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Training and certifying in the United Kingdom and Europe
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Training and Certifying in the United Kingdom and Europe Anthony B. Ward, MD ABSTRACT. Ward AB. Training and certifying in the United Kingdom and Europe. Arch Phys Med Rehabil 2000;81: 1242-4. Key Words: Certification; Clinical competence; Great Britain; Europe; Rehabilitation. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
B
ECAUSE THE DIFFERENCES in training, certification, and measurement of competency in the specialty of physical rehabilitation and medicine (PR&M) among the various countries in Europe are as great as are those between Great Britain and the United States, I shall not attempt to describe the situation in each European country. Rather, I will discuss some of the main issues specific to Britain and Europe and, in particular, the work of the European Board of PR&M. TRAINING Training of physical medicine and rehabilitation specialists falls into 4 categories: apprenticeship, formal training, teaching, and assessment. What are the aims of training and of measuring competence? For training, the answer is fourfold: knowledge of the specialty to produce doctors who are clinically competent, have good professional knowledge, and can serve in a consultant role. GREAT BRITAIN In Great Britain, trained specialists are called consultants. They are more than just specialists; they are managers, they are department heads, they are the ‘‘thinkers and doers’’ within the specialty. With that in mind, an important question is: What are the tasks to be undertaken by an individual in training? It is assumed that the physician will grow with the changing professional role, developing new skills and competencies, gaining leadership experience, and engaging in significant research and development projects. In Britain, this specialty is called rehabilitation medicine. The Royal College of Physicians (RCP) controls all training and the curricula in all medical specialties. Entry requirements for specialist training specify that an individual complete the standard training of a 1-year internship, followed by at least 2 years as a junior doctor in common trunk training (a general medical or general surgical specialty). At this point, the doctor may stand for RCP’s membership examination (MRCP) if he/she completes the physician’s route, or for the Royal College of Surgeons’ (RCS) fellowship exam (FRSC), if through a surgical basic training.
From the North Staffordshire Rehabilitation Centre, Staffordshire, England. Presented in part at the meeting ‘‘Physical Medicine and Rehabilitation: International Certifying Boards,’’ sponsored by the American Board of Physical Medicine and Rehabilitation, November 13, 1999, in Washington, DC. Reprint requests to Anthony B. Ward, MD, North Staffordshire Rehabilitation Centre, The Haywood, High Lane, Burslem, Stoke-on-Trent, Staffordshire ST6 7AG, United Kingdom. 0003-9993/00/8109-6123$3.00/0 doi:10.1053/apmr.2000.17846
Arch Phys Med Rehabil Vol 81, September 2000
Rehabilitation medicine training in Great Britain takes 4 years, though an application has recently been made to increase this requirement to 5 years. The curriculum is composed of training attachments or rotations, some of which are obligatory (7 components of varying length) and others of which are optional: neurologic rehabilitation (12 months); spinal injuries for general rehabilitation medicine trainees (3 months); rheumatology (6 months); amputation rehabilitation/assistive technology (6 months); environmental control assessments (experience with 5 patients); and psychological aspects of disabilities (3 months). In addition to these obligatory experiences, an individual may select from several training options for a maximum of 1 year’s credit. These options include: neurology, geriatric medicine, cardiology, respiratory medicine, pediatrics, psychiatry, learning disabilities, trauma, neurosurgery, orthopedic surgery, plastic surgery, urology, vascular surgery, and sports medicine. To enhance their training, doctors may also select from several short-term attachments to the training option specialties that enhance their experience and parallel their interests. The number of rotations selected may extend the training, but 6 months is the maximum allowable credit granted. These short-term attachments are pain management, sexuality, continence services, palliative care, sensory deficits, community rehabilitation, disabled school-leavers, rehabilitation in the developing world, orthotics, rehabilitation engineering, disabled driving, vocational rehabilitation, or computer technology. Rehabilitation medicine in Great Britain differs from physical medicine and rehabilitation in other European countries. It is more neurologically oriented, but extends to trauma and amputation rehabilitation, adopting different influences from other European countries. In addition to the obligatory and optional training, short-term attachments can be done on a part-time basis. For an individual who wants to specialize in spinal cord injuries (SCIs), there is an alternative curriculum with a minimum of 2 years in a spinal injuries unit. It is not possible to be a consultant in rehabilitation medicine in a SCI unit without fulfilling this requirement. Great Britain recognizes SCIs as a subspecialty of rehabilitation medicine. The same applies to amputation rehabilitation, which requires 1 year in a rehabilitation unit. There will be other subspecialties; eg, sports medicine is anticipated. What are the common expectations of all training programs? Doctors move from 1 hospital to another within a training program, which is important as they gain exposure to and participate in the different rehabilitation experiences available. Each training program is coordinated by a program director. Doctors enrolled in a particular program know these stages in advance, specifically when it is that they are expected to move to a new experience and where they will be in the 4 years of their training. Assessment The RCP Specialist Advisory Committee on Rehabilitation Medicine (SACRM) has developed the curriculum with 3 elements in mind: knowledge, experience, and skills. There has
