the european database for subspecialist training in neonatology transparency achieved

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Original Paper

Neonatology 2013;103:74–82 DOI: 10.1159/000342932

The European Database for Subspecialist Training in Neonatology – Transparency Achieved

Morten Breindahl a Mats Blennow b Jean-Claude Fauchère c Marta Thio Lluch d

Daniele De Luca e Neil Marlow f Jean-Charles Picaud g Charles Christoph Roehr h

Mireille Vanpée b Eduardo Vilamor i Gabriela Zaharie j Gorm Greisen a

on behalf of the European Society for Neonatology (ESN) a

Department of Neonatology, The National University Hospital Rigshospitalet, Copenhagen , Denmark; b

Department of Neonatology, Karolinska Institutet and University Hospital, Stockholm , Sweden; c Division of

Neonatology, University Hospital Zurich, Zurich , Switzerland; d Newborn Research, The Royal Women’s Hospital,

Melbourne, Vic. , Australia; e Paediatric Intensive Care Unit, Department of Emergency and Intensive Care,

University Hospital ‘A. Gemelli’, Rome , Italy; f UCL Institute for Women’s Health, London , UK; g Department of

Neonatology, Hôpital de la Croix Rousse, Université Claude Bernard, Lyon , France; h Department of Neonatology

and Dieter Scheffner Center for Medical Teaching and Educational Research, Charité University Medical Center, Berlin , Germany; i Department of Paediatrics, Maastricht University Medical Center, Maastricht , The Netherlands; j Obstetrics-Gynaecology I Clinic, Emergency Clinical University Hospital, Cluj , Romania

ress. National neonatal representatives from all 30 member states of the Union of European Medical Specialties (UEMS) provided data on national training programmes. Results: Al-though only one country (3%) based its neonatology train-ing entirely on the ESN Curriculum, we found high levels of uniformity among the UEMS member countries regarding knowledge, skills, and key competencies needed to practice neonatology at a tertiary care level. Discrepancy was en-countered on ethical and legal issues and on personal devel-opment of the trainees. Mentoring and professional evalua-tion was generally not implemented in the participating countries. Conclusions: There is an awareness and readiness to focus on educational demands for neonatal trainees. Fur-ther discussions about the overall educational goals of neo-natal training and the essence of practicing neonatology in each country are needed. The ESN will undertake this pro-cess to provide an updated and effective syllabus aimed to harmonize care and outcomes for babies and their families across Europe. Copyright © 2012 S. Karger AG, Basel

Key Words

Neonatology � Subspecialist training � Postgraduate medical education � Fellowship � Curriculum � Syllabus � Assessment framework � European Society for Neonatology � Union of European Medical Specialties

Abstract

Background: The European Society for Neonatology (ESN) developed a curriculum for subspecialist training in Europe recommending standards for national neonatal training pro-grammes. We speculate whether these official recommen-dations are widely accepted or used in practice. Objectives: To characterize the variation in national neonatal training programmes, to enhance transparency, and to compare them to the ESN Curriculum. Methods: We constructed adatabase based on the backbone of the ESN Curriculum:(1) training – knowledge, (2) training – skills, (3) key compe-tencies, (4) personal development, and (5) recording of prog-

Received: March 2, 2012 Accepted after revision: August 21, 2012 Published online: October 31, 2012

Morten Breindahl, MD, PhD Department of Neonatology, GN 5021 The National University Hospital Rigshospitalet 9 Blegdamsvej, DK–2100 Copenhagen (Denmark) E-Mail Breindahl @ dadlnet.dk

© 2012 S. Karger AG, Basel 1661–7800/13/1031–0074$38.00/0

Accessible online at: www.karger.com/neo

http://dx.doi.org/10.1159%2F000342932

Subspecialist Neonatal Training in Europe

Neonatology 2013;103:74–82 75

Introduction

To guide and harmonize the development of national training programmes for neonatal trainees undergoing subspecialist training in tertiary care neonatology, the European Society for Neonatology (ESN) produced the ‘European Curriculum and Syllabus for Training in Neo-natology’ (henceforth: ESN Curriculum) and the ‘Assess-ment Framework for Specialist Trainees in Neonatology’ (henceforth: ESN Assessment Framework). These docu-ments describe in detail the recommended standards for national training programmes with respect to content, learning objectives, and personal development. Both doc-uments are accessible on www.esn.espr.info/. They have been ratified by the European Board of Paediatrics (the paediatrics section of the Union of European Medical Specialties (UEMS)) and are endorsed by several Euro-pean neonatal and perinatal organisations, e.g. the Euro-pean Union for Perinatal and Neonatal Societies (UENPS).

We speculated whether these official recommenda-tions for subspecialist training in neonatology were fol-lowed in Europe.

To enhance transparency about national training pro-grammes and explicitly to compare their content with the ESN Curriculum, we gathered and categorized informa-tion from the neonatal societies in Europe. First, we wanted to identify similarities and differences with the aim of further harmonizing neonatal training through national self-reflection on deviations from the majority of participating countries. Second, we intended to iden-tify necessities of adjusting set ESN standards to the ‘real life scenario’ of neonatology across Europe.

Background

With the foundation of the European Society for Pae-diatric Research (ESPR) Working Group on Neonatology (WGN) – the predecessor of ESN – in Oslo in 1988, there was an immediate focus on the need to specify minimum training requirements for the accreditation of neonatolo-gists. The work developing a common European curricu-lum for neonatology was originally a co-project between the European Association of Perinatal Medicine (EAPM) and the ESPR. The first draft version of the ESN Curricu-lum [1] and the ESN Assessment Framework [2] was orig-inally developed by Michael Obladen and later under Sid-arto Bambang Oetomo’s guidance accepted by the Con-federation of European Specialties (CESP). In 2007 it was rewritten by Neil Marlow. In 2008, Gorm Greisen called

for transparency to allow simple comparisons. The ESN board sponsored this process which lasted from March 2010 to September 2011.

