Nephrol Dial Transplant ( 1996) ll: 1657-1660


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Nephrol Dial Transplant ( 1996) ll: 1657-1660

  1. 1. Nephrol Dial Transplant ( 1996) ll: 1657-1660 Special Feature Nephrology Dialysis Transplantation Programme for harmonization of training in nephrology in the European Union Specialty Section in Nephrology UEMS Introduction The European Union of Medical Specialists (UEMS) was founded in Brussels on 20 July 1958, with one of its objectives being to study, promote and defend the quality of a comparably high level of specialist care given to patients in the European Community (Article 2 of the Statutes of the UEMS). The UEMS acts as an advisory body to the Advisory Committee in Medical Training (ACMT) which is a statutory committee of the European Union. Specialist Sections (previously known as Monospecialist Sections) were created for a number of specialties at that time with the aim of the Specialist Sections being to study the problems raised by the Treaty of Rome concerning the definition, training qualifications, and the exercise of the profession in that particular Specialty (Article 24 of the Rules and Procedures of the UEMS). Each Specialty Section consists of two representatives from each country of the European Union appointed by their specialist national professional association through the national organization representing specialist doctors. The Specialist Section in Nephrology was not formed until 2 April 1993. The specialist section was asked by the Management Committee of the UEMS to prepare a programme for training in nephrology which would allow harmonization of training throughout the European Union. On 3 April 1993 the representatives of the Specialist Sections interested in internal pathology (internal medicine., cardiology, endocrinology, gastroenterology, nephrology, pneumonology, and rheumatology) met in Brussels and discussed the status of these various specialties in the European Union member states, concerning the duration and content of training, and in particular, a common trunk of training in general (internal) medicine. They discussed thoroughly the problems raised related to training harmonization and a mutual recognition of this training according to the provisions of the European Union Medical Directives. The following motion was passed by an overwhelming majority. 'Training in internal medicine and any one of its specialties should take a minimum of 6 vears, of which a minimum of 2 Years should be spent in general (internal) medicine (the common trunk). The balance of the 6 vears should be spent in specialty training of' which a minimum of 3 years should be spent in clinical practice in that discipline. The other year could be spent in research or related disciplines.' Subsequently the Specialty Section in Nephrology met on a number of occasions and produced a draft training programme. This was then circulated to the Presidents of all the National Societies of Nephrology involved in the European Renal Association. The National Presidents were asked to discuss the training programme within their society. They were asked to comment on the proposed training programme and to suggest appropriate modifications to the programme. The programme was then modified taking into consideration the comments and suggestions, resulting in the programme detailed below. European programme for medical training in nephrology Entry requirements Doctors enrolling in training programmes in Nephrology should have completed a minimum of 2 years general medical training. General medical training (GMT) should include acute unselected medical intakes. A period of experience in nephrology of up to 6 months is considered desirable before entry to the training programme, although not essential. If GMT is divided into four periods of 6 months, all four should involve contact with patients, at least three should be concerned with acute medical problems, and at least two should involve acute unselected medical intake. Duration and organization of training
  2. 2. The duration of training in nephrology is 4 years. Three years of the training must be in clinical practice in nephrology. The other year may be in nephrology, general medicine, a related specialty or research. This year may be taken at any stage of, or may be spaced out over, the period of nephrology training. The programme to which the trainee is appointed will have a named trainer or trainers who will be responsible for the development and direction of a co-ordinated and complete training programme. A written record of training will be maintained by the trainee, to be counter-signed by the relevant trainer (programme director) annually. Medical training in nephrology A specialist training programme must ensure that the trainee becomes competent in a range of areas agreed by members of the specialty and their professional bodies. Competencies consist of cognitive skills (knowledge and problem solving), practical skills and attitudes. Cognitive skills. A competent specialist should be able to. (i) describe the normal anatomy and physiology of the kidney and urinary tract. (ii) describe the pathogenesis, clinical features, natural history and management of: disorders of fluids, electrolytes and acid-base balance; hypertension; hereditary, congenital and acquired disease of the kidney and urinary tract; renal disorders associated with systemic conditions, eg. diabetes, vasculitis and pregnancy; infections of the kidney and urinary tract; acute renal failure; chronic renal failure; disorders of mineral metabolism and nephrolithiasis. (iii) describe the basic principles of immunology and the immunological mechanisms of renal disease. (iv) describe the effects of renal impairment on drug metabolism and pharmacokinetics; (v) describe the effects of renal impairment on drug metabolism and pharmokinetics; describe the toxic effects of drugs on renal structure and function; prescribe drugs appropriately to patients with renal impairment. (vi) interpret results of the following investigations: urinalysis and urine microscopy; haematological, biochemical, histological and immunological tests relevant to renal disease. (vii) describe the indications, contraindications and complications of the following procedures and assess and interpret their results where appropriate: ultrasound of the urinary tract; intravenous urography; radio-nuclear imaging and measurement of renal function; CT and MRI scanning; percutaneous biopsy of native and transplanted kidneys; renal angiography and angioplasty; percutaneous nephrostomy; common urological procedures including lithotripsy; plasmapheresis. (viii)describe: the biophysical and technical principles of haemodialysis, peritoneal dialysis, haemofiltration and other allied techniques; the indications, techniques and complications of dialysis access; methods for assessing the adequacy of dialysis, including the uses and limitations of urea kinetics and protein catabolic rate; the short and long-term complications of each mode of dialysis and their management; the influence of various dialysis modes on drug metabolism; the features of different types of artificial membranes used in haemodialysis; the requirements for purification of the water used for haemodialysis; the methods of re-use of artificial kidneys including their potential complications. (ix) advise patients appropriately about nutritional aspects of renal disorders. (x) describe: the medical and legal indications and contraindications to live and cadaveric renal transplantation; the principles of organ harvesting, preservation and storage; the mechanisms of action and the use of immunosuppressive drugs; the pathophysiology, histopathology and diagnosis of transplant rejection; the short and long-term complications of transplantation; interpret the results of histocompatibility tests; evaluate and select recipients for transplantation; evaluate potential renal transplant donors, both live and cadaveric. Practical skills. A competent specialist should be able to: obtain medical histories which are precise, logical, thorough and reliable; elicit physical signs by thorough physical examination relevant to the clinical situation; keep accurate, comprehensive and legible medical notes; communicate effectively with colleagues and other staff involved in the care of patients; obtain temporary vascular access; biopsy native and transplanted kidneys; write a dialysis prescription and manage a dialysis session. All these skills should be carried out while minimizing risk and discomfort to the patient. It is desirable that a specialist should be able to place a catheter for temporary or permanent peritoneal access.
