Post on 23-Aug-2018
The ESA and education in Europe
Daniela Filipescu, MD, PhD, DEAA
Associate Professor of Anaesthesia & Intensive Care MedicineDepartment of Cardiac Anaesthesia & Intensive Care Medicine
Emergency Institute for Cardiovascular DiseasesBucharest, Romania
CEEA Kosice 2014
EU health strategy
• Ensuring patient safety and the quality of healthcare to facilitate cross border healthcare, as well as the mobility of health professionals and patients
www.ec.europa.eu/health-eu accessed 2008
Basic principles of the EU
• Free movement of students– Bologna process
• Free movement of doctors– Directive on Recognition of Qualifications
• Free movement of patients
- Directive on cross-border care (2011) Bernard Maillet-UEMS
Mobility
Health and the EU
• The organisation and delivery of health care is the responsibility of each member state
• Co-ordination of health matters is difficult at European level
• National rules and regulations prevail
• Directives can be introduced
• Difficulties to implement them on national level
Subsidiarity
Bernard Maillet-UEMS
Fundamental contradiction:
• The delivery of health care involves people,goodsand services that are subject to EU law
• Health care is the responsibility of member states
Health care in EU
Why is this becoming an issue now ?
Assumption:Health services provided according to national regulations in any EU country will be of adequate quality
Legido-Quigly H et al. BMJ 2008;336:920
…Yet,The approach to quality in different countries varies.There is unacceptable variation in practice.
European citizens cannot be guaranteed that the care they will receive in another part of the EU is of high quality.
Legido-Quigly H et al. BMJ 2008;336:920
Why is this becoming an issue now ?
Lancet 2012:1059
EuSOS study498 hospitals in Europe28 countries46,539 pts.Non cardiac surgery
Main results:Mortality rate 4%Great variability
1. Financial resources2. Functioning institutions3. Effective government4. Willingness of decision makers to act
Relation between national income and health policy performance
Mackenbach J et al. BMJ 2013:346
Elements of a high quality health system
• Approval of drugs and medical devices
• Training of health professionals
• Registration, licensing, and accreditation of facilities
• Patient safety
• Clinical guidelines
• Peer review
• Quality indicators
Legido-Quigly H et al. BMJ 2008;336:920
What is needed for a good (specialist) training?
Harmonization
• Clear definition of specialties throughout Europe
• Harmonized training program
• Log book
• Decent working conditions for
the trainees (income and working times)
Bernard Maillet-UEMS
Council of EuropeCommittee of Ministers
The European Directive on recognition of professional qualifications (Directive
2005/36/CE of the European Parliament)
Who is driving the process ?
• EU
• Government
• International or national agencies
• Professional associations
Van Gessel EF et al. Best Pract & Res Clinic Anesth 2012:55
Who is driving the process ?
U.E.M.S.
Union Européenne des Médecins Spécialistes
European Union of Medical Specialists
Umbrella organization of National Associations of Medical Specialists located
in Brussels www.uems.net
Consulation withother European
MedicalOrganisations:
AEMH – CEOM –CPME – EANA –
EJD– FEMS –UEMO
EuropeanCommission
EU Council
EU
Legislation
Decide jointly
Prepares & proposes
EuropeanParliament
The EU institutional triangle (simplified)
UEMS political involvement in EU Affairs
Bernard Maillet-UEMS
Objectives of the UEMS
Harmonisation and improvement of quality of medicalspecialist training and practice in Europe
Ensure that all Medical Specialists have the same main core competencies in their specialty across Europe
Ensure that all member states adopt the curricula and translate them into their national system
Objectives of Sections of UEMS
Professional defense of their specialtyHarmonization of the profession at the European level
European Board of Anaesthesiology
Lennart Christianson
22
23
Competence based training and assessment
ANAESTHESIOLOGY, PAIN AND INTENSIVE CARE MEDICINEPostgraduate training program
UEMS/EBA GUIDELINES
NEW in 2011!
the total training time of a specialist lasts a minimum of 5 years in the light of the broadened competences required nowadays, of which at least 1 year can be specifically directed to Intensive Care Medicine training.
Working Group EBA
• After 3 years of hard work
• EBA Vision = Identification of roles (or generic competences) that anesthesiologists will have on the medical scene (Outcome System)
• Defining Domains of competence: In which domains should an anesthesiologist be competent?
