Minding the gap: training in adolescent medicine when formal training programmes are not available
- 1Israel Center for Medical Simulation, the Chaim Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Israel
- 2Adolescent Clinics, Sharon-Shomron District, Clalit Health Service, Israel
- 3Adolescent Clinic, Schneider Children’s Medical Center of Israel, Petah Tiqva and Sackler Faculty of Medicine, Tel Aviv University, Israel
- 4Adolescent Medicine, Pediatric Division, Assaf Harofe medical center, Zrifin and Sackler Faculty of Medicine, Tel Aviv University, Israel
- 5Adolescent Clinic, Safra Children’s Hospital, The Chaim Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Israel
- Correspondence to Dr Daniel Hardoff, Israel Center for Medical Simulation, the Chaim Sheba Medical Center, Tel Hashomer, Israel 52621; drhardoff{at}gmail.com
- Accepted 19 July 2009
Abstract
There is a growing need for healthcare professionals to extend their knowledge in adolescent health care. Formal training curricula in adolescent medicine have been developed in only the United States, Canada and Australia. The Israeli experience in building an infrastructure that allows physicians to train in adolescent medicine is described. It includes the development of hospital-based and community-based multidisciplinary adolescent health services, a 3-year diploma course in adolescent medicine and a simulated patient-based programme regarding communication with adolescents. In the course of one decade an infrastructure has been developed to create a cadre of physicians who are able to operate adolescent clinics and to teach adolescent medicine. Consequently a formal fellowship training programme in adolescent medicine has been recently approved by the Scientific Council of the Israel Medical Association. This model can be applied in countries where formal training programmes in adolescent health care are not yet available.
Adolescent medicine emerged as a subspecialty in the second half of the 20th century as a result of the growing recognition of the special health needs of adolescents related to physical and emotional growth and development, nutritional disorders, risky behaviours and chronic illness.1 2 In-patient and outpatient services for adolescent health care and promotion have been established in North America, South America, Australia and New Zealand, as well as in several countries in Europe such as Great Britain, Switzerland, Sweden, Portugal, Spain, Italy, Greece and Turkey and in Israel.2 3 4 Formal training programmes in adolescent medicine were developed first in the United States and then in Canada and Australia, but only the American Medical Association offers official board certification examination in adolescent medicine. The 3-year fellowship programmes in the US are geared to advance the knowledge and experience in adolescent health care of physicians from different specialties, who elect to broaden their capacity in caring for adolescents. Medical centres that provide fellowship programmes in adolescent medicine also offer short periods of clinical exposure to adolescent health issues to residents and primary care practitioners in various specialties, such as paediatrics, family medicine and internal medicine.5 6 7 8 Several undergraduate and postgraduate educational programmes in adolescent medicine have included in their curricula simulated patient-based education to improve practitioners’ communication skills with adolescents.9 10 11
Throughout the world, there is a growing need for health professionals to have extended knowledge in adolescent health care and promotion. In Canada, for example, family medicine residents have been reported to receive only limited exposure to adolescent health issues in primary care settings.12 13 Only recently adolescent medicine was endorsed as a new paediatric subspecialty at the Royal College of Physicians and Surgeons of Canada (RCPSC) Council.14 In the United Kingdom a demand for all professionals working with adolescents to receive training in adolescent health has been stated.15 Until recently no formal adolescent training specialist registrar posts in adolescent medicine were planned by the Department of Health.16 17 In 2008 the Royal College of Paediatrics and Child Health (RCPCH) has led the development of a new project which aims to improve the care young people receive from the health service and their quality of life. The “Adolescent Health Project” includes face-to-face learning as well as a set of detailed e-learning modules covering all aspects of adolescent health. They are designed to help doctors, nurses and other health professionals to work with young people more effectively.18 In a large survey of Swiss primary care doctors, a strong interest in adolescent medicine has been expressed, and continuing medical education courses in adolescent medicine were recommended.19
The growing need of European practitioners to expand their knowledge in adolescent medicine led a group of physicians with special interest and experience in adolescent health care from several European countries to establish a detailed syllabus in adolescent medicine-European Training in Effective Adolescent Care and Health (EuTEACH).20 Its aim is to select and propose a set of knowledge, attitudes and skills essential for the care of adolescents; to encourage the development of adolescent health multidisciplinary networks; and to set up training programmes in as many European countries as possible. It consists of 17 thematic modules, each containing detailed objectives, learning approaches, examples and evaluation methods.21 A web-based adolescent health curriculum has been developed also in the US, which may be used as supplemental material to the EuTEACH curriculum. It includes text background, cases, questions and answers, web links and a reference section.22
The International Association for Adolescent Health (IAAH) declared in 2006 that professionals who wish to provide health care to adolescents are required to receive training in the field of adolescent medicine and health care.23 Indeed, suggestions have been articulated as to what would be expected of physicians and other health professionals working with youths at various levels of expertise,24 and guidelines for preventive health screening (GAPS) have been developed.25 The necessity for health professionals to sensitively and proactively screen young people for health risks has been recognised with emphasis on active listening and non-judgmental questioning as a basic requirement in the management of adolescent patients.26 Theoretical principles in the design and delivery of adolescent health education programmes have been proposed,27 and an intervention project that used these principles demonstrated an effective and quick way to achieve sustainable improvements in knowledge, skill and self perceived competency of family physicians caring for adolescents.28 11
Guidelines for stepwise establishment of national training programmes in adolescent health care are still unavailable. In this paper we describe the Israeli experience in developing educational modalities as an infrastructure for the establishment of a formal training programme in adolescent medicine that can be applied in other countries.
