Higher Specialist Training Programme

Infectious Diseases

Higher Specialist Training Programme

Malta April 2011

INTRODUCTION

Training in Infectious Diseases provides a generic programme for specialists who may practice in a variety of infection related disciplines for example tropical medicine, HIV medicine, infection control and aspects of public health medicine.

SELECTION for and ACCESS to the TRAINING

Teachers and training institutions or other responsible bodies select and appoint trainees in accordance with the established selection procedure.

ENTRY REQUIREMENTS

• Registration with the Medical Council Malta.
• Certificate of Completion of Basic Specialty Training in General Medicine

DURATION of TRAINING

A minimum of 4years postgraduate training is required, in addition to at least a minimum of 2 years must be in General Internal Medicine which forms the “common trunk”. The common trrunk should be completed beforeembarking on the specialist training (this 2 year period is subsequent to the compulsory post qualification training internship otherwise known as the Foundation Programme).

Infectious Diseases training should thus not be less than four years full-time or equivalent

TRAINING CENTRE

Training shall take place in an institution or group of institutions which together offer the trainee practice in the full range of the specialty. They must have an intensive care unit and other specialties must also be represented (particularly the medical specialties and surgery) so as to provide an opportunity for inter-specialty consultation. They must have access to a full range of microbiological, biochemical, haematological and imaging investigations and fulfil other criteria that the Association of Physicians may, from time to time, determine.

TRAINING PROGRAMME, TRAINING LOG-BOOK

General Description of Higher Medical Training for Infectious Diseases: (These requirements are in addition to the general principles for Higher Specialist Training as described in the document Specialist Training Programmes in Adult Medical Specialties issued by the Medical Specialists Accreditation Committee).

The training programme will include agreed periods undertaken in the management of unselected community acquired infection(s) and the management of imported infection, both as in patient and out patient, and hospital acquired infection. Attachment to a Medical Microbiology/Clinical Virology department is also necessary during the training to enable the trainee to acquire the ability to use the laboratory appropriately and to interpret data originating from the Clinical Microbiology laboratory. Involvement in the management of immuno-compromised patients (for example HIV infection, transplant patients, patients with infected prostheses) and a period of involvement in an Intensive Care Unit will be obligatory. Research will be regarded as an integral component within the training programme. It is recognised that in some countries infectious diseases is practised with clinical responsibility for patients in a ward and in others it may be more on a consultation basis but the underlying principles included in this training programme should be relevant to both styles of training.

KNOWLEDGE-BASED ASSESSMENT

In order to be awarded the CCST at the end of training, the trainee should be in possession of specialty certificate awarded by the Federation of Royal Colleges of the UK and the relevant speciality society or the UEMS speciality certificate or an equivalent qualification recognized by the Association of Physicians of Malta.

The Curriculum

Community Acquired Infection and hospital acquired infection:

Involvement in management (clinical assessment, investigation, diagnosis, treatment and follow up) of unselected patients suffering from infections, preferably predominantly community acquired, and imported infection(s) forms a central theme within the training programme.

Typical examples would be community acquired pneumonia, MRSA infections, vector-borne diseases such as leishmaniasis, typhus andleptospirosis.

Consult experience should be obtained during this period e.g. in other hospital associated infections such as surgical infections, intensive-care related infections, orthopaedic infections, device related infections and infection in immune compromised patients.

At least 3years should usually be spent in an approved post which meets the above requirements of the curriculum. It must include both inpatient and out patient care. (A maximum of one year of training outside the European Community at a recognised training centre approved prior to the period of training by the specialist national authority will be acceptable).

Organ-specific infections

The trainee is expected to have extensive experience in the diagnosis and management of the following organ-specific infections

Pneumonias and other respiratory infections

Endocarditis (native/prosthetic)

Joint and bone infection

Skin and soft tissue infection

Central Nervous System infections: Meningitis/Encephalitis

Urinary tract infections

Infectious diarrhea

Complicated intra-abdominal infections

Pyrexia of Unknown Origin (PUO)

Training in the management of patients suffering from PUO must be given during the training period. The trainee is expected to be well-experienced in the management of such patients.

HIV/AIDS

Experience in HIV/AIDS must form part of the training programme and may require rotation to a unit possessing a high component of suitable patients or to a dedicated HIV unit if it cannot be provided in the primary ID training centre.

Cross specialty infections including tuberculosis and viral hepatitis

Experience in the management of cross speciality infections such as tuberculosis and viral hepatitis (including B and C) must be part of the training programme.

Immuno-compromised patients:

The training programme must include experience in the management of opportunistic infection(s) in immunocompromised patients such as neutropenic hosts, transplant patients, congenital immune deficiencies as well as those compromised by illness such as diabetes mellitus and infected prosthetic devices.

