Medical specialty training
in Croatia
Nada Cikes,
University of Zagreb School of Medicine
National Authority for Specialty Training of Medical Doctors in Croatia
UEMS ORL Section and Board, Dubrovnik, 4. October 2014.
Medical education in Croatia
• 4 medical schools
• 2004 new harmonised core curriculum was
introduced in all four schools
• 2007 medical schools invited in specialty training
programmes developments
• 2007- 2011 new competency based specialty training
programme was developed for all specialties
• from 2011 implementation
Introduction of new specialty programes
• Need for competency and learning outcomes based
programmes
• Harmonisation with European documents:
– European commission (EU Directive 2005/36 EC)*
– UEMS (Charter on specialty training ..... Ch. 6)
– Recommendation of intrnl. scientific societies
• New specialties proposals:
- new specialties
- common trunks
- reforms of old specialties
• Proposal for a new Ordinance on specialty training of
medical doctors in Croatia
* qualification recognition: subject of negotiation with Croatia for EU accetion
Development of specialist training
programmes in Croatia
• New competency based programmes for 46
specialties
• Common trunk for internistic and surgical
specialties
• For all specialty programmes
– duration
– training plan
– required level of competencies - generic
- specific
– list and number of procedures
– logbook
Croatian medical schools and other institutions in
training programme development
Agreement on collaboration in development of
specialty education program between:
• all four medical schools
• Croatian Medical Association
• Croatian Medical Chamber
• Croatian Academy for Medical Sciences
Development of programmes of specialists
education in Croatia
46 task forces:
• Programme of specialist education defining
competences
• Requirements for training institution
• Requirements for mentor
• Requirements for trainee and logbook
Goals
Objectives of training programme
– generic competences
- all physicians in training in all medical specialties
– specific competences: knowledge, skills and attitudes
– competence-based education, focused on learner
performance - learning outcomes in reaching specific
objectives of the curriculum
Outcome of training programme
– specialist able to practice in a professional, ethical and
patient-focused way
COMPETENCIES
skills
knowledge
competencies
professional
behaviour
Competencies in specialty training programmes
• Characeristic for each specialty
– common trunk
– “main” program of the specialty
• All educational units in the programme
• Also the number of interventios
• Evaluation of comparable competencies in groups of specialties
(surgical, internistic)
• Determine teaching methods
• Determine assessment methods
Important: generic competencies for all specialists
DESCRIPTION OF THE LEVEL OF COMPETENCIES
1
2
3
Trainee is informed
about thematic area on
basic level, needs
support and supervision
in work and problem
solving in the thematic
area
Trainee is partially
competent, able to work
and solve problems with
support and partial
supervision
Trainee is fully
competent, familiar
with relevant literature,
able to work and solve
all problems in the
thematic area
Specific competencies – goals*
•
•
•
•
•
•
Medical knowledge
Patient care
Practice based learning and improvement
Systems based practice
Professionalism
Interpersonal and communication skills
*ACGME Outcome Project 2006
Generic competencies in medicine
• Tomorrow’s Doctor (GMC, UK) – generic and specific
• The Scottish Doctor – generic and specific
• Generic Curriculum for the Medical Specialties Federation of
the Royal Colleges of Physicians
• The Royal College of Physicians and Surgeons of Canada
Physicians Competency Framework
• European Board of Internal Medicine Core Competencies
• Etc.........
Generic competencies in specialty training
The CanMEDS 2005 Framework: The Physician Roles
•
•
•
•
•
•
•
Medical Expert Role
Communicator Role
Collaborator Role
Manager Role
Health Advocate Role
Scholar Role
Professional Role
Definitions of 7 roles of physicians
• As Medical Experts, physicians integrate all of the CanMEDS Roles,
applying medical knowledge, clinical skills, and professional
attitudes in their provision of patient-centered care. Medical Expert
is the central physician Role in the CanMEDS framework.
