Success rates in specialist training and certification programs should be nearly 100%. This can be achieved by a structured and supervised specialist training program. In such programs, the need for end-of-five year examination is questionable. These slides are basis of a lecture that illustrates the specialist training and certification program in internal medicine in Sweden

1. Examination endgame
Md. Shahidul Islam, M.D., Ph.D
Associate Professor, Group Leader,
Karolinska Institutet, Stockholm,
Sweden.
Senior consultant physician, Internal
Medicine, Uppsala, Sweden
shaisl@me.com

2. Examinations for certification as
specialists
How many should pass?
0%,10%, 50%, 80%, 100%

3. Actors in specialist education in
Sweden
1
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).

4. Actors in specialist education in Sweden
2
Swedish Society of Internal Medicine
Workgroup for special recommendation
Special recommendations for mission statements
for specialist training in internal medicine
(A 40 page document)

5. 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

6. 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

7. Complementary courses
• Theoretical courses, usually one week courses
• Continuing medical education programs in the
work-place
• Other quality controlled courses

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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!

18. 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)

19. Medical competence
(Milestones 1-12)
Milestone 1 Method for learning Documentation
To manage “On the job training”, Certificate from the
the under supervision, supervisor in the unit
acute in units that deal with
illnesses such patients
in areas of
internal
Medicine Courses Course certificate
and from curse leader
Adjacent
specialties

20. 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

21. Common, and important diseases/
conditions
• 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

22. Disease, Assess/handle Have knowledge about Knows about
Condition
Master Pathophysiology Heart
Diastolic failure catheterizati
Heart failure Acute heart Cardiomyopathies on,
Valvular failure Indication for surgery Heart biopsy,
disease Chronic systolic Indication for Surgical
failure transplantation methods,
Anticoagulation Pathogens in Aortic
in endocarditis balloon
prosthetic valves Endocarditis prophylaxis pump
Palliative ------------------ ---------------
treatment ------------------- -------------
------------------ --------------
Practical ------------------
Arterial puncture
CPAP treatment
Initial handling
Infectious
endocarditis

23. “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

24. 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

25. “End of five year” examination
• is optional
• mainly for the purpose of learning, not for
certification
• most do not go for it

26. 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

27. 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

28. Specialist training and
certification programs?
The goal is 100%
success

29. 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 society
There is huge scarcity of specialists
Focus should be on education per se, and not
just on examination