1. NEURON: training programme in neurology

2. Extended skills and knowledge in more complex areas of a specialisation should be learned by systematic, supervised acquisition of additional competencies. in fellowships after the regular training or as modules within the regular training programme in an accredited training institute under supervision of a programme director. Sub-speciality training

3. Particular qualifications Neurology Neuro- muscular disorders Movemen t disorders Neuro- oncology Neurology Neuro- genetics Sleep medicine Neuro- vascular medicine Neurology Neuro- rehab. Neuro- ophthalm. Neuro- immuno- logy

5. An example of a project on display: neuromuscular disorders Goal of the neuromuscular apprenticeship: to provide training on pathophysiology, pathology, diagnosis and management of patients with neuromuscular diseases with the purpose to enhance quality of care. After completion of the training the fellow has: sufficient knowledge and skills to evaluate patients with a variety of neuromuscular disorders specific expertise in the diagnosis and management of these disorders become acquainted with the three crucial areas of neuromuscular disorders i.e. genetics, neuro-immunology and rehabilitation medicine.

6. A.Content of the training programme Should comply with the format of the general neurological training B.Facilities for the training In case of nmd: genetic dept., dept. of rehab medicine, muscle pathology dept., …… C.Qualifications of the Program Director > 5 years expertise in nm patient care, research, CME D.Evaluation of the trainee Portfolio, assessments Requirements for the Training

7. Does the new curriculum lead to a better doctor? responsibility autonomy supervision

8. Duration of the training: ‘Medical specialists are too old, too smart and too expensive’ Moving away of the traditional medical specialities (re-shaping) due to emerging technologies Generalism or subspecialism? What is the core business of the medical specialist? Definition of professional role, new professionals in the care Residents stop their training Concerns

9. Time for a change Medisch Contact 1999

10. Specialties determined by specific parts, tissues or organ systems within the human body (e.g., ophthalmology, dermatology, internal medicine, neurology, psychiatry) or by a specific skill (e.g., surgery, anaesthesiology). Definition of speciality

11. Technological developments lead to a shift of the classical domains (e.g. interventional radiologists ‘compete’ with neurosurgeons). Multidisciplinary treatment (e.g. oncological patient care, endoscopic surgery of patient with hypophyseal tumour by neurosurgeon and ENT specialist) is on the rise. Subspecialisation (endocrinology, vascular surgeons, neuromyologists) becomes the norm. Change in the definition of specialities

12. Generalisation vs subspecialisation

13. Why subspecialisation? Increase in diagnostic and therapeutic possibilities in medicine driven by developments in molecular genetics and technology, in particular imaging has fuelled the tendency to acquire additional or particular competencies within all medical fields because medical specialists are finding it increasingly difficult to deal with the ever growing body of knowledge in the field.

14. Gone is the widely experienced general physician, and general surgeons are replaced by an ever expanding list of “ologists” who now seem to be almost single cell specialists. BMJ 2010; 341:c4903 Des Spence, Glasgow Views & Reviews We are passing the tipping point: increasing specialisation is harming care. Specialism is breaking down continuity, promoting the “not my clinical area” that fuels endless internal specialist referrals and wasting time and resources. Bad medicine: specialisation

15. Pros of subspecialisation Pros Focused competency in complex areas... or in orphan diseases More volume, better outcome

16. Indeed, old chap: Practice makes perfect! Competencies

17. Pros and cons of subspecialisation Pros Focused competency in complex areas... or in orphan diseases More volume, better outcome Cons Fragmentation Big picture is gone Poor service (patient as ‘nomade’) Legal and financial implications Extension of the already lengthy training period of medical specialist

18. Demographic & societal changes More elderly people with comorbidity Demand driven patient care More female health care workers Increasing wish to work part time  Shortage of medical specialists  More medical students?  Substitution of medical tasks by new professionals?

19. RVZ report (2002) on re-demarcation between existing professions and the creation of new professional groups. The assumption was that this will raise quality standards and lead to more efficient care. Some evidence to suggest that the quality of care is improved by role redefinition. However, the improvement is attributable mainly to better patient supervision and support. At present, there is an increasing number of new health professionals; there is no redesign of the care process. Furthermore, doctors do not feel that their burden has been significantly alleviated by the changes made to date. Redefinition of professional roles

21. Let us enjoy the new curriculum However, we should not close our eyes for the major issues that I have just mentioned. Time for a change