• In each domain, what are the Competences required to be able to keep our roles in medicine? (Educational Model)
• Learning outcomes and objectives (Syllabus)
Modified from Jannicke Mellin Olsen 2012
• A combination of skills, knowledge and attitude that enables an individual to perform a task to the standards required for successful job performance.
• Deals with "what is expected in the workplace."
• Emphasis on performing an actual job and not gaining knowledge or skills for their own sake.
What is a competence?
knowledge
skill
attitude
= COMPETENCE
Doctor…
Competence based education/training....
EBA: Generic Competences and Roles
Leader
Medical expert
Scholar Professional
The following four generic competences or roles have been identified as the most important for any European specialist in anaesthesiology:
Competency frameworksCanMedsCanada
Good Medical practice (UK)
ABMS /ACGME (US) EBA
Medical expert God clinical care Patient care and procedural skillsMedical knowledge
Expert
Communicator Relationship with patients
Intrapersonal and communication skills
Collaborator Working with colleagues System-based practice
Manager Maintain good medical practice
Health advocate
Scholar Teaching and training, appraising and assessing
Practice-basedLearning and Improvement
Scholar
Professional Probity Health Professionalism Professional
Example of our roles: Professional
The specialist in anaesthesiology will exhibit irreproachable behaviour and be aware of duties and responsibilities inherent to his/her role as a professional:
– Provision of high quality care with empathy, integrity, honesty and compassion;
– Recognition of one’s personal limits and abilities, and appropriate consultation with/or delegation to others when caring for the patient;
Courtesy of Jannicke Mellin Olsen, 2012
– Medical decision-making based on thorough consideration of ethical aspects in patient care, management of ethical conflicts;
– Knowledge of medico-legal aspects of anaesthesiology practice, with particular emphasis on the management and prevention of conflicts of interest;
– Appropriate management of anaesthetic incidents and accidents, including near-misses.
Example of our roles: Professional
Courtesy of Jannicke Mellin Olsen, 2012
Carraccio C et al. Acad Med 2002
– Disease management, Patient assessment and preparation– Intra-operative patient care and anaesthetic techniques– Postoperative patient care and acute pain management– Emergency medicine: management of critical conditions
including trauma and initial burn management– Medical and perioperative care of critically ill patients /
General Intensive Care– Practical anaesthetic procedures / Invasive and Imaging
techniques / Regional blocks– Quality - Management - Health economics– Anaesthesia Non-Technical Skills (ANTS)– Professionalism and Ethics– Education, self-directed learning, research
Domains (10) of general core competencies identified
Domains and competences (like CoBaTRice)
7 domains of specific core competencies:
2.1 Obstetric Anaesthesiology
2.2 Airway Management and Surgery
2.3 Thoracic and Cardiovascular Anaesthesiology
2.4 Neuroanaesthesiology
2.5 Paediatric Anaesthesiology
2.6 Anaesthesiology in remote locations / Ambulatory Anaesthesiology
2.7 Multidisciplinary Pain Management
–A: Has knowledge of, describes…– B: Performs, manages, demonstrates
under supervision– C: Performs, manages, demonstrates
independently–D: Teaches or supervises others in
performing, managing, demonstrating.
