Medical Education

Chapters V and IV of the book: Medical Education in Internal Medicine. The postgraduate formation in the speciality. Roberto M. Cataldi Amatriain, Ramón Pujol Farriols and Pierre Bou Khalil. International College of Internal Medicine. CABA, 2014. ISBN 978-987-33-5267-6.

Internal Medicine Residency Program in the Middle East

Prof. Dr. Pierre Bou Khalil (American University of Beirut, Lebanon)

Introduction

Medical education in the Middle East countries has positively evolved in the past decades. The adopted new strategies are oriented towards the achievement of specialty degrees in most of the major clinical specialties, with requirements similar to those in North America and Europe. Postgraduate students are integrated into modern medical centers that provide advanced medical services and better educational quality. This emerging higher training is faced with multifactorial limitations, either directly related to the involved country or to a more global problem.

The infrastructure of an internal medicine program will be outlined, in addition to the curriculum implemented in one of the most reputed universities in the Middle East region.

Medical Universities

As an example, the medical education in Jordan is provided by four state-supported universities, of which is the premier University of Jordan. The residency program is supervised by the Ministry of Health and, as of 1982, by the Jordan Medical Council. Moreover, residents are actively involved in medical research as Jordan is one of the leading Middle East countries in research and development [1,2].

A similar medical system exists in Syria. The Ministry of Higher Education, in addition to various governmental organizations, are directly responsible for the internal medicine training program in the country’s five medical universities. Action plans and strategies are being developed in order to achieve an effective student-centered learning and curricula [3].

In comparison to these two medical system models, six out of seven medical centers and universities in Lebanon belong to the private sector. This encourages contributions for higher residency training: as assistance in implementation of strategic plans, donations and associate teaching. The medical training is merged with the continuous aim of international standards and criteria, taking account of the National Quality Assurance and Accreditation Commission. A detailed outline of the internal medicine residency program will be reviewed, based on a module of one of the best university of Lebanon and the Middle East region, the American University of Beirut-Medical Center (AUBMC) [4].

Internal Medicine Residency Program at AUBMC

The American University of Beirut-Medical Center is a tertiary care center where a diverse group of doctors gather from different universities in Lebanon and Middle East region. It provides a well-reputed training program under the mentorship of some of the top attending physicians in their fields.

This institution has a long tradition of fostering a family atmosphere for a melting pot of medical students seeking high quality training. Challenges are various, including general problems seen in any medical school. But more interestingly, particular concerns and defies characterize this area of the world. These comprise healthcare and financial limitations, in addition to domestic and regional challenges.

The mission of this program is tripartite of patient care, education, and research. It provides superior education in a supportive environment that will help in the growth and development of young physicians.

The Internal Medicine Residency Program at AUBMC is a three year program whose main purpose is to train residents in the specialty of general internal medicine. The broad objectives of the program are as follows:

  • To graduate residents who are able to understand basic mechanisms of disease
  • To graduate residents who are compassionate and proficient in the basic clinical skills of gathering data, clinical reasoning, and planning diagnosis and management in an economically efficient way
  • To teach residents the process of self-education, thus, ensuring their success in the future
  • To graduate residents with a sense of community and leadership skills

Program Director and Faculty Qualifications

There are many full-time, part-time faculty members and associates. A good number of the faculty are American trained with certification by the American Board of Internal Medicine and its subspecialties. The ratio of faculty: resident is 3.7:1. The residents are supervised by a program director who is an American Board certified physician and has undergone American Residency in Internal Medicine.

Admission to the Program

The Residency Program in the Department of Internal Medicine offers limited positions for categorical (3 years) and preliminary (1 year) training.
To qualify for internship, the candidate has to be an MD from AUB or another institution and provide proof of a good performance in medical school. Non-AUB graduates should pass either the USMLE or the AUB Dean’s examination and a clinical practical examination.

