Sleep medicine practices, training, and attitudes: a wake-up call for pulmonologists

STUDY OBJECTIVES: To determine attitudes and knowledge about sleep medicine among chest physicians. DESIGN:: Interactive survey of self-selected respondents. SETTING: Interactive session at the 1998 American College of Chest Physicians (ACCP) annual meeting. PARTICIPANTS: Approximately 60 chest physicians. INTERVENTIONS: Interactive questions about the knowledge, training, attitudes, and practice of sleep medicine. MEASUREMENTS AND RESULTS: Response rates demonstrated that 65% of respondents directed or were on the staff of a sleep laboratory, 18% had American Board of Sleep Medicine (ABSM) certification, and only 3% had completed formal sleep medicine training, and performance on test questions about sleep-disordered breathing was better than that on questions about "nonpulmonary" sleep disorders. We polled approximately 60 participants in an interactive session called "Issues in Sleep Medicine Education and Practice" at the ACCP annual meeting in October 1998. The group was well-credentialed, with about one third of participants being board-certified in pulmonary medicine and critical care medicine, and about 17% having passed the ABSM examination. About two thirds of the group spent < or = 25% of their time in the practice of sleep medicine, but > 30% directed sleep laboratories. Respondents thought that sleep training was better addressed in pulmonary fellowship training than in medical school or other postgraduate training experiences. Forty-three percent of the group had received training in sleep medicine as part of a pulmonary fellowship. About half of the sample thought that formal training should be required for eligibility to take the ABSM examination. When presented with two "nonpulmonary" sleep disorder cases, this well-trained and self-selected group did not perform very well. The findings suggest that pulmonologists are actively involved in the practice of sleep medicine and that they both need and desire formal training in sleep disorders during pulmonary fellowship training. CONCLUSIONS: Participants were actively involved in the practice of sleep medicine, most had trained informally, and performance on questions about nonpulmonary sleep disorders was not good.     

Education and training in the field of sleep medicine

Sleep disorders are highly prevalent but are under-recognized and under-diagnosed by the majority of health care providers. This article reviews recent studies of sleep medicine education in the United States and abroad and the reasons offered by most instructors for the lack of adequate education at their institutions. Quantity and quality of sleep medicine education have been lacking. Knowledge assessment is an important aspect of educational research, and several instruments for the assessment of sleep knowledge have been developed. A noteworthy development is the Sleep Academic Award program of the National Center on Sleep Disorders Research. This twenty-site, NIH-funded program has developed model interventions and sleep training curricula that are being widely disseminated. Sleep medicine fellowship training programs have also been established in the past decade and serve as the major vehicle for advanced specialty training. Finally, a number of strategies for introducing sleep medicine topics and issues into the medical curriculum have been proposed. Considering the paucity of publications in this area, our review was not restricted to studies in the past year.     

The American Society of Tropical Medicine and Hygiene initiative to stimulate educational programs to enhance medical expertise in tropical diseases

More than a decade ago, at a time when current and emerging tropical diseases posed growing threats to the United States, expert panels convened by the Institute of Medicine of the U.S. National Academy of Sciences concluded that medical expertise within the United States competent to address diseases of the tropics had declined. Recognizing a national need to encourage and enhance such, The American Society of Tropical Medicine and Hygiene developed a program to stimulate new postgraduate medical education in diseases of the tropics. The Society formally requested academic institutions within the United States and Canada to propose new postgraduate programs. To assure the quality of these new curricular offerings, the Society developed an outline of key areas of competency and agreed to offer an examination that would grant physicians a Certificate of Knowledge in Clinical Tropical Medicine and Travelers Health. The certifying examination was to be an integral component of a program to stimulate academic institutions to provide instructional programs in tropical diseases and to encourage physicians to become trained, evaluated, and recognized for their knowledge of clinical tropical diseases and travelers' health. The Society's initiative to stimulate educational programs in tropical medicine is reviewed.     