The level of expertise for each competence in the new curriculum
Courtesy of Jannicke Mellin Olsen 2012
ANAESTHESIOLOGY, PAIN AND INTENSIVE CARE MEDICINE
Syllabus
Knowledge, Skills, and Attitudes
SYLLABUSDomain 1.3: Postoperative patient care and Acute pain management
a. Knowledge Transport to PACU (Post Anaesthesia Care Unit) or ICU:
a) Positioning/Transportation of the patient b) Oxygenation (diffusion hypoxia, etc.) c) Monitoring and care of venous and arterial lines, care of drains d) Standard PACU monitoring: Blood pressure- pulse-respiratory rate-temperature-pulse
oxymeter-ECG- VAS; as well as other non invasive and invasive modalities
PACU scoring systems for care and discharge (Alderete Score, etc…) Airway:
b. Skills Technical skills:
Basic vascular access
Basic airway management
BLS, ALS
Management of arrhythmias and DC
Regional anaesthesia techniques: neuraxial and peripheral nerve blocks Clinical and case management skills: Trainees are expected to understand relevant principles, apply knowledge in practice and to demonstrate clinical skills and case management in the following areas:
Indications and interpretation of common laboratory and radiological exams, performed in the context of postoperative recovery and care
c. Specific Attitudes Demonstrate knowledge of the policies to safely and effectively treat postoperative pain,
monitor its efficacy and promote safety within a multidisciplinary team
Demonstrate responsibility for the Acute Pain Service and management of patients in a timely and professional manner; follow up on patients who experienced complications and/or side effects in PACU
Courtesy of Jannicke Mellin Olsen, 2012
• For each domain…
• Listed core competencies keeping in mind the holistic/integrative approach:
Domain 1.1: Disease management, Patient assessment and Preoperative preparation
During the course of their training, residents must acquire clinical abilities and skills in the anaesthetic and perioperative care of patients. These include the acquisition of following competences:
a. Identifies, optimizes, and treats all relevant patient pathologies, including those with direct impact on anaesthetic techniques, including monitoring: C
b. Assesses preoperative risks: D c. Uses and interprets preoperative investigations appropriately and rationally: D d. Assesses airway for potential difficulty with intubation and /or ventilation: D e. Knows and applies recognized principles of preoperative therapy, fasting and
premedication: D f. Elaborates an individualized preoperative anaesthetic strategy, including rational use of
drugs and techniques: D g. Provides appropriate information and obtains informed consent for anaesthesia: D
Level of acquisition
Courtesy of Jannicke Mellin Olsen, 2012
Traditional learning: knowledge and skills
Modern learning: competence-based
We are prepared for the next generation
Remaining challenge: Assessment
–Assessment of different components of a competence?
Traditional• MCQ
• Oral exams
• Logbook
Modern• Mini-CEX• Simulation-based• Direct observation • 360 ° assessment• Portfolio• Publications• Research• Participation in CME-CPD
Learning opportunities and assessment tools at the different levels of clinical competence required
Learning opportunities Assessment
Clinical performance and feedback
DOESDirect observation; evaluation of clinical performance
Role play; simulationSHOWS
HOWOSCE; standardised patient exams
Case conference; demonstration
KNOWS HOW
Patient management problem; oral examinations
Lecture; independent reading
KNOWS MCQ; essay
Van Gessel et al. Eur J Anaesth 2010
What assessment tools do we have?
• European Diploma of Anaesthesia and Intensive Care EDAIC
• In training assessment ITA
• We would like to have:
– Regular formative evaluations
– Portfolio (credit system)
– Other summative exam periods (pass/fail)?
Modified from Jannicke Mellin Olsen, 2012
∙ 30th Anniversary of the European Diploma in Anaesthesiology and Intensive Care∙ First specialty introducing
European examinations∙ Followed by 31 other specialties∙ Endorsed by EBA UEMS ∙ Offered in 12 languages∙ Recognized in 13 countries
Examinations
European Examinations
1. Allergology and Clinical Immunology2. Anaesthesiology3. Dermatology & Venereology4. ENT+ORL-Head and Neck Surgery5. Hand Surgery6. Intensive Care7. Internal Medicine8. Neurology9. Neurosurgery10. Nuclear Medicine11. Ophthalmology12. Oral and Maxillofacial Surgery13. Orthopaedics and Traumatology14. Pathology15. Pediatric Surgery16. Physical and Rehabilitation Medicine
17. Plastic Surgery18. Respiratory Medicine19. Surgery (General Surgery)20. Coloproctology21. Endocrine Surgery22. Surgical Oncology23. Thoracic Surgery24. Transplantation25. Trauma Surgery26. Thoracic and Cardiovascular Surgery27. Urology28. Vascular Surgery29. Angiology30. Emergency Medicine31. Gastroenterology32. Pediatric Intensive Care
Glasgow Declaration
1. European Board Examinations do not give the right to practice in any European Country
2. European Board Examinations is complimentary to National Examinations
3. Promotion of the European Examinations
4. To be considered as a Label of Excellence
5. Clear Curriculum and Reference Book
6. Clear Eligibility criteria
7. Certificates for successful application
Last year achievements
EDAIC
12 languages48 centres 3 outside Europe7 new centres
2076 candidates sat the part I in 2013 compared with 1541 in 2012 (increase of 34.5%)2400 candidates in 2014
Examinations – Part I
638 candidates sat the part II in 2013 compared with 493 in 2012 (increase of 29.%)727 candidates registered the part II in 2014 (increase of 14 %)
Examinations – Part II
Part II Centers
2013• Gottingen: 64• Barcelona: 60• Madrid: 65• Zürich: 62• London: 67• Uppsala: 62• Vienna: 60• Athens: 63 (2-day exam for the first time and full!)• Erlangen: 64• Istanbul: 51• Porto: 42 (2-day exam for the first time)
Courtesy of Dr Zeev Goldik
Countries where EE are recognized
Courtesy of Zeev Goldik
Switzerland
Austria
Hungary
Poland
Netherlands
Romania
Malta
Finland
Turkey
Slovenia
Moldova
Portugal
Czech Republic
THE EUROPEAN DIPLOMA IN ANAESTHESIOLOGY AND INTENSIVE CARE IS OFFERED IN:
1. English2. German3. Spanish4. French5. Italian6. Russian7. Polish8. Hungarian9. Romanian10. Portuguese11. Turkish12. Slovenian
Mutual Recognition
•
Courtesy of Dr Zeev Goldik
OLA in Anaesthesiology
• Multi-country examination administered simultaneously throughout different time zones and continents.