Clinical Rotations

House staff accepted in the categorical program is expected to maintain satisfactory performance to continue in the program. The internal medicine program is run by the Department of Internal Medicine at AUBMC. Currently, the training of the residents takes place in the following settings:

  • Inpatient wards
  • Emergency Department (ED) with around 18,000 yearly visits
  • Critical Care Units which include the Coronary Care Unit (CCU), the Medical Intensive Care Unit (MICU), the Respiratory Care Unit (RCU) and the Neurology Intensive Care Unit (NICU)
  • Outpatient Department (OPD) where residents get their ambulatory continuity experience, serving approximately 15000 patients annually
  • Consultation services and physician offices for subspecialty training

The above mentioned rotations are done at AUBMC. Residents will also benefit from rotations in a public tertiary care center, allowing a different exposure and a variety of medical cases.

Moreover, house staff are exposed to elderly patients with common medical problems. This monthly-based rotation is spent in another tertiary elderly care center. Patients can either be self-referred or referred from general Internal Medicine or specialty clinics. A geriatrician, or an internist with special interest in geriatrics, will supervise all residents. At the end of the rotation, residents will present an evidence-based review of a specific topic related to a patient problem.

The distribution of the rotations for the categorical residents is as follows:

First Year Residents (PGY 1) Weeks
General medicine inpatient wards 20
Emergency Department (ED) 4
Cardiac Care Unit (CCU) 4
Intensive Care Unit (MICU) 4
Respiratory Care Unit (RCU) 4
Outpatient Department (OPD) 4
Elective (consultation services) 4
Vacation 4

Second Year Residents (PGY  2) Weeks
General medicine inpatient wards 12
ED 8
CCU 8
MICU 4
Elective 12
Vacation 4
General inpatient wards 20
Elective 20
Vacation 4
OPD 4

All residents spend an average of 24 to 26 months of meaningful patient responsibility. During these months, residents have the responsibility of record keeping, order writing, discharge summary preparation, and appropriate level of decision making all under the supervision of one or several faculty members. During these rotations, residents work in a team where senior residents supervise junior residents. This ensures both close supervision and increasing responsibility in patient care and decision making.

Formal Teaching Program

  • Morning report is held 4 out of 5 days of the week and is usually run by the chief resident and a faculty member.
  • Inpatient teaching rounds 3/5 days of the week each for 11/2 hrs/day in the inpatient unit. Those rounds are patient oriented, usually run by a faculty member and attended by residents and medical students. Discussion during those sessions focuses on history, physical examination, interpretation of clinical data, patho-physiology, differential diagnosis and management of the case under discussion
  • Daily rounds in CCU
  • Daily rounds in MICU
  • Daily rounds in RCU and NICU
  • An emergency medicine didactic curriculum
  • A core curriculum
  • Daily subspecialty conferences
  • Journal club twice per month with faculty supervision that involves teaching the basics of critical appraisal and evidence based medicine
  • Weekly grand rounds
  • Monthly morbidity and mortality
  • Chairman’s round once a week
  • Clinico-pathologic conferences (CPC) 3 times per week
  • Board review sessions twice per week
  • Morbidity and mortality conferences once per month
Procedures and Technical Skills

All residents are required to complete a certain number of procedures prior to graduation. These procedures follow the tradition of “see one, do one, teach one.” All residents are provided by a procedure book to keep track of their performance. Those books are reviewed twice a year to follow up on the progress of the residents.
Participation in Departmental Conferences

In addition to participation in journal clubs, conferences and clinical discussions all PGY2 and PGY3 residents are required to prepare and present a grand round under the supervision of a faculty member before their graduation.

Team Structure and Goals
The Medical Inpatient Service at AUBMC consists of four teams; three subspecialties and one general Internal Medicine. These teams provide comprehensive care for acutely ill patients.

