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R2S2 2nd Edition – Porto Potenza Picena (MC) ITALY - May 13-18, 2019 Needs for PRM and allied health professional education at the European and National Levels Maria Gabriella Ceravolo

Needs for PRM and allied health professional

education at the European and National

LevelsMaria Gabriella Ceravolo

President of the UEMS PRM Board

Neurorehabilitation Clinic, United Hospitals of Ancona, Dept of Experimental and Clinical Medicine

Faculty of Medicine, Politecnica delle Marche University, [email protected]

May 13th 2019

mailto:[email protected]


DISCLOSURE

I HAVE NO CONFLICTS OF INTERESTS TO DISCLOSE


The need to scale up rehabilitation


N. HOSPITAL BED S/1000 people.


N. REHABILITATION BEDS IN GERMANY:

240 /100000 people

ITALY70 /100000 people


N. PHYSICIANS /1000 PEOPLE


0 500 1000 1500 2000 2500 3000

UkraineMalta

CyprusIreland

LuxembourgSlovenia

LatviaFYROM

IsraelUnited Kingdom

GreeceNorway

HungaryCroatia

GeorgiaBulgaria

Slovakia RepublicPortugalBelgium

NetherlandsRomania

Czech RepublicRussiaSpain

PolandItaly

PRM Doctors (n°)


Many countries, especially in western Europe, have well-developed tertiary care services of a high quality, although not always available to all sections of society.In many cases disease registries, risk factor survey instruments and surveillance systems are lacking or not fit for purpose, with only limited disaggregation of data by sex, age or social strata. This presents problems for comparative analysis and benchmarking between and within countries, and means that monitoring of trends and the impacts of interventions is limited.


SWOT ANALYSIS OF MAJOR STRENGTHS, WEAKNESSESOPPORTUNITIES AND THREADS OF HEALTH SYSTEMS IN THE EU COUNTRIES


10 CORE ESSENTIAL PUBLIC HEALTH OPERATIONS

1. Surveillance Of Population Health And Well-being;

2. Monitoring And Response To Health Hazards And Emergencies;

3. Health Protection, Including Environmental, Occupational And Food

Safety And Others;

4. Health Promotion, Including Action To Address Social Determinants

And Health Inequi-y;

5. Disease Prevention, Including Early Detection Of Illness;

6. Assuring Governance For Health;

7. Assuring A Competent Public Health Workforce;

8. Assuring Organizational Structures And Financing;

9. Information, Communication And Social Mobilization For Health;

10. Advancing Public Health Research To Inform Policy And Practice.


10 CORE ESSENTIAL PUBLIC HEALTH OPERATIONS


EPHO REQUISITES

1. Surveillance Of Population Health And Well-being

statistics system, health-related surveys, the health management information system and existing disease registries

2. Monitoring And Response To Health Hazards And Emergencies;

identification and monitoring of health hazards (natural, human-caused and technological)

3. Health Protection, Including Environmental, Occupational And Food Safety And Others;

protection of environmental, occupational health; food safety, patient safety, road safety and consumer product safety

4. Health Promotion, Including Action To Address Social Determinants And Health Inequity

government and health system responses to the main risk factors and determinants of health; promotion of changes in lifestyle, practices and environmental and social conditions

5. Disease Prevention, Including Early Detection Of Illness;

Vaccination; maternal and neonatal health programmes, smoking cessation services ; secondary prevention ; services in place to foster good quality of life (tertiary and quaternary prevention), support for patient groups and rehabilitation, survivorship and disease management programmes. social support systems that create a supportive environment for behaviour change and assist caregivers at a psychosocial level.

6. Assuring Governance For Health; capacity of the ministry of health to lead public health efforts both within and outside the health system; effectiveness of the health policy cycle

7. Assuring A Competent Public Health Workforce;

capacities to plan for, manage, educate and govern the public health workforce.

8. Assuring Organizational Structures And Financing;

financing public health services; describe the decision-making criteria used to allocate resources.

9. Information, Communication And Social Mobilization For Health;

public health communication campaigns; use of ICT in the health system

10. Advancing Public Health Research To Inform Policy And Practice.

setting a national research agenda ; capacity-building for public health research; integration of research in educational activities and public health practice, dissemination of evidence and knowledge-brokering;


Needs for PRM and allied health professional

education at the European and National

Levels


THE “ADDED VALUE” OF THE UEMS INCLUDES:

❑ greater strength through mutual co-operation;

❑ a unified voice in the international representation of medical specialists;

❑ international excellence in key areas of relevance to the medical profession;

❑ effective interaction and support between NMAs and the UEMS, and between individual specialties and the UEMS;

❑ addressing interdisciplinary issues in emerging areas of specialist medical practice;

❑ setting the basis for the robust accreditation of the educational meetings attended by our colleagues;

❑ the development of new, harmonized models for the training of the next generation of medical specialists, and of high standards of clinical practice, hence improved care for patients throughout Europe.


