1. Medical specialty training in Croatia
Nada Cikes,
University of Zagreb School of Medicine
National Authority for Specialty Training of Medical Doctors in Croatia
UEMS ORL Section and Board, Dubrovnik, 4. October 2014.

2. Medical education in Croatia
4 medical schools
2004 new harmonised core curriculum was introduced in all four schools
2007 medical schools invited in specialty training programmes developments
new competency based specialty training programme was developed for all specialties
from 2011 implementation

3. Introduction of new specialty programes
Need for competency and learning outcomes based programmes
Harmonisation with European documents:
European commission (EU Directive 2005/36 EC)*
UEMS (Charter on specialty training Ch. 6)
Recommendation of intrnl. scientific societies
New specialties proposals:
- new specialties
- common trunks
- reforms of old specialties
Proposal for a new Ordinance on specialty training of medical doctors in Croatia
* qualification recognition: subject of negotiation with Croatia for EU accetion

4. Development of specialist training programmes in Croatia
New competency based programmes for 46 specialties
Common trunk for internistic and surgical specialties
For all specialty programmes
duration
training plan
required level of competencies - generic
- specific
list and number of procedures
logbook

5. Croatian medical schools and other institutions in training programme development
Agreement on collaboration in development of specialty education program between:
all four medical schools
Croatian Medical Association
Croatian Medical Chamber
Croatian Academy for Medical Sciences

6. Development of programmes of specialists education in Croatia
46 task forces:
Programme of specialist education defining competences
Requirements for training institution
Requirements for mentor
Requirements for trainee and logbook

7. Goals Objectives of training programme generic competences
- all physicians in training in all medical specialties
specific competences: knowledge, skills and attitudes
competence-based education, focused on learner performance - learning outcomes in reaching specific objectives of the curriculum
Outcome of training programme
specialist able to practice in a professional, ethical and patient-focused way

8. COMPETENCIES
skills
knowledge
professional
behaviour
competencies

9. Competencies in specialty training programmes
Characeristic for each specialty
common trunk
“main” program of the specialty
All educational units in the programme
Also the number of interventios
Evaluation of comparable competencies in groups of specialties (surgical, internistic)
Determine teaching methods
Determine assessment methods
Important: generic competencies for all specialists

10. DESCRIPTION OF THE LEVEL OF COMPETENCIES1 2 3
Trainee is informed about thematic area on basic level, needs support and supervision in work and problem solving in the thematic area
Trainee is partially competent, able to work and solve problems with support and partial supervision
Trainee is fully competent, familiar with relevant literature, able to work and solve all problems in the thematic area

11. Specific competencies – goals*
Medical knowledge
Patient care
Practice based learning and improvement
Systems based practice
Professionalism
Interpersonal and communication skills
*ACGME Outcome Project 2006

12. Generic competencies in medicine
Tomorrow’s Doctor (GMC, UK) – generic and specific
The Scottish Doctor – generic and specific
Generic Curriculum for the Medical Specialties Federation of the Royal Colleges of Physicians
The Royal College of Physicians and Surgeons of Canada Physicians Competency Framework
European Board of Internal Medicine Core Competencies
Etc

13. Generic competencies in specialty training
The CanMEDS 2005 Framework: The Physician Roles
Medical Expert Role
Communicator Role
Collaborator Role
Manager Role
Health Advocate Role
Scholar Role
Professional Role

14. Definitions of 7 roles of physicians
As Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.
As Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.
As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.

15. As Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.
As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.
As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.
As Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

16. Implementation
The CanMEDS framework accepted, incorporated in the training programme:
as a teaching module obligatory for all specialties
parts of clinical teaching programmes
content in the logbook
Evaluation:
At the end of the module
Continuous evaluation by mentor
Multisource feedback degrees

17. Introductory teaching module on generic competencies
Two weeks programme
Each competency: two half – days
Trainees participate with case studies from personal experience
Discussion between participants
Supporting documents and teaching materials (manual, e-learning...), additional reading

18. Competency teaching in the module
Definition
Description
Elements
(communicator: empathy, effective listening.....
collaborator: respect for others in the team,
constructive negotiations.....)
Key competencies
Specific training requirements

19. Teachers in the generic module
2 coordinators for each competency
Group of experienced and younger teacher in the group
- clinicians ( family medicine, pediatrics, internal
medicine, psychiatry...)
- experts from public health
Workhops organised – for each competency
- for the whole module

20. Results of teachers’evaluation and general observation
Teachers’ positive attitude for generic skills increased
Educating students and understanding the teaching process motivated them to be good role models for students
Communication between teachers increased
Good relationship between students and young clinicians
Improvement of working environment in academic hospital was initiated
The generic skills in medical community are promoted

21. Difficulties in teaching generic competences
Teaching environment in the training institution
Lack of understanding generic competencies
Need for education of mentors in teaching and evaluating generic competencies
Need for education of other physicians and other medical professionals in generic competencies

22. Requirements
Training institution
Mentor
Trainee

23. Requirements for training institution
Learning environment
General requirements
High level of educational and professional expertise, informatic technology, research
Requirements relevant for particular specialty fulfilling the conditions for study program (no. of relevant patients, procedures etc..)
Preparedness for regular visitation
Adaptation of Croatian regulations on health institutions!