INTERNATIONAL CERTIFICATION—UK AND EUROPE, Ward
been much discussion on how to assess competence, and on how the various elements of the curriculum are scored. In Great Britain, both the trainee and the trainer participate in this assessment. The trainer gives a detailed account of the competence, aptitude, and attitude of the trainee during his/her rotation. Trainees measure their own performance in a particular area and this assessment is counter-measured by the trainers. This balance provides good learning experience and dialogue between the 2 individuals involved in the process. To achieve this, trainees are given a formal appraisal at the beginning of each rotation and a summative assessment at the end. All evaluations are entered into a personalized logbook that is given to each trainee. The whole assessment process tests both the trainer and the trainee; the RCP tests training units through site visits at least every 5 years, with more frequent visits if deemed necessary. The RCP program evaluation also looks at the relation between trainees and trainer in the assessment process. Assessment is conducted on a regional basis for all specialties working with the individual program directors. Each region has a training committee, and all the educational supervisors are members of that committee, together with a trainee representative. Thus, there is a direct link with trainees. This training committee annually assesses each trainee in rehabilitation medicine. This is manageable because rehabilitation medicine is a small specialty in Great Britain, with only about 120 consultants and 60 trainees. A RCP representative follows an established format during each of the 4 annual assessments; the representative works with the program director and each trainee’s educational supervisor. These assessments inform the trainee whether he/she will qualify for the next training phase. The penultimate assessment is the most important because it reveals whether the trainee is likely to gain a certificate of completed specialty training after 4 years. The trainee prepares to respond to questions that are broad in scope during the assessment. The questions range from clinical areas to knowledge of the work experience. Exit examinations are a poor way to judge the competence of trainees. The doctors’ ability to acquire knowledge has already been assessed through the MRCP/FRCS examinations before entering specialty training, so more formal training assessments of their specialty training have been adopted. At each assessment, doctors are examined and documentation is carried out through the Record of In-Training Assessment forms. Doctors either pass onto the next stage of training, defer assessment in the areas just completed, or fail. The theoretical aspects of the curriculum are taught through formal teaching meetings at which trainee attendance is obligatory. These are provided nationally, regionally, or locally. Trainees sometimes interact with trainees in other disciplines in these teaching meetings. Research and education time is sacrosanct and dedicated time (1 day per week) is given to this throughout the program. Training the teachers is an important area in which experience is still being gained. Trainers are encouraged to develop and improve their teaching skills; their evaluation of the trainees is appraised; and they are expected to participate in research—which means that publishing research findings is still important. Dual specialty certification is permissible; the usual length of the program is 6 years, depending on the specialty. Part-time training programs for people with external commitments are also possible. The RCP, through the SACRM, puts together a mutually convenient and appropriate package that spans 6 or
1243
more years. Such arrangements must be made at the beginning of the training attachment. To conclude my review of Great Britain, we need many more doctors, but we know that rehabilitation medicine is a growing specialty. Training junior doctors takes time, and hospital managers must realize that doctors who are involved in training must be excused from some clinical work. EUROPE There are 19 countries in the Union of European Medical Specialists (UEMS), which include the 16 European Union countries as well as Switzerland, Iceland, and Norway. The practice of the rehabilitation medicine specialty varies greatly between the member states: some practice rehabilitation medicine, as in the United Kingdom; others practice in physical medicine; but most practice physical rehabilitation medicine. European medicine is ‘‘governed’’ by the UEMS and each specialty has its own monospecialist section. Within each section, there is a European board that is responsible for training. Physiatry is the responsibility of the European Board of P&RM, which has 4 primary