The Israeli experience
The total population in Israel is 7 180 000, of whom 959 000 (13.4%) are adolescents between 11 and 18 years.29 The healthcare system in Israel is based on national health insurance, and primary health care is provided to adolescents either by paediatricians or by family physicians.
During the past two decades 25 multidisciplinary healthcare centres dedicated to adolescents have been developed in Israel, to address adolescent health problems that could not be solved in primary care settings or that adolescents wished not to share with their primary care providers. These clinics have grown within paediatric services in the community or in medical centres. Among the physicians who established these services only a few had received formal training in adolescent medicine in the US and in Canada. The Israel Society for Adolescent Medicine (ISAM), which was established in 1992, included in its main goals to promote physicians’ knowledge and capacity in addressing adolescents’ special health needs related to their uniqueness as emerging adults. To that end, as a first step, several venues of exposure to adolescent medicine and healthcare issues were developed in undergraduate as well as in postgraduate frameworks. Nowadays, frontal lectures within introductory courses in paediatrics (one 90-minute lecture among 30 lectures) and bedside teaching during clerkship in paediatric wards, are provided in all four Israeli medical schools. Optional regional one-day conferences on adolescent health issues are held twice a year for primary care physicians, and dedicated sessions on adolescent medicine and health care are included in the yearly national conferences in paediatrics, family medicine and gynaecology. The topics vary according to the conferences’ main themes and the specialties of the physicians in audience. Except for feedback questionnaires commonly used at the end of conferences, no attempt has yet been made to assess the impact of the lectures and discussions on the clinical practice of the participating physicians.
Soon it became clear that extensive training would be necessary in order to develop a cadre of experts in adolescent medicine who would be able to provide comprehensive health care to adolescent patients, and further on would serve as consultants and trainers in adolescent medicine. At that point the Scientific Council of the Israel Medical Association formally advised the ISAM that in order to establish formal training programmes in adolescent health care, physicians with appropriate knowledge and expertise would be required, and that the teams of the newly developed centres were not sufficiently trained for that purpose. Two initiatives, to be described in detail, were generated by ISAM to overcome this gap: (1) to open a postgraduate 3-year diploma course in adolescent medicine at the postgraduate school of the faculty of medicine at the Tel Aviv University, approved by the school’s academic board; (2) to collaborate with MSR—the Israel Center for Medical Simulation—and develop simulated-patient-based experiential training programmes aimed at improving communication skills of physicians who provide health care to adolescents.
The postgraduate 3-year diploma course in adolescent medicine
This 400-hour course (weekly 4 hours meetings for six academic semesters) exposes the participants—primary care paediatricians and family physicians—to a large array of issues that are relevant in the comprehensive health care of adolescents. The course’s curriculum is based on topics that are presented in most of adolescent medicine textbooks (for example, Neinstein’s Adolescent Health Care: A Practical Guide30) as well is in curricula of different adolescent medicine fellowship programmes in the United States and Canada. An academic committee of the Tel Aviv University Post Graduate Medical School that included programme directors of postgraduate studies in paediatrics, family medicine, psychiatry, gynaecology and endocrinology approved the course’s curriculum (table 1). The diploma is granted, based on physicians’ attendance in all the course’s activities and successful passage of six semesterial examinations. Forty-four physicians have already completed two such courses and one course is still in progress. So far 22 diploma-holding physicians have already taken on careers involving adolescent medicine by directing adolescent clinics in the community.
Curriculum of the diploma course
The simulated-patient-based workshops on communication with adolescents
The simulated-patient (SP)-based workshops are carried out at the Israel Center for Medical Simulation (MSR), which is a world leader in simulation-based medical education. MSR works to reduce errors and improve quality of care by exposing trainees to simulated challenging clinical and humanistic encounters.
