White Book of PRM

Chapter 9 –Education and continuous professional development: shaping the future of PRM

European PRM Bodies Alliance

For this paper, the collective authorship name of European PRM Bodies Alliance includes:

  • European Academy of Rehabilitation Medicine (EARM), 
  • European Society of Physical and Rehabilitation Medicine (ESPRM),
  • European Union of Medical Specialists PRM Section (UEMS-PRM Section)
  • European Union of Medical Specialists PRM Board (UEMS-PRM Board)
  • The Editors of the 3rd edition of the White Book of Physical and Rehabilitation Medicine in Europe: Maria Gabriella Ceravolo, Pedro Cantista, Nicolas Christodoulou, Alain Delarque, Christoph Gutenbrunner, Carlotte Kiekens, Sasa Moslavac, Enrique Varela-Donoso, Anthony Ward, Mauro Zampolini, Stefano Negrini
  • The contributors: Maria Gabriella Ceravolo, Wim Janssen, Jacinta McElligott, Angela McNamara, Calogero Foti, Saša Moslavac, Raquel Valero, Enrique Varela Rolf Frischknecht, Alvydas Juocevicious, Coleen T Dy Rochelle, Alain Yelnik

Abstract

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with the education of PRM physicians in Europe. To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. In fact they are required to develop not only medical knowledge, but also competence in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. This paper provides updated detailed information about the education and training of specialists, delivers recommendations concerning the standards required at a European level, in agreement with the UEMS rules of creating a Common Training Framework, that consists of a common set of knowledge, skills and competencies for postgraduate training.. The role of the European PRM Board is highlighted as a body aimed at ensuring the highest standards of medical training and health care across Europe and the harmonisation of PRM specialists’ qualifications. To this scope, the theoretical knowledge necessary for the practice of PRM specialty and the core competencies (training outcomes) to be achieved at the end of training have been established and the postgraduate PRM core curriculum has been added. Undergraduate training of medical students is also focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the aging population and the increase of disability in our continent. 

Finally, the problems of continuing professional development and medical education are faced in a PRM European perspective, and the role of the European Accreditation Council of Continuous Medical Education is outlined.

Key words

Physical and Rehabilitation Medicine; Europe; Education, medical; curriculum; training

Introduction

The White Book (WB) of Physical and Rehabilitation Medicine (PRM) in Europe is produced by the 4 European PRM Bodies and constitutes the reference book for PRM physicians in Europe. It has multiple values, including to provide a unifying framework for the European Countries, to inform decision-makers at the European and national level, to offer educational material for PRM trainees and physicians and information about PRM to the medical community, other rehabilitation professionals and the public. The WB states the importance of PRM, that is a primary medical specialty. The contents include definitions and concepts of PRM, why rehabilitation is needed by individuals and society, the fundamentals of PRM, history of PRM specialty, structure and activities of PRM organizations in Europe, knowledge and skills of PRM physicians, the clinical field of competence of PRM, the place of PRM specialty in the healthcare system and society, education and continuous professional 

development of PRM physicians, specificities and challenges of science and research in PRM and challenges and perspectives for the future of PRM.

This chapter deals with the education of PRM physicians in Europe. Detailed information are provided about the education and training of specialists, discussing the standards the duration required at a European level – even if these are not (yet) the actual reality in all European countries. Undergraduate training of medical students is focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the aging population and the increase of disability in our continent. The problems of continuing professional development and medical education are faced in a PRM European perspective. Finally, the principles and the contents of the European curriculum are detailed. 

Education and Training

PRM practice is uniquely characterized by a team-based, patient-centred, goal-directed approach aimed to optimize patient function and quality of life, prevent complications and increase community participation. Therefore, PRM specialists are required to develop not only medical knowledge, competence in patient care and specific procedural skills, but also attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. 

As leaders of the multi-professional rehabilitation teams involved in the continuum of care delivery from hospital to the community, they must also exhibit managerial competences, know and apply the principles of evidence-based medicine, incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate. 

PRM is an independent medical speciality in all European countries, except Denmark. The recognition of the specialty is under way in Russia and Ukraine, thanks to an action of the UEMS PRM Section and Board, whose delegates have organized several educational activities, in strict collaboration with local physicians, claiming for the establishment of PRM as a full and independent medical specialty. 

Standards in education and training of PRM physicians 

According to UEMS rules, the establishment of a common set of knowledge, skills and competencies for postgraduate training allows to create a Common Training Framework, enabling specialists in that discipline to move from one country to another. In line with the aims of the UEMS, the European PRM Board aims to promote patient safety and quality of care through the development of the highest standards of medical training and health care across Europe and the harmonisation of PRM specialists’ qualifications. In doing so, the European PRM Board does not aim to supersede the National Authorities’ competence in defining the content of postgraduate training in their own State but rather to complement these and ensure that high quality training is provided across Europe.