  3. 3. Attitudes. A competent specialist should demonstrate: empathy and rapport with patients, their relatives and friends; a willingness to provide patients with appropriate verbal and written information; a willingness to practice as part of a team of health care professionals; a willingness to participate in research, audit and standard setting; an appreciation of the ethical issues in dialysis and transplantation. Training outwith the European Community Approval of training in a Renal Unit outwith the European Community will only be considered if evidence of the nature of training has been submitted in advance to the appropriate training authority. This will normally require a written statement from the Department which the trainee will visit and written support from the trainee's own programme director. This training could be clinical or in research and will be recognized for up to a maximum of 2 years. Assessment of training Assessment of the trainee will be made by the appropriate authority within each country and will be based on both personal interview and review of the written record of training signed annually by the training programme director. In the future arrangements may be made for an international representation at the time of the final assessment with the aim of awarding a European Diploma in Nephrology. Clinical experience At least two years must be spent in Training Centres fulfilling the following requirements: (i) At least three specialists in Nephrology, each practising nephrology for at least 5 half-days a week. (ii) Facilities for treatment of acute renal failure by haemodialysis, continuous haemofiltration or allied techniques and offering experience of the management of patients with multi-organ failure in Intensive Care Units. (iii) Provision of renal replacement therapy including haemodialysis and CAPD. The total experience gained in haemodialysis should be 6 months with 3 months in peritoneal dialysis although these periods of time may run concurrently. If the Centre does not offer renal transplantation, arrangements must be made for the trainee to be seconded to a Transplant Unit for at least 6 months. (iv) Weekly renal clinics for non-dialysis patients. (v) Full diagnostic facilities including ultrasound, CT scan, angiography, radio-nuclear investigation and renal biopsy. (vii) Full laboratory service for diagnosis and management of renal patients including medical biochemistry, haematology, microbiology and histology. (vii) Regular meetings with radiology, pathology, and urology departments. (viii) Regular audit. (ix) Provision of multidisciplinary clinical meetings. (x) Full library facilities. (xi) An on-going research programme in nephrology is highly desirable. The balance of the training in clinical nephrology may be in Units where all these facilities may not all be available. Discussion At present there are considerable variations in the practice of nephrology within the European Union. Nephrology is regarded as a sub-speciality of general medicine and practised along side it in some countries but in the majority of countries in the European Union, specialist practice is in nephrology alone. This creates some difficulty in producing a training programme that will be acceptable in both circumstances but it is widely recognized that nephrologists must have a sound training in general medicine due to the many medical problems that occur in patients with renal disease. The training programme can allow up to three of the 6 years to be spent in general practice (internal) medicine but will also accept 4 years of clinical practice in nephrology. Some degree of
  4. 4. flexibility is also possible in the programme for those trainees who wish to become involved in research or those who wish experience in another related specialty. We believe that a structured programme of training is necessary for those who wish to become specialists in nephrology. This teaching programme must cover, within the minimum of 3 years of clinical nephrology, all aspects of nephrology, dialysis and transplantation. Practical experience is also required but we have not specified the minimum number of procedures that are required for an individual to become competent in renal biopsy or temporary vascular access. The Specialty Section in Nephrology believes that the best way of achieving harmonization to ensure that a similar quality of training is achieved throughout Europe is by regular approval of the training centres. Many European Union countries already have a system of peer review of units and it is thought that the most appropriate way of proceeding would be for an observer from the UEMS to attend at least some of these reviews in each country. The first such review took place in September 1995 when Professor Ray Krediet attended as an observer from the UEMS a routine visit by the Joint Committee for Higher Medical Training of the Royal Colleges of Physicians in the UK to a training post in one of the London teaching hospitals. The Directives of the European Union indicate that a doctor recognized as a specialist in one member state must be recognized as a specialist in all other member states. This has caused some concern due to a perceived difference in the training standards throughout the European Union. If the training programme is accepted for widespread use throughout Europe the concern about the inequalities in training should disappear with time. The Specialty Section in Nephrology of the UEMS recognizes that it will take time for some countries to move from their current training programmes to the proposed European standard but it is hoped that all member states of the European Union would be able to comply by the year 2000. Correspondence and offprint requests to: B. J. R. Junor, Secretary, Specialty Section, Western Infirmary, Dumbarton Road, Glasgow G11 6NT, UK.