PGY 1 Level
At the completion of this rotation, the PGY 1 should be able to:

  • formulate a differential diagnosis and outline a plan for evaluating and managing diverse inpatient medical problems
  • demonstrate organizational skills necessary for the care of medicine inpatients
  • efficiently and effectively chart in the medical record
  • anticipate and formulate comprehensive discharge plans
  • demonstrate leadership and teaching skills through interactions with members of the medical team
  • demonstrate the appropriate utilization of consult services and diagnostic studies
  • explain the indication, contraindications, risks and process of venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, placement of Foley catheters. PGY 1 should also gain competence in performing all required procedures per procedure manual by the completion of the PGY 1 year

PGY 2 Level and PGY 3 Level
At the completion of this rotation, the PGY 2 and PGY 3 should be able to:

  • function as an effective team manager, leader and teacher
  • discuss the differential diagnosis and direct the evaluation of diverse inpatient medical problems
  • demonstrate baseline competency and improvement in physical diagnosis and medical interviewing skills
  • demonstrate baseline competency and improvement in knowledge and clinical skills in critical care medicine
  • work effectively as a member of a health care team to ensure proper care and welfare of patients
  • respond in person to “Code Blue” and will function as the leading physician coordinating resuscitation. He/she is responsible to document all events during the code

Team Structure
The specialty service consists of 3 teams covering all internal medicine wards. Each team consists of one PGY2 or PGY3, two to three PGY1s and four fourth-year medical students.
A fourth team covers all general internal medicine patients admitted on a designated floor. This team consists of one PGY3, two or three PGY1s and five to seven third year medical students.
The float team consists of one PGY3 and two PGY1s. This team will work 6 days per week (from Sundays till Fridays) taking care of all the inpatient service, from 9:00 pm till 8:00 am of the next morning.
Electives

Residents have the opportunity to undergo monthly-based rotations in internal medicine subspecialties, and other departments at AUBMC. They also take advantage of good connections with foreign medical schools, mostly in the united states, allowing abroad electives. This will add various clinical exposures in addition to having good bounds for a future fellowship training abroad.

Continuity Clinic

Each resident typically cares for 50-75 patients by the end of the third year, and assumes responsibility for their outpatient care. If patients require hospitalization, the first and second year residents are required to act as the attending physician for the patient. Preceptors will provide on-site guidance for residents. All cases must be discussed with a preceptor and evidence of the discussion should be documented in the chart.
 
 

Evaluations

All residents are evaluated monthly using a standard electronic evaluation form. At least twice yearly, and as necessary, the program director or associate program directors discuss the evaluations of each resident to provide feedback. Faculty members get yearly evaluations by residents.

The resident’s evaluation form is based on six core competencies, as following:

  • Interpersonal and Communication Skills
  • Medical Knowledge
  • Patient Care
  • Professionalism
  • Systems Based Practice
  • Practice Based Learning and Improvement

Self Assessment

All residents sit for ACP-ASIM in-training examination given in October of each year. The results of this exam are used for self evaluation of the housestaff and the program, and identify areas of self improvement in the subspecialties of Internal Medicine.
Certification

Residents in Internal Medicine are eligible to participate and sit for the examinations of the Arab Board in Internal Medicine. The requirement of this Board is four years of training in internal medicine or its specialties. Residents can sit for the first written exam in their second year (PGY2) and the second written exam during their first year of fellowship in a subspecialty of internal medicine. If they pass the two written exams, they are qualified to take a medical clinical examination.

On regular basis, residents are also trained for Basic and Advanced Life Support.

Hospital Committees and Organizations

All MD’s duly appointed for postgraduate, clinical training by the Faculty of Medicine are eligible for Resident Staff Organization (RSO) membership. This includes interns, residents and clinical fellows. Their mission is to convey the requests of the residents to the appropriate university authorities. The RSO also promote participation of its members in the development and maintenance of high standards of medical education.

Selected residents also join the Resident Staff Quality Control (RSQC) that will focus on quality of service, in addition to improving and training students on communication skills and ethics related to patient interactions and rights.

