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GH Cirriculum: Clive Taylor

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Pathology as a Model for Medical and Post-graduate Training in a Global Context

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GH Cirriculum: Clive Taylor

  1. 1. Clive R Taylor, M.D., D.Phil. University of Southern California Jan Van den Tweel, M.D. University of Utrecht, Netherlands Pathology as a model for the challenges of post graduate medical training in a global context.
  2. 2. <ul><li>Definition : </li></ul><ul><li>apply medical knowledge, diagnostic skills, and professional attitudes to provide expert diagnostic services. </li></ul><ul><li>Description : </li></ul><ul><li>At the end of training pathologists possess a defined body of knowledge, diagnostic and procedural to provide expert histopathological and cytopathological diagnoses . </li></ul><ul><li>- draws on competencies as </li></ul><ul><li>Scholar , </li></ul><ul><li>Communicator , </li></ul><ul><li>Health advocat e, </li></ul><ul><li>Manager , </li></ul><ul><li>Physician </li></ul>
  3. 3. Focus on Post-graduate medical education - GME * <ul><li>Confusion - as in some countries ‘residency training’ </li></ul><ul><li>is termed ‘Graduate ME’, in others ‘Post –Grad ME’. </li></ul>Pathology Education- three phases ---- Undergraduate Medical Education - Medical Students (Post) Graduate Medical Education* – residents; fellows CME (Continuing Medical Education)
  4. 4. 1400 medical schools on Planet Earth, + greater number of teaching hospitals all conducting GME graduates practice locally , in disciplines that increasingly are global in scope, - a troublesome divergence of education and real life experience.
  5. 5. These are the ‘technologies’ that made us what we are --and make our students what they are TECHNOLOGY DRIVES EDUCATION
  6. 6. AUTOPSIES ‘ preserved specimens’ MUSEUM MODELS MICROSCOPY Courtesy Robin Cooke
  7. 7. Museums ----are just museums
  8. 8. Henry Crouch London 1870 Benjamin Martin B 1747 Simple barrel scope made early 1800s R K Beck London 1840? Technology of teaching
  9. 9. CARSWELL, Robert Professor of Pathology, University College Hospital Pathological Anatomy. Illustrations of the Elementary Forms of Diseases. London: Longman, Rees, Orme (and others) 1838. But ‘gave up pathology’ as living too poor - copy sold on ebay 2004 $25,000
  10. 10. Standards of practice are similar at many major institutions across national boundaries Globalization of medical specialties has occurred - international journals international meetings World Wide Web increased mobility of doctor increased mobility of patients
  11. 12. Variously defined - the period of specialty training after medical school --differs among specialties TWO COMPONENTS of TRAINING **Experience -partly defined **desired knowledge base – not defined . TRAINING EXPERIENCE -- 4 - 6 YEARS ?? PATHOLOGY
  12. 13. International Bodies - with an interest in Pathology Training ? Royal College of Pathologists (& Australasia) European Board of Pathology American Board of Pathology Prescribe some elements of training/experience Administer examinations for ‘certification’ But offer no written curriculum
  13. 14. EXPERIENCE -- <ul><li>US Residency Review Committee – </li></ul><ul><li>4 years. </li></ul><ul><li>at least 50 autopsies, </li></ul><ul><li>2000 surgical specimens, </li></ul><ul><li>1500 cytology specimens </li></ul><ul><li>and 200 frozen sections </li></ul>Royal College Pathology 2 + 3 years
  14. 15. TRAINING DURATION <ul><li>4 YEARS : SPAIN, TURKEY, FRANCE </li></ul><ul><li>5 YEARS : BELGIUM, DENMARK, </li></ul><ul><li>FINLAND, GREECE, IRELAND, ITALY, </li></ul><ul><li>NORWAY, NETHERLANDS, </li></ul><ul><li>PORTUGAL, SWITZERLAND </li></ul><ul><li>2+3= 5 Y EARS : UK </li></ul><ul><li>6 YEARS : AUSTRIA </li></ul>
  15. 17. George N. Papanicolaou (1883-1962), Advances in medical knowledge Occur Worldwide Yet Medical schools are parochial Medical degrees are ‘national’ No Accepted International Curriculum / Certification PAP smear