Expert ratings of primary care goals and objectives

OBJECTIVE: To develop consensus on proficiencies internal medicine residents should master in the area of primary and managed care. DESIGN: A draft compendium of primary care educational objectives including important clinical topics was developed at the Sepulveda Veterans Health Administration Medical Center Pilot Ambulatory Care and Education (PACE) Program as part of a local and regional primary care curricular review. Fifty-one experts, including leaders in the Society of General Internal Medicine, the Association of Program Directors in Internal Medicine, the American College of Physicians, general internal medicine division chiefs, and Veterans Affairs (VA) associate chiefs of staff for ambulatory care rated the compendium. MEASUREMENTS AND MAIN RESULTS: Eleven objectives and nine clinical topics were rated “critically important” (4.7 or above on a five-point scale). General internal medicine chiefs and associate chiefs of staff for ambulatory care judged them to be covered adequately in fewer than half of the 17 VA Western Region-affiliated internal medicine programs. Forty-five objectives and 77 clinical topics were considered at least somewhat important to the education of general internal medicine residents in primary care. The VA raters reported that in the prior academic year, their housestaffs had spent between 21% (postgraduate year I) and 33% (postgraduate year III) of their time in ambulatory care settings. CONCLUSION: With the emphasis on primary and managed care, there is a need for national consensus on educational objectives in primary care general internal medicine. This review provides educators with a benchmark to test the adequacy of their institutions’ curricula in primary care internal medicine. Presented in abstract Jorm at the annual meeting of the Society of General Internal Medicine, April 28, 1994, Washington, DC.     

Geriatric medicine in the European Union: unification of diversity

The numbers of older people in the European Union are increasing and, with their associated health needs, there is a requirement for the specialty of Geriatric Medicine to be available throughout Europe. At present, specialists in Geriatric Medicine are not recognised in some of the European Union member countries. It is imperative that training in Geriatric Medicine should take place throughout Europe, starting at undergraduate level and progressing through postgraduate training. There must be a programme of continuing medical education and personal development. This paper highlights some of these challenges and suggests a possible way forward.     

Competency-based education and training in internal medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.     

Meeting the Need for Training in Geriatrics: The Geriatrics Education for Specialty Residents Program

The imperative created by increasing numbers of aging Americans coupled with increasing longevity has generated recognition and acceptance within american medicine that education, from medical school through postgraduate training through continuing medical education, must include appropriate knowledge and skills in aging and geriatrics to provide for effective care of older adults. Such education and training is necessary not only for traditional primary care providers, but also for specialty physicians, including those in most surgical specialties and in related fields such as anesthesiology, emergency medicine and physical medicine and rehabilitation. To fill this demand, the American Geriatrics Society Geriatrics for Specialist Initiative established the Geriatrics Education for Specialty Residents Program (GSR). This article reviews the process by which the GSR created a dynamic cohort of geriatric surgical educators and researchers who in turn created a vibrant body of educational tools and scientific works that continue to advance the cause of improving medical care of older adults.     

Patient education through teaching for conceptual change

Summary It is not enough for clinicians to gather good patient information and then dictate management plans. If patient education is to be successful, attention must be paid to tailoring educational input to the patient’s particular needs. If the conceptual change approach is followed, patient differences due to factors such as age and culture will be taken into account. Likewise, the different types of patient education described earlier can be accommodated, since the patient and his or her particular needs are always the focus of all medical conversations. The conceptual change approach for patient education potentially can help clinicians avoid the temptation to ignore patients’ perspectives and provide instruction tailored to patient needs, thereby reducing the possibility of educational negligence. Received from the Departments of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin. Supported by the USPHS/HRSA training grants D28-PE-15218 and DE-PE-55024, and MCHB training grant MCJ-559-072.     