24. Mentor Experienced specialist Experienced teacher
Need to define time protected for teaching (hospital burden!)
Need to define relevant regulations
Number of trainees per mentor
Mentor’s education and evaluation
Important: employment policy (medical school and university hospital

25. Trainee General requirements Logbook for particular specialty
Trainee follow up through training
progression of competence
Definition of evaluation methods
Requirements for final examinations
Special attention: trainees doctoral students

26. Dual role of trainee: student and health care provider
Work in health care is part of education
Patient care is the integral part of learning
Every contact with patient is educational experience
Supervision is integral part of learning experience
Responsibility of all – trainee’s progress: education, competency, responsibility, patient safety....
Goal of the advencement of specialty training process: enhancement of patient care

27. Follow up of trainee progress
THEME
LEVEL OF PROGRESS
MENTOR 1 2 3
GENERIC/ SPECIFIC
COMPETENCIES
Date and signature

28. Follow up of interventions
Part of the training programme
Name of the intervention
Number of interventions
Level of progress
MENTOR 2 3
Date and signature
Date and signatue

29. National authority responsible for specialty training
definition of national standards
supervision of training programmes
developments of assessment methods
accreditations for institutions
quality assurance
institution visitation
planing strategy

30. Task force for evaluation and methods of assessment
Assessment is part of the educational programme
Base: UEMS Policy Statement on Assessment during Postgraduate Medical Training (2006):
Selfevaluation (trainee)
Continuous follow up (mentor)
Test 360˚
Final exam – written and practical
UEMS CESMA:
European exam
Evaluation of mentor
Evaluation of training institution

31. Training programmes were presented:
Association of Medical Schools in Europe 2009.
International Association for Medical Education (AMEE)
2010 Glasgow
2014 Milano
Policy dialogues, Investing in Europe’s health workforce of tomorrow: scope for innovation and collaboration . Follow up to the Green Paper on Europe’s health workforce, Leuven, Belgium, 2010
Education for Physicians: A Comparison of Slovenia, Croatia and Italy, Brioni, 14 May 2011
Various meetings and congresses in Croatia

32. Zagreb Declaration, 2009
The Role of the Medical School in Postgraduate Education

33. Conclusion Largest project in medical education in Croatia
(600 MD specialists involved in programme development)
Involvement and responsibility of
Medical schools
Health institutions
Mentors
Trainees
Professional societies (Croatian Medical Association)
Croatian Medical Chamber
Other organisations
Ministry of Health

34. Teaching generic competencies

35. Fundamentals of Medical Skills - longitudinal course
two parallel tracks: Clinical practical skills and Communication skills
emphasis on teaching communication skills, gradually developing medical students' competence from basic to specific communication associated with clinical courses in higher grades of medical study
expected: greater effectiveness of a longitudinal, integrated communication approach in teaching medical students compared with concentrated courses

36. Study year
Teaching content in longitudinal course in communication skills
1st
Basic communication skills. Communication with colleagues, teachers, administrators and other members of the school and hospital staff
2nd
Medical interview
3rd
Informed consent. Written communication in medicine. Working in team
4th
Giving information and counselling. Communication in clinical setting. Communication with severely ill patients. Breaking bad news. Palliative medicine. Aggressive patient
5th
Communication with children. Breaking bad news to children. Communication with parents and family members. Pregnancy and childbirth. Elderly patients. Psychiatric patient
6th
Communication in family and community. Communication as a part of professionalism. Communication with other professions. Communication with media.

37. Workshops for teachers education
Role-playing
Simulated patient
Analysing specific videotapes of:
Real patient cases in health care
Pateint cases scenarios filmed by students of University of Zagreb Drama Academy
Observation and constructive feedback discussions with peers and facilitator
Organisation and training for OSCE

38. OSCE After 15 weeks of traning:
Standardised patients in simple clinical situations
Opening and closing the interview
Some stations: combined practical skills with communicational task

39. Reasons why clinicians can be good teachers in communication
Good understanding of communication theories
Positive attitude towards communication based on personal clinical experience
Understanding of patients’ centeredness in communication process
Additional impact: teachers became highly competent in communication with patients, colleagues and others
Influence on communication climate in health care environment
Students appreciate colleagues being their teacher in communication

40. Generic competencies in internship
Internship is organised in rotations
Competencies included in the programme:
communication skills
team work
professionalism
Elements of each competencies defined
Tasks recorded during whole programme

41. Conclusion
Continuous enhancement of generic competences through the graduate and postgraduate education is essential for professional development
Continuous reinforcement and longitudinal development of skills is critical for their retention and expansion
Teaching generic skills on all levels of medical education exerts influence on development of professionalism in hospital environment
Influence on health care