World Health Organization IPCS/INTOX/Clin Tox Curric/ Report - draft
International Labour Organization
United Nations Environment Programme
International Programme on Chemical Safety
Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology
Held at the Royal Infirmary of Edinburgh, Edinburgh, UK.
19th to 21st July 2006
Draft Report
1 Welcome and introductory remarks
1.1 Mrs Alison Good from the Scottish Poisons Information Bureau welcomed the participants to the meeting.
2 Selection of officers and approval of agenda
2.1 It was decided that there would be a rotating Chair. Professor Balali Mood chaired the meeting on the first day and Dr Fountain chaired for the remaining 1.5 days. Ms Tempowski took the meeting record. The agenda is given at Annex 1. The list of participants is given at Annex 2.
3 Background and purpose of the workshop
3.1 Clinical toxicology was not a recognized specialty is most countries and, consequently, was little taught. One obstacle to better teaching was the lack of accessible, good quality teaching materials. This was particularly true in developing and in-transition countries, yet these were the countries that saw large numbers of poisoning cases with a high morbidity and mortality. If frontline health professionals were better educated in clinical toxicology this would improve the management of poisoning and contribute to reducing morbidity and mortality.
3.2 WHO was committed to assisting Member States to improve the training of their health professionals, in particular by making innovative use of information and communication technology. These activities were coordinated through the technical unit for E-Health in the Department of Knowledge Management and Sharing.
3.3 The Global Plan of Action agreed under the Strategic Approach to International Chemicals Management (SAICM) included the need to improve capacities in countries to manage poisonings, and to access and use scientific knowledge. The Quick Start Programme would provide funds to countries, and possibly to non-governmental organizations, for activities directed towards meeting these needs.
3.4 Professor Andrew Dawson of the South Asian Clinical Toxicology Research Collaboration (SACTRC) approached IPCS with a proposal for developing and delivering teaching materials on clinical toxicology using the Internet. The purpose of the meeting was to explore Dr Dawson's proposal and to agree a plan for putting the proposal into practice.
4 Proposal for developing and disseminating a clinical toxicology curriculum
4.1 Professor Dawson's proposal was to use a web-based open-source platform such as a wiki site for the compilation and delivery of teaching materials. Contributors would upload their teaching materials to the site and these could then be freely used by anyone wishing to teach themselves or others. Contributors would, for the most part, use pre-existing materials rather than be expected to create new materials.
4.2 There was already a lot of material on the Internet, however, it was difficult for the user to judge its quality. This project would offer a collection of high quality material for teaching, as well as links to other vetted websites.
5 Experiences in developing clinical toxicology education and in e-learning
5.1 Six presentations were given:
Ø Ms Tempowski spoke about the WHO Health Academy and the Global Public Health Platform. The Health Academy provided interactive teaching packages aimed at changing behaviours that contributed to bad health (http://www.who.int/healthacademy/courses/en/). WHO was collaborating with the Department of Public Health, University of Iowa to explore the use of advanced telecommunication tools for distance learning through the Global Public Health Platform http://www.who.int/kms/events/Events/en/index.html).
Ø Dr Besbelli presented the WHO/UNEP Multi-Level Resource Tool for the Safe Management of Pesticides. This included information on safe handling of pesticides and on management of poisoning, as well as links to authoritative websites. The teaching materials were stratified into basic, intermediate and advanced. The resource tool was available on CD-ROM.
Ø Dr Groszek presented the results of a survey of clinical toxicology teaching in Central and Eastern Europe. Only four countries: Poland, Bulgaria, Serbia and Russia had formal post-graduate specialization and training in clinical toxicology.
Ø Professor Faiz spoke about the profile of poisoning in Bangladesh, and the teaching of clinical toxicology. This was not a recognized specialty, but some teaching modules had been developed for both undergraduate and postgraduate teaching. Poisoning was usually managed by forensic medicine specialists.
Ø Professor Balali Mood described clinical toxicology training in Iran. There were three teaching centres: Shiraz, Mashhad and Tehran. Clinical toxicology had been incorporated into national medical boards for internal, forensic and industrial medicine. A curriculum for a formal fellowship and sub-specialty Board in Clinical Toxicology was submitted last year to the Ministry of Health and Medical Education.
Ø Dr Thompson described the Medical Toxicology diploma and masters course taught by distance learning from the University of Wales College of Medicine. This course was taken by a range of health professionals. He also demonstrated the web-based platform used to provide learning materials and to enable students to submit their work.
5.2 These presentations highlighted the fact that different types of health professionals would require teaching materials, and that the priorities in terms of subject varied from country to country, according to the different patterns of poisoning.
6 Definition and prioritization of the key elements of the curriculum content
6.1 Teaching materials were needed for the education of professionals from a range of specialties and backgrounds e.g. forensic medicine, emergency medicine, nursing, poisons information. Materials were needed for both undergraduate and postgraduate teaching. They were also needed at different levels of content (basic, intermediate and advanced). It was decided, however, that contributors should not be required to adapt their existing materials for different levels of teaching. The aim was to provide a package of materials that was sufficiently comprehensive that it could be adapted by the user for these different target and levels. On the other hand, if a contributor had materials aimed at a specific target group, they could identify this group when they submitted their material.
6.2 It was felt that priority should be given to dealing with the issues that caused the highest morbidity and mortality. While the needs, in terms of substance-specific materials varied in different countries, there was core material that would be needed by everyone e.g. diagnosis of poisoning, initial patient management. There were also some poisonings that were common to many developing and in-transition countries e.g. pesticides and snake bite.