Hospital to Home: A Geriatric Educational Program on Effective Discharge Planning

There has been increased attention on the needs of the burgeoning older adult population, with focus on the limited education and training experiences available in geriatric care. Older adults transitioning between levels of care often require increased attention, and the American Geriatrics Society (AGS) Task Force on the Future of Geriatric Medicine has encouraged greater training opportunities be provided to better understand the needs of this population. The Hospital to Home Program is one model of geriatric training emphasizing many of the AGS recommendations. Through qualitative analyses of 51 internal medicine residents’ reflections, the authors report how this educational program is meeting the above need and share how Hospital to Home is enhancing residents’ skills in creating a safe discharge for geriatric patients and their families.     

Capturing the power of academic medicine to enhance health and health care of the elderly in the USA

As in Japan, the US population is aging progressively, a trend that will challenge the health-care system to provide for the chronic, multiple and complex needs of its elderly citizens. and as in Japan, the US academic health enterprise has only belatedly mounted a response to that challenge. Herein is reviewed a quarter of a century of the author's personal experience in developing new programs in gerontology and geriatric medicine from a base in the Department of Internal Medicine at three US academic health centers (AHC): The University of Washington (as Division Head), Johns Hopkins University (as Vice-Chair), and Wake Forest University (as Chair). Rather than to build a program from a new department of geriatrics, this strategy was chosen to capture the power and resources of the department of internal medicine, the largest university department, to 'gerontologize' the institution, beginning with general internal medicine and all of the medical subspecialties (the approach also chosen to date at all but a handful of US AHC). The keystone of success at each institution has been careful faculty development through fellowship training in clinical geriatrics, education and research. Over the same interval major national progress has occurred, including expanded research and training at the National Institute on Aging and the Department of Veterans Affairs, and accreditation of more than 100 fellowship programs for training and certification of geriatricians. However, less than 1% of US medical graduates elect to pursue such training. Hence such geriatricians will remain concentrated at AHC, and most future geriatric care in the USA will be provided by a broad array of specialists, who will be educated and trained in geriatrics by these academic geriatricians.     

La formación especializada en neumología en Europa. El proyecto HERMES

Given the movement of medical specialists across borders in recent years, and the changes in legislation affecting the structure and operation of boards responsible for the various medical specialties, the task of harmonizing the training of respiratory medicine residents across the European Union has become crucial. The project for Harmonised Education in Respiratory Medicine for European Specialists (HERMES) is a collective response to this need. After 3 years of work toward building consensus, HERMES is entering its second phase. The Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has the aim of informing our resident trainees, their instructors, and others concerned with postgraduate education in respiratory medicine in Spain about this undeniably difficult task of harmonization.     

Internal medicine in the next millennium: whither vascular medicine?

Cardiovascular diseases cause a staggering amount of morbidity and mortality. The knowledge derived from advances in vascular biology and vascular medicine has provided the practicing clinician with an already impressive number of effective treatments, but these treatments need to be applied more consistently and more effectively. The field of vascular medicine is growing at a high rate. In order to better apply existing knowledge and to be prepared for new developments, education in vascular medicine should be enhanced both in the training programme for Dutch internists and in postgraduate education. Academic and large community hospitals should consider the founding of multidisciplinary centres for vascular medicine. General internists should play a coordinating role in such centres.     

The relationship between features of residency training and ABIM certifying examination performance

The purpose of this study was to provide data concerning the relationship between features of residency training and a test of cognitive achievement gathered at the end of residency. To accomplish this, data collected in the late 1970s by three national organizations were joined and analyzed with the aid of experts in internal medicine. Although graduate medical education has evolved since this information was gathered, it does provide a baseline for assessing the impact of changes on the cognitive skills of residents. The findings suggest that better program performance on the examination is associated with attracting more knowledgeable residents to begin with and that programs are able to maintain the advantage of their residents throughout training. Moreover, program characteristics have an impact on the cognitive skills of residents over and above what would be predicted by test scores at the end of medical school. Programs with better examination performance tend to provide residents an extensive, well-supervised educational experience stressing ambulatory care. Received from the American Board of Internal Medicine, Philadelphia, Pennsylvania. Supported by The American Board of Internal Medicine. This report does not necessarily reflect the opinions or policies of the American Board of Internal Medicine.     