Problems and Limitations

It is only a milestone in the never ending journey of continuing education and training that are necessary to practice good medicine in the Middle-East region. Because things are far from perfect. And that medical trainees should gauge themselves not by what is available but rather by what is achievable. It is this singular dedication to continued development, despite limited financial means, despite regional and domestic political instability, that is the hallmark of medical training program in this region.

There is always room for more improvement. For example, the pursuit of Accreditation Council for Graduate Medical Education (ACGME) accreditation in major medical schools. Programs should also attract more international society conferences by mobilizing alumni and actively facilitate fellowships and workshops abroad for residents.

Other fields for improvement are an engagement with the community through various means such as mobile and satellite clinics, diffidently practiced in our region. Further effort is required to introduce new ways of thinking into the community, boldly addressing taboo issues such as end of life care and patient autonomy. Medical schools also have to strengthen and promote homegrown research publications and journals, overcoming restricted and poor funding as in most cases.

As to the aspirations of graduating residents, they are many. And so are their reservations and fears. They are entering a job market which is locally saturated. A problem which is compounded by the inexplicable licensing of more new medicals schools; and a regional policy that prefers foreign certification and western nationalities. Thus, graduating residents are forced to join the vanguard of the infamous brain drain, leaving the country in pursuit of further training or in search of employment. However what is really frightening is that contrary to previous generations that left with heavy hearts and a promise to return as soon as possible, the members of this generation are leaving with a smile and a skip in their step. They are genuinely happy to leave and have full intention to establish their lives elsewhere.

Can they be blamed for wanting to leave when they are expected to compete in a global economy and interconnected world while, in many regions, they still lack basic academic requirements. As an example, out of many, internet connection is possibly the world’s slowest. Of concern are flagships in public healthcare, planned to be a massive medical hub, with the most updated equipment and technology. But shortly after, it suffers from overstretching of resources, shortages of the most basic medical supplies and frequent equipment failure, oftentimes compromising patient care.

Tackling these problems in such backward countries is never a limitation. It argues the notion of the positive ripple effect; the idea that implementing one good policy or public initiative by some medical schools, will encourage others to do the same. Examples are numerous, as different medical schools in the Middle East region revealed their ambitious plans for future growth and commitment to innovative medical education and research.

References:

    1. Tamimi AF, Tamimi F. Medical education in Jordan. Med Teach. 2010 Jan;32(1):36-40.
    2. BeniHani, I., Al Saudi, K., Alkafagel, A. Innovative learning approaches in an established  medical school: the experience at JUST in Jordan. Eastern Mediterranean Health Journal. 2003 Sep-Nov; 9(5-6):1084-92.
    3. Higher Education in Syria- An Overview. Available at: http://eacea.ec.europa.eu/tempus/participating_countries/higher/syria.pdf (Accessed: March 20th 2013).

TRAINING OF INTERNISTS IN EUROPE

Prof. Dr. Ramón Pujol (University of Barcelona, Spain)

Globalisation influencing professional profiles

The 21st century has made so many changes in our lives that we have to make a great effort to adapt as quickly as possible to the new globalised environment.

In healthcare systems, this has been especially remarkable. The role of doctors, and consequently their training, is paradigmatic. Who could have imagined ten or fifteen years ago the enormous movements of citizens and doctors from one country to another that would take place a few years later?. Who could have anticipated how technologies would have an impact on our clinical practice?. These are some examples of factors that, among others, are forcing educators to modify the training of future internists, and doctors in general, in order to maintain their crucial role in health care.

Europe, as part of the old world, has its own particular situation. An extraordinary increase in the elderly population has had immediate consequences in social and health care policies. An elderly and very elderly population obliges health care systems to pay attention to chronic diseases, to disability, and to everything related to ageing.

Doctors practicing Internal Medicine (IM) will be trained for this new scenario, consequently, the training authorities should determine whether a new profile of internist is needed. I would state beforehand that my opinion is clearly ‘yes’.

In this chapter I will set forward my reasons.

