewest hours of palliative care education during residency, fellowship, and CME combined (median 10, IQR 2-15) compared to medical oncologists (median 30, IQR 20-80) and intensivists (median 50, IQR 30-100), p < 0.05. 19.6% of surgeons reported receiving no palliative care education compared to none of the medical oncologists and 7.7% of intensivists. Analysis of physician treatment recommendations for the 4 clinical vignettes showed disagreement among physicians regardless of specialty. Absence of palliative care training was associated with recommending major surgical intervention more frequently compared to physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs. 1.6 ± 0.8, p = 0.01). Conclusions: Deficiencies in palliative care education persist and adversely impact quality of care. Recent national society recommendations for palliative care services are well founded given these deficiencies. Additionally, our findings highlight a sustained failure of the current postgraduate medical education system and the need for greater efforts system-wide in palliative care education across medical and surgical specialties.

Historia de la formación sanitaria especializada en España y sus claves docentes

La modernización de la sanidad española en las décadas del 60 al 80 del siglo xx fue paralela a la creación y desarrollo de la formación sanitaria especializada (FSE) en España (sistema MIR-Médico Interno Residente). Este sistema fue una traslación del modelo de «aprender trabajando» de EE. UU. El Hospital General de Asturias (Oviedo) en 1963 (por iniciativa de Fernando Alonso Lej de las Casas y Carles Soler Durall) y la Clínica Puerta de Hierro (Madrid) en 1964 (por iniciativa de José María Segovia de Arana), fueron los primeros hospitales en iniciar el sistema MIR en España, que se generalizó en 1972 y se consolidó en 1984 como única vía legal de especialización. Desde entonces la FSE es responsabilidad exclusiva del Sistema Nacional de Salud y está dirigida y regulada por el Ministerio de Sanidad y los Departamentos de Salud de las comunidades autónomas (gobiernos regionales). La universidad española no tiene responsabilidad en la FSE. La formación se garantiza a través de un contrato de trabajo por el que el residente tiene la obligación de prestar un trabajo y el derecho a recibir una formación acorde a lo establecido en los programas nacionales de formación de cada especialidad. The modernisation of the National Health System (NHS) in Spain occurred in parallel with the creation and development of the Postgraduate Medical Education system (medical specialty training system, the so-called “residency system”) throughout the 60's to 80's of the 20th century. The system was a translation of the “to learn by working” US model. The Hospital General de Asturias (Oviedo) in 1963 (an initiative by Fernando Alonso Lej de las Casas and Carles Soler Durall), and the Clínica Puerta de Hierro (Madrid) in 1964 (initiative of José María Segovia de Arana), were the first two hospitals to start the Spanish Specialty Training system, which was extended to the whole NHS in 1972, and was legally consolidated in 1984 as the only official specialisation route. Since them, the system continues to be developed by the NHS according to the Ministry of Health and the Departments of Health (Regional Governments) instructions and criteria. The Spanish university has no responsibility in this process. The training is guaranteed through an employment contract, whereby the resident has the obligation to be provided a job and the right to receive training according to the national residency programs of each specialty.