The UEMS PRM Board

IS a Working Group of Physical and Rehabilitation Medicine Section of the Union Européenne des Médecins Specialistes (U.E.M.S., European Union of Medical Specialists).

was founded by a separate statute in 1991.

IS INTERESTED in defining in clear terms "European Standards", i.e. the basic elements for a European training programme, the opportunities and conditions for training rotation, attachments, exchanges and the average level of required knowledge and technical competence.

aims to harmonize the training in E.U. so as to ensure optimal rehabilitative care for patients in the countries of European Union.

WILL PURSUE the objectives of UEMS in so far as they apply to Physical and Rehabilitation Medicine.


MAIN ACTIVITIES OF THE UEMS PRM BOARDHarmonization of PRM training in Europe

Certification of PRM specialists (by examination and equivalence

Certification of PRM trainers

Certification/Recertification of PRM training centres

Continuing Medical Education and Recertification of PRM Specialists

Accreditation of European congresses and Teaching Programmes


Harmonization of PRM training in Europe represents one of the primary commitments of the UEMS PRM Board.

This goal is currently pursued

- Delivering documents, position papers on standards of PRM education

- Delivering educational material published on the Board educational platform

- Offering a graduate educational programme, accessible by

trainees at European Congresses accredited by the Board ,

Board organized Teaching Programmes (ESM, EMRSS, RSS)

Board organized Teaching Sessions during European Congresses


White Book of PRM in Europe. Chapter 9 – Education and continuous professional development: shaping the

future of PRM

- Documents, position papers on standards of PRM education


It develops through dealing with the following issues

WHAT is the state of art of education in PRM across European countries

WHAT is the recommended standard in the Education and training of PRM specialists across Europe

WHAT is needed to any physician to understand the role of PRM physicians and rehabilitation? (undergraduate PRM training)

HOW are knowledge and competencies maintained as the PRM physicians grow older and the contextual factors change

WHAT competencies should any PRM physician achieve, based on the epidemiology of diseases and the main concept of the highest efficacy and soundness of a patient-centered approach

White Book of PRM in Europe. Chapter 9 – Education and continuous professional development: shaping the

future of PRMThis Chapter answers the following MAIN question:

WHAT is needed to a physician to become (and remain) a Specialist in PRM ?(education and training requirements, core curriculum of theoretical knowledge and main competencies, skills and attitudes)

EDUCATION AND TRAINING

Standards in education and training of PRM physicians • Training duration• Directors of Training, Trainers and training

units• Assessment of learning /training outcomes • Certification procedures Undergraduate Training

CONTINUING PROFESSIONAL DEVELOPMENT (CPD) AND MEDICAL EDUCATION (CME)

CURRICULUM IN PRM: MAIN PRINCIPLES

TABLE OF CONTENTS

- Documents, position papers on standards of PRM education


TRAINING REQUIREMENTS IN PHYSICAL

AND REHABILITATION MEDICINE


TRAINING REQUIREMENTS FOR TRAINEES

1. Content of training and learning outcome

a. Theoretical knowledge

b. Practical and clinical skills

c. Professionalism

…the trainee should become familiar with the theoretical knowledge about the full spectrum of Bodystructure/Body function impairments, the mechanisms of tissue damage and repair, the principles of motorlearning, the epidemiology and natural history of diseases, the tools for clinical, functional and instrumentaldiagnosis, the effects of pharmacological, surgical and complementary treatments, as well as of specificrehabilitation interventions.

• clinical and instrumental assessment to determine the pathophysiology mechanisms and the underlying diagnosis of the patient’s condition.• functional assessment in the frame of ICF, including assessment of body function/structure impairment, assessment of activity limitation and

participation restriction and discrimination between capacity and performance, based on the detection of contextual (personal characteristics) andenvironmental barriers/facilitators

• implementation of clinical and instrumental assessment tools to explore motor, cognitive, behavioural and autonomic functions.• prognosis of disease/disability course, detection of adverse/favourable factors of functional recovery and definition of the means (ways) of recovery,

compensation and adaptation;• devising and conducting a rehabilitation plan, through a team-based approach that consists of setting achievable short, medium and long-term goals,

agreed with the patient and carers, and eventually leading to patient’s reintegration in the community and improved quality of life;• prescription, as much evidence-based as possible, of medical and physical treatments (including drug treatment, physical modalities, innovative

technologies, natural factors and others), as well as of technical aids (orthotics, prosthetics, wheelchairs and others), effective to achieve the goals of therehabilitation plan;