  16. 18. If we do not have a detailed curriculum - perhaps we do not need one ?? A Google search for ‘curriculum’ yields 16,700,000 hits !!!!! So the ‘Globe’ is interested in ‘curricula’ for something or other – even if we are not. Curricula seem to be a ‘good thing’ – globally. Serious educational programs have serious curricula
  17. 19. Curriculum - defined by examination --- UK European Board Voluntary exam <ul><li>USA CANADA </li></ul><ul><li>Three part process </li></ul><ul><li>Accredited program - RRC and ACGME </li></ul><ul><li>Qualified Program Director </li></ul><ul><li>Certifying Examination </li></ul><ul><li>(American Board of Pathology </li></ul>UK Australia-Asia Royal College Path exam histopathology + 4 other specialties just get hold of the old exams
  18. 20. <ul><li>Exit Exam only : Italy, Portugal, Greece, UK </li></ul><ul><li>Site visits + Obligatory </li></ul><ul><li>Courses : Denmark, France, Norway, Sweden, Netherlands </li></ul><ul><li>Exit Exam+ O.C : Austria, Belgium, Finland, Germany, Switzerland </li></ul><ul><li>Site visits only : Spain </li></ul>But --- Many differences among examinations
  19. 22. SYMPOSIUM 20 - Wednesday 8.30 – 12.00 room P POST-GRADUATE TRAINING IN PATHOLOGY Chairperson: C.R. Taylor (USA) TESTING APTITUDE FOR DIAGNOSTIC HISTOPATHOLOGY S.S. Cross (UK) ADAPTING TRAINING PROGRAMS TO THE FUTURE PRACTICE OF PATHOLOGY C.D.M. Fletcher (USA) TESTING AND MAINTAINING COMPETENCE AFTER COMPLETION OF TRAINING C. Du-Boulay (UK) HARMONIZATION OF PATHOLOGY TRAINING ON A EUROPEAN AND GLOBAL BASIS J. Prat (Spain) THE STATUS OF PATHOLOGY TRAINING IN THE ASIA PACIFIC REGION R.J. Collins (Hong Kong) THE ROLE OF THE EUROPEAN SCHOOL OF PATHOLOGY AND EUROCELLPATH IN INTERNATIONAL TRAINING M. Sobrinho-Simoes (Portugal)
  20. 23. Jan Van Den Tweel. MD. University of Utrecht. Clive R Taylor MD D Phil Unversity of Southern California Human Pathology, 33: 861-862,2002.
  21. 24. <ul><li>What is the importance of experience? </li></ul><ul><li>Can we agree on duration? </li></ul><ul><li>Can we agree and define knowledge base? </li></ul><ul><li>Possibility of ‘one’ examination? </li></ul><ul><li>What technical, educational and management skills are needed? </li></ul><ul><li>Is research experience important? </li></ul><ul><li>Can one ‘teach’ attitude? </li></ul>What are the challenges For a common program ??
  22. 25. 1. Competency criteria 2. Universal Educational Materials 3. Universal courses / online 4. Online examinations – available World wide.
  23. 26. 1. Competency criteria ------ advanced in the American and British systems, are similar, - - offering opportunities for harmonization of medical school and post graduate training around the world
  24. 27. Good professional practice Maintaining good medical practice Relationships with patients Working with colleagues Teaching and training Health Probity www.rcpath.org Medical Knowledge Patient Care Practice-Based Learning & Improvement Interpersonal & Communication Skills Professionalism Systems-Based Practice www.acgme.org/Outcomes/ UK US
  25. 28. <ul><li>3 . casimage Teaching Files </li></ul><ul><li>( http://www.casimage.com ): </li></ul><ul><li>Medical images Geneva University Hospital , </li></ul><ul><li>mostly radiology and pathology. </li></ul><ul><ul><li>4 . PathoPic – Pathology Image Database </li></ul></ul><ul><ul><li>( http://alf3.urz.unibas.ch/pathopic/intro.htm ): </li></ul></ul><ul><ul><li>Pathological images of University of Basel </li></ul></ul><ul><ul><li>7805 cases </li></ul></ul><ul><li>1. PEIR – Pathology Education Resource </li></ul><ul><li>( http://peir.path.uab.edu ): </li></ul><ul><li>Pathological images of University of </li></ul><ul><li>Alabama at Birmingham </li></ul><ul><ul><li>2. ETH-ISIS, Zurich </li></ul></ul><ul><ul><li>Radiology and pathology images </li></ul></ul>TEACHING MATERIALS ARE EVERYWHERE AVAILABLE 2. Universal Educational Materials.
