ΣΥΝΕΧΗΣ ΕΚΠΑΙ ΕΥΣΗ, ΕΛΕΓΧΟΣ ΠΟΙΟΤΗΤΟΣ, ΠΙΣΤΟΠΟΙΗΣΗ: ΠΡΟΚΛΗΣΕΙΣ ΚΑΙ ΑΝΑΓΚΑΙΟΤΗΤΑ ΣΤΗ ΣΥΓΧΡΟΝΗ ΚΑΡ ΙΟΛΟΓΙΑ Λουτράκι 19/02/11. Γ.

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1 ΣΥΝΕΧΗΣ ΕΚΠΑΙ ΕΥΣΗ, ΕΛΕΓΧΟΣ ΠΟΙΟΤΗΤΟΣ, ΠΙΣΤΟΠΟΙΗΣΗ: ΠΡΟΚΛΗΣΕΙΣ ΚΑΙ ΑΝΑΓΚΑΙΟΤΗΤΑ ΣΤΗ ΣΥΓΧΡΟΝΗ ΚΑΡ ΙΟΛΟΓΙΑ Λουτράκι 19/02/11 Γ. Καρατασάκης

2 QUESTIONS What is the aim of cardiology training? How much does a cardiologist need to know? What is the level of skills a cardiologist need? Who defines and checks the competence of cardiologists? National or international level?

3 POLICIES OF MEDICAL EDUCATION VERTICAL: Subspecialties, expensive diagnostic and therapeutic modalities. Pro: Development of knowledge, skills and experience. Medicine advances through subspecialties Contra: Too expensive, possibility of mistakes because of unilateral thinking, need for large number of doctors

4 POLICIES OF MEDICAL EDUCATION HORIZONTAL: Low cost procedures, no subspecialties. Pro: Cost-effective, socially acceptable, medicine oriented to the patient. Contra: Retardation of knowledge development, no specific skills

5 MEDICAL EDUCATION Clinical education has not kept pace with: Changing health system expectations Evolving practice requirements New information A focus on improving quality New technologies

6 MEDICAL EDUCATION Medical schools and teaching hospitals should share learning resources Greece?? Simulation laboratories Standardized patient programs, Information technology applications

7 AIM The clinical subject of cardiology aims to deliver competent care for patients presenting with disorders of the heart, the pulmonary vasculature and the systemic arterial and venous systems

8 Training in Cardiology Cardiology is expanding (subspecialties) Knowledge required for all cardiologists often confused with knowledge of specific fields Coordination of training Assurance that the knowledge and skills of a cardiologist are independent of the location (hospital, town, country) of training.

9 TRAINING Knowledge of and exposure to a broad range of medical conditions Generic knowledge and skills, communication, bioethics, biostatistics, ability to analyze, interpret and utilize medical literature The trainee should have the linguistic ability to communicate with pts and colleagues in the country of training

10 Duration- recommendations Six years of postgraduate training Two years of common trunk medicine Four years of cardiology LABS OUTPATIENTS- ER Consultation for other services

11 Σύμφωνα με τις απαιτήσεις του CHAPTER ON TRAINING OF MEDICAL SPECIALISTS IN THE EUROPEAN UNION κάθε ειδικευόμενος πρέπει να αποκτήσει εμπειρία στις εξής παρακλινικές-εργαστηριακές εξετάσεις, τις οποίες πρέπει να έχει μελετήσει προσωπικά: ΗΚΓφήματα : 1000 Holter: 200 Hλεκτροκαρδιογραφικές οκιμασίες κόπωσης : 300 Υπερηχοκαρδιογραφικές μελέτες : 500 Προγραμματισμός βηματοδοτών 50 Τοποθέτηση προσκαίρου βηματοδότη 10 Τοποθέτηση καθετήρων Swan-Ganz 20

12 TRAINING Trainees should have the opportunity to rotate through different institutions for several aspects of the curriculum that do not exist in the initial center

13 TRAINERS Accredited Experience in research and teaching Equal number of trainers and trainees Director of training

14 Elzubeir, Rizk, United Arab Emirates, Med Education 2001

15 EXAMPLES OF CRITICAL INCIDENTS REPORTED BY RESIDENTS WITHIN 8 DIMENSIONS OF FACULTY TEACHING EFFECTIVENESS Clinical competence Enthusiasm for teaching Respect for colleagues Respect for patients Integrity Acceptance of responsibility for patient care Ability to admit errors Responsible use of resources

16 TRAINING INSTITUTIONS Beds Labs OP ER Surgery Cmbination of institutions

17 USA In programs with a total of more than six trainees, for each 1.5 residents there must be no less than one faculty member who must devote at least 20 hours per week to teaching, research, administration, and/or the critical evaluation of the performance, progress, and competence of the residents.