• prevention and management of complications

PRM practice is uniquely characterized by a team-based, patient-centred, goal-directed approach aimed to optimize patient function and quality of life, preventcomplications and increase community participation. Therefore, PRM specialists are required to develop not only medical knowledge, competence in patient care and specific procedural skills, but also attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabledpeople into society, apply principles of quality assurance and promote a practice-based continuous professional development. As leaders of the multi-professional rehabilitation teams involved in the continuum of care delivery from hospital to the community, they must also exhibit managerial competences, know and apply the principles of evidence-based medicine, incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate


TRAINING REQUIREMENTS FOR TRAINEES

2. Organization of training

a. Schedule of training

b. Curriculum of training

c. Support of trainees

d. Assessment and evaluation

e. Governance

the PRM educational program in Europe is usually configured in 48-month format, rising up to 72 months in some countries,including a minimum 36 months of clinical training (of which 24 months spent in a PRM department).However, considering the tremendous increase in life expectancy all over Europe, and the consequent increase in age-relateddisabling illnesses with acute onset and chronic course, the frequency and complexity of comorbidities in rehabilitationwards have markedly increased. Patients are admitted to wards much earlier after the onset of acute illness or injury and the

complexity of the disabilities is also rising. For this reason the UEMS PRM Section and Board requires a duration oftraining of 60 months including 12 months rotations in external departments (like internal medicine, neurology,intensive care and others).

A written Training Curriculum must be designed to provide a diversified and balanced quality (theoretical and practical) of PRM education describing the contents and aims in each year of training. There should be established rotation periods covering all main areas of PRM practice.

There should be a documented, continuous Education Programme which should include seminars, conferences and meetings at a regular basis (weekly, monthly, yearly).

Logbook Each trainee must keep an authorized Logbook for documentation of professional experience (not only, functional assessments, rehabilitation plans, active participation in team meetings, procedural skills; but also, multisource feedback from other members of the rehabilitation team)Patient feedback)

The minimal numbers per year of each of these items should be determined nationally

E-Portfolio (.including an up-to-date curriculum vitae - EUROPASS style)i

Exit examinationThe Training Director certifies the attainment of adequate competency level for each training outcome.

The final year examination must verify that the trainee has demonstrated sufficient competence to enter practice

without direct supervision and has achieved the standard level of entrustable professional activity.

The minimum levels of applied clinical knowledge and applied clinical skills that a trainee must exhibit at the exit

examination are reported for each single item of the whole Curriculum of Studies in PRM.


II. TRAINING REQUIREMENTS FOR TRAINERS1. Process for recognition as trainera. Requested qualification and experience

b. Core competencies for trainers

2. Quality management for trainers

To be recognized as a trainer, a physician should: • Be certified as a specialist in PRM by the responsible national authority in his or her country.• Be recognized as a trainer in PRM by the responsible national authority in his or her country.• Demonstrate his or her clinical activity as being within this discipline.• Practice in the specialty for at least 80% of his or her time in an establishment recognized as

a training centre by the national responsible authority over 5 years.• Practice within a defined rehabilitation team.Actively participate in training and research in PRM with regular publications

To be recognized as a PRM training unit of European level, an institution/department must:

• Be recognized as a training facility in PRM by the responsible national authority in its Country.

• Be directed by a doctor, who is:

- a specialist in PRM, recognized as a trainer by the European Board,

- responsible for a team comprising: one more Board certified specialist in PRM, professionals allied to medicine, including physiotherapists and occupational

therapists as well as a group of other personnel (speech therapists, psychologists, social workers).

• Have all the necessary infrastructure to provide the training in PRM as defined in the curriculum (i.e. the facilities to perform diagnostic assessments, functional

investigation and measurement, and treatments relevant to the discipline of PRM)

• Have adequate teaching staff

• Provide the trainee with space and opportunities for practical and theoretical study and access to adequate national and international professional literature

• Have a structured training program, which includes theoretical teaching sessions, training duties for each trainer and adequate numbers of practical procedures

per trainee

• Undergo monitoring in a structured way by the national authorities including visits and appraisal of their standards as training centres on a regular basis

• Have an internal system of medical audit or quality assurance including features such as reporting of accidents in accordance with a structured procedures

• Maintain a network of contacts among clinical colleagues and professionals allied to medicine in hospital settings and services assisting the discharge of

patients into the community.