• Web-based online examination in a secure environment
• Centrally organized with national administration and global co-ordination by the European Society of Anaesthesiology
• Upon completion of validation, the goal is then to extend the test and to include all trainees enrolled in the Anaesthesiology curriculum across all UEMS/EBA and ESA-member countries.
Modified from Dr Zeev Goldik
On Line Assessment 38 centres in Europe1 centre outside Europe5 languages 356 applications in 2014
Examinations - OLA
We are moving to computer-based examinations
Strategic road map:In Training Assessment
• ITA OLA
Strategic road map:Part I- Written
Paper Exam Computer Based Exam
Strategic road map: Part II (Oral)
Paper Based Laptop Based
How do we assess learning in the areas other then
medical expert?
• Direct observation
• 360° assessment
• Portfolio
Assessment in the workplace:The trainee integrates history with clinical examination
What is a portfolio?
• “a collection of evidence maintained and presented for a specific purpose”
• “collection of material, made by a professional that records and reflects on key events in that person’s career”
Portfolios: presenting the evidence
Fragneto RY et al. J Graduate Med Educ 2010
The future…we’ve come a long way
Knowledge Assessment
Practical Skills Assessment
Assessment of Professionalism
MCQs on EACCME/S&B accreditedTextbook chaptersGuidelinesArticlesCME Products
E-logbookE-portfolio
DOPS (direct observation of practical skills)
CPD activities360° Appraisal
Upon satisfactory completion Diploma issued by ECCIS/S&B
Form
ative pro
cess
@ @ @
European Certification: How Should it Work?
Applicant applies on-line, provides requested documentation (i.e. licences, diplomas) and
proceeds with the 3 assessments
Adapted from: Mills P, Kearney P, et al. EBSC, 2008
• To promote the highest level of training of anaesthesiologists in Europe by setting appropriate minimum standards of quality, content and duration of training
• Respect diversity!• Agree on minimum standards
Goals of the new competence-based curriculum
• Should be developed in a context-specific manner, respecting the needs, culture and facilities of host institutions
Dubowitz G et al. Best Pract & Research Clinical Anaesthesiol 2012:19
Competency-based training
Romania:• Duration of training in anaesthesia and intensive care
increased from to 3 to 5 years (1993)• European Diploma of Anaesthesia and Intensive Care
(2010)• Endorsement of EBA competence based curriculum (2012)• Continuous Professional Development credits (1999)
Training of health professionals
Should European curriculum be adopted by all European countries?
Yes, it’s time to work in harmony!
How do we evaluate a (transnational) training programme?
• What impact would you expect an effective training programme to have?
– Uptake by national programmes– Mobility of professionals using the program– Better doctors
• Knowledge, skills, behaviours• Continuing professional development
– Safer patients– More reliable care
Competency-based trainingPotential criticism
• Focus on simply recognising satisfactory performance, rather than driving learners to achieve excellence
• Specifically identified as one of the root causes of mediocrity
Smith AF, Greaves JD. Anaesthesia 2010: 184-91
“if competence is defined as an observable minimum standard, is excellence simply an extension of competence – a sort of upper extreme – ordoes it imply something else again, something qualitatively different?
Excellence includes good interaction both with patients and the team and personal qualities which are as important as knowledge and skills in making the difference between good enough and excellent.
Experience does not by itself lead to excellence;active use of experience to develop own competence is needed, striving for perfection .