18 USA There must be laboratories that provide resources for electrocardiography, ambulatory electrocardiogram (ECG) recording, exercise testing, echocardiography (including Doppler and transesophageal studies), and radionuclide techniques. Other hospital resources should include facilities for assessment of peripheral vascular disease and pulmonary physiology.

19 USA Diagnostic techniques, including: a. Magnetic resonance imaging b. Fast computed tomography c. Positron emission tomography

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22 ΕΛΛΑΣ ΤΟ ΠΡΟΓΡΑΜΜΑ ΕΞΕΤΑΣΕΩΝ ΑΠΗΡΧΑΙΩΜΕΝΟ Οι ερωτήσεις θεωρίας - έκθεση ιδεών Ηεξέταση«παρά «παρά την κλίνη του ασθενούς» ατελής Αραιότερες-σοβαρότερες εξετάσεις

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24 ECHO Most used cardiac imaging test 23 million echo studies in US annually 2.5 million stress echo Most common use LV function assessment Valvular heart disease Haemodynamics Essential in management of all forms of heart disease

25 Tx List 13 years ago LVFn

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31 TEE When not

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33 STRESS

34 EXAMS

35 RE-ACCREDITATION

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37 QUALITY

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40 GO DIGITAL No Snapshots

41 SERIAL EVALUATION

42 Sonosite, Vivid i

43 Echo and imaging Stetho-scope Σκοπώ Echo is a stethoscope in real terms Probably an adjunct to the clinical evaluation Part of the physical examination?

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45 POSITION PAPER OF THE EAE Aid to the clinical exam No extra charge No independent echo report

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55 THANK YOU

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59 Clinical application of quantitative stress echo systolic velocity reproducible, accurate simple, practical regression models matched controls normative series high NPV non-specific strain rate / PSS index reproducibility suboptimal difficult in clinical practice time-consuming automated analysis less affected by tethering suitable after infarction best for LAD, viability

60 Evaluation of Coronary Artery Disease Left ventricular inotropic reserve Surrogates of arterial inflammation Interleukin-6, CRP Myocardial perfusion Coronary flow reserve Epicardial flow+microvascular functional integrity

61 Picano Am J Hypert 2001 PROGNOSTIC IMPACT OF CFR: A COMBINED APPROACH BY INTERPLAYING WITH MYOCARDIAL DYSYNERGY AND CORONARY ANATOMY

62 baseline Adenosine CFR=2.8

63 Review : Hell J Card : Roelandt, Bom, Thoraxcenter

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69 Feasibility of remote echocardiography with satellite transmission and real-time interpretation to support medical activities in the austere medical environment The study demonstrates the feasibility and diagnostic accuracy of remote, real-time echocardiography using satellite transmission for mass casualty triage or humanitarian relief efforts. Huffer LL et al J Am Soc Echocardiogr Jun;17(6):670-4.

70 The robot and the satellite for teleoperating echographic examination in Earth isolated sites or onboard ISS At the expert center, the ultrasound medical expert moves a fictive probe, connected to a computer (n degrees 1) which sends, the coordinate changes of this probe via an ISDN or satellite line to a second computer (n degrees 2), located at the isolated site, which applies them to the robotic arm holding the real echographic probe. The system was also tested successfully using satellite links in a limited number of cases (approx 30). Arbeille et al J Gravit Physiol Jul;11(2):P233-4

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73 1 msv = 50 chest x-rays The threshold of 50 msv of epidemiological evidence is surpassed by a typical cardiologic patient with known or suspected coronary artery disease, in one single hospital admission.