The intention of the ESN Curriculum is to support na-tional programmes for subspecialist training in neona-tology. It aims specifically at harmonizing training in neonatology by establishing clearly defined standards of knowledge and skills needed to practice neonatology at a tertiary care level.

Table 1 shows the specified key competencies in the ESN Assessment Framework and the three levels each trainee must achieve during subspecialist training.

The additional demands cover key areas of knowledge and experience, reflective notes on each key competence, participation in academic meetings with documented learning outcome, CME-related activities, copies of ab-stracts and publications produced during subspecialty training, reports of at least three audits, and certification of courses.

Materials and Methods

We constructed a database based on the structure of the ESN Curriculum and categorized information according to five main domains: (1) training – knowledge, (2) training – skills, (3) key competencies, (4) personal development, and (5) recording of progress.

We contacted the national paediatric and/or neonatal societies of all 30 member states of the UEMS (including all 27 members of the European Union (EU) and three non-EU countries – Norway, Iceland and Switzerland) by e-mail and identified primary con-tact persons (see Acknowledgements). They provided the coun-try-specific data which was registered and verified through a con-tinuous dialogue with the primary investigator.

We also collected information on length of basic paediatric and subspecialist training in neonatology, minimum number of years in a university-based NICU, as well as the total number of NICUs in each country.

Level of agreement with the ESN Curriculum was marked with three colours: ‘light grey’ indicating total agreement, ‘dark grey’ partial, and ‘black’ no agreement ( table 2 ). Basic character-istics were quantified if applicable with nonparametric statistics.

Descriptive statistics were applied to sum up the overall agree-ment with the ESN Curriculum and finally the database was pub-lished on the ESN website [3] . Preliminary results were presented at the ESPR Congress in Newcastle, UK [4] .

Results

The response rate was 100%. National consensus was the most commonly used curriculum (67%) for subspe-cialist training in neonatology. Only one country (3%)

Breindahl et al. Neonatology 2013;103:74–8276

Com

pete

nce/

desc

ript

ion

Leve

l ILe

vel I

ILe

vel I

II

Resu

scita

tion

The

trai

nee

will

be

able

to in

stitu

te a

nd le

ad

neon

atal

resu

scita

tion

both

of t

he te

rm a

nd

pret

erm

bab

y. T

he tr

aine

e m

ust h

ave

dem

onst

rate

d a

full

unde

rsta

ndin

g of

the

phys

iolo

gy a

nd tr

eatm

ents

invo

lved

.

Cer

tific

atio

n of

a su

itabl

e ad

vanc

ed li

fe

supp

ort c

ours

e, w

hich

incl

udes

the

care

of

the

new

born

(NLS

, PA

LS, A

PLS

or

equi

vale

nt).

Can

dem

onst

rate

abi

lity

to in

tuba

te

succ

essf

ully

.

Has

adv

ance

d re

susc

itatio

n sk

ills –

has

kno

wle

dge

and

skill

s to

unde

rtak

e th

e te

chni

cally

diff

icul

t re

susc

itatio

n.H

as d

emon

stra

ted

team

lead

ersh

ip in

resu

scita

tion

situa

tions

.

Abl

e to

take

full

deci

sions

in e

thic

ally

diff

icul

t sit

uatio

ns (p

rem

atur

ity, m

alfo

rmat

ion,

faile

d re

susc

itatio

n) (e

ssen

tial).

Reac

hed

inst

ruct

or st

atus

on

a su

itabl

e ad

vanc

ed

life

supp

ort c

ours

e as

abo

ve (d

esira

ble)

.

Neu

rolo

gyTh

e tr

aine

e w

ill d

emon

stra

te p

rofic

ienc

y at

clin

ical

as

sess

men

t, in

vest

igat

ion

(incl

udin

g ce

rebr

al

ultr

asou

nd sc

anni

ng) a

nd m

anag

emen

t of a

rang

e of

neu

rolo

gica

l diso

rder

s, in

clud

ing

pret

erm

and

te

rm b

rain

inju

ry, c

onge

nita

l mal

form

atio

ns,

intr

acra

nial

trau

ma

and

seiz

ures

.

Abl

e to

car

ry o

ut a

stru

ctur

ed

neur

olog

ical

exa

min

atio

n.C

an d

iagn

ose

and

initi

ate

first

-line

m

anag

emen

t for

enc

epha

lopa

thy

and

seiz

ures

.

Can

form

ulat

e on

goin

g m

anag

emen

t pla

ns fo

r co

mm

on n

euro

logi

cal c

ondi

tions

(enc

epha

lopa

thy,

se

izur

es, I

VH

).A

ble

to p

erfo

rm n

euro

logi

cal a

nd d

evel

opm

enta

l as

sess

men

t of t

he n

ewbo

rn a

nd o

f bab

ies t

o 2

year

s of

age

.

Can

initi

ate

inve

stig

atio

n of

rare

and

com

plex

ne

urol

ogic

al a

nd n

euro

mus

cula

r diso

rder

s.C

an d

iscus

s the

use

of M

RI, C

T sc

anni

ng, E

EG

in th

e in

vest

igat

ion

of n

euro

logi

cal d

iseas

e.A

ble

to p

erfo

rm a

nd in

terp

ret a

cer

ebra

l ul

tras

ound

exa

min

atio

n (e

ssen

tial)

and

have

at

tend

ed a

stru

ctur

ed c

ours

e (d

esira

ble)

.

