MODELS OF POSTGRADUATE TRAINING: the Italian experience

1. MODELS OF POSTGRADUATE TRAINING: the Italian experience Antonio Cherubini, MD, PhD Institute of Gerontology and GeriatricsUniversity of Perugia Medical School European union Geriatric Medicine Society

2. GERIATRIC POSTGRADUATE TRAINING • In Italy the training of residents is under control of the Universities that have Schools for each discipline. Only recently, with the 2009 reform, there is the requirement for residents to train in health care services that are not under direct control of the University School.

3. GERIATRIC POSTGRADUATE TRAINING • The School of Geriatrics is placed in the group of General Medicine Schools, together with the School of Internal Medicine, Sports Medicine, Thermal Medicine, Medical Oncology, Community Medicine and, more recently, Emergency medicine. • For each type of School there is a specific professional learning profile that defines the knowledges, attitudes and skills that the specialist should acquire during the training.

4. GERIATRIC POSTGRADUATE TRAINING • The length is 5 years since 2009 (300 credits). The School has a restricted access, with a yearly nationally defined number of trainees. • It can be started right after Medical School (full specialty).

5. Considering that 300 CFU, provided for the 5 years, develop a total of 7,500 hours (1,500 hours per year) and that the time of service of a resident is 38 hours per week, equivalent to 1824 hours/year (9120 hours in 5 years, except for 4 weeks of justified absence per year, corresponding to the annual leave), it is agreed to allocate to 1 CFU of formal education 25 hours and to 1 CFU of professional training 33 hours. In this way, the working load (2250 +6930 = 9180 hours in 5 years) is basically the same of an attending physician. CREDITS

7. CORE CREDITS (270 CFU) Are represented by the training activities aimed at acquiring knowledges, skills and behaviors needed in the practice of Geriatrics. They are named “characterizing activities” differentiated in : a) Formalteaching activities (30% of CFU): activities conducted in the presence of the teacher and in moments of self-learning; b) Professional activities (70% of CFU): the application of knowledge and skills gained from formal activities in a real clinical context, in which the resident progressively acquires autonomy and responsibility.

8. FORMAL TEACHING ACTIVITIES PROFESSIONAL ACTIVITIES 70% total credit (210 CFU 42 /year) 30% total credit (90 CFU 18 /year) 1° anno 21 21 3 1 8 8 5 1 21 21 2° anno 11 31 31 11 1 1 2 2 10.5 10.5 3 3 1 0.5 0.5 11 31 31 11 3° anno 1 1 2 2 10.5 10.5 3 3 1 0.5 0.5 10.5 1 3 2 31 11 0.5 4° anno 1 3 1 11 2 10.5 31 1 5° anno 31 3 3 3 11 11 31 1 1 2 2 7.5 3 7.5 0.5 0.5 Attività Formative Formal AD CFU Didattiche Basal 5 Di Base 5 Similar 5 Affini 5 Common Trunk 16 Tronco Comune 16 44 Characterizing Total of 5 years Caratterizzant i 44 15 Thesis Tesi 15 Other 5 Altre 5 Total FTA 90 Specific Professional A 210 Total CFU 300 HYPOTHESIS of DISTRIBUTION OF ACTIVITIES

9. THE COMMON TRUNK …“an area aimed at providing common knowledge, coordinated by a teacher that in the medical and surgical area should be identified with the Professor of Internal Medicine and Professor of General Surgery, respectively… “….the recommendation regarding the adoption of a CT in the postgraduate curricula of different specialties, i.e. a common cultural base, arises from an attempt to counteract the fragmentation of knowledge, which has negative consequences, both for clinical practice and the organization of clinical activities”

10. OBJECTIVES OF THE COMMON TRUNK • To provide a satisfactory theoretical knowledge and professional competence in the recognition and treatment, even in emergency-urgent situations, of the most common diseases of adulthood and advanced age. • This common core should give residents a methodological uniformity in the approach to solving health problems of the elderly, differentiating them from those of adults.

11. OBJECTIVES IN THE CLINICAL SETTING: learn clinical evaluation of the elderly; understand the atypical presentation and special features of diseases in the elderly, particularly in the frail elderly; recognize the multifactoriality of chronic conditions in the frail elderly; become able to adequately manage chronic conditions; SPECIFIC EDUCATIONAL OBJECTIVES OF THE SSG (189 CFU) 1

12. OBJECTIVES IN THE CLINICAL SETTING • assess the effects of aging, lifestyle, socio-environmental factors, diseases and their interaction on the functionality of organs, systems and the autonomy of the elderly; • diagnose and treat major psychogeriatric disorders (dementia, depression, psychosis, eating disorders, etc.); • understand and treat geriatric syndromes: urinary and fecal incontinence, falls and their consequences, and immobility syndrome, pressure sores, delirium, malnutrition and dehydration, sensory deprivation; • perform comprehensive geriatric assessment (CGA) also by means of second and third generation instruments; 2