74 Acute chromosomal DNA damage in human lymphocytes after radiation exposure in invasive cardiovascular procedure: Eur Heart J 2007 Micronucleus levels after ionizing radiation following invasive cardiac procedures:

75 Lack of radiological awareness among physicians working in a tertiary-care cardiological centre. Int J Cardiol Sep 1;103(3): Contribution of nuclear and radiological tests in overall radiation exposure of average US inhabitant: as <0.01% (36% of physicians) or <1% (31%) or <10% (22%): correct answer given by 11% of physicians: >10% Risk of fatal cancer associated with a stress myocardial perfusion scintigraphy procedure: as "zero" (48%) or "<1 in 10 million"(19%) or "<1 in 1 million" (28%) correct answer given by 5%: >1 in 10,000 tests Dose exposure of a myocardial stress perfusion scintigraphy: as equal to one (13%), or one-half (9%), or three times (49%) that of a chest X-ray correct answer given by 29%: 500 times The average level of radiological awareness was not correlated to the number of radiological-

76 American College of Radiology : "White Paper on Radiation Dose in Medicine April 2007 The White Paper set forth practical suggestions to minimize radiation risk, including education for all stakeholders in the principles of radiation safety and preferential use of alternative (nonionizing) imaging techniques, such as MRI and ultrasound. These recommendations are especially relevant for cardiologists, who prescribe and/or practice medical imaging examinations accounting for at least 50% of the total effective dose by radiation medicine, which amounts to an equivalent of about 160 chest x-rays per head per year in US (=3.2mSv). Were they be enacted, these simple recommendations would determine a revolution in the contemporary way of teaching,

77 From benefit to risk-benefit The ALARA principle recognizes that there is no magnitude of radiation exposure that is known to be completely safe. This principle confers a responsibility on all physicians to minimize the radiation injury hazard to their patients, to their professional staff, and to themselves

78 Picano, E. Informed consent and communication of risk from radiological and nuclear medicine examinations: how to escape from a communication inferno. Education and Debate. BMJ 2004, 329,

79 Pennell et al: Working Group on Cardiovascular Magnetic Resonance of the European Society of Cardiology: Clinical indications for cardiovascular magnetic resonance [CMR]: Consensus Panel report. / Eur Heart J 2004, 25:

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83 Wikis, Blogs and Podcasts: Emerging Tools for Virtual Collaborative Practice and Learning/CPD in Medicine The lecturer should give the audience full reason to believe that all his powers have been exerted for their pleasure and instruction. Michael Faraday ( ) - English physicist

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87 USA Program Requirements for Residency Education in Cardiovascular Disease (Internal Medicine)

88 ΕΚΕ Σύμφωνα με τις απαιτήσεις του CHAPTER ON TRAINING OF MEDICAL SPECIALISTS IN THE EUROPEAN UNION κάθε ειδικευόμενος πρέπει να αποκτήσει εμπειρία στις εξής παρακλινικές-εργαστηριακές εξετάσεις, τις οποίες πρέπει να έχει μελετήσει προσωπικά: ΗΚΓφήματαατα : 1000 Holter: 200 Hλεκτροκαρδιογραφικές οκιμασίες κόπωσης : 500 Υπερηχοκαρδιογραφικές μελέτες : 400 Õðåñç ïêáñäéïãñáöéêýò ìåëýôåò Doppler: 200 Õðåñç ïêáñäéïãñáöéêýò ìåëýôåò, äéïéóïöüãåéåò: 50 Åðßóçò ðñýðåé íá Ý åé óõììåôüó åé, ôïõëü éóôïí ùò âïçèüò óôéò ðáñáêüôù åðåìâüóåéò: Óôåöáíéïãñáößá - áñéóôåñü êïéëéïãñáößá: 300 Äåîéüò-áñéóôåñüò êáèåôçñéáóìüò : 100 ÁéìáôçñÝò çëåêôñïöõóéïëïãéêýò ìåëýôåò (+ICD) : 50 Ðñïãñáììáôéóìüò âçìáôïäïôþí : 20 Ðñïãñáììáôéóìüò ICD : 10

89 ΠΡΟΫΠΟΘΕΣΕΙΣ ΚΕΝΤΡΩΝ ΓΙΑ ΕΚΠΑΙ ΕΥΣΗ Εξωτερικά ιατρεία/τμήμα επειγόντων Πλήρης Μονάς εμφραγμάτων 6 κλίνες Ολες οι μη επεμβατικές μέθοδοι Στεφανιογραφία Αίθουσα σεμιναρίων Χώρος για ειδικευομένους Πρόγραμμα εκπαίδευσης