Com

mun

icat

ion

skill

s and

coun

selli

ngTh

e tr

aine

e w

ill d

emon

stra

te in

crea

sing

skill

s in

com

mun

icat

ion

with

par

ents

and

staf

f, bo

th

indi

vidu

ally

and

as p

art o

f a te

am, d

urin

g th

eir

trai

ning

. Thi

s inc

lude

s exp

erie

nce

at b

reak

ing

bad

new

s, ha

ndlin

g pe

rina

tal d

eath

and

disc

ussin

g pr

ogno

sis w

ith p

aren

ts.

Can

und

erst

and

and

have

disc

usse

d pr

inci

ples

beh

ind

coun

selli

ng a

nd

com

mun

icat

ing

info

rmat

ion

to

pare

nts.

Is su

ppor

tive

in te

am w

orki

ng in

ne

onat

al in

tens

ive

care

.

Has

had

exp

erie

nce

of c

ouns

ellin

g pa

rent

s an

ticip

atin

g an

ext

rem

ely

pret

erm

del

iver

y.H

as o

bser

ved

coun

selli

ng o

f par

ents

of b

abie

s who

ar

e dy

ing

or a

re a

t hig

h ri

sk o

f disa

bilit

y, th

e di

sclo

sure

of a

nten

atal

dia

gnos

es o

r the

disc

losu

re

of d

iagn

osis

of c

ereb

ral p

alsy

in o

utpa

tient

s.

Has

cou

nsel

led

pare

nts o

f a b

aby

who

is d

ying

or

at h

igh

risk

of d

isabi

lity

and

requ

este

d pe

rmiss

ion

for a

utop

sy.

Has

led

a pr

enat

al c

ouns

ellin

g se

ssio

n an

d un

dert

aken

ber

eave

men

t cou

nsel

ling

unde

r su

perv

ision

.H

as d

emon

stra

ted

the

nece

ssar

y co

mm

unic

atio

n sk

ills t

o m

ake

the

conc

epts

and

m

echa

nism

s of g

enet

ic d

iseas

es u

nder

stan

dabl

e to

par

ents

, usin

g no

n-te

chni

cal l

angu

age.

Cong

enita

l ano

mal

ies a

nd g

enet

ic d

iseas

eTh

e tr

aine

e w

ill b

e ab

le to

reco

gnise

com

mon

co

ngen

ital a

nom

alie

s, to

inve

stig

ate

babi

es w

ith

such

lesio

ns a

nd to

use

lite

ratu

re a

nd d

atab

ase

sear

ches

to id

entif

y ra

re c

ondi

tions

and

co

mm

unic

ate

such

info

rmat

ion

to p

aren

ts.

Abl

e to

reco

gnise

com

mon

synd

rom

es

(e.g

. tri

som

y 21

, tri

som

y 18

, V

AC

TERL

) and

has

obs

erve

d co

unse

lling

of p

aren

ts b

y a

cons

ulta

nt.

Abl

e to

use

com

mon

text

s and

gen

etic

/abn

orm

ality

da

taba

ses t

o id

entif

y ra

re d

isord

ers.

Can

obt

ain

a ge

netic

hist

ory

and

unde

rsta

nds

gene

tic in

vest

igat

ions

.

Abl

e to

pla

n di

agno

stic

and

clin

ical

m

anag

emen

t of a

bab

y bo

rn w

ith a

con

geni

tal

anom

aly

with

a m

ultid

iscip

linar

y te

am.

Has

und

erta

ken

coun

selli

ng o

f par

ents

who

se

baby

has

a g

enet

ic c

ondi

tion.

Card

iore

spira

tory

inte

nsiv

e car

eTh

e tr

aine

e w

ill b

e ab

le to

inst

itute

and

mai

ntai

n fu

ll ca

rdio

resp

irat

ory

inte

nsiv

e ca

re fo

r pre

term

an

d sic

k te

rm n

ewbo

rn b

abie

s. Th

is w

ill in

clud

e a

full

wor

king

kno

wle

dge

of th

e pr

inci

ples

and

ap

plic

atio

n of

a ra

nge

of v

entil

ator

y m

odal

ities

,of

cir

cula

tory

supp

ort a

nd th

e tr

aine

e m

ust b

e ab

le

to m

anag

e co

mpl

icat

ions

. In

addi

tion,

the

trai

nee

mus

t be

able

to p

lan

care

for t

he b

aby

with

chr

onic

re

spir

ator

y di

seas

e an

d be

aw

are

of th

e po

tent

ial

long

-ter

m c

ompl

icat

ions

.

Abl

e to

inst

itute

ven

tilat

ory

supp

ort

and

adm

inist

er su

rfac

tant

.A

ble

to m

ake

clin

ical

ass

essm

ent o

f ad

equa

cy o

f neo

nata

l cir

cula

tion

and

inst

itute

supp

ort f

or h

ypot

ensio

n.A

ble

to m

ake

clin

ical

dia

gnos

is of

PD

A.

Abl

e to

dia

gnos

e an

d tr

eat c

omm

on

com

plic

atio

ns o

f mec

hani

cal

vent

ilatio

n (e

.g. p

neum

otho

rax,

di

spla

ced

or o

bstr

ucte

d tr

ache

al tu

be).

Und

erst

ands

the

aetio

logy

and

pr

ogre

ssio

n of

bab

y w

ith C

LD.

Und

erst

ands

and

use

s diff

eren

t ven

tilat

ory

mod

aliti

es.