Training duration

To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. Their basic medical training must give them certain competencies, which are enhanced by knowledge and experience acquired during their common trunk training in internal medicine, orthopaedics, neurology, etc. Due to different national traditions and laws, the name and focus for the PRM specialty varies, as well as the duration of the training (see Table 1). Although the mean duration of all specialties training in Europe has increased in the period 1989-2013 (1) (  Figure 1), there is a trend, at the moment, in a few European countries, towards decreasing the duration of the medical specialty training for economic and societal accountability reasons (2). The PRM educational program in Europe is usually configured in 48-month format, rising up to 72 months in some countries, including a minimum 36 months of clinical training (of which 24 months spent in a PRM department).

However, considering the tremendous increase in life expectancy all over Europe, and the consequent increase in age-related disabling illnesses with acute onset and chronic course, the frequency and complexity of comorbidities in rehabilitation wards have markedly increased. Patients are admitted to wards much earlier after the onset of acute illness or injury and the complexity of the disabilities is also rising. For this reason the PRM Board advocates a duration of training of 60 months including 12 months rotations in external departments (like internal medicine, neurology, intensive care and others). Moreover, in order to provide patients with optimal care; PRM trainees are expected to develop decision-making abilities, based on finding, understanding and using the best available evidence. On such premise, it is recommended that PRM trainees are offered at least six months training in research methods, as a mandatory component of their postgraduate education. Rehabilitation is a complex activity and affected by multiple factors. Specific research methodology issues have to be learnt and applied in order to achieve those levels of evidence, in the scientific literature, that can help the specialty to flourish and compete successfully in future health economies. Hence, potential academics should be supported in pursuing PhD programmes within an appropriately staffed unit.

Directors of Training, Trainers and training units

The education of PRM doctors to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Training must be realized in dedicated centres where qualified personnel and adequate resources are available. 

The Director of PRM training has the overall responsibility for the training programme; he/she oversees and ensures the quality of didactic and clinical education and monitors resident supervision in all sites that participate in the educational program. He/she must exhibit PRM specialty expertise and be recognised as a trainer in PRM by the responsible national authority in his/her own country. It is also recommended that he/she has achieved the status of PRM Board certified trainer. 

Each trainee must receive supervision by one trainer (a PRM physician, hopefully) with documented qualification to instruct and supervise residents. The trainers are continuously involved in a tutoring role, to help trainees to develop the skills, knowledge, and attitudes relevant to PRM practice and assume graded and progressive responsibility for the care of individual patients.

Assessment of learning /training outcomes 

The achievement of learning/training outcomes must be assessed at least on an annual basis by the Director of Training together with the faculty. Adequate permanent records of the evaluation must be maintained. Such records must be available in the trainee file and must be accessible to the trainee and other authorized personnel. The assessment must be objective and document progressive trainee performance improvement appropriate to their educational level. In particular, the final year examination must verify that the trainee has demonstrated sufficient competence to enter practice without direct supervision. In the evaluation process, the trainee’s rights must be protected by due process procedures. The trainee must be provided with the written institutional policy concerning his/her rights and the institution’s obligations and rights 

Certification procedures 

Specialists in PRM have freedom of mobility across UEMS member states, but require certification from their national training authorities (3). Those with the latter are eligible to be recognised by the European Board of PRM, which has a comprehensive specification on several aspects of postgraduate education for PRM-specialists. This consists of:

  • a curriculum for postgraduate education containing basic knowledge and the application of PRM in specific health conditions;
  • a specimen of a training course of at least four years in a PRM department with detailed registration in a specimen of a uniform official logbook;
  • a single written annual examination throughout Europe ;
  • a system of national managers for training and accreditation to foster good contacts with trainees in their country;
  • standard rules for the accreditation of trainers and a process of certification;
  • quality control of training sites performed by site visits of accredited specialists; and
  • continuing professional development within the UEMS covering the continuing medical education system for the purpose of ten yearly revalidation.

Further information on the regulations of this education and training system can be found on the section’s website, www.euro-prm.org , where application forms are also available.

There are currently around 20000 PRM-specialists in Europe and 3000 PRM trainees; out of 3897 PRM doctors who have been European Board certified since 1993, 1094 are active Fellows of the PRM European Board: 260 of them have achieved the status of Senior Fellows; 24 training sites (whose list is available on the website at http://euro-prm.org/certification_docs/TC.htm) are Board certified centres for PRM education according to the European standard.