Medical Microbiology:

Experience in Medical Microbiology is essential. It is envisaged that attachment, collaborative research, and/or direct involvement in these disciplines will be necessary.

An attachment will typically be between 2-3 months (flexible timing may be allowed), and should ideally be organised in the first year of training.

Intensive Care:

A period of attachment to and a period providing consults to an Intensive Care Unit to gain experience in the management of these patients must form part of the training programme. A period spent in this environment should provide additional experience in the prevention and treatment of nosocomial infection and sepsis.

This period of attachment is expected to be from 2-4 weeks and should ideally be done during the second year of training.

Sepsis

A firm grasp of the pathogenesis, diagnosis and management of the sepsis syndrome is considered very important

Control of Infection:

Experience in the prevention and control of community and healthcare related infections or hospital outbreaks e.g. MRSA, SRSV is important.

Epidemiology and Public Health Medicine

A period of interface with these disciplines is regarded as desirable and will enable the trainee to become familiar with the principles and practicalities of immunisation and vaccination, investigation and control of notifiable diseases and community outbreaks.

Research:

Training to develop a basic understanding and ability in clinical and/or laboratory research methodology is essential. Supervised research or further formal postgraduate training, is encouraged.

The trainee will be expected to publish at least one manuscript in an international, peer reviewed journal. During the training, the trainee is also expected to initiate and participate in at least 2 Clinical Audits pertaining to the local Infectious Disease practice.

Tropical Medicine

To enhance their training in tropical medicinethe following would be considered valuable and desirable:

1. Attendance at a tropical medicine training course at one of the internationally approved centres such as those leading to the Diploma in Tropical Medicine and Hygiene or equivalent or
2. A twelve month period in a recognised training centre in the tropics or a period of experience in an approved parasitological laboratory may be considered.

Post-graduate Qualifications

Other post-graduate qualifications will be considered valuable after discussion a priori (before committing to any specific course or examination) with the Infectious Disease Lead Trainer/s.

Diseases of travel:

The training must include aspects of prevention of travel associated diseases as well as the regular clinical assessment, diagnosis and management of travel related infections. If this training cannot be provided at the primary training centre, the experience must be obtained elsewhere.

Viral Haemorrhagic Fevers (VHFs)

A clear understanding of the management of VHFs, the strict infection control measures and public health implications must form part of the training programme.

Bioterrorism

An understanding of the issues related to the clinical presentation, early recognition, epidemiology and management and control of infections which could potentially be deliberately released into a community for example, smallpox, anthrax, plague, botulism and tularaemia.

Sexually Transmitted Diseases (STD)

An understanding of the basic principles of STD as they relate to infectious diseases is desirable.

This may include a short period of attachment to the Genito-urinary Clinic of between 1-2 weeks.

Antimicrobial Chemotherapy

Knowledge of the issues relating to optimal use of antimicrobial chemotherapy including an understanding of the pharmacokinetics and principles of prevention, mechanisms of resistance and management of antimicrobial resistance must be obtained during the training.

Practical Skills to be acquired by completion of infectious diseases training:

The underlying objective is to produce an individual who can function independently at specialist level by the end of training. Requirements can be summarised as follows:

1. Appropriate management of an emergency admission suffering from severe infection.
2. Competence in acute assessment of patients suffering from infections and the day-to-day care of patients suffering from severe infections and its sequelae.
3. Management of severe infection in an ICU setting.
4. Management of patients with imported infections - e.g. malaria.
5. Care of immuno-compromised patients - including neutropenic and those with HIV infection/AIDS. It is essential that the trainee must develop the skill to effectively use and monitor combination antiviral regimes.
6. Management of nosocomial infections, with knowledge of infection control, and appropriate liaison with laboratory services.
7. Practical knowledge of common clinical diagnostic procedures

It is also essential that the trainee be:

1. Regularly involved in under-graduate and post-graduate teaching.
2. Involved in audit and quality control relating to the speciality.
3. Conversant with clinical pharmacological aspects of and appropriate use of antimicrobial

chemotherapy (where possible with involvement with the Antibiotic Sub-Committee).

1. Conversant with aspects of infection control (where possible by being co-opted onto the Infection Control Committee).
2. Aware of resource management implications related to practice in the speciality.
3. Able to lead a multidisciplinary team in the clinical setting.

During infectious diseases training, the trainee must:

1. Be competent to supervise work and training of staff undergoing general professional training (common trunk general internal medicine), and to contribute to the training of those in the earlier stages of infectious diseases training.
2. Have understanding of clinical and/or laboratory research methods.
3. Have been exposed to ‘management’. This should include attendance at agreed courses and committee experience.
4. Be familiar with administrative duties relevant to modern consultant practice in the speciality.
5. Be aware of the importance of involvement in continuing medical education (CME) and utilisation of resources for this purpose.
6. Actively contribute towards the improvement in systems of patient-care and safety, and in health-care management.