tasks. (1) Recognition of the Specialists. To be recognized by the European Board, a doctor must first be a recognized specialist in his own country. (2) Certification of trainees who have already been nationally approved. Trainees must pass an examination to be recognized by the European Board. Trainees register with the Board, are given a personalized logbook, and are advised on what to expect during their training. When they are approved by their own country, they are eligible for recognition by the European Board. (3) Approval of trainers and training units via site visits. (4) Recertification. The European Board is now considering how to provide continuing education programs that will make possible recertification 10 years after the initial certification. The European Board’s Training and Education Commission is responsible for developing and maintaining the theoretical curriculum, for administering the examinations, and for awarding the Board’s diploma. The Board has been busy in the last 8 years in the following areas: • producing personalized logbooks, with the curriculum enclosed, that allow doctors to compare their own national training with training on the European level; • administering exit examinations, which provide a measure of the level of the physician’s theoretical competence, for trainees seeking the Board’s diploma; and • conducting site visits to identify the composition of a training program in a particular country and the experience that doctors may have received in their own country. The purpose of the European Board is to: • harmonize training throughout Europe; • manage continuing medical education, an important aspect of the Board’s role; and • serve as an information resource for training programs in Europe. Countries can share ideas and share experiences through the European Board. Physical and rehabilitation medicine is well developed in Europe, and the Board is well organized when compared with those of other specialties. It has taken on a heavy workload in a short space of time. CHALLENGES I see 4 challenges ahead for the European PM&R community: (1) change must be managed effectively and proactively; Arch Phys Med Rehabil Vol 81, September 2000
1244
INTERNATIONAL CERTIFICATION—UK AND EUROPE, Ward
(2) the need for teachers and academics in the specialty must be addressed; (3) a strategic plan for better teacher training must be developed and implemented; and (4) ongoing evaluations of the accreditation system must be implemented. I believe that the United Kingdom has a good system for certifying competence of trainees in physical medicine and rehabilitation. It is now a matter of spreading information about model systems across Europe, combining it with
Arch Phys Med Rehabil Vol 81, September 2000
positive experiences of member countries of the UEMS. Such action will ensure a high level of certifying and measuring competence. As is evidenced by the American Board of Physical Medicine and Rehabilitation survey, there are many physiatrists in Europe, including Eastern Europe. It is important that all the expertise be harnessed and applied to the task of measuring competence in physical medicine and rehabilitation.
Training and Certifying in the United Kingdom and Europe Anthony B. Ward, MD ABSTRACT. Ward AB. Training and certifying in the United Kingdom and Europe. Arch Phys Med Rehabil 2000;81: 1242-4. Key Words: Certification; Clinical competence; Great Britain; Europe; Rehabilitation. r 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
B
ECAUSE THE DIFFERENCES in training, certification, and measurement of competency in the specialty of physical rehabilitation and medicine (PR&M) among the various countries in Europe are as great as are those between Great Britain and the United States, I shall not attempt to describe the situation in each European country. Rather, I will discuss some of the main issues specific to Britain and Europe and, in particular, the work of the European Board of PR&M. TRAINING Training of physical medicine and rehabilitation specialists falls into 4 categories: apprenticeship, formal training, teaching, and assessment. What are the aims of training and of measuring competence? For training, the answer is fourfold: knowledge of the specialty to produce doctors who are clinically competent, have good professional knowledge, and can serve in a consultant role. GREAT BRITAIN In Great Britain, trained specialists are called consultants. They are more than just specialists; they are managers, they are department heads, they are the ‘‘thinkers and doers’’ within the specialty. With that in mind, an important question is: What are the tasks to be undertaken by an individual in training? It is assumed that the physician will grow with the changing professional role, developing new skills and competencies, gaining leadership experience, and engaging in significant research and development projects. In Britain, this specialty is called rehabilitation medicine. The Royal College of Physicians (RCP) controls all training and the curricula in all medical specialties. Entry requirements for specialist training specify that an individual complete the standard training of a 1-year internship, followed by at least 2 years as a junior doctor in common trunk training (a general medical or general surgical specialty). At this point, the doctor may stand for RCP’s membership examination (MRCP) if he/she completes the physician’s route, or for the Royal College of Surgeons’ (RCS) fellowship exam (FRSC), if through a surgical basic training.
