NEURON: training programme in neurology

Extended skills and knowledge in more complex areas of a specialisation should be learned by systematic, supervised acquisition of additional competencies.in fellowships after the regular training or as modules within the regular training programme in an accredited training institute under supervision of a programme director.

Sub-speciality training

Particular qualifications

Neurology

Neuro-musculardisorders

Movement

disorders

Neuro-oncology

Neurology

Neuro-genetics

Sleepmedicine

Neuro-vascularmedicine

Neurology

Neuro-rehab.

Neuro-ophthalm.

Neuro-immuno-

logy

An example of a project on display: neuromuscular disorders

Goal of the neuromuscular apprenticeship: to provide training on pathophysiology, pathology, diagnosis andmanagement of patients with neuromuscular diseases with thepurpose to enhance quality of care.

After completion of the training the fellow has: sufficient knowledge and skills to evaluate patients with a variety

of neuromuscular disorders specific expertise in the diagnosis and management of these

disorders become acquainted with the three crucial areas of neuromuscular

disorders i.e. genetics, neuro-immunology and rehabilitation medicine.

A.Content of the training programme• Should comply with the format of the general

neurological training

B.Facilities for the training• In case of nmd: genetic dept., dept. of rehab

medicine, muscle pathology dept., ……

C.Qualifications of the Program Director• > 5 years expertise in nm patient care, research,

CME

D.Evaluation of the trainee • Portfolio, assessments

Requirements for the Training

Does the new curriculum lead to a better doctor?

responsibility

autonomy

supervision

Duration of the training: ‘Medical specialists are too old, too smart and too expensive’

Moving away of the traditional medical specialities (re-shaping) due to emerging technologies

Generalism or subspecialism? What is the core business of the medical

specialist? Definition of professional role, new professionals in the care

Residents stop their training

Concerns

Time for a change

Medisch Contact 1999

Specialties determined by specific parts, tissues or organ systems within the human body (e.g., ophthalmology, dermatology, internal medicine, neurology, psychiatry) or by

a specific skill (e.g., surgery, anaesthesiology).

Definition of speciality

Technological developments lead to a shift of the classical domains (e.g. interventional radiologists ‘compete’ with neurosurgeons).

Multidisciplinary treatment (e.g. oncological patient care, endoscopic surgery of patient with hypophyseal tumour by neurosurgeon and ENT specialist) is on the rise.

Subspecialisation (endocrinology, vascular surgeons, neuromyologists) becomes the norm.

Change in the definition of specialities

Generalisation vs subspecialisation

Why subspecialisation?

Increase in diagnostic and therapeutic possibilities

in medicine driven by developments in molecular

genetics and technology, in particular imaging has

fuelled the tendency to acquire additional or

particular competencies within all medical fields

because medical specialists are finding it

increasingly difficult to deal with the ever growing

body of knowledge in the field.

Gone is the widely experienced general physician, and general surgeons are replaced by an ever expanding list of “ologists” who now seem to be almost single cell specialists.

BMJ 2010; 341:c4903 Des Spence, GlasgowViews & Reviews

We are passing the tipping point: increasing specialisation is harming care. Specialism is breaking down continuity, promoting the “not my clinical area” that fuels endless internal specialist referrals and wasting time and resources.

Bad medicine: specialisation

Pros of subspecialisation

Pros Focused competency

in complex areas ... or in orphan diseases More volume, better outcome

Indeed, old chap:Indeed, old chap:Practice makes perfect!Practice makes perfect!

CompetenciesCompetencies

Pros and cons of subspecialisation

Pros Focused competency

in complex areas ... or in orphan

diseases More volume, better

outcome

Cons Fragmentation Big picture is gone Poor service (patient

as ‘nomade’) Legal and financial

implications Extension of the

already lengthy training period of medical specialist

Demographic & societal changes

More elderly people with comorbidity Demand driven patient care More female health care workers Increasing wish to work part time

Shortage of medical specialists More medical students? Substitution of medical tasks by new

professionals?

RVZ report (2002) on re-demarcation between existing professions and the creation of new professional groups. The assumption was that this will raise quality standards and lead to more efficient care.

Some evidence to suggest that the quality of care is improved by role redefinition. However, the improvement is attributable mainly to better patient supervision and support.

At present, there is an increasing number of new health professionals; there is no redesign of the care process. Furthermore, doctors do not feel that their burden has been significantly alleviated by the changes made to date.

Redefinition of professional roles

Let us enjoy the new curriculum However, we should not close our

eyes for the major issues that I have just mentioned.

Time for a change