Undergraduate Training

Disease management is a team-based aspect of medical practice that is patient-centred, goal directed and aims to optimize patient function and quality of life, prevent complications and increase community participation. Medical students will be responsible for the care of patients with disabilities regardless of what field they choose to enter, as postgraduate trainees. In the present times, patients treated by virtually all specialties express rehabilitation needs, when we consider that people currently survive what had formerly been a lethal disease but are now left to struggle on with impairment and disability, or to better say, with limitations in their activities and participation (4).

As a result, all physicians need to gain a basic knowledge of rehabilitation, recognising that most will not practise as specialists in the field or carry out specific rehabilitation measures. It is thus important that well-trained PRM specialists teach PRM in all undergraduate medical faculties and the following topics are required as a minimum:

  • The principles of PRM and the bio-psycho-social model of the international classification of functioning, disability and health;
  • The organisation and practice of PRM (acute and post-acute rehabilitation, as well as rehabilitation programmes for patients with chronic conditions);
  • The principles and aims of functional assessment and the main adverse factors of functional recovery 
  • The principles and potential of physiotherapy, occupational therapy, (neuro)psychology, speech and language therapy and other rehabilitation therapies;
  • The principles and effects of drug treatments used to improve function, prevent complications, alleviate pain or any other source of discomfort;
  • Comprehensive rehabilitation programmes and their main indications;
  • The rehabilitative needs of patients with special conditions (e.g. stroke, multiple trauma, low back pain, arthritis, cancer, etc.);
  • Knowledge of the social system and legislation concerning disability and rehabilitation at national level, as well as ethical and human rights issues in rehabilitation.

These concepts already form part of obligatory training in PRM in most European countries. The European Board of PRM has defined a core for an Undergraduate Training Curriculum with practical skills and definition of training period in a PRM department. In the action plan of the European Board of PRM 2014-2018 an e-book supporting such a curriculum is provided. 

Continuing Professional Development (CPD) and Medical Education (CME)

In the interests of patient safety and good quality care, all doctors have a duty to engage in a continuum of education, training and life-long learning to maintain good professional practice. Quality assurance must demonstrate that national standards are comparable to international standards. In this global context, Continuing Professional Development (CPD) must take account of international innovations and good practices, requiring all practicing physicians to keep up to date, gain new skills and ensure that existing practices are updated to incorporate new evidence and guidelines as they become available. National regulatory authorities oversee the maintenance of this. 

In line with the above requirements, CPD and Continuous Medical Education (CME) are an integral part of PRM specialists’ professional practice. All PRM specialists must demonstrate their continued competence. This should be transparent, accountable, amenable to regulation and useful for assuring quality in the process of maintaining re-certification.

CPD consists of all the educative means of updating, developing and enhancing how doctors apply the knowledge, skills, attitudes (and behaviours, and the ethical standards) required in their working lives. CPD for example, involves activities to enhance team building, management, professionalism, interpersonal communication, information technology, teaching, research, peer review, audit and accountability. In this sense, CPD incorporates and goes beyond CME (clinical knowledge); however, CME credits can be regarded as a simple means of confirming involvement in CME/CPD, and as a common “CME currency”. The UEMS has harmonised its CME accreditation around the European CME Credit (ECMEC) that can be used throughout Europe and, via a mutual recognition agreement with the American Medical Association, also in North America. The American Board of Physical Medicine and Rehabilitation (ABPMR) is one of 24 medical specialty boards that make up the American Board of Medical Specialties (ABMS) (5). The ABMS aims to protect the public by establishing common standards for physicians to achieve and maintain board certification in their respective specialties. The ABMS assesses and certifies physicians who meet specific educational and training requirements. The ABPMR establishes the requirements for certification and maintaining certification, creates its examinations, strives to improve training, and contributes to setting the standards for physical medicine and rehabilitation (see for reference www.abms.org). 