13. OBJECTIVES IN THE CLINICAL SETTING: • promote measures for the prevention of chronic diseases and disabling conditions; • recognize frailty and prevent its consequences; • assess the quality of life of older using specific methods; • prescribe non-pharmacological treatments, with particular reference to physical activity, nutrition, behavior and healthy lifestyles; • prescribe drug therapies, taking into account the pharmacokinetic and pharmacodynamic changes of aging, the interaction between drugs, and the level of compliance of the elderly patient; • prevent, recognize and know how to treat adverse drug reactions; 3

14. OBJECTIVES IN THE CLINICAL SETTING: • know the principles of extensive and intensive rehabilitation care in different diseases; • understand the principles of bioethics applied to geriatrics and related forensic issues, with particular reference to the mistreatment or discrimination against older people (ageism); • apply the methodology of palliative care in the elderly terminal patient; • critically examine the data in the scientific literature, to be able to transfer it to clinical practice; • know the limits of EBM in its applicability to the very old and the frail patient. 4

15. GERIATRIC MANAGEMENT: • understand the principles of management of the frail older patient care in the different health care services of the long term care network; • understand the criteria for the proper allocation of older patients in different services; • adapt the process of care and CGA to the specific setting; • understand the problems of communication with the patient's frail elderly and caregivers; • coordinate the multidisciplinary team in different settings, to guarantee the continuity of care. SPECIFIC EDUCATIONAL OBJECTIVES OF THE SSG (189 CFU)

18. service for at least 4 weeks in a nursing home, service in a psychogeriatric service, in an osteoporosis and fall prevention clinic, in a syncope unit, in urology, ophthalmology, otolaryngology and / or Audiology, in a rehabilitation ward. PROFESSIONAL ACTIVITIES AND PROCEDURES (210 CFU)

19. SPECIALISED ELECTIVE CREDITS (45 CFU) They are chosen by residents among those offered by each School. These activities may constitute up to 45 of the 189 credits allocated to specific ones.

20. Neurodegenerative diseases of the elderly and psychogeriatrics Cardiogeriatris Geriatric rehabilitation Geriatric oncology and palliative care for the elderly Geriatric epidemiology and pharmaco-epidemiology Comprehensive geriatric assessment in different settings (NH, HC, etc.) Malnutrition SPECIALISED ELECTIVE CREDITS (45 CFU)

21. Human Sciences (Forensic Medicine) Interdisciplinary Integration (Urology, Diseases related to dentistry, Diseases of the eye, Audiology and phoniatrics, Physical Medicine and Rehabilitation, Dermatology, Gynecology) Public health, health management, statistics and epidemiology OBJECTIVES OF THE BASIC ACTIVITIES (5 CFU)

22. GENERAL AND SPECIFIC STANDARDS OF RESIDENCY SCHOOLS: ACCREDITATION • Structural capability: to have adequate space. • Technological capability: to have necessary equipment. • Organizational capability: to have necessary professional abilities. • Care capability: to garantee an adequate quantity and tipology of clinical activities.

23. ACCREDITATION • Assumptions and conditions (of University) for instituting a postgraduate School; • Standard, modalities and limits for accreditation of structures for postgraduating school; • Suitability of the health care services connected to the postgraduate School

24. GENERAL AND SPECIFIC STANDARDS FOR ACCREDITATION OF RESIDENCY SCHOOLS

25. STRUCTURES Official structures University controlled structures, suitable for the training of residents Related structures Structures of the same speciality that are officially linked to guarantee that residents can perform all the activities that are requested Supplementary structures Structures of different specialities that are officially linked to allow activities not present in the official structure or in the related structures; Official + Related + Supplementary Structures constitute the School network

26. GERIATRIC

31. GENERAL AND SPECIFIC STANDARDS FITNESS TRAINING NETWORK

32. Minimum volume of activities for the whole training of a resident. a) The minimum total volume of activities of the training network must be such that the activities of the residents do not exceed 30% of the total network activities[(NX100) / 30]. b) The volume of activities of the training network should be such to enable a minimum number of residents of 3. If it is not, than the residency School should functionally merge with other Schools in different Universities.

35. CRITICAL ISSUES • Except few cases, the majority of training is still hospital-based, with scanty training performed in community services and nursing homes or in palliative care • Frontal teaching activities are now being increasingly centralized, as it was difficult to guarantee them within each School

36. CRITICAL ISSUES • The activities included in the common trunk are still not well defined • There is a large variability in the autonomy granted to residents: in some Schools they are on call with the attending physicians available on the phones, in others they are not allowed to do night shifts even under the direct supervision of the attending physician.