• As Communicators, physicians effectively facilitate the doctorpatient relationship and the dynamic exchanges that occur before,
during, and after the medical encounter.
• As Collaborators, physicians effectively work within a healthcare
team to achieve optimal patient care.
• As Managers, physicians are integral participants in healthcare
organizations, organizing sustainable practices, making decisions
about allocating resources, and contributing to the effectiveness of
the healthcare system.
• As Health Advocates, physicians responsibly use their expertise and
influence to advance the health and well-being of individual patients,
communities, and populations.
• As Scholars, physicians demonstrate a lifelong commitment to
reflective learning, as well as the creation, dissemination, application
and translation of medical knowledge.
• As Professionals, physicians are committed to the health and wellbeing of individuals and society through ethical practice, professionled regulation, and high personal standards of behaviour.
Implementation
• The CanMEDS framework accepted, incorporated in
the training programme:
– as a teaching module obligatory for all specialties
– parts of clinical teaching programmes
– content in the logbook
• Evaluation:
– At the end of the module
– Continuous evaluation by mentor
– Multisource feedback - 360 degrees
Introductory teaching module on
generic competencies
• Two weeks programme
• Each competency: two half – days
• Trainees participate with case studies from
personal experience
• Discussion between participants
• Supporting documents and teaching materials
(manual, e-learning...), additional reading
Competency teaching in the module
• Definition
• Description
• Elements
(communicator: empathy, effective listening.....
collaborator: respect for others in the team,
constructive negotiations.....)
• Key competencies
• Specific training requirements
Teachers in the generic module
• 2 coordinators for each competency
• Group of experienced and younger teacher in the
group
- clinicians ( family medicine, pediatrics, internal
medicine, psychiatry...)
- experts from public health
• Workhops organised – for each competency
- for the whole module
Results of teachers’evaluation and general
observation
• Teachers’ positive attitude for generic skills increased
• Educating students and understanding the teaching
process motivated them to be good role models for
students
• Communication between teachers increased
• Good relationship between students and young
clinicians
• Improvement of working environment in academic
hospital was initiated
• The generic skills in medical community are
promoted
Difficulties in teaching generic competences
• Teaching environment in the training
institution
• Lack of understanding generic competencies
• Need for education of mentors in teaching
and evaluating generic competencies
• Need for education of other physicians and
other medical professionals in generic
competencies
Requirements
• Training institution
• Mentor
• Trainee
Requirements for training institution
• Learning environment
• General requirements
• High level of educational and professional
expertise, informatic technology, research
• Requirements relevant for particular specialty
fulfilling the conditions for study program (no. of
relevant patients, procedures etc..)
• Preparedness for regular visitation
• Adaptation of Croatian regulations on health
institutions!
Mentor
• Experienced specialist
• Experienced teacher
• Need to define time protected for teaching
(hospital burden!)
• Need to define relevant regulations
• Number of trainees per mentor
• Mentor’s education and evaluation
• Important: employment policy (medical school
and university hospital
Trainee
• General requirements
• Logbook for particular specialty
• Trainee follow up through training
– progression of competence
• Definition of evaluation methods
• Requirements for final examinations
• Special attention: trainees doctoral students
Dual role of trainee: student and health care
provider
•
•
•
•
•
Work in health care is part of education
Patient care is the integral part of learning
Every contact with patient is educational experience
Supervision is integral part of learning experience
Responsibility of all – trainee’s progress: education,
competency, responsibility, patient safety....