The UEMS European Accreditation Council of CME (EACCME) ® is an institution of the UEMS which formally represents European countries: therefore, its credits are recognised by National Accreditation Authorities, as complementary, not competitive, to their competence and activities. The European provisions are the same for all specialties. EACCME is responsible for coordinating his activity for all medical specialties and the UEMS website gives details of the continuing medical education requirements for all specialists in Europe (see for reference www.uems.org). Obligatory CPD/CME is established in certain countries of Europe and is becoming increasingly required in medical practice. Professional competence schemes are the formal structures provided by member states, to ensure that registered specialists maintain their competence at the desired level. Each doctor has a duty to register with such a scheme. At the National level, these countries have developed their own rules and most have obligatory requirements. Some countries have made these legal requirements. The PRM-Board has created the CME/ CPD Committee, which is responsible for the relevant continuing programs within our specialty, for the accreditation of the several scientific events at the European level and the scientific status of the Board Certified PRM specialists. The international teaching programmes serve to educate PRM specialists and their colleagues in rehabilitation teams; they cover basic science and clinical teaching topics, as well as investigational and technical programmes.. The CME/CPD programme organised on European level for accreditation of international PRM congresses and events is based on the provisions of the mutual agreement signed between the EACCME and the UEMS PRM Section and Board, whose details are published on the Board website (http://www.euro-prm.org/index.php?option=com_content&view=article&id=23&Itemid=168&lang=en).

According to this mutual agreement, the National Accreditation Authority of each Member State of the EU (EEA) is:

  • the relevant authority guiding and controlling the accreditation of the Doctors working in its country and determining the number of credits required
  • is responsible for the relevant programmes within the specialty, for the accreditation of the scientific events at the European level and the scientific status of the Board certified PRM specialists. 

Each Board recognised PRM specialist is required to gain 250 educational credits over a five-year period for the purposes of revalidation (www.euro-prm.org). Credits can be achieved through different CME activities, including passive or active participation in scientific events, publications in journals/books, academic activities (e.g. Ph.D.), and self-education (through personal subscription to PRM journals, or documented attendance to internet PRM teaching lessons). In line with the UEMS rules, the PRM Board recognises that considerable advances are being made in the methodologies by which CME and CPD can be provided, and by which these educational opportunities are accessed by doctors. Therefore, it acknowledges the use of new media for the delivery of CME/CPD, that go beyond traditional lectures, symposia and conferences. Doctors are required to fulfil their CME requirements before they can be validated and this is becoming an essential part of national as well as European life. 

The PRM Board also takes the responsibility of enhancing the opportunities of education for PRM trainees and young PRM doctors through sponsoring international teaching programmes and delivering educational material. Even only considering the 2015, the PRM Board has accredited 18 International Courses, delivering a total 293 CME credits..

The first European Board sponsored event has been the European School in Marseille on Posture and Movement Analysis, which was established in 2000. This is an annual two-week course, which attracts doctors, engineers and other rehabilitation professionals from all over Europe. The EuroMediterranean Rehabilitation Summer School was started in Syracuse in 2005. It is an annual high level residential course on rehabilitation topics, offered for free to 40 PRM trainees from UEMS and Mediterranean countries. 

Several e-books with educational content have been published and distributed to many Fellows and trainees for free. They are currently downloadable from the Board website (http://www.euro-prm.org/index.php?option=com_content&view=article&id=28&Itemid=178&lang=en)

Curriculum in PRM: main principles

The different fields of competence and intervention of PRM specialists are typically described by categories taking into account the underlying medical conditions or the impaired body system. In fact, acute care medicine/general medicine is centred very much on organs, diseases and mechanisms of injury based on the International Classification of disease – ICD model of medicine. This influences the way of categorizing patients far beyond the medical world. This is not optimal for a function-centred medical specialty like PRM (6). Instead, the fields of competence and intervention of PRM specialists should be listed using function-related categories based on the International Classification of Functioning, Disability and Health – ICF. According to this model, PRM specialists need

  • To know the biopsychosocial determinants of health and the complex interaction of factors that limit a disabled person’s participation and autonomy in the context of their medical condition.
  • The skill to communicate this to the patient, the patient’s family and to colleagues and the rehabilitation team so that there is an effective combined approach that is focused on the patient’s particular priorities.
  • To demonstrate highly person-centred clinical practice with an emphasis on assessment, planning and teaching in close liaison with team members and within a culture of empowerment and risk management.

On such premise, competencies to be acquired during the training, or expected to have by the end of training, include: 