Und

erst

ands

the

diffe

rent

pha

rmac

olog

ical

effe

cts

of in

otro

pic

drug

s and

thei

r use

.A

ble

to se

lect

and

mon

itor a

ppro

pria

te m

edic

al o

r su

rgic

al m

anag

emen

t.U

nder

stan

ds th

e pr

inci

ples

of m

anag

emen

t of t

he

diffi

cult

airw

ay (e

.g. P

ierr

e Ro

bin

anom

aly)

.U

nder

stan

ds a

nd a

ble

to p

lan

resp

irat

ory,

nu

triti

onal

and

pha

rmac

olog

ical

supp

ort f

or C

LD.

Supe

rvise

s who

le re

spir

ator

y co

urse

of s

ick

baby

w

ith R

DS,

incl

udin

g w

eani

ng fr

om v

entil

ator

, us

e of

seda

tion

and

mus

cle

rela

xant

s.A

ble

to d

iagn

ose

and

man

age

com

plex

cir

cula

-to

ry p

robl

ems,

incl

udin

g PP

HN

and

car

diac

ta

mpo

nade

; und

erst

ands

indi

catio

ns fo

r EC

MO

.A

ble

to id

entif

y pa

tent

art

eria

l duc

t usin

g ul

tras

ound

(des

irabl

e).

Abl

e to

man

age

com

plex

resp

irat

ory

prob

lem

s in

clud

ing

PIE,

subg

lotti

c st

enos

is, p

ulm

onar

y hy

popl

asia

, chy

loth

orax

, dia

phra

gmat

ic h

erni

a.A

ble

to m

anag

e lo

ng-t

erm

ven

tilat

ory

supp

ort,

hom

e ox

ygen

trea

tmen

t and

ong

oing

out

patie

nt

man

agem

ent o

f bab

ies w

ith C

LD.

Ta

ble

1. S

peci

fied

key

com

pete

ncie

s in

the

ESN

Ass

essm

ent F

ram

ewor

k, e

ach

divi

ded

into

thre

e di

ffere

nt le

vels

of c

ompe

tenc

e (le

vel I

II m

ust b

e co

mpl

eted

for e

ach

trai

nee

duri

ng su

bspe

cial

ty tr

aini

ng)


Neonatology 2013;103:74–82 77

Com

pete

nce/

desc

ript

ion

Leve

l ILe

vel I

ILe

vel I

II

Flui

d ba

lanc

e, th

erm

oreg

ulat

ion

and

rena

l fai

lure

The

trai

nee

will

be

able

to in

itiat

e an

d m

anag

e th

e th

erm

al e

nvir

onm

ent o

f pre

term

and

term

bab

ies,

and

man

age

fluid

bal

ance

in su

ch b

abie

s, de

mon

-st

ratin

g a

full

unde

rsta

ndin

g an

d kn

owle

dge

of th

e un

derly

ing

phys

iolo

gy –

with

spec

ial r

efer

ence

to

the

rapi

d po

stna

tal c

hang

es in

bod

y w

ater

dist

ribu

-tio

n an

d tr

anse

pide

rmal

wat

er lo

ss. T

he tr

aine

e w

ill b

e ab

le to

dia

gnos

e an

d in

itiat

e tr

eatm

ent o

f re

nal f

ailu

re.

Abl

e to

inst

itute

ven

tilat

ory

supp

ort

and

adm

inist

er su

rfac

tant

.A

ble

to su

perv

ise th

e en

tire

fluid

bal

ance

regi

men

in

a c

ompl

ex c

ase,

arr

angi

ng a

nd in

terp

retin

g th

e ap

prop

riat

e la

bora

tory

inve

stig

atio

ns.

Abl

e to

man

age

com

plex

flui

d ba

lanc

e pr

oble

ms

in v

ery

pret

erm

bab

ies;

able

to m

anag

e re

nal

failu

re in

clud

ing

deci

ding

whe

n di

alys

is is

indi

cate

d.

Hae

mat

olog

y an

d tr

ansfu

sion

The

trai

nee

will

be

able

to d

iagn

ose

and

man

age

the

rang

e of

hae

mat

olog

ical

diso

rder

s fou

nd in

ne

wbo

rn b

abie

s. To

be

conv

ersa

nt w

ith th

e fu

ll ra

nge

of b

lood

pro

duct

s ava

ilabl

e fo

r tra

nsfu

sion

and

the

appr

opri

ate

use

of e

ach.

Abl

e to

mak

e cl

inic

al a

sses

smen

t of

adeq

uacy

of n

eona

tal c

ircu

latio

n an

d in

stitu

te su

ppor

t for

hyp

oten

sion.

Can

des

crib

e an

d di

scus

s cas

es o

f hae

mat

olog

ical

di

sord

ers d

iagn

osed

and

trea

ted

by th

e tr

aine

e.H

as e

xper

ienc

e of

man

agem

ent o

f the

rang

e of

ha

emat

olog

ical

diso

rder

s of b

abie

s.C

an u

se b

lood

pro

duct

s app

ropr

iate

ly a

nd

effe

ctiv

ely,

incl

udin

g ex

chan

ge tr

ansf

usio

n.

Met

abol

ism a

nd en

docr

ine d

isord

ers

The

trai

nee

will

dem

onst

rate

pro

ficie

ncy

in th

e re

cogn

ition

, ass

essm

ent,

inve

stig

atio

n an

d m

anag

emen

t of t

he m

ore

com

mon

and

impo

rtan

t m

etab

olic

and

end

ocri

ne d

isord

ers.

Abl

e to

mak

e cl

inic

al d

iagn

osis

and

man

age

com

mon

met

abol

ic

dist

urba

nces

incl

udin

g hy

pogl

ycae

mia

, ne

onat

al ja

undi

ce a

nd e

lect

roly

te

abno

rmal

ities

.