  26. 29. Spanish Society of Pathology (SEAP), 9th European Congress on Telepathology and 3rd International Congress on Virtual Microscopy Toledo, Spain, May 15th–17th, 2008 3 . Universal Courses - online
  27. 30. <ul><li>Eliminates paper handling, speeds results </li></ul><ul><li>Items are not in circulation in the programs, performance is validated and can be used on future exams </li></ul><ul><li>Permits worldwide availability </li></ul><ul><li>Proctoring examination may be challenging </li></ul><ul><li>Test materials not retained </li></ul><ul><li>Up to date equipment and internet access necessary </li></ul>
  28. 31. <ul><li>Pathology Certification Program is Voluntary </li></ul><ul><li>No member of the EU is forced to participate </li></ul><ul><li>-- A country with a difficult exam for its own candidates has to accept specialists from EU countries without an exam at all. </li></ul><ul><li>Candidates that fail in one country can get recognition in another country, and thus circumvent the exam </li></ul>ALL QUALIFICATIONS FREELY TRANSFERABLE ?? --CONSEQUENCES SEEN IN EUROPE ALREADY <ul><li>free movement of doctors within the EU, regardless of examination status. </li></ul>
  29. 32. -enhancement of the quality of the specialty around the world - Improved patient care World wide -movement of pathologists around the world -exchange of fellowships -sabbaticals of senior pathologists seeking specialist experience. Adoption of ‘International Standards’ for training , or a ‘global curriculum’ would facilitate --
  30. 33. <ul><li>Training programmes and requirements show important differences World wide: fact </li></ul><ul><li>Need to harmonize: inevitable, but when </li></ul><ul><li>Focus on training outcome and not on training programs: reality, but slow </li></ul><ul><li>Define what to expect from a trainee at the end of the program: underway, but slow </li></ul>
  31. 34. We are still a long way from a “Global Training Program”.
  32. 35. “ 640K (of memory) ought to be enough for anybody.” Bill Gates 1981 CEO Microsoft.. The ‘experts’ are beginning to look at the problem – But no solution is in sight.
  33. 37. Three different examinations Royal College Pathology (MRCP) American Board of Pathology European Board Examination - (s imilar to American Board (is derived from it in part) , but 1 day, instead of 2) no oral/practical component (unlike MRCP) General curriculum published Not - KNOWLEDGE BASE ---No syllabus No objectives - defined by examination ---
  34. 38. ORGANISATION OF PATHOLOGY <ul><li>NATIONAL PATHOLOGY SOCIETIES </li></ul><ul><li>INTERNATIONAL PATHOLOGY SOCIETIES </li></ul><ul><li>INDEPENDANT EXAMINATION BOARDS </li></ul><ul><li>PROGRAM DIRECTORS </li></ul><ul><li>POLITICIANS </li></ul><ul><li>... too many players in the field, all with an own agenda </li></ul>
  35. 39. DMIN'06 The 2006 International Conference on Data Mining WWW.DMIN-2006.COM WORLDCOMP06 Programme Parallel & Distributed Processing Techniques & Applications and Real-Time Computing Systems & Applications (PDPTA'06 + RTCOMP'06) Grid Computing & Applications (GCA'06) Software Engineering Research & Practice (SERP'06) Programming Languages & Compilers (PLC'06) Internet Computing (ICOMP'06), Semantic Web & Web Services (SWWS'06), and Computer Games Development (CGD'06) Engineering of Reconfigurable Systems & Algorithms (ERSA'06) Computer Design (CDES'06) and Computing in Nanotechnology (CNAN'06) Artificial Intelligence (ICAI'06) Machine Learning ; Models, Technologies & Applications (MLMTA'06) Data Mining (DMIN'06) Information & Knowledge Engineering (IKE'06) e-Learning , e-Business, Enterprise Information Systems, e-Government,& Outsourcing (EEE'06) Bioinformatics & Computational Biology (BIOCOMP'06) Image Processing, Computer Vision, & Pattern Recognition (IPCV'06) Modeling, Simulation & Visualization Methods (MSV'06) Computer Graphics & Virtual Reality (CGVR'06) Security & Management (SAM'06) Wireless Networks (ICWN'06) Communications in Computing (CIC'6) Embedded Systems & Applications (ESA'06) Pervasive Systems & Computing (PSC'06) Scientific Computing (CSC'06) Frontiers in Education : Computer Science & Computer Engineering (FECS'06) Foundations of Computer Science (FCS'06) beyond the microscope