Competency-based training for internal medicine

The Central College of Medical Specialities has presented guidelines for modernisation of all postgraduate speciality training programmes. These guidelines include the definition of seven general competency fields, each of them described in more detail with four key competencies. By 2006, all postgraduate speciality training programmes will be based on these competency fields. Furthermore, by then assessment of residents will be focused on the achievement of competence, rather than only on fulfilment of length of specified rotations, numbers of clinical experiences and numbers of performed skills. The application of this competency model emphasises the fact that the education of medical doctors entails more than providing them with the required theoretical and clinical knowledge and skills.     

Knowledge and attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine fellows

OBJECTIVES: To evaluate the attitudes and knowledge of medical students (MS1-3), internal medicine residents (postgraduate years 1 to 3 (PGY1-3)), and geriatric medicine fellows about elderly patients before implementation of a new geriatrics curriculum. DESIGN: Cross-sectional study. SETTING: An academic medical center. PARTICIPANTS: Two hundred eleven people participated: 54 MS1, 52 MS2, 50 MS3, 20 PGY1, 12 PGY2, 12 PGY3, and 11 geriatric medicine fellows. MEASUREMENTS: Each participant completed a questionnaire, including a 16-item geriatrics attitude scale, and a 23-item knowledge test (both revised versions of the University of California at Los Angeles (UCLA) Geriatrics Survey). Pearson correlation coefficients and t tests were used for statistical analyses. RESULTS: Both surveys demonstrated high internal consistency (alpha=0.70 and 0.71, respectively). Knowledge test scores increased with advancing level of training. MS1 and MS2 scored significantly lower and fellows scored significantly higher than others. PGY3 scored significantly higher than PGY1 on the knowledge test. All groups demonstrated positive attitudes toward geriatric patients (score>3.5). MS1 and fellows had significantly more favorable attitudes scores than more advanced students and residents. CONCLUSION: The results suggest that the UCLA Attitudes Scale and Knowledge Test can be used reliably to assess attitudes and knowledge level across all levels of medical education and training. The information from this study will be used to implement a more structured and comprehensive geriatrics curriculum across all trainee levels to improve attitudes and knowledge in the care of the geriatric patient.     

Professional organisation profile: the New Zealand Society of Travel Medicine

The New Zealand Society of Travel Medicine was established in 1995 and its membership has been active in several areas, including networking, scientific meetings, and the development of postgraduate educational courses in travel medicine in New Zealand. Information is given on purpose, membership, and the various activities of the Society.     

Curriculum Spezielle Rhythmologie

The German Cardiac Society (GCS) hereby proposes a curriculum for acquisition of the additional qualification in specific heart rhythm disorders which follows the requirements of the European Heart Rhythm Association (EHRA). The purpose is to acknowledge special knowledge, experience and abilities in this expanding subspecialty. Besides striving for the additional qualification in specific heart rhythm disorders (24?months), candidates can follow separate tracks for invasive electrophysiology or cardiovascular implantable electronic devices (15?months each). Whereas training can start early during postgraduate training, the certificate will only be awarded after having finished postgraduate training in internal medicine and cardiology. To define a specified level of competence, this document presents the standards for the necessary levels of knowledge and experience as well as of practical skills and the number of required procedures. Besides this, the requirements for training centres and supervisors have been delineated. The trainee will document the procedures and other activities in a logbook and progress will be assessed by the local supervisor of the program. The German Cardiac Society is responsible for maintenance of standards and quality control within the program. During the initial period of 2 years, there will be transitional regulations. It is the aim of this program to promote optimal quality of patient care in clinical cardiac electrophysiology.     

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.