6.3 A priority list of topics was agreed, and this is given in Annex 3. The aim was to populate this 'skeleton' with teaching materials during the pilot phase of site development. The priority list was a cut-down version of the curriculum developed by the American Board of Emergency Medicine. It was not intended to be exclusive: if contributors had materials on topics not included in the cut-down list they could still submit these to the site. Professor Dawson would add the 'skeleton' to the site and would provide instructions for contributors.
7 Structure and content of the site
7.1 For each topic there would be 3 sections: section 1 would provide additional information on the topic that could be added to, or edited by, contributors. Section 2 would be the teaching package. The third section would be a discussion board.
7.2 The teaching package would comprise: PowerPoint slides (as .ppt so that they could be adapted by the user) and supporting background text to the slides, either as a .pdf or as notes attached to the slides in the PowerPoint file. If appropriate the contributor could indicate the level or target group towards which their material was aimed. Test questions and answers could also be provided. There would be links to materials on other sites though it was preferable to have as much supporting material as possible provided in one place. This was particularly important if the site was going to be downloaded to a CD-ROM or other stand-alone medium for dissemination.
7.3 The possibility was raised of adding an image library in the future.
8 Issues of quality, intellectual property rights
8.1 The quality of the teaching content would be assured by inviting contributions from experienced and well-regarded clinical toxicologists and by peer review. The Home page of the site would list the people, and also possibly the institutions, that had contributed material to the site. In addition the names of steering group members would be listed. This would enable users to make a judgment about the quality and credibility of the teaching materials.
8.2 Peer review would be carried out by fellow contributors. It was also suggested that a small number of external experts be identified who, though they might not be willing to submit materials themselves, would be willing to carry out peer review. Before approaching people for this task some information about the concept and the tasks of the external reviewers needed to be written. This should probably wait until the project group had gained some experience in the process themselves, but could nevertheless start within the pilot phase of the project.
8.3 After the start-up phase the pool of contributors would widen, as users of the website would also be invited to submit their materials. How these materials should be peer-reviewed was yet to be decided in detail. One proposal was to provide a list of peer reviewers of the website from which the contributor could select one individual to carry out the peer-review. It was agreed that when the project group had gained more experience in the process of submitting and reviewing materials this procedure would be further developed.
8.4 It was recognized that there were many uncertainties in clinical toxicology and there could therefore be a range of views on best management. Moreover, in many parts of the world 'best management' was determined by the availability of resources. It was important to reflect these different positions in the teaching materials. Section 1 of each topic provided a medium through which controversies could be discussed.
The process of moderating submitted materials would ensure that those containing information that was a long way from accepted norms would be excluded. The Home page would alert the user to the fact that they might find differing views expressed, and would explain why this was.
8.5 There was an audit trail, in that the wiki site enabled contributors to see where changes had been made, and old versions of documents were retained .
8.6 A draft procedure for submitting materials is given at Annex 4. A code of conduct for authors would also be written.
8.7 The decision whether to put their name on their materials was left to the contributor. The site would in any case list the contributors. Contributors would be advised about the possible need to remove institutional logos or other identification.
8.8 Authors should remove any material from their slides that was copyrighted to others unless they had permission to use the material for the purpose of putting it on the website. A copy of the permission document should be sent to the site moderator. This issue needed further clarification, however, and Professor Dawson would consult with a copyright lawyer about liability for the use of copyrighted material, since this could happen inadvertently.
8.9 Photographs of patients should only be included if they added to the understanding of the subject being described. Such photographs should be anonymised as far as possible and the use of such pictures should comply with the standard requirements of medical journals, e.g. with respect to patient permission.
8.10 Contributors to the site should understand that acceptance of their submissions was on the basis that the materials would have unrestricted use for educational purposes.
8.11 There would need to be a disclaimer on the site. This would incorporate the usual text about not accepting liability for the way in which the site content was used and interpreted, and would also draw attention to the fact that users might find a number of different views expressed about the same subject.
9 Promotion of the site
9.1 In order to be promotable, the site needed to have an attractive and appropriate name. The choice might be limited by the availability of domain names. The name would be decided at the next meeting but could be discussed on the wiki site.
9.2 A number of means for promoting the site were suggested. It was important to repeat promotional activities at intervals. Possible means included:
Ø Asking toxicological and medical societies and associations to include a link on their websites.
Ø Sending information via list serves e.g. INTOX-general, those belonging to medical/toxicological societies.
Ø Identifying a 'champion' in each country who could publicize the site nationally and encourage its use.
Ø Asking medical journals, both those with an international and those with a primarily national readership, to include information about the site.
Ø Informing medical schools and medical libraries.
Ø Giving presentations at congresses and writing papers about the initiative.
Ø Asking websites used for continuing professional development to include a link.
9.3 In addition, users would be asked to acknowledge the source of their materials by means of a slide about the site that would be provided for them.
10 Functional requirements
10.1 A wiki site would be used in the first instance, though it was possible that this might change as the site developed. Some functionality requirements identified so far were:
Ø Ability to track changes made to materials
Ø Ability to have threaded discussions about topics
Ø Back-up functionality
Ø Assignment of differential rights to users e.g. for uploading, editing, read-only
Ø Ability to download the entire content onto another website or into a different medium such as a CD-ROM or the eGranary Digital Library [1]
11 Evaluation of the site
11.1 A number of evaluation methods were agreed:
Ø Check that all the priority topics have materials
Ø Monitor of web hits – look at country/region and the topics downloaded