Excellence
Smith A, et al. BJA 2011
ESA Mission Statement
To aim for the highest standards of practice and safety in anaesthesia, peri-operative medicine, intensive care medicine, emergency medicine and pain treatment through education, research and professional development throughout Europe.
Striving for excellence
ESA is recognized as a world leader in setting standards and promoting excellence in anaesthesia, peri-operative medicine, intensive care medicine, emergency medicine and pain treatment
“Vision without action is a daydream. Action without vision is a nightmare.”
Anonymous
Robert Sneyd, Dec. 2012
ESA Academy The New Structure
Members
HVTAP L. ChristianssonTrainee Exchange Programm C. GomarExaminations Committee Z. GoldikScientific Committee St. de HertCEEA K. LebedinskiyNASC D. LongroisUEMS, EBA E. van GesselMedia Committee A. Ahmer
Plus:
ESA Board I. BobekResearch Committee A. HoeftESA Secretary M De Bisschop
A. Dewaegenaere
• Basic Anaesthetic Course 3rd edition68 registered participants
• 1st new format of the Teach the Teachers Course has been successful (25 participants)
• Trainee exchange programme (TEP) (8 fellows selected form 28 candidates)
• Accreditation of hospital & training programmes (HVTAP)(2 centres)
Education
• Programme of the six courses was revised
• The list of regional centres has been updated
• 4 new regional centres in 2013 & 2014
Education
E-learning
ESA
Follow us!
Abstracts submission closes 15 December 2014
Early bird fee – book before 25 February 2015
Intensive care medicine
• In most European countries, intensive care medicine can be obtained as a particular competence with a common training program for specialists with a Board certification in a variety of base disciplines:
anaesthesiology, cardiac surgery, cardiology, internal medicine, neurology, neuro surgery, paediatrics, pneumology, surgery.
Common Training Framework
Training Requirements for the Core Curriculum of Multidisciplinary Intensive Care Medicine
European Standards of Postgraduate Medical Specialist Training
• based on a common set of knowledge, skills and competences or common training tests
• cover specialties that currently do not benefit from automatic recognition provisions under Directive 2005/36/EC
• should offer a high level of public health and patient safety
• professional qualifications obtained under common training frameworks should automatically be recognised by Member States
Common Training Framework
Training requirements for trainees
Content of training and learning outcomes required to be become an Intensivist are based on:
• CoBaTriCE
• Training requirements in Anaesthesiology
• Curriculum in respiratory critical care medicine
• Specialty input of all UEMS sections involved
Competency Based Training in Intensive
Care Medicine in Europe(and Elsewhere)
ESICM; University of Birmingham; Charles University; Picker Institute
Europe; Intensium Oy
CoBaTrICE is supported by an EU FP6
grant Leonardo da Vinci Programme.
Additional supporters: GlaxoSmithKline;
SSCM; Pfizer (HK); ESICM
CoBaTrICE102 competence statements grouped into 12 domains:
A Resuscitation & initial management of the acutely ill patient
B Assessment, investigation, monitoring and data interpretation
C Diagnosis and disease management
D Therapeutic interventions / organ system support
E Practical procedures
F Peri-operative care
GH Continuity, comfort and recovery
I End of life care
J Paediatric care
K Transport
L Patient safety & systems management
M Professionalism
Learning objectives
For each domain of competence identified above, a detailed list of “learning objectives” has been identified, that constitute the syllabus covering aspects such as:
• Theoretical and practical knowledge
• Practical and clinical skills (case management)
• Attitudes, behaviours and professionalism
Level of expertise
• A: Has knowledge of and is able to describe
• B: Performs and manages independently
• C: Understands, seeks multidisciplinary advice, discusses with or refers to expert
Organisation of training
1. After training and certification in a primary specialty
2. In tandem with a relevant acute core primary speciality
• training of at least 3 years should give recognition as qualified in Intensive Care Medicine
• up to 2 years can be accepted from the primary specialty training provided that at least 1 year is conducted in a multidisciplinary intensive care
• for other more distantly related primary specialities it is expected that training will rather need an additional third year in order to attain a required level of competence
3. If accessible as a primary speciality, trainees should be recognised as qualified in Intensive Care Medicine after at least 5 years of training.
• Depending on primary speciality, training can to a varying extent be integrated, but most important of all is that the training is competency based and no recognition will be achieved until requirements are met.
Organisation of training