Abl

e to

reco

gnise

and

inst

itute

em

erge

ncy

trea

tmen

t for

inbo

rn e

rror

s of m

etab

olism

and

en

docr

ine

abno

rmal

ities

, inc

ludi

ng re

cogn

ition

, in

vest

igat

ion

and

man

agem

ent o

f bab

ies w

ith

ambi

guou

s gen

italia

.

Can

dev

elop

a m

ultid

iscip

linar

y m

anag

emen

t pl

an fo

r bab

ies w

ith m

etab

olic

and

end

ocri

ne

diso

rder

s.

Nut

ritio

n, fe

edin

g an

d ga

stro

inte

stin

al d

iseas

eTh

e tr

aine

e w

ill u

nder

stan

d th

e im

port

ance

of

neon

atal

nut

ritio

n an

d be

abl

e to

pro

vide

co

mpr

ehen

sive

nutr

ition

al su

ppor

t to

wel

l and

sick

new

born

bab

ies,

incl

udin

g th

e re

cogn

ition

an

d tr

eatm

ent o

f com

mon

com

plic

atio

ns.

Abl

e to

dia

gnos

e an

d tr

eat c

omm

on

com

plic

atio

ns o

f NEC

.U

nder

stan

ds im

port

ance

of b

reas

t m

ilk.

Can

est

ablis

h nu

triti

onal

supp

ort,

incl

udin

g in

trav

enou

s nut

ritio

n.

Abl

e to

pre

scri

be a

nd m

anag

e in

trav

enou

s nu

triti

on, t

o be

aw

are

of th

e lik

ely

com

plic

atio

ns o

f in

trav

enou

s nut

ritio

n an

d m

anag

e pr

oble

ms o

f fee

d in

tole

ranc

e.C

an m

anag

e th

e m

edic

al c

ours

e of

a c

hild

with

ne

crot

ising

ent

eroc

oliti

s.

Abl

e to

form

ulat

e a

man

agem

ent p

lan

for

nutr

ition

al su

ppor

t for

a si

ck n

ewbo

rn b

aby

thro

ugho

ut th

eir c

linic

al c

ours

e an

d ca

n di

scus

s th

e ro

le o

f ear

ly n

utri

tion

in d

eter

min

ing

long

-ter

m o

utco

me.

Abl

e to

man

age

pre-

and

pos

tope

rativ

e ca

re fo

r a

child

with

con

geni

tal g

astr

oint

estin

al

anom

alie

s and

thos

e w

ith h

epat

obili

ary

dise

ase.

Imm

unity

and

infe

ctio

nTh

e tr

aine

e w

ill u

nder

stan

d th

e de

velo

pmen

t of

imm

unity

and

the

vuln

erab

ility

of t

he n

ewbo

rn to

in

fect

ion.

Und

erst

ands

the

aetio

logy

and

pr

ogre

ssio

n of

bab

y w

ith e

arly

and

late

(nos

ocom

ial)

onse

t inf

ectio

ns.

Abl

e to

man

age

surv

eilla

nce

and

prev

entiv

e m

easu

res i

n in

fect

ion

cont

rol.

Has

det

aile

d un

ders

tand

ing

of th

e m

ode

of a

ctio

n an

d re

gim

ens o

f ant

ibio

tics a

nd o

f inv

estig

atio

n an

d m

anag

emen

t of c

omm

on p

erin

atal

and

ne

onat

al in

fect

ions

.

Can

reco

gnise

and

man

age

com

plex

infe

ctio

ns

such

as f

unga

l inf

ectio

ns, H

IV a

nd in

trau

teri

ne

infe

ctio

n.U

nder

stan

ds th

e m

ultid

iscip

linar

y ap

proa

ch

and

can

man

age

a nu

rser

y ep

idem

ic.

Fam

ily ca

re a

nd ca

re o

f the

wel

l new

born

The

trai

nee

will

hav

e a

wid

e kn

owle

dge

of n

orm

al

deve

lopm

ent,

com

mon

min

or p

robl

ems a

nd

mor

phol

ogic

al v

aria

tion

and

the

impo

rtan

ce o

f co

mm

unic

atio

n w

ith o

ther

hea

lthca

re

prof

essio

nals

and

the

pare

nts.

Dem

onst

rate

s exa

min

atio

n of

the

norm

al b

aby

incl

udin

g ps

ycho

soci

al

aspe

cts a

nd is

abl

e to

pro

vide

par

enta

l ad

vice

on

feed

ing.

Abl

e to

man

age

com

mon

neo

nata

l pr

oble

ms,

e.g.

jaun

dice

, hip

dys

plas

ia.

Abl

e to

disc

uss t

he ro

le o

f neo

nata

l sc

reen

ing

test

s (PK

U, t

hyro

id, h

eari

ng)

with

par

ents

.

Abl

e to

teac

h an

d su

perv

ise m

idw

ifes,

nurs

es a

nd

doct

ors p

rovi

ding

rout

ine

post

nata

l fam

ily su

ppor

t.A

ble

to te

ach

pare

nts b

asic

life

supp

ort.

Kno

wle

dge

of le

gal p

roce

dure

s in

child

pr

otec

tion,

soci

al se

rvic

es, f

oste

ring

and

ad

optio

n.

Ta

ble

1 (c

ontin

ued)


(Cyprus) based its training entirely on the ESN Curricu-lum. Three countries (10%) (Denmark, Ireland, and Slo-vakia) combined the ESN Curriculum with their nation-al consensus. Six countries (20%) (Estonia, Iceland, Lux-embourg, Norway, Portugal, and Slovenia) did not have any national consensus at all, or only to some extent ( fig. 1 ).

