FAQ – Specialisation Schools: Medical Area

As provided for by Article 40, paragraph 1 of Legislative Decree No. 368/1999, “the commitment required for specialist training is equivalent to that required of full-time medical staff of the National Health Service, while ensuring the right to carry out intramural private practice.”

Overall, this amounts to 38 hours per week.

Specialist trainees receive remuneration consisting of a fixed component and a variable component.

The fixed component is €22,700.00 gross per year.

The variable component is €2,300.00 gross per year for the first two years of the programme, and €3,300.00 gross per year for the subsequent years.

The remuneration is paid to the specialist trainee on a monthly basis.

The 2006 Finance Act (Article 1, paragraph 300) provided for doctors with a specialist training contract to be registered with the Separate Pension Scheme as from the 2006/2007 academic year.

Following differing interpretations regarding the contribution obligation for these individuals, the Ministry of Labour, Health and Social Policies, in agreement with the Ministry of Economy and Finance, clarified that, in the same way as all other members of the Separate Pension Scheme, they are subject to:

• the reduced rate, if they are already registered with their professional pension fund;
• the full rate otherwise.

Doctors in specialist training are subject to the same rules as those applying to coordinated and continuous collaborators with regard to:

• registration;
• allocation of contributions;
• payment and reporting;
• financing rates, ceiling and contribution crediting.

Further information can be found on the INPS website.

Article 41, paragraph 3 of Legislative Decree No. 368/1999 provides that “the healthcare organisation where the doctor in specialist training carries out their training activity shall, at its own expense, provide insurance cover for professional risks, third-party civil liability and accidents connected with the healthcare activities carried out by the doctor in training within its facilities, under the same conditions as its own staff.”

The grounds for early termination of the contract are those provided for in Article 37, paragraph 5 of Legislative Decree No. 368/1999, according to which the following constitute grounds for early termination of the contract:

a) withdrawal from the programme by the doctor in specialist training;
b) breach of the provisions on incompatibility;
c) prolonged unjustified absences from the training programmes or exceeding the protected period in the event of illness (12 months);
d) failure to pass the examinations established for the course of study of each individual Specialisation Schoo

The only permitted suspensions are for periods of illness, maternity leave or parental leave.

As provided for by Article 40, paragraph 3 of Legislative Decree No. 368/1999, “temporary impediments exceeding forty consecutive working days due to military service, pregnancy or illness shall suspend the training period, without prejudice to the fact that its overall duration shall not be reduced as a result of such suspensions. The provisions on the protection of pregnancy under Law No. 1204 of 30 December 1971, as amended, and those on the fulfilment of military service under Law No. 958 of 24 December 1986, as amended, shall remain unaffected.”

Therefore, periods of suspension due to illness exceeding 40 days must be fully made up.

Pursuant to Article 40, paragraph 5, during periods of absence only the fixed component of the remuneration is paid, whereas during recovery periods the full amount is paid.

The maximum period of suspension allowed during the entire specialisation programme is 12 months.

You must submit a suitable application to the Administrative Office of the Specialisation Schools within three days of the start of the suspension period, together with a medical certificate issued by a National Health Service doctor or by a public healthcare facility, indicating the number of sick days granted.

The same notification must also be submitted to the Teaching Office of the School.

Pregnant specialist trainees are subject to Legislative Decree No. 151/2001, as amended. The following are therefore provided for:

• mandatory maternity leave of 5 months;
• optional parental leave of 6 months.

Without prejudice to the total duration of maternity leave referred to in point 1 — normally 2 months before the expected date of childbirth and 3 months after childbirth — pregnant specialist trainees may choose to take leave during the month before the expected date of childbirth and the 4 months following childbirth, provided that they obtain certification from a National Health Service specialist stating that this does not pose any risk to either the pregnant trainee or the unborn child.

Naturally, the training period may not be shorter than that provided for by law; therefore, suspension periods must be fully made up.

During periods of absence, only the fixed component of the remuneration is paid, whereas during recovery periods the full amount is paid, as provided for by Article 40, paragraph 5 of Legislative Decree No. 368/1999.

Pursuant to Article 40, paragraph 4 of Legislative Decree No. 368/1999, “absences for personal reasons, authorised in advance except in cases of force majeure, which do not exceed a total of thirty days in the academic year and do not compromise the achievement of the training objectives, do not interrupt the training and do not have to be made up. In such cases, remuneration is not suspended.”