37. CONCLUSIONS • Postgraduate training in geriatrics has been existing in Italy for at least 40 years and the number of residents has been increasing over time • Postgraduate training in geriatrics is progressively moving from being hospital based to include training in the community services, including nursing homes.

38. Geriatric Medicine ? Regina Roller-Wirnsberger Medical University Graz

39. Postgraduate teaching program for future opinion-leaders in Geriatric Medicine in Europe Cornel Christian Sieber President of the European Academy for Medicine of Ageing Society (EAMAS)‏

40. Missions ... ... to promote the postgraduate training of academically-oriented younger Geriatricians within Europe. ... to establish a network between actual and former students. ... to foster (clinical) research projects on an international level. ... to thrive for more appearance of Geriatric Medicine in an ageing society.

41. Roberto Bernabei, I Atanase Benetos, F Reto Kressig, CH Nele Van Den Noortgate, B Cornel Sieber, G Tischa van der Kammen, NED Alfonso Cruz-Jentoft, ES Thorsten Nikolaus, G Kaisu Pitkala, FN

42. Students are expected ... ... to acquire skills in the identification of learning deficiencies and setting priorities within different geriatric topics as well as in the formulation of important messages. ... to lead discussions and presentations with the use of the most recent and appropriate teaching technology. ... to generate new research ideas and develop abilities for data gathering and critical data interpretation.

43. ... improve knowledge and skills in geriatric medicine for junior faculty members and promising candidates for future teachers in Geriatrics. ... attune the attitudes and goals of future opinion leaders in geriatric medicine throughout Europe. ... establish a network among medical doctors responsible for the care of elderly persons and those responsible for student instruction, as well as general physicians caring for the aged. ... develop new ideas for geriatric health programs and harmonize practises. ... stimulate clinical and epidemiological research in community and institutional geriatric medicine. ... encourage scientific interest in Gerontology and Geriatrics at local, national and international levels.

44. Structure of Courses • Courses held at the „Institut Universitaire Kurt Bösch“ in Sion. • 1 week in January and June for 2 years (4 weeks in total). • 40 - 45 students each course. • Key-note lectures (international faculty), students state of the art lectures, students group discussions.

45. Courses Held Until Present • 6 full 2-years courses organized. • More than 200 students (40 % females) of more than 30 countries have finished the EAMA and are now EAMA - Network members. • January 2007: Start of course VII with 45 students (17 countries).

46. Career Success Story • Mean age at diploma around 40 yrs. • 90 % had a career step after EAMA. • 40 % had a career step both in their clinical and academic work. • 40 % became Professors in Geriatric Medicine.

47. THANK YOU FOR ATTENTION

48. INTRODUCTION • 1989 The ItalianParliamentapproved a documentconcerninghealth care servicesforolder people: “.. ..a newmodelof care that can ensuretimely and effectiveresponsestocomplexhealth and social needs, that are multiple and changingovertime, ofolder people withcomorbidity, disability and frailty. Thismodelisbased on the network ofgeriatricservices, integratinghealth and social care and providingcontinuityof care.” • 1992 The "Project forHealthProtectionof the Elderly" (POA) in the National HealthProgramconfirmedthat the geriatric care isdevotedto “oldersubjectswithdisability or complete non self-sufficiency , comorbiditywith high riskofdisability, withemphasis on over 75 yearspatients“ … "GeriatricAssessmentUnits” (UVG) are established in orderto coordinate the provisionof care.”

49. MODALITY OF CONTROL REQUIREMENTS Disciplinary scientific fields compulsory and indispensable • MED/05 Clinical Pathology • MED/06 Medical Oncology • MED/09 Internal Medicine • MED/11 Cardiovascular Diseases • MED/12 Gastroenterology • MED/13 Endocrinology • MED/14 Nephrology • MED/15 Diseases of Blood • MED/16 Rheumatology • MED/17 Infectious Diseases • MED/18 General Surgery • MED/25 Psychiatry • MED/26 Neurology • MED/33 Diseases of the locomotor • system • MED/36 Diagnostic Imaging and Radiotherapy Examination of documents and any direct examination BASIC LESSONS

50. • to complete and sign 100 geriatric medical records of older patients in acute care hospitals, post-acute care, home care and nursing home; • to participate in at least 30 meetings of the geriatric team, in the production of individual care plan in different settings; • to perform at least 15 times CGA for the definition of the degree of non-self-sufficiency, including objective assessment of physical performance; • to participate in at least 10 geriatric consultations in other departments; • to care for at least 20 older patients with chronic diseases in different health care settings in the network of geriatric services; PROFESSIONAL ACTIVITIES AND PROCEDURES (210 CFU) 1