  36. 40.                                                                                                                The Department of Pathology and Laboratory Medicine at Indiana University General and Systemic Path Numerous images by category TEACHING MATERIALS ARE EVERYWHERE AVAILABLE
  37. 41. Globalization of medical specialties has occurred - international journals international meetings World Wide Web increased mobility of doctors increased mobility of patients quality of education at most US and EU medical schools is comparable standards and quality of the practice are similar at many of the major institutions across national boundaries
  38. 42. <ul><li>Anatomic Pathology is practiced in approximately the same way all over the world. </li></ul><ul><li>But - there is an enormous variation in training requirements, including such fundamentals as : </li></ul><ul><li>duration of training </li></ul><ul><li>content of training </li></ul><ul><li>manner of ‘certification </li></ul><ul><li>definition of training institutions </li></ul><ul><li>definition of ‘program directors </li></ul>siege mentality, especially in Europe and the US limited numbers of medical graduates apply for positions in pathology training programs.
  39. 43. <ul><li>Examination in Pathology in Europe is very heterogeneous </li></ul><ul><li>most EU countries do not test at all. (A favourable opinion of the Head of Training is sufficient) </li></ul><ul><li>in some countries there is a basic examination </li></ul><ul><li>in others (e.g. the UK) a rather difficult examination, comprising several days, exists. </li></ul>
  40. 44. <ul><li>European Board of Pathology </li></ul><ul><li>(a section of the European Union of Medical Specialists, UEMS) </li></ul><ul><li>constituted to work on harmonisation of Pathology training and practise in the countries of the EU. </li></ul><ul><li>training duration (5 years) </li></ul><ul><li>training contents (4500 histopathology specimens, 2500 cytological examinations, 1000 examinations do be decided by the trainee and 100 autopsies) </li></ul><ul><li>minor differences still exist between individual member states. </li></ul>
  41. 45. EU MEDICAL HISTORY (UEMS) <ul><li>1957 TREATY OF ROME </li></ul><ul><li>1958 UEMS </li></ul><ul><li>1959 STANDING COMMITTEE OF DOCTORS </li></ul><ul><li>1962 SPECIALIST SECTIONS </li></ul><ul><li>1992 EUROPEAN BOARDS </li></ul>
  42. 46. TOPICS OF EBP, THE PROPOSALS <ul><li>Inventarisation of training programs </li></ul><ul><li>Harmonisation of training duration … </li></ul><ul><li>… of contents of training </li></ul><ul><li>… of certification </li></ul><ul><li>Manpower planning </li></ul><ul><li>CME </li></ul><ul><li>Quality Assurance </li></ul><ul><li>........... AND THE RESULTS (18 years later) ...................? </li></ul>
  43. 47. TOPICS OF EBP, THE REALITY <ul><li>STILL NO UNIFORM TRAINING DURATION </li></ul><ul><li>STILL NO UNIFORM TRAINING PROGRAM </li></ul><ul><li>STILL NO UNIFORM CERTIFICATION </li></ul><ul><li>STILL NO EU MANPOWER PLANNING </li></ul><ul><li>STILL NO UNIFORM QUALITY ASSURANCE </li></ul><ul><li>STILL NO EU CME POINTS </li></ul>
  44. 48. REA SONS FOR POOR RESULTS IN EBP <ul><li>National individualism (in EBP and EU) </li></ul><ul><li>Insufficient mandate for EBP representatives </li></ul><ul><li>No/little feedback at home and thus little/no support from the persons who have to implement the changes i.e. the Chairs and Prods </li></ul><ul><li>Decision making in EU is very slow </li></ul><ul><li>European expansions complicate the situation </li></ul>

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