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91 ΗΠΑ ΧΡΟΝΙΚΟ ΙΑΣΤΗΜΑ ΕΚΠΑΙ ΕΥΣΗΣ Μήνες Θάλαμοι 8 τουλάχιστον Αιμοδυναμικό Εργ. 4 τουλάχιστον Μη αιματηρά Εργ έτη ΗΛΦ Εργαστήριο 4 Σύνολο 36 Αναγκαίες ελάχιστες πράξεις Καθετηριασμοί στεφανιογραφίες 100 οκιμασίες κόπωσης 50 Υπερηχοκαρδιογραφικές εξετάσεις 150 There must not be excessive reliance on residents for service

92 ΗΠΑ -OI ΥΠΟΕΙ ΙΚΟΤΗΤΕΣ ΚΛΙΝΙΚΗ ΗΛΕΚΤΡΟΦΥΣΙΟΛΟΓΙΑ 2 ανά 1.5 ειδικευομένους Κατάλληλα εξοπλισμένο εργαστήριο Εξωτερικά ιατρεία Μονάδα εμφραγμάτων Καρδιοχειρουργικό Τμήμα 2 επεμβάσεις / εβδομάδα Τουλάχιστον 100 πράξεις / 50 ασθενείς Επίσημη διδασκαλία Απαραίτητα άφθονα εφόδια βηματοδοτών απινιδωτών πρώτος χειριστής βοηθός

93 Οι ειδικευόμενοι πρέπει να γράφουν μόνοι τους υπό επίβλεψη και συζήτηση τις εντολές νοσηλείας Teaching Rounds Τλχ 3 / εβδομάδα 4½ώρες Συνεδριάσεις Σεμινάρια

94 ΗΠΑ ΕΠΕΜΒΑΤΙΚΗ ΚΑΡ ΙΟΛΟΓΙΑ 1 έτος 127 προγράμματα μόνο 56 δίδουν στοιχεία 1.6 ειδικευόμενοι/πρόγραμμα 6.3 full-time διδάσκαλοι (1.5/1 με ειδικευομένους) 4.8 ομιλίες/συνεδριάσεις/εβδομάδα 71.4% πρόγραμμα βελτίωσης δεξιοτήτων διδασκαλίας 39% Research rotation

95 ΑΠΑΙΤΗΣΕΙΣ ΕΞΑΣΚΗΣΗΣ Τουλάχιστον 250 επεμβατικές πράξεις με σαφή συμμετοχή Συμμετοχή στο σχεδιασμό επεμβάσεων «μετράει» είναι για κάθε πράξη υπό τον έλεγχο διδακτικού προσωπικού

96 Curriculum for interventional cardiology subspecialty training in Europe Six months prepares the patient for the intervention assists angioplasty procedure Six months primary operator for simple angioplasties under close supervision and assists for the most complex angioplasty procedures Second year performs angioplasty procedures

97 Requirements for training center and training supervisors Independent interventional cardiology unit Units not integrated in a cardiology department can be exceptionally considered Program should perform at least 800 coronary angioplasties per year At least two supervisors with an experience of at least 1000 coronary interventions At least 200 interventions as primary operator

98 ΚΟΙΝΑ ΣΤΟΙΧΕΙΑ ΕΠΙΤΥΧΗΜΕΝΩΝ ΙΝΣΤΙΤΟΥΤΩΝ (CENTERS OF EXCELLENCE) Ταχεία αναταπόκριση σε οικονομικές μεταβολές Εστιασμός πολυ- έρευνας σε κοινούς στόχους Συντονισμός έσω eξωτερικών δραστηριοτήτων Lobby για οικονομικές ενισχύσεις Κυριαρχεί στην τοπική κλινική αγορά Ακολουθούν επιθετικά προγράμματα ανάπτυξης Παρακάμπτουν τη γραφειοκρατία Πρέπει να συνεισφέρουν στα υπάρχοντα συστήματα υγείας Feldman et al Am J Med 2005;118: Association of Professors of Medicine

99 ACADEMIC HEALTH CENTERS

100 Educating Doctors to Provide High Quality Medical Care A Vision for Medical Education in the United States Report of the Ad Hoc Committee of Deans

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103 Tell the learner exactly what to expect, including the methods of student support Advise the teacher what to do to deliver the content and support the learners in their tasks of personal and professional development Help the institution to set appropriate assessments of student learning and implement relevant evaluations of the educational provision Tell society how the school is executing its social responsibilities

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105 Steinert Medical Education 2004 Effective small group tutors A positive group atmosphere Active student participation and group interaction Adherence to small group goals Clinical relevance and integration Cases that promote thinking and problem solving

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