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