European diversity in Internal Medicine

The European unification is moving difficult and is taking place slowly in many fields, including those relating to education and health. Different traditional cultures, languages, beliefs and habits have made a mosaic that is very interesting to know of and analyse, but difficult to unify. The practice of Medicine should be one of the easiest to standardise because patients, diseases and therapies are, nowadays, similar throughout the developed world. Nevertheless, surveys done by EFIM (1) have shown that the practice of IM differs in accordance with country (figure 1). Some countries, mainly belonging those in Southern Europe, still consider IM a general specialty that can embrace a wide range of clinical disorders. Consequently, the training period is longer (usually five years) during which time trainees can be ‘experts’ in some specific disorders (infectious diseases, ageing, emergency, palliative care,…). Conversely, in these countries other medical specialties (Cardiology, Neurology, Gastroenterology,etc……) follow a training programme in which IM has been reduced to a few months. To return to figure 1, these countries placed on the right side (in red) include in the practice of IM some subspecialties considered in the previous group specialties separate from IM. In this case the training period usually last for 2 – 3 years in IM and are followed by another 2 – 3 involving the content of the subspecialty.

There are still attempts to progress to a common programme, but the results, so far, are poor. There are also considerable differences in regard to the setting where internists carry out their clinical tasks.  This issue depends on the health care organisation of each country. Although internists are working mainly in hospitals, in some countries their role is also very important in Primary Care and increasingly in those facilities addressed to caring for patients with chronic diseases (2).

When the role of internists is considered in teaching activities we can say that in the undergraduate period of training this role is important everywhere and must be so if we agree that the aim in this period is to educate future general doctors.

Finally, internists have to learn how to carry out research. The principles of clinical and translational research have been included in the majority of European training programmes.

The ultimate objective of a thorough programme of training is to create a professional competent in clinical practice but also able to teach others and to produce new knowledge.

European internists have a commitment to professionalism (3), therefore all its principles are operative in their minds.  The main difficulties involve the diversity already mentioned but EFIM, UEMS and other institutions are commited to some projects that are intended to help in this regard.

A debate between generalism and specialism ?

From time to time this debate arises, what do we need: more generalsts or more specialists?.

During the 20th century Medical Sciences advanced much more than had at any previous time. The contribution of specialisation was crucial in this regard. In clinical terms to be specialist means to be devoted in depth to a specific part of Medicine, but at the expense of losing basic competencies (4).

Generalism is, on the other hand, the ability to cope with the majority of clinical problems, but to a limited depth that makes the contribution of specialists necessary for some patients.

IM is considered a generalist specialty although as mentioned before, in some countries it is possible to be a subspecialist without losing one’s IM background.

The proportion of generalists/specialists also differs and sometimes is the consequence of the influence of professional lobbies.

Generalists consider that uncontrolled specialisation has fragmented clinical care and created a rigid, impermeable and inefficient health care system. This is especially important nowadays, as the prevalence of elderly population in Europe implies chronic diseases and plurypathology.

Specialists consider, in turn, that in our highly technical world they can offer higher quality in their practice. This is not only clinical; these specialists also have, in their hands, procedures that generalists do not.

The debate has been underway for many years, even though it is becoming more heated since the start of economic crisis affecting Europe and other continents.

In this new scenario the contribution of IM seems essential. We have moved from a position in which some managers were questioning the future of this specialty to another in which internists are asked to undertake a variety of clinical tasks.

In parallel to the emergence of a new way to practice IM in the US (the hospitalist movement) (5) in the UK Acute Care Doctors appeared (6). These are a group of internists who take care of inhospital medical patients during their first 72 hours of stay. Other countries in Europe are updating the practice of IM to the current organisation. For instance in Spain (7) and in a similar way in Portugal, France and Italy IM departments are moving from large wards with long medium-stay to alternative areas where patients can be attended in a similar way but more efficiently (8). As a consequence of this new organisation, the training of internists should necessarily be adapted.