From the North Staffordshire Rehabilitation Centre, Staffordshire, England. Presented in part at the meeting ‘‘Physical Medicine and Rehabilitation: International Certifying Boards,’’ sponsored by the American Board of Physical Medicine and Rehabilitation, November 13, 1999, in Washington, DC. Reprint requests to Anthony B. Ward, MD, North Staffordshire Rehabilitation Centre, The Haywood, High Lane, Burslem, Stoke-on-Trent, Staffordshire ST6 7AG, United Kingdom. 0003-9993/00/8109-6123$3.00/0 doi:10.1053/apmr.2000.17846
Arch Phys Med Rehabil Vol 81, September 2000
Rehabilitation medicine training in Great Britain takes 4 years, though an application has recently been made to increase this requirement to 5 years. The curriculum is composed of training attachments or rotations, some of which are obligatory (7 components of varying length) and others of which are optional: neurologic rehabilitation (12 months); spinal injuries for general rehabilitation medicine trainees (3 months); rheumatology (6 months); amputation rehabilitation/assistive technology (6 months); environmental control assessments (experience with 5 patients); and psychological aspects of disabilities (3 months). In addition to these obligatory experiences, an individual may select from several training options for a maximum of 1 year’s credit. These options include: neurology, geriatric medicine, cardiology, respiratory medicine, pediatrics, psychiatry, learning disabilities, trauma, neurosurgery, orthopedic surgery, plastic surgery, urology, vascular surgery, and sports medicine. To enhance their training, doctors may also select from several short-term attachments to the training option specialties that enhance their experience and parallel their interests. The number of rotations selected may extend the training, but 6 months is the maximum allowable credit granted. These short-term attachments are pain management, sexuality, continence services, palliative care, sensory deficits, community rehabilitation, disabled school-leavers, rehabilitation in the developing world, orthotics, rehabilitation engineering, disabled driving, vocational rehabilitation, or computer technology. Rehabilitation medicine in Great Britain differs from physical medicine and rehabilitation in other European countries. It is more neurologically oriented, but extends to trauma and amputation rehabilitation, adopting different influences from other European countries. In addition to the obligatory and optional training, short-term attachments can be done on a part-time basis. For an individual who wants to specialize in spinal cord injuries (SCIs), there is an alternative curriculum with a minimum of 2 years in a spinal injuries unit. It is not possible to be a consultant in rehabilitation medicine in a SCI unit without fulfilling this requirement. Great Britain recognizes SCIs as a subspecialty of rehabilitation medicine. The same applies to amputation rehabilitation, which requires 1 year in a rehabilitation unit. There will be other subspecialties; eg, sports medicine is anticipated. What are the common expectations of all training programs? Doctors move from 1 hospital to another within a training program, which is important as they gain exposure to and participate in the different rehabilitation experiences available. Each training program is coordinated by a program director. Doctors enrolled in a particular program know these stages in advance, specifically when it is that they are expected to move to a new experience and where they will be in the 4 years of their training. Assessment The RCP Specialist Advisory Committee on Rehabilitation Medicine (SACRM) has developed the curriculum with 3 elements in mind: knowledge, experience, and skills. There has
INTERNATIONAL CERTIFICATION—UK AND EUROPE, Ward
been much discussion on how to assess competence, and on how the various elements of the curriculum are scored. In Great Britain, both the trainee and the trainer participate in this assessment. The trainer gives a detailed account of the competence, aptitude, and attitude of the trainee during his/her rotation. Trainees measure their own performance in a particular area and this assessment is counter-measured by the trainers. This balance provides good learning experience and dialogue between the 2 individuals involved in the process. To achieve this, trainees are given a formal appraisal at the beginning of each rotation and a summative assessment at the end. All evaluations are entered into a personalized logbook that is given to each trainee. The whole assessment process tests both the trainer and the trainee; the RCP tests training units through site visits at least every 5 years, with more frequent visits if deemed necessary. The RCP program evaluation also looks at the relation between trainees and trainer in the assessment process. Assessment is conducted on a regional basis for all specialties working with the individual program directors. Each region has a training committee, and all the educational supervisors are members of that committee, together with a trainee representative. Thus, there is a direct link with trainees. This training committee annually assesses each trainee in rehabilitation medicine. This is manageable because rehabilitation medicine is a small specialty in Great Britain, with only about 120 consultants and 60 trainees. A RCP representative follows an established format during each of the 4 annual assessments; the representative works with the program director and each trainee’s educational supervisor. These assessments inform the trainee whether he/she will qualify for the next training phase. The penultimate assessment is the most important because it reveals whether the trainee is likely to gain a certificate of completed specialty training after 4 years. The trainee prepares to respond to questions that are broad in scope