Download - Examination endgame
Examination endgame
Md. Shahidul Islam, M.D., Ph.DAssociate Professor, Group Leader,
Karolinska Institutet, Stockholm, Sweden.Senior consultant physician, Internal
Medicine, Uppsala, [email protected]
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