III. TRAINING REQUIREMENTS FOR TRAINING INSTITUTIONS1. Process for recognition as training centera. Requirement on staff and clinical activities


III. TRAINING REQUIREMENTS FOR TRAINING INSTITUTIONS2. Quality Management within Training institutions

a. Accreditation

b. Clinical Governance

c. Manpower planning

d. Regular report

Training centers must be recognized as a training facility in PRM by the responsible national authority. It is expected that trainingcenters undergo regular audit within their country with respect to their clinical, scientific and educational activity; therefore theaudit would include data relating to the progress of trainees and their acquisition of specialist accreditation.The UEMS-PRM Board will recognize a PRM department/center as a European training center after successful completion of their

procedure of a European appraisal, according to the rules published athttp://www.euro-prm.org/index.php?option=com_content&view=article&id=22&Itemid=300&lang=en

Training centers should undertake internal audits of their performance as part of the requirements for continuing national accreditation. Any national evaluation of a training center’s performance is expected to include the demonstration that it is:- providing care for patients with a wide range of disabling health conditions- providing educational and training support for trainees - part of a healthcare system that provides immediate access to relevant laboratory and other investigations as well as providing when necessary immediate access to other clinical specialties that maybe required by their patients- ensure the continuum of careTraining centers should keep records of the progress of their trainees.

There are currently around 20000 PRM-specialists in Europe and 3000 PRM trainees, with a median ratio of 4 PRM physicians and 0,5 PRM trainees/100000 inhabitants, across different countries; the median number of hospital beds for intensive rehabilitation is around 100/100000 inhabitants. These figures account for a prospective increase of the total number of PRM specialists, in line with the increasing demand for rehabilitation provision and adequately staffed rehabilitation facilities

http://www.euro-prm.org/index.php?option=com_content&view=article&id=22&Itemid=300&lang=en


CURRICULUM OF STUDIES IN

PHYSICAL AND REHABILITATION MEDICINE

Content /Learning UnitStandard minimum levels to be achieved on completion of postgraduate course

Applied clinical knowledge Applied clinical skillCHAPTER 1.

THE FUNDAMENTALS OF PRM

CHAPTER 2.

BODY STRUCTURES AND BODY

FUNCTIONS

Human anatomy, physiology,

applied physics, biochemistry,

biomechanics

CHAPTER 3.

CLINICAL DIAGNOSIS AND FUNCTIONAL

ASSESSMENT IN PRM

Use (indications, application and

interpretation) of selective clinical

and instrumental measures.

Ability to administer selective clinical measures ,

interpreting the results and exploiting them for clinical

decision making ;

CHAPTER 4. INTERVENTIONS IN PRM

Indications and evidence-based

cost-to-benefit ratio

Indications and prescription/referral for intervention by

allied health professionals based on the expected outcome

and within the framework of the individual rehabilitaton

project/plan

Direct administration of the intervention .

CHAPTER 5.

REHABILITATION APPROACHES TO

DISEASE –SPECIFIC DISABILITIES

Epidemiology, pathogenesis,

clinical assessment, rehabilitation

techniques, prognostic factors of

recovery, for each health condition

Functional diagnosis and prognosis of functional recovery

in the affected subject, planning the individual

rehabilitation project, team work coordination, monitoring

of intervention delivery and assessment of outcome,

throughout the continuum of care in the inpatient and

outpatient setting, with special attention to the early PRM

intervention in the acute hospital stay, the involvement of

family carers and social workers , the development of

community rehabilitation projects aimed at preventing

functional decline and complications; the adaptation of

rehabilitation goals to the changing needs of disabled

individuals during growth, also through the active

involvement of parents, caregivers, school teachers and

other education professionals

CHAPTER 6.

PRM APPROACH TO DISABLING

CONDITIONS IN THE ELDERLY

CHAPTER 7.


CONDITIONS IN CHILDREN.

CHAPTER 8.

RESEARCH IN REHABILITATION Theoretical bases of each

thematic area and their relevance

to clinical practice and research

in PRM

Ability to develop the different components of the research

studies

CHAPTER 9.

INTEGRATIVE AND CLINICAL

REHABILITATION SCIENCES

Ability to transfer theoretical knowledge to clinical practice


For applied clinical knowledge the following levels are used:1. The trainee masters a thematic area on a

basic level 2. The trainee has partially mastered a

thematic area 3. The trainee has fully mastered the

thematic area and is familiar with relevant literature

For applied clinical skills the following levels are used:1. The trainee has experience of selecting

the procedure appropriately and interpreting the results but not necessarily experience of performing the procedure.