The Training Programme

Infectious diseases training for any individual trainee must be co-ordinated by an individual person or body. There should be a training programme with a regular formal review for the trainee on a minimum of an annual basis.

The ID Training Programme shall be based on the Curriculum outlined in this document.

Joint Training with General Internal Medicine:

This may be undertaken and will have to be in accordance with guidelines produced by the National Authorities to meet European requirements.

Log-Book and General Conditions

A log-book will be kept with details concerning experience gained which must be signed by the appropriate supervisor(s). (Appendix 1)

A Clinical Supervisor shall be assigned for an ideal period of one year after which the trainee shall rotate to another Clinical Supervisor. The role of the Clinical Supervisor is primarily that of monitoring and supporting the trainee’s day to day clinical and professional work

An appraisal shall be carried out at intervals of 6 months (minimum) or ad hoc as necessary at the discretion of the Clinical Supervisor. At these appraisal meetings, a review of the logbook will also be done. The Appraisal form in Appendix 2 will be used and filed in the trainee’s logbook. Any Ad hoc meetings with the Clinical Supervisor may be recorded in the Clinical Supervisor’s Ad hoc meeting form (Appendix 3)

In addition, the trainee shall have an Educational Supervisor. The role of the Educational Supervisor is primarily that of monitoring and supporting the trainee’s Educational Programme and progress.

A meeting with the Educational Supervisor shall be carried out at intervals of 6 months (minimum) or as necessary at the discretion of the Educational Supervisor. At these Review meetings, the educational programme and progress of the trainee may be discussed along with any other relevant matters.The Educational Supervisor Review Meeting form in Appendix 4 will be used and filed in the trainee’s logbook.

Communication between the Clinical and Educational Supervisors may be done if any relevant information regarding the trainee’s clinical, and educational progress needs to be shared with the interest of the trainee and patient safety in mind.

It will be the onus of the trainee to approach the Clinical and Educational Supervisor to organise the regular meetings as well as the ad hoc meetings when necessary. The Clinical and Educational Supervisors may however also themselves call an ad hoc meeting as necessary.

All meeting encounters will be recorded in the Meeting Encounters form (Appendix 5) and filed in the trainee’s logbook.

Annual Review of Progression

An Annual Review of Progression will be done by an Annual Review of Progression Board. The Board will consist of the Clinical and Educational Supervisors as well as an External Reviewer. The logbook will be reviewed and achievements noted. Recommendations for progress or otherwise in the Infectious diseases Programme will be made, as well as recommendations for further development if necessary.

Any difficulties with progression will be referred to the Training Committee. In addition, the Training Committee will be undertaking a separate review, based on Supervisor Appraisals and other assessments as necessary.

Training Board In The Eu/Efta

Trainees should have the opportunity to be trained in recognised training institutions in other UEMS member countries during their training with priorapproval by the Specialist Advisory Committee.

TEACHER/TRAINEE RATIO

The ratio between the number of qualified Infectious Diseases physicians in the teaching staff and the number of trainees should provide for adequate close personal monitoring of the trainee during his/her training and provide adequate exposure of the trainee to the training. This ratio should be no less than 1:1.

Overseas Training

A period of training in an approved overseas training centre is encouraged and highly desirable.

Educational Activities

Attendance at weekly Journal Club meetings is expected. Other teaching activities will be actively encouraged.

Conferences

Attending of Infectious diseases related conferences is encouraged and desirable at least once every year.

Other Requirements For Trainees

EXPERIENCE

To build up his/her experience the trainee should be involved in the management and treatment of a sufficient number of in-patients and out-patients and perform a sufficient number of the practical procedures relevant to the specialty which may not be provided by other hospital professionals.

LANGUAGE

The trainee should have sufficient linguistic ability to communicate with patients and to study international literature and to communicate with foreign colleagues. In some countries this may be subject to a formal test.

HUMANISTIC SKILLS

The specialty of Infectious Diseases traverses all other specialties and inter-specialty consultations make up a substantial part of the work load of ID physicians. Trainees are therefore expected to have particularly good communication skills, be able to work in a team without problems, and maintain excellent doctor-healthcare worker and doctor-patient relationships.

Appendix 1

LOGBOOK FOR INFECTIOUS DISEASES

KEY AREAS AND COMPETENCE

MaltaInfectious diseases Training Programme

KEY AREAS OF INFECTIOUS DISEASES

KEY AREAS OF INFECTIOUS DISEASES SIGN OFF

LEVEL OF COMPETENCE

LEVEL OF COMPETENCE SIGN OFF