The participating countries varied markedly (popula-tion 0.3–65.3 million), with corresponding differences in the number of university-based NICUs in each country (0–50). In order to illustrate a potential difference be-tween the included countries, we looked at EU member status as the denominator and chose not to include pop-ulation differences since all UEMS member countries are partners in approving of the Curriculum and have equal votes. Basically we found no significant differenc-es between EU and non-EU member states in their rela-tive concordance, and variations were small and infre-quent.

Basic paediatric training preceded subspecialty train-ing in all countries. Length of basic training, however, varied with a median (range) of 5 (2–6) years. Similarly, length of subspecialty training in neonatology was 2 (1–6) years. Though in two countries the basic paediatric trunk and the subspecialty training could be accom-plished within 4 years, duration of specialty and subspe-cialty training in our cohort was 7 (4–9) years. Service in a university-based NICU was 1 (0–4) years. Of the three C

ompe

tenc

e/de

scri

ptio

nLe

vel I

Leve

l II

Leve

l III

War

d or

gani

zatio

n/m

anag

emen

t ski

lls/c

linic

al g

over

nanc

eTh

e tr

aine

e w

ill h

ave

dem

onst

rate

d sk

ills a

t le

adin

g cl

inic

al ro

unds

, be

able

to c

arry

out

the

adm

inist

rativ

e du

ties r

equi

red

to ru

n a

neon

atal

un

it an

d w

ill h

ave

orga

nise

d an

d at

tend

ed

peri

nata

l mee

tings

, uni

t mee

tings

and

clin

ical

go

vern

ance

mee

tings

Has

exp

erie

nce

of o

rgan

ising

dut

y ro

tatio

ns, a

nnua

l lea

ve a

nd st

udy

leav

e.Sh

ows a

n un

ders

tand

ing

of th

e iss

ues

and

impo

rtan

ce o

f clin

ical

gov

erna

nce.

Has

org

anise

d pe

rina

tal a

nd u

nit m

eetin

gs.

Abl

e to

con

duct

war

d ro

unds

and

del

egat

e ta

sks

appr

opri

atel

y.

Has

atte

nded

clin

ical

gov

erna

nce

mee

tings

(e

ssen

tial)

and

take

n a

lead

role

in su

ch

mee

tings

(des

irabl

e).

Has

atte

nded

a re

cogn

ised

man

agem

ent c

ours

e (e

ssen

tial).

Has

take

n pa

rt in

the

inve

stig

atio

n of

a c

linic

al

inci

dent

.

Tran

spor

t of t

he n

ewbo

rn b

aby

The

trai

nee

will

be

com

pete

nt a

t ret

riev

al a

nd

tran

spor

t of t

he si

ck n

ewbo

rn b

aby

and

will

be

able

to

teac

h ot

hers

to c

arry

out

tran

sfer

s

Has

thor

ough

kno

wle

dge

of e

quip

men

t us

ed d

urin

g ne

onat

al tr

ansp

ort a

nd o

f th

e te

am a

ppro

ach

to tr

ansf

er/s

afet

y as

pect

s.H

as b

een

on a

neo

nata

l tra

nspo

rt a

s an

obse

rver

.

Abl

e to

per

form

tran

sfer

of s

ick

med

ical

or s

urgi

cal

new

born

bab

y, in

clud

ing

abili

ty to

dea

l with

em

erge

ncie

s ari

sing

duri

ng th

e jo

urne

y (e

.g.

extu

batio

n, lo

ss o

f pri

mar

y ox

ygen

sour

ce).

Aw

are

of th

e ne

ed to

be

sens

itive

to th

e ne

eds a

nd

effo

rts o

f the

refe

rrin

g ho

spita

l.

Abl

e to

take

full

deci

sions

abo

ut c

linic

al

suita

bilit

y fo

r tra

nsfe

r and

pla

cem

ent o

f the

ba

by, a

nd to

supe

rvise

a tr

ansf

er re

mot

ely

(e.g

. ab

le to

pro

vide

tele

phon

e ad

vice

).A

sses

smen

t of c

linic

al c

ompe

tenc

y of

staf

f to

perf

orm

tran

sfer

.

ESN Curriculum3%

ESN Curriculum +national consensus

10%

National consensus67%

No nationalconsensus

20%

Fig. 1. Distribution of countries in Europe using ESN (3%), ESN + national consensus (10%), no national consensus (20%), and na-tional consensus only (67%) for subspecialist training in neona-tology.

Ta

ble

1 (c

ontin

ued)


Neonatology 2013;103:74–82 79

Ta

ble

2. R

egis

trat

ion

of th

e tr

aini

ng sk

ills n

eede

d to

pra

ctic

e ne

onat

olog

y at

a te

rtia

ry c

are

leve

l in

Euro

pe, a

s pub

lishe

d on

the

ESN

web

site

Exte

nsiv

e sk

ills

ESN

Yes

%

No

%

Yes/

no %

EU %

Non

-EU %

AUT

BEL

BUL

CH

CYP

CZE

DEU

DNK

ESP

EST

FIN

FRA

GRE

HUN

ICE

IRL

ITA

LAT

LTU

LUX

MLT

NLD

NOR

POL

POR

ROU

SLO

SVK

SWE

UK

Prac

tical

pro

cedu

res

94

33

9595

Resu

scita

tion

of th

e ne

wbo

rn10

00

010

010

0Tr

ache

al in

tuba

tion

970

396

100

Art

ifici

al v

entil

atio

n10

00

010

010

0A

rter

ial c

athe

ters

100

00

100

100

Intr

aven

ous i

nfus

ion

973

096

100

Long

intr

aven

ous l

ines

873

1089

68Bl

ood

tran

sfus

ion

100

00

100

100

Exch

ange

tran

sfus

ion

970

396

100

Art

eria

l pun

ctur

e93

33

9310

0D

rain

age

of p

neum

otho

rax

970

396

100

Supr

apub

ic b

ladd

er p

unct

ure

7720

378

68Lu

mba

r/ve

ntri

cula

r pun

ctur

e90

010

8910

0D

iagn

osis

87

94

8794

Inte

rpre

ting

X-r

ay10

00

010

010

0U

nder

stan

d M

RI, C

T97

30

9610

0In

terp

retin

g U

S ex

amin

atio

n 90

010

8910

0La

bora

tory

inve

stig

atio

n10

00

010

010

0EE

G e

tc.