2. The trainee is able to go beyond level 1 and perform the procedure with limited supervision/assistance in routine cases.

3. The trainee independently is able to recognise the indication for, perform and interpret the results of the procedure and manage any complications arising.

For core competencies the following levels are used 1. The trainee needs help and supervision

to work and solve the problems of the thematic area

2. The trainee needs partial professional supervision to work and solve the problems of the thematic area

3. The trainee is able to work independently and solve the problems of the thematic area, has knowledge of own capacities and limitations, is ready for referral to other specialists

CURRICULUM OF STUDIES IN PHYSICAL AND REHABILITATION MEDICINEContent /Learning Unit

Standard minimum levels to be achieved on completion of

postgraduate courseApplied clinical knowledge Applied clinical skill

CHAPTER 1.

THE FUNDAMENTALS OF PRM

CHAPTER 2.

BODY STRUCTURES AND BODY

FUNCTIONS

Human anatomy, physiology,

applied physics,

biochemistry, biomechanics

CHAPTER 3.

CLINICAL DIAGNOSIS AND

FUNCTIONAL ASSESSMENT IN PRM

Use (indications,

application and

interpretation) of selective

clinical and instrumental

measures.

Ability to administer selective clinical measures ,

interpreting the results and exploiting them for

clinical decision making ;

CHAPTER 4. INTERVENTIONS IN PRM

Indications and evidence-

based cost-to-benefit ratio

Indications and prescription/referral for

intervention by allied health professionals based

on the expected outcome and within the

framework of the individual rehabilitaton

project/plan

Direct administration of the intervention .

CHAPTER 5.

REHABILITATION APPROACHES

TO DISEASE –SPECIFIC

DISABILITIES

Epidemiology, pathogenesis,

clinical assessment,

rehabilitation techniques,

prognostic factors of

recovery, for each health

condition

Functional diagnosis and prognosis of functional

recovery in the affected subject, planning the

individual rehabilitation project, team work

coordination, monitoring of intervention delivery

and assessment of outcome, throughout the

continuum of care in the inpatient and outpatient

setting, with special attention to the early PRM

intervention in the acute hospital stay, the

involvement of family carers and social workers ,

the development of community rehabilitation

projects aimed at preventing functional decline

and complications; the adaptation of

rehabilitation goals to the changing needs of

disabled individuals during growth, also through

the active involvement of parents, caregivers,

school teachers and other education

professionals

CHAPTER 6.


CONDITIONS IN THE ELDERLY

CHAPTER 7.


CONDITIONS IN CHILDREN.

CHAPTER 8.

RESEARCH IN REHABILITATION Theoretical bases of each

thematic area and their

relevance to clinical

practice and research in

PRM

Ability to develop the different components of the

research studies

CHAPTER 9.

INTEGRATIVE AND CLINICAL

REHABILITATION SCIENCES

Ability to transfer theoretical knowledge to

clinical practice


1 The trainee has mastered a thematic area on a basic level and he needs help and supervision to work and solve the problems of the thematic area

2 The trainee has partially mastered a thematic area and with partial professional supervision is able to work and solve the problems of the thematic area

3 The trainee has fully mastered the thematic area, is familiar with relevant literature and is able to work independently and solve the problems of the thematic area.

THEMATIC AREA LEVEL OF ADVANCEMENT

1 2 3GENERAL COMPETENCIES Date and mentor’s

signatureKnowing and applying the principles of medical ethics and deontologyPossessing professionalism, humanity and ethics with the obligation to protect the privacy and dignity of the patientKnowing the art of dealing with patients, colleagues and other experts - communication skillsBeing able to convey relevant information and explanations in a comprehensible and appropriate manner to the patient (verbally and in writing) and his family and to colleagues and other experts with the goal of joint participation in planning and implementation of health careBASIC KNOWLEDGE OF THE SPECIALIZATION

Date and mentor’s signature

Anatomy and physiology of the musculoskeletal systemPathophysiology of the musculoskeletal systemPathophysiology of pain, the interaction of pain and movementGeneral and Applied Biomechanics

Kinesiology

ELECTRODIAGNOSTICS:ELECTROMYOGRAPHY,CONDUCTIVITY STUDY OF NERVESAND EVOKEND POTENTIALS

Date and mentor’ssignature

Electromyography

Electroneurography and evoked potentials


THANKS TO……