• Goal of the advencement of specialty training process:
enhancement of patient care
Follow up of trainee progress
THEME
LEVEL OF PROGRESS
1
GENERIC/ SPECIFIC
COMPETENCIES
2
Date and signature
MENTOR
3
Date and signature
Follow up of interventions
Part of the training
programme
Name of the intervention
Number
of
inte
rve
ntio
ns
Level of progress
2
MENTOR
3
Date and signature
Date and signatue
National authority responsible for specialty
training
•
•
•
•
•
•
•
definition of national standards
supervision of training programmes
developments of assessment methods
accreditations for institutions
quality assurance
institution visitation
planing strategy
Task force for evaluation and methods of
assessment
• Assessment is part of the educational programme
• Base: UEMS Policy Statement on Assessment during
Postgraduate Medical Training (2006):
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–
–
–
Selfevaluation (trainee)
Continuous follow up (mentor)
Test 360˚
Final exam – written and practical
• UEMS CESMA:
– European exam
Evaluation of mentor
Evaluation of training institution
Training programmes were presented:
• Association of Medical Schools in Europe 2009.
• International Association for Medical Education (AMEE)
– 2010 Glasgow
– 2014 Milano
• Policy dialogues, Investing in Europe’s health workforce of
tomorrow: scope for innovation and collaboration . Follow up
to the Green Paper on Europe’s health workforce, Leuven,
Belgium, 2010
• Education for Physicians: A Comparison of Slovenia, Croatia
and Italy, Brioni, 14 May 2011
• Various meetings and congresses in Croatia
Zagreb Declaration, 2009
The Role of the Medical School in Postgraduate
Education
Conclusion
Largest project in medical education in Croatia
(600 MD specialists involved in programme development)
Involvement and responsibility of
–
–
–
–
–
–
–
–
Medical schools
Health institutions
Mentors
Trainees
Professional societies (Croatian Medical Association)
Croatian Medical Chamber
Other organisations
Ministry of Health
Teaching generic competencies
Fundamentals of Medical Skills
- longitudinal course
• two parallel tracks: Clinical practical skills and
Communication skills
• emphasis on teaching communication skills, gradually
developing medical students' competence from basic to
specific communication associated with clinical courses
in higher grades of medical study
• expected: greater effectiveness of a longitudinal,
integrated communication approach in teaching
medical students compared with concentrated courses
Study
year
Teaching content in longitudinal course in communication skills
1st
Basic communication skills. Communication with colleagues, teachers,
administrators and other members of the school and hospital staff
2nd
Medical interview
3rd
Informed consent. Written communication in medicine. Working in team
4th
Giving information and counselling. Communication in clinical setting.
Communication with severely ill patients. Breaking bad news. Palliative medicine.
Aggressive patient
5th
Communication with children. Breaking bad news to children. Communication
with parents and family members. Pregnancy and childbirth. Elderly patients.
Psychiatric patient
6th
Communication in family and community. Communication as a part of
professionalism. Communication with other professions. Communication with
media.
Workshops for teachers education
• Role-playing
• Simulated patient
• Analysing specific videotapes of:
– Real patient cases in health care
– Pateint cases scenarios filmed by students of
University of Zagreb Drama Academy
• Observation and constructive feedback
discussions with peers and facilitator
• Organisation and training for OSCE
OSCE
After 15 weeks of traning:
• Standardised patients in simple clinical
situations
• Opening and closing the interview
• Some stations: combined practical skills with
communicational task
Reasons why clinicians can be good teachers
in communication
• Good understanding of communication theories
• Positive attitude towards communication based on
personal clinical experience
• Understanding of patients’ centeredness in
communication process
• Additional impact: teachers became highly competent in
communication with patients, colleagues and others
• Influence on communication climate in health care
environment
• Students appreciate colleagues being their teacher in
communication
Generic competencies in internship
• Internship is organised in rotations
• Competencies included in the programme:
– communication skills
– team work
– professionalism
• Elements of each competencies defined
• Tasks recorded during whole programme
Conclusion
• Continuous enhancement of generic competences
through the graduate and postgraduate education
is essential for professional development
• Continuous reinforcement and longitudinal
development of skills is critical for their retention
and expansion
• Teaching generic skills on all levels of medical
education exerts influence on development of
professionalism in hospital environment
• Influence on health care