Examination endgame

Md. Shahidul Islam, M.D., Ph.DAssociate Professor, Group Leader,

Karolinska Institutet, Stockholm, Sweden.Senior consultant physician, Internal

Medicine, Uppsala, Swedenshaisl@me.com

Examinations for certification as specialists

How many should pass?

0%,10%, 50%, 80%, 100%

Actors in specialist education in Sweden1

The Swedish board of health and welfare(A government agency under the ministry of

health and welfare)Issues the mission statements, regulations and

general advices (A 17 page document).

Swedish Society of Internal MedicineWorkgroup for special recommendation

Special recommendations for mission statements

for specialist training in internal medicine

(A 40 page document)

Actors in specialist education in Sweden2

Other actors

• The doctors – actively participates in the planning • Head of the department• Study rector (usually a 50% position)• Supervisor– One main supervisor– Other “current” supervisors

Together they take responsibility for the contract, planning, financing, and informal evaluation of the achievements during the training

Broad goals of specialist training are to acquire the specified..

• ..knowledge• ..skills, and• ..approaches

by working as a doctor under supervision, and by participating in complementary courses

Complementary courses

• Theoretical courses, usually one week courses• Continuing medical education programs in the

work-place• Other quality controlled courses

Mission statement, regulations and general advices issued by the board

• General conditions for all specialties• Mission statement specific for different

specialties– Educational structures– Milestones– Learning methods– Follow-ups and documentations

Swedish Society of Internal Medicine

• Designs detailed special recommendations– Complementary to the advices of the board– Defines the competence requirements– Structure of the rotations during specialist training

Making of a specialist is not easy

• Most important is the mission statement and setting the milestones

• A good system will produce good specialist• A good system will ensure essentially 100%

success• A good system is one that the “students” like• A good system is dynamic, flexible, up-to-date.

Purposes of the mission statement

• Guidance for the doctors, employers, department heads, and the supervisors for completing the training in an effective way and within reasonable time

• Guidance for planning of individual curriculum and “on the job training” placements

Training of the supervisors

• Compulsory• Two days on two occasions a few months

apart– Philosophy of higher education– Communication and feed-back skills– Evaluations

• “Student” participate in the course with the supervisor

Common competencies for all specialties(Milestones 13-20)

• Competence in communication– Respect for patients self-determination and

accountability, cultures – Supervision of med students and later on the interns– Take a course on teaching

• Leadership skills– Minimum 10 days allocated for this

• Competence in medical science and quality work– Individual scientific work: At least 10 weeks be allocated

for this

Proficiency levels

• Master (can completely assess, handle, treat..• Assess (obtain an well informed view of a patient and

the problems)– Initially assess (suspect important conditions)

• Handle (actively performs actions for ….– Initially deal with the problem (e.g 1st 24 hours)

• Have knowledge (have basic knowledge and insight)• Have the ability (personal capacity to do something

independently) • Knows about (have some knowledge)

Education structure for obtaining medical competence

• Fulltime “on the job training” for minimum five years

• About 15% of this time for complementary courses

• Placement in a limited number of subspecialties for continuous periods

• Characterized by general perspective with some possibility for individual choice

Planning of placement for “on the job training” • Emergency & acute medicine departments

(milestones 1-2) 12-15 mo• Branch specialties– Cardiology (milestone 4) 4 mo– Endocrinology/diabetes (milestone 4) 3 mo– Lung diseases (milestone 4) 3 mo– Medical kidney diseases (milestone 4) 0-3 mo– Medical gastroenterology (milestone 4) 0-3 mo– Hematology (milestone 4) 0-3 mo– Allergology (milestone 4) 0-3 mo

Planning of placement for on the job training

• Adjacent specialties– Neurology, stroke (milestone 5) 3-6 mo– Rheumatology (milestone 5) 0-3 mo– Infection (milestone 5) 0-3 mo– Anesthesia & intensive care

(milestone 1-2) 0-3 mo• Individual choice of branch specialty 12 mo

(milestone 4) during the last part of the training). Start working as specialist!

Some special recommendations

• Knowledge about use of medicine, specially in the elderly, from the viewpoint of multiple illnesses, and poly-pharmacy (milestone 7)

• Good knowledge about geriatric medicine, palliative medicine, addiction treatment (milestone 9)

• Disaster medicine (milestone 10)

Milestone 1 Method for learning Documentation

To manage theacute illnessesin areas of internalMedicine andAdjacent specialties

“On the job training”,under supervision, in units that deal withsuch patients

Certificate from the supervisor in the unit

Courses Course certificate from curse leader

Medical competence (Milestones 1-12)

Common and important diseases and conditions

• Cardiology• Medical gastroenterology and hepatology• Endocrinology and diabetology• Medical kidney diseases• Respiratory medicine• Hematology• Allergology• Angiology• Rheumatology• Neurology• Psychiatry• Pain and palliative medicine• Acute medicine

• Cardiology– Coronary artery diseases/chest-tpain– Arrhythmias/syncope– Heart-failure, valvular heart diseases– Pericarditis, myocarditis– Aortic diseases

• Rheumatology– Inflammatory joint diseases– Inflammatory systemic diseases– Non-inflammatory conditions– Others, e.g. elevated SR, Tietze´s syndrome

Common, and important diseases/ conditions

Disease,Condition

Heart failureValvular disease

Assess/handle

Master

Acute heart failureChronic systolic failureAnticoagulation in prosthetic valvesPalliative treatment

PracticalArterial punctureCPAP treatment

Initial handlingInfectious endocarditis

Have knowledge about

PathophysiologyDiastolic failureCardiomyopathiesIndication for surgeryIndication for transplantationPathogens in endocarditisEndocarditis prophylaxis-------------------------------------------------------------------------

Knows about

Heart catheterization,Heart biopsy,Surgical methods,Aortic balloon pump------------------------------------------

“Examination” everyday

• Feed-backs from the nursing and auxiliary staffs• Complaints from the patients and relatives• Feed-backs from the colleagues, specialists• Discussion at the meetings of the specialists• Feed-back from the supervisor to the doctor• Observe the doctor at work, work together• The aim is to prevent failure with early

interventions

Time for applying to the board for specialist certification

• Detailed application forms• Approval by the main supervisor• Approval by the study director• Approval by the department head• Final decision by the board

“End of five year” examination

• is optional• mainly for the purpose of learning, not for

certification• most do not go for it

Flaws of a “end-of-five year” exam

• it can not simulate real life situations• it cannot assess all of the 20 goals/milestones• individual curriculums would require

individual examinations• examinations test abstract knowledge, but

cannot guarantee that knowledge will be used• success in the exam may be a matter of luck• contributes to corruptions

Specialist training and certification programs in Sweden:

• Nearly 100% success rate• Some need more time than initially planned– often due to pregnancies and child-care– Accidents– Illnesses– Substance abuses– Combined M.D, Ph.D programs

Specialist training and certification programs?

The goal is 100% success

Examination as a quality control

Imagine if Volvo produced cars, and the quality control departments returned 50% of them as “failed”.

Failures are expensive for the societyThere is huge scarcity of specialistsFocus should be on education per se, and not

just on examination