Between 2003 and 2007 41 one-day SP-based workshops focusing on common adolescent health issues that require unique communication skills were held at MSR (box 1). At each training day at MSR eight simulated scenarios are exercised several times with different physicians encountering the SPs, and all encounters are video recorded. At the end of each 12-minute encounter with the SP, the actor provides a personal feedback to the physician about his or her impression regarding the physician’s attitude and communicative performance during the encounter. Following the simulation sessions a group debriefing session is held with an experienced adolescent medicine physician utilising the video recorded scenarios, where clinical and communication issues are discussed. Among the 470 physicians who participated in these workshops 327 (70%) were primary care physicians, 44 physicians attending the 3-year diploma course in adolescent medicine, 34 (7%) gynaecologists and 65 (14%) physicians practising in military recruitment centres. In a feedback questionnaire, they ranked with highest scores the workshops’ quality and contribution to their clinical work.31 The effect of the SP-based programme on medical encounters’ quality was assessed in physicians practising in military recruitment centres. An increase in physicians’ interest in the adolescent candidates for military services’ personal lives and in a more relaxed atmosphere during the encounters were noted as well as a decrease in omission of medical information, following the educational intervention.32 As a consequence of the successful educational intervention, military recruitment centre physicians are required to attend SP-based workshops at MSR as part of their training.
Box 1 Scenarios for simulated-patient workshops
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Dysfunctional uterine bleeding presenting as fatigue and social withdrawal.
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Physical abuse by a parent presenting as recurrent abdominal pain.
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An adolescent girl who has been raped.
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Recommendations for birth control and sexually transmitted infection prevention.
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Pregnancy presented as secondary amenorrhoea.
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First time pelvic examination.
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Explaining normal pubertal development to a mentally retarded adolescent girl.
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Eating disorder.
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Exacerbation of asthma.
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Recent onset of a malignant condition.
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Confidentiality regarding the disclosure of drug abuse.
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Crohn’s disease presenting as underweight.
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Depression presenting as underweight.
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Consulting for human papillomavirus immunisation.
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Parent’s reluctance to medication for attention deficit disorder.
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Multiple physical complaints to avoid military service.
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Sexually transmitted disease presenting as dysuria.
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Drug abuse presenting as tiredness and decrease in school performance.
A further initiative has been taken to increase the awareness of other national medical societies of the need for specific training programmes in adolescent health care for their members. So far ISAM members have joined the executive committees of the Israel Society for Clinical Paediatrics, the Israel Society for Paediatric and Adolescent Gynecology and the Israel Society for Smoking Prevention. Recently, a plea has been made to include SP-based educational programmes in communication with adolescents for all Israeli residents in paediatrics, family medicine and gynaecology.
Discussion
We have described the process of developing a national infrastructure for the establishment of a formal training programme in adolescent medicine by creating a cadre of physicians who are able to operate adolescent clinics and to teach adolescent medicine. The 3-year diploma course curriculum corresponds to other initiatives that have been developed to enhance physicians’ capacity to provide comprehensive health care to adolescents.18 20 22 27 It is based on the five steps of learning new skills: presentation of theory; discussion about implementation; practice in a simulated setting; feedback on performance; and coaching for transfer of skills into the work environment.27 Simulation-based medical education is a rapidly growing field that has become a powerful force in addressing patient safety through quality-care training.9 10 11 33 34 35 Training in communication with adolescents utilising a simulated patient is therefore a significant means to improve communication skills of practitioners who encounter adolescents in their clinical work.11 28 33 As a consequence of the stepwise establishment of a national infrastructure for training in adolescent medicine, the Scientific Council of the Israel Medical Association has recently approved the introduction of a formal fellowship training programme in adolescent medicine that will be based on the established educational modalities as well as on clinical training in existing adolescent clinics guided by graduates of the diploma course.
The need for development of dedicated adolescent health services was already recognised by the health maintenance organisations two decades ago. Now, that a training infrastructure in adolescent medicine has been established and approved by the Scientific Council of the Israel Medical Association, these services will turn into training centres for healthcare professionals who wish to gain knowledge and experience in adolescent health care.
The process that is described here can be applied in countries where formal training programmes in adolescent health care are not yet available.
What is already known on this topic
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Formal training curricula in adolescent medicine have been developed in only the United States, Canada and Australia.
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The “Adolescent Health Project” developed by the Royal College of Paediatrics and Child Health is designed to help UK doctors, nurses and other health professionals to work with young people more effectively.
What this study adds
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A process description of developing a national infrastructure for the establishment of a formal training programme in adolescent medicine by creating a cadre of physicians who are able to operate adolescent clinics and to teach adolescent medicine.
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This model can be applied in countries where formal training programmes in adolescent health care are not yet available.
Footnotes
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Competing interests None.
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Provenance and Peer review Commissioned; externally peer reviewed.