Therefore, 30 days of justified absence are provided for during the academic year, although these are improperly referred to as days of annual leave.

All absences of less than 40 days — such as marriage, the birth of a child, bereavement, leave for serious reasons, etc. — fall within this type of absence.

Legislative Decree No. 368 of 17 August 1999 states that “for the duration of full-time training, doctors are prohibited from carrying out private professional activities outside the healthcare facilities where the training takes place, as well as from entering into any contractual or temporary relationship with the National Health Service or with public or private bodies and institutions.”

Therefore, no work activities of any kind, including non-medical activities, may be carried out outside the specialisation programme.

The only permitted exceptions, following the amendments introduced by Law No. 448 of 28 December 2001 and Decree-Law No. 81 of 29 March 2004, converted into law on 19 May 2004, are:

• intramural private practice, in line with the qualifications held and subject to the definition of specific agreements;
• out-of-hours medical service;
• substitution of a general practitioner;
• tourist medical service;
• substitution duties within Prison Medicine.

The above activities may be carried out exclusively outside the time dedicated to specialist training, provided that such external activity does not, under any circumstances, prejudice the obligations incumbent upon the specialist trainee. These activities are not covered by the insurance provided to the specialist trainee during training.

The doctor in specialist training must notify the Director of the School in advance of any such activities.

Since the Covid-19 health emergency, the legislator has made certain types of employment relationship compatible with specialist medical training.

Following the conversion into law of the “Calabria Decree” — Law No. 145/2018, Article 1, paragraphs 547 to 548-ter, as amended — specialist trainees, from the second year of training onwards, may be employed by healthcare organisations under a fixed-term employment contract, with part-time hours according to training requirements. The contract may not exceed the remaining duration of the specialist training programme.

Decree-Law No. 18/2020, Articles 2-bis and 2-ter, paragraph 5, as amended, and Law No. 234/2021, Article 1, paragraph 268, as amended, provide that, until 31 December 2024, specialist trainees enrolled in the final or penultimate year of their specialisation programme may be employed by National Health Service organisations under a self-employment contract, including a coordinated and continuous collaboration contract (Co.Co.Co), or under a fixed-term contract with reduced working hours. Such contracts may last for six months and may be extended.

Decree-Law No. 198 of 29 December 2022, Article 4, paragraph 9-quater, extended until 31 December 2024 the possibility for doctors enrolled in the specialisation programme in Paediatrics to take on temporary or substitute assignments for family paediatricians affiliated with the National Health Service.

Pursuant to Article 12, paragraph 2 of Decree-Law No. 34 of 30 March 2023, until 31 December 2025, on an experimental basis, by way of derogation from the incompatibilities provided for by Article 40 of Legislative Decree No. 368 of 17 August 1999 and from the provisions of Article 7 of Legislative Decree No. 165 of 30 March 2001, and without prejudice to Article 11, paragraph 1 of Decree-Law No. 35 of 30 April 2019, converted with amendments by Law No. 60 of 25 June 2019, doctors in specialist training who are duly enrolled in the relevant programme may voluntarily take on private professional assignments, including coordinated and continuous collaboration contracts, at hospital emergency departments of the National Health Service, outside the time dedicated to training, for a maximum of 8 hours per week.

It is possible to have a VAT number only in order to invoice the services provided for by law, namely intramural activities, substitution of general practitioners, and night-time, holiday and tourist medical cover.

Article 40, paragraph 6 of Legislative Decree No. 368/1999 provides that, “within the framework of integrated teaching and scientific collaboration agreements between Italian universities and universities in foreign countries, specialist training may also take place in healthcare facilities in those countries, in accordance with the doctor’s personal training programme and upon recommendation of the School Board, without prejudice to Article 12 of Presidential Decree No. 162 of 10 March 1982.”

Pursuant to Article 12, paragraph 3 of Presidential Decree No. 162/1982: “for the purposes of attendance and practical activities, the activity carried out by the specialist trainee in social and healthcare service facilities relevant to the specialisation, including abroad or within the framework of Law No. 38 of 9 February 1979 on Italy’s cooperation with developing countries, shall be recognised as valid on the basis of suitable documentation.”

It is therefore possible to carry out training activities outside the training network and also abroad, provided that authorisation is granted by the School Board.

In the case of training abroad, insurance is the responsibility of the specialist trainee, although a mixed form of supplementary cover by the host organisation may be arranged.

The maximum period of training abroad is 18 months, as established by the State-Regions Conference of 18 April 2007.