during the assessment. The questions range from clinical areas to knowledge of the work experience. Exit examinations are a poor way to judge the competence of trainees. The doctors’ ability to acquire knowledge has already been assessed through the MRCP/FRCS examinations before entering specialty training, so more formal training assessments of their specialty training have been adopted. At each assessment, doctors are examined and documentation is carried out through the Record of In-Training Assessment forms. Doctors either pass onto the next stage of training, defer assessment in the areas just completed, or fail. The theoretical aspects of the curriculum are taught through formal teaching meetings at which trainee attendance is obligatory. These are provided nationally, regionally, or locally. Trainees sometimes interact with trainees in other disciplines in these teaching meetings. Research and education time is sacrosanct and dedicated time (1 day per week) is given to this throughout the program. Training the teachers is an important area in which experience is still being gained. Trainers are encouraged to develop and improve their teaching skills; their evaluation of the trainees is appraised; and they are expected to participate in research—which means that publishing research findings is still important. Dual specialty certification is permissible; the usual length of the program is 6 years, depending on the specialty. Part-time training programs for people with external commitments are also possible. The RCP, through the SACRM, puts together a mutually convenient and appropriate package that spans 6 or
1243
more years. Such arrangements must be made at the beginning of the training attachment. To conclude my review of Great Britain, we need many more doctors, but we know that rehabilitation medicine is a growing specialty. Training junior doctors takes time, and hospital managers must realize that doctors who are involved in training must be excused from some clinical work. EUROPE There are 19 countries in the Union of European Medical Specialists (UEMS), which include the 16 European Union countries as well as Switzerland, Iceland, and Norway. The practice of the rehabilitation medicine specialty varies greatly between the member states: some practice rehabilitation medicine, as in the United Kingdom; others practice in physical medicine; but most practice physical rehabilitation medicine. European medicine is ‘‘governed’’ by the UEMS and each specialty has its own monospecialist section. Within each section, there is a European board that is responsible for training. Physiatry is the responsibility of the European Board of P&RM, which has 4 primary tasks. (1) Recognition of the Specialists. To be recognized by the European Board, a doctor must first be a recognized specialist in his own country. (2) Certification of trainees who have already been nationally approved. Trainees must pass an examination to be recognized by the European Board. Trainees register with the Board, are given a personalized logbook, and are advised on what to expect during their training. When they are approved by their own country, they are eligible for recognition by the European Board. (3) Approval of trainers and training units via site visits. (4) Recertification. The European Board is now considering how to provide continuing education programs that will make possible recertification 10 years after the initial certification. The European Board’s Training and Education Commission is responsible for developing and maintaining the theoretical curriculum, for administering the examinations, and for awarding the Board’s diploma. The Board has been busy in the last 8 years in the following areas: • producing personalized logbooks, with the curriculum enclosed, that allow doctors to compare their own national training with training on the European level; • administering exit examinations, which provide a measure of the level of the physician’s theoretical competence, for trainees seeking the Board’s diploma; and • conducting site visits to identify the composition of a training program in a particular country and the experience that doctors may have received in their own country. The purpose of the European Board is to: • harmonize training throughout Europe; • manage continuing medical education, an important aspect of the Board’s role; and • serve as an information resource for training programs in Europe. Countries can share ideas and share experiences through the European Board. Physical and rehabilitation medicine is well developed in Europe, and the Board is well organized when compared with those of other specialties. It has taken on a heavy workload in a short space of time. CHALLENGES I see 4 challenges ahead for the European PM&R community: (1) change must be managed effectively and proactively; Arch Phys Med Rehabil Vol 81, September 2000
1244
INTERNATIONAL CERTIFICATION—UK AND EUROPE, Ward
(2) the need for teachers and academics in the specialty must be addressed; (3) a strategic plan for better teacher training must be developed and implemented; and (4) ongoing evaluations of the accreditation system must be implemented. I believe that the United Kingdom has a good system for certifying competence of trainees in physical medicine and rehabilitation. It is now a matter of spreading information about model systems across Europe, combining it with
Arch Phys Med Rehabil Vol 81, September 2000
positive experiences of member countries of the UEMS. Such action will ensure a high level of certifying and measuring competence. As is evidenced by the American Board of Physical Medicine and Rehabilitation survey, there are many physiatrists in Europe, including Eastern Europe. It is important that all the expertise be harnessed and applied to the task of measuring competence in physical medicine and rehabilitation.