A new internist for new needs

General internists with some expertise in specific areas, but who maintain their competencies as generalists are, in my opinion, the key to this era. Obviously they must work together with specialists in teams.

Why I am defending this expertise instead of new specialisation?. I will try to clarify this because it is of paramount importance. As I have insisted in this chapter, in Europe we need to find solutions to merge diversity in order to define as much as possible a European internist, not a local internist.

For this purpose we cannot lose a strong competence based on generalist training, and then become experts in some field. On the other hand it is crucial not to lose our roots.

The complexity and rapid evolution of Medicine will not support non-stop specialisation. We need specialists, of course, but only after a general training. There are a lot of examples that illustrate how to proceed. Cancer, AIDS, unsuccessful ageing, are common chronic disorders that need the much more than chemotherapy, antiretroviral therapy or the management of plurypathology. Doctors attending those populations must be trained in IM in order to manage comprehensively those patients. Otherwise such specialists will need internists to complement their role as chemotherapists, antiretroviralists or limited geriatricians.

In addition, policymakers must work together with educational authorities in order to adapt the training of doctors, and of internists, to the current needs of European citizens. This is not an easy task, but if it is not undertaken we shall lose a valuable time in which to offer the best internists to society. To do so is one of the principles of professionalism (3).

EFIM is interested in educational topics and we are working together with other institutions (WFME, UEMS, RCP) in order to reach a consensus about the doctor and the internist we need in the future.

EFIM has defined the core competencies of the modern internist (table 1); this definition sets out quite precisely his or her role in the near future.

The ability of internists to adapt to a changing society has been outstanding. When I was a resident, more than 30 years ago, the clinical wards of our hospitals were completely different from the current ones and so was clinical management (table 2).

Now, being responsible for the direction of an IM Service I analyse in perspective these changes, and I am still satisfied to have chosen IM and have contributed to the professional development of the internists of the future.

References

  1. Palsson R et al. Organisation of Internal Medicine Services in Europe. Eur J Int Med 2012 (in press)
  2. Sociedad Española de Medicina Interna (SEMI). IV Congreso Nacional de Atención al paciente crónico. Alicante 2012. www.semi@fesemi.org
  3. Blank L et al. Medical professionalism in the new millennium. A physician charter 15 months later. Ann Intern Med 2003;138:839-841
  4. Busing N. et al. The future of Medical Education in Canada. AFMC,2010: 1-48
  5. Peterson MC. A Systematic Review of Outcomes and Quality Measures in Adult Patients Cared for by Hospitalists vs Nonhospitalists, Mayo Clin Proc 2009;84:248-254
  6. Wachter RM. Renaissance of hospital generalism. BMJ 2012;34:e652
  7. Garcia Alegria J, Pujol Farriols R. Internal Medicine in Spain BMJ 2012;344:e652/rr/574331
  8. Cataldi Amaitriain RM. Internal Medicine: past, present and future. Current Medicine: conflicts and dilemmas. Dunken, Buenos Aires 2011;25-28

 

Latin America Medical Education Board (JEMAL) meets 40 years of activity.

“IVº Simposio sobre Educación Médica” y “IIº Jornada Riopla­tense de Educación Médica”, JEMAL, 1995

From left to right: Dres. Carvajal and Niso Gatenio (University of the Republic, Uruguay), Cataldi Amatriain (chairman), Guillermo Jaim Etcheverry (UBA), Abraam Sonis (University Maimonides) and Dra. Kumiko Eitguchi (USAL).

 

JEMAL: round table on bioethics, medical education and epistemology (1997)

From left to right: Dres. Marcos Meeroff, Cataldi Amatriain, Dietrich von Engelhardt (Germany) and Gregorio Klimovsky.

 

Medical Drafting Manual and Documentaire Techniques (1983)

Roberto M. Cataldi Amatriain

 

Medical Education (199

Roberto M. Cataldi Amatriain

 

Medical Education: science, technical & art (2008)

Roberto M. Cataldi Amatriain

 

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