5040

1048

68C

linic

al p

ract

ice

99

10

9910

0

Ex

amin

atio

n of

the

new

born

100

00

100

100

Def

orm

atio

n/m

alfo

rmat

ion

100

00

100

100

Ass

essm

ent o

f GA

100

00

100

100

Dev

elop

men

tal a

sses

smen

t 97

30

9610

0A

sses

smen

t of d

isabi

lity

973

096

100

Com

mun

icat

ion

95

14

9510

0

C

ouns

ellin

g/co

mm

unic

atio

n97

03

9610

0D

isclo

sure

of b

ad n

ews

970

396

100

Han

dlin

g of

aut

opsy

repo

rts

970

396

100

Staf

f and

team

dyn

amic

s90

37

8910

0C

oope

ratio

n an

d co

nsul

tatio

n 97

03

9610

0T

echn

olog

y

941

593

100

Radi

ant h

eate

rs93

33

9310

0In

cuba

tors

930

793

100

Ven

tilat

ors

930

793

100

Mon

itori

ng e

quip

men

t97

03

9310

0T

each

ing

90

100

8910

0

Te

achi

ng a

ctiv

ities

9010

089

100

Teac

hing

pro

gram

s 90

100

8910

0

Tota

l agr

eem

ent w

ith th

e ES

N C

urri

culu

m.

Part

ial a

gree

men

t with

the

ESN

Cur

ricu

lum

.

No

agre

emen

t with

the

ESN

Cur

ricu

lum

.


countries that did not have any university-based NICUs, two out of three (67%) sent their neonatal trainees abroad for 0.5–1 year of service.

Overall we saw a high degree of uniformity among countries and agreement with the ESN Curriculum on several areas of expertise. A particular high agreement (97%) was encountered on the need for comprehensive knowledge on epidemiology, pathology and pathophysi-ology of the fetus, premature and mature infant, on phar-macology, neonatal care, and follow-up of high-risk in-fants. Knowledge about ethical and legal issues was ac-cepted by 90% as part of the training.

There was also a high level of agreement (93%) con-cerning skills within practical procedures, diagnosis, clinical practice, communication, teaching, and technol-ogy, though only 20% included suprapubic aspiration of urine. Even more diverse, interpreting EEG tracings, cor-tical evoked responses and neuromuscular electrophysi-ological tests were deemed necessary diagnostic skills in only 50% of countries.

94% agreed upon the need for most key competencies. Discrepancy existed on communication skills and coun-selling. In most countries (90%) communication, disclos-ing bad news, handling perinatal death, and discussing prognosis with parents were key competencies for a trained neonatologist. Still, 10% either partially or com-pletely disagreed. With respect toward organization, management skills, and clinical governance, overall agreement with the ESN Curriculum was 70%. While 80% of national curriculums included the competence of leading clinical rounds, 70% identified the need for orga-nizing and attending perinatal meetings, unit meetings, and clinical governance meetings; only 60% incorporated administrative duties to run a neonatal unit.

Neonatal trainees are taught how to retrieve and trans-port newborns in 80% of the countries, and in 67% the trainee is expected to teach others how to carry them out.

The ESN Curriculum recommends that trainees de-velop special expertise in one or more areas relevant to their practice in neonatology, such as perioperative care, fetal medicine, clinical genetics, and ability to perform developmental assessments. Overall, 77% complied with this recommendation.

Significant differences were discovered in terms of personal development during subspecialist training. Per-sonal skills and competencies needed to fulfil the leader-ship role within the clinical team, unit or hospital, such as being a counsellor, manager, leader, teacher, being ca-pable of conducting clinical governance and audits, and having statistical and interpretative skills, were agreed

upon by only 67% of the participating countries. Person-al development within management, leadership, and clinical governance had the lowest scores (50, 53 and 63%, respectively).

Recording of progress was also not well developed in the curriculums of all countries. Trainees are encouraged to keep track of their development in a log book including an assessment framework to record their individual prog-ress. This log book should, amongst other items, contain evidence of attendance at academic meetings and re-search activities. The overall coherence with the ESN Curriculum on recording of academic and research ac-tivities was around 55%, but varied from 23 to 80%, the lowest being on reports of audits.

The log book should also contain reflective notes cov-ering each of the predefined key competencies. Reflective notes have been introduced to stimulate the neonatal trainee to broaden his/her knowledge by self-reflection, based on a single case to be discussed with their individ-ual supervisor. A little more than half (57%) of the in-cluded countries had adapted this into their national training programmes.

Finally, the ESN Curriculum recommends that each trainee is allocated to a mentor, responsible for assessing and recording the competence level of the trainee. Al-though mentoring and professional assessment are being valued higher than a structured examination, only 47% (14/30) of the countries had implemented this structure. Of the remaining 53% (16/30), half of them (8/16) con-ducted examinations/confrontations of the trainee as part of the subspecialist approval.