  • clinical and instrumental assessment to determine the pathophysiology mechanisms and the underlying diagnosis of the patient’s condition.
  • Learning principles/neuroplasticity/repair/recovery ….
  • functional assessment in the frame of ICF, including assessment of body function/structure impairment, assessment of activity limitation and participation restriction and discrimination between capacity and performance, based on the detection of contextual (personal characteristics) and environmental barriers/facilitators 
  • implementation of clinical and instrumental assessment tools to explore motor, cognitive, behavioural and autonomic functions.
  • prognosis of disease/disability course, detection of adverse/favourable factors of functional recovery and definition of the means (ways) of recovery, compensation and adaptation
  • devising and conducting a rehabilitation plan, through a team-based approach that consists of setting achievable short, medium and long-term goals, agreed with the patient and carers, and eventually leading to patient’s reintegration in the community and improved quality of life;
  • prescription, as much evidence-based as possible, of medical and physical treatments (including drug treatment, physical modalities, innovative technologies, natural factors and others), as well as of technical aids (orthotics, prosthetics, wheelchairs and others), effective to achieve the goals of the rehabilitation plan;
  • prevention and management of complications
  • leadership and teaching skills appropriate to coordinate and prioritize teamwork 
  • communication skills appropriate to convey relevant information and explanations to the patient/carers, to colleagues in charge of the patient and other health professionals with the objective of joint participation in the planning and implementation of continuous health care from the initial stage to the post-acute and steady state
  • commitment to carrying out professional responsibilities and adherence to ethical principles, demonstrating compassion, integrity, and respect for others; responsiveness to patient needs , respect for patient privacy and autonomy, sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation
  • active cooperation with the public health agencies and other bodies involved in the health care system 
  • identification of the health needs of the community and implementation of appropriate measures aimed at the preservation and promotion of health and healthy lifestyles and prevention of diseases 
  • conducting programmes of therapeutic education for disabled people and caregivers. 
  • participation in education of physicians and other professionals involved in care for disabled people.
  • implementation of cost awareness and risk-benefit analysis in patient and/or population-based care 
  • ability to improve the quality of professional work through continuous learning and self-assessment, managing practice and career with the aim of professional development 
  • ability to apply the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care 

Under the perspective of a disease-centred approach, PRM specialists must develop progressive responsibility in diagnosing, assessing, and managing the conditions commonly encountered in the rehabilitative management of patients of all ages in the following areas: 

  • -acute and chronic musculoskeletal syndromes, including sports-related injuries, occupational injuries, rheumatologic disorders, post-fracture care and post-operative joint arthroplasty; 
  • acute and chronic pain conditions, including use of medications, physical modalities, exercise, therapeutic and diagnostic injections, and psychological and vocational counselling; 
  • congenital or acquired amputations; 
  • stroke;
  • congenital or acquired brain injury; 
  • congenital or acquired spinal cord disorders; 
  • congenital or acquired myopathies, peripheral neuropathies, motor neuron and motor system diseases, and other neuromuscular diseases; 
  • pulmonary, cardiac, oncologic, infectious, immunosuppressive, and other common medical conditions seen in patients with physical disabilities;
  • tissue disorders such as ulcers and wound care.
  • medical conditioning, reconditioning, and fitness
  • metabolic conditions

The postgraduate PRM curriculum details the theoretical knowledge necessary for the practice of the medical specialty of Physical Medicine and Rehabilitation and the core competencies (training outcomes) to be achieved at the end of training. 

Although the route to start training varies across European countries, the curriculum has much similarity across the continent and is consistent with that of the American Board (see the www.abprm.org website for reference) or other Rehabilitation Medicine Senior Residency programs (http://www.singhealthresidency.com.sg/Pages/RehabilitationMedicine.aspxhttp://www.singhealthresidency.com.sg/Pages/RehabilitationMedicine.aspx). 

References

1.                                                                                                                                                                Duchatteau DC, Rol M Van Der, Smit Jongbloed LJ, Jong EM De, Vos P. Eindrapportage Quickscan Opleidingsduur en Bekostiging Medisch Specialistische Vervolgopleidingen in de EU. 2013. 

2.                                                                                                                                                                Kiekens C, Moyaert M, Ceravolo MG, Moslavac S, Juocevicius A, Christodoulou N, et al. Education of physical and rehabilitation medicine specialists across Europe: a call for harmonization. Eur J Phys Rehabil Med. 2016 Dec;52(6):881–6. 

3.                                                                                                                                                                The European Parliament and the Council of the European Union. Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications. Off J Eur Union. 2005;22–142. 

4.                                                                                                                                                                Ward AB, Gutenbrunner C, Damjan H, Giustini A, Delarque A. European Union of Medical Specialists (UEMS) section of Physical & Rehabilitation Medicine: a position paper on physical and rehabilitation medicine in acute settings. J Rehabil Med. 2010 May;42(5):417–24. 

5.                                                                                                                                                                American Board of Physical Medicine and Rehabilitation. Curriculum of Knowledge [Internet]. Available from: https://www.abpmr.org/partI/documents/PartIOutline_Weights.pdf

6.                                                                                                                                                                Wade D. Rehabilitation – a new approach. Part four: a new paradigm, and its implications. Clin Rehabil. 2016 Feb;30(2):109–18.