Discussion

Though only a very limited number of countries fol-lowed the ESN Curriculum in practice (one country com-pletely, three countries partly), all seemed to agree upon the essence of educational demands to neonatal trainees. We found a high level of uniformity on knowledge, skills, and key competencies needed to practice neonatology at a tertiary care level. This is not surprising since medical care of extremely preterm infants and sick newborns is essentially the same across Europe [5–7] . The lack of co-herence with the ESN Curriculum on specific skills (EEG, suprapubic bladder puncture, etc.) suggests that these competencies may not be deemed essential or are the re-sponsibility of other dedicated staff.

Of interest is the discrepancy from the ESN Curricu-lum on ethical and legal issues. Further, there is great


Neonatology 2013;103:74–82 81

variation in emphasis on personal development of the neonatal trainee across Europe. This may represent dif-ferences in how these aspects of professional work are for-mally included in medical training or how they may be utilized during assessment for employment. Difference in cultures, prerequisites, and healthcare systems may also influence the role(s) of medical specialists. Another possible explanation may be related to competition for posts, reflecting in part the size and numbers of neonatal departments in each country.

Though mentoring and professional evaluation of the trainee is highly prioritized by the ESN, it was generally not implemented in the participating countries. Alloca-tion of a senior, more experienced colleague trained in basic rules of mentorship, coaching, and feedback tech-niques would be applicable at little or no cost at all with a potential high value for each trainee. Also role-modelling and mentoring are essential in medical education, includ-ing postgraduate, specialist, and subspecialist training.

This is in line with the common programme require-ments from the Accreditation Council for Graduate Med-ical Education (ACGME) in the United States of America [8] and the Royal Australian College of Physicians (RACP) Advanced Training Programmes in Neonatology in Aus-tralia [9] .

The high level of agreement between UEMS member states highlights the common understanding of the edu-cational demands to neonatologists, and sustains the ne-cessity of regarding neonatology an independent specialty.

As shown in table 1 each neonatal trainee must accom-plish and ultimately complete three levels of competence on key issues during training according to the ESN Cur-riculum and Assessment Framework. Though not all par-ticipating countries follow the ESN guidelines, the vast majority express the same attitude concerning the neces-sity of practical skills and key competencies. This survey, however, does not provide insight into the explicit nation-al standards or quality control and surveillance systems on how and when these competencies are completed.

Further research and/or the establishment of an ESN on-site inspection agency are needed to obtain transpar-ency on this issue. Overall, this work is only a small step towards providing more insight into neonatal subspe-cialty training in Europe, and the answers achieved from our survey need to be verified and followed up continu-ously.

We hope these findings lead to discussions about the educational goals of neonatal training and the very es-sence of practicing neonatology in each country. Is a neo-natologist primarily a skilled healthcare professional ca-

pable of handling and treating neonatal patients with the challenges of instrumentation and medication, or is he/she also expected to handle holistic aspects of care, i.e. moral and ethical issues, taking into account the whole family, the society and medicolegal and economical is-sues? Furthermore, the health system will determine to what extent management and leadership is part of the neonatal subspecialist training programme. These chal-lenges indicate the need for discussion across the neona-tal specialty in Europe, for cooperation and exchange of information and experiences. Within the existing frame-work of the ESN, we wish to provide an updated and ef-fective European syllabus which harmonizes care and outcomes for babies and their families.

Apart from the data collection, this initiative has given insights into the awareness and readiness of the Europe-an countries to focus on educational demands for neona-tal trainees. We achieved inclusion of data from all UEMS members, despite anxiety of exposing deficiencies. It re-veals a Europe-wide interest in changing and adapting operational standards of care, and in developing a profes-sional, international relationship.

Training programmes in medical disciplines are con-tinuously updated and renewed. Neonatology is a rapidly developing paediatric specialty, and new aspects of diag-nosis, therapy and care need to be incorporated in the ESN Curriculum. The transparency achieved by our sur-vey may prompt each country to reflect on their national training programmes, and contribute actively to the next edition of the ESN Curriculum. Thus, we believe this is a significant step towards harmonization and acceptance of high-quality neonatal training across Europe.

Acknowledgements

Sincere thanks to the contact persons without whom this da-tabase would never have become a reality: Berndt Urlesberger (Austria), Bart van Overmeire (Belgium), Nelly Jekova (Bulgaria), Jean-Claude Fauchère (Switzerland), Andreas Hadjidemetriou (Cyprus), Jan Miletin (Czech Republic), Corinna Peter (Germa-ny), Thorkild Jacobsen (Denmark), Marta Thio Lluch (Spain), Heili Varendi (Estonia), Miko Hallman (Finland), Jean-Charles Picaud (France), Ben Shaw (United Kingdom), Gabriel Dimitriou (Greece), Tibor Ertl (Hungary), Thordur Thorkelsson (Iceland), Eleanor Molloy (Ireland), Luca A. Ramenghi (Italy), Daiga Kvi-luna (Latvia), Arunas Liubsys (Lithuania), Jean Bottu (Luxem-bourg), Paul Soler (Malta), Djien Liem (The Netherlands), Ragnhild Støen (Norway), Jerzy Szczapa (Poland), Maria Teresa Neto (Portugal), Gabriela Zaharie (Romania), Borut Brataníc (Slovenia), Mirko Zibolen (Slovakia), and Eva Engström (Sweden). We are grateful to Mrs. Anastasia Mlotek from Kenes in setting up the ESN web-page.


Contributors

Gorm Greisen initiated the work which was funded by a grant from ESPR. Morten Breindahl constructed the database, identi-fied contact persons in every UEMS member country, established and maintained this network. He was in charge of the data sam-pling, registration and verification and made the first draft of this article. The ESN Board and the ESN Advisory Board supervised the project, reviewed and approved the article.

Disclosure Statement

The authors have no conflicts of interest to disclose.

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