The HERMES projects: adult respiratory medicine
The important milestones reached by the first HERMES project to establish European standards for training in adult respiratory medicine provided clear evidence that similar methodology could be employed in the standardisation of education in other specialty areas of respiratory medicine (figure 3).
A survey conducted in 2005 jointly by the ERS and the pneumology section of the UEMS showed large variation in respiratory training between countries, particularly concerning the length of the training period (ranging from 3 to 7 years for pre-specialist training and 2.5 to 8 years for specialist training). Although UEMS issued a recommendation on training requirements in Europe in 1994, which was updated in 2002, a benchmark analysis in 2005 revealed that wide discrepancies still existed in the length and quality of training in respiratory medicine (figure 4).
A further survey conducted by the ERS showed that not all countries have a unified syllabus and training programme, that some do not even have an ‘exit’ examination and that a few countries have no official list of accredited training centres. This confirmed the need to develop standardised educational documentation and activities in adult respiratory medicine and to move through each of the phases for development of European standards. This model was used in a similar way for all of the other HERMES projects, but is described in detail here only for adult respiratory medicine.
Experts from 29 countries came together to develop the syllabus, and input was sought from all clinical specialist members of the ERS and national respiratory societies. The final consensus-based syllabus was published in 2006. It contained 229 competencies, split into 51 modules and nine sections:
1) Structure and function of the respiratory system
2) Knowledge of respiratory diseases
3) Symptoms and signs
4) Diagnostic procedures including monitoring techniques
5) Treatment modalities and prevention measures
6) Core generic abilities
7) Competence in fields shared with other specialities
8) Knowledge of associated fields relevant to adult respiratory medicine
9) Further areas relevant to adult respiratory medicine
The syllabus also included recommendations about the levels of knowledge required for each item listed. No recommendation was made relating to numbers of procedures to be performed in order to become qualified, but clear recommendations were made regarding overall training duration and structure. General recommendations were divided into sections pertaining to:
- Clinical field of respiratory medicine
- Principles underpinning the development of a curriculum for respiratory medicine
- The education of respiratory medicine trainees
- Characteristics and responsibilities of key training personnel
- Accountability and regulation
- Quality assurance, validation, accreditation and evaluation of the programme
The final curriculum contains 34 disease-based modules structured in a form which can be implemented and taught in practice, setting out the main core competencies that trainees are required to have knowledge of and demonstrate competence in. It also lists existing clinical guidelines pertaining to the modules.
The first European examination in adult respiratory medicine took place in 2008 at the ERS Annual Congress, and examinations have been held at each subsequent Congress. Candidates who pass the examination are eligible to be awarded the European Diploma in Adult Respiratory Medicine only if they have already acquired their national diploma as a specialist in adult respiratory medicine. Since 2010, trainees studying for their national specialist qualification have also been allowed to sit the European Examination as an exercise in in-training self-assessment of their progress, but such trainees are not eligible for the diploma until successful completion of their training. Local examinations are now organised for this purpose. Trainees in the Netherlands now take the examination as an in-training or self-assessment examination annually. In 2012, the examination took place for the first time in Moscow for in-training and self-assessment candidates.
The aim is for the European examination to be officially recognised in all European countries. Since 2008, Switzerland has used the HERMES European Examination in Adult Respiratory Medicine as the official part of its national exit examination for adult respiratory medicine specialists. Austria also formally recognises the HERMES European examination as equivalent to its official national exit examination, and avenues for collaboration with authorities in Greece, Ireland, Malta, Portugal, Romania, Saudi Arabia, Spain, Sweden and the UK are being explored. The number of voluntary participants, including candidates from outside Europe, is increasing, and it is hoped that the examination will gain international recognition as a state-of-the-art knowledge assessment.
Accreditation of training centres
The criteria for accreditation have been developed and agreed, and were published in December 2010. Following best- practice guidelines in accreditation of postgraduate education established by the World Federation of Medical Education, the ERS has partnered with the accreditation body EBAP.
Training centres or networks that gain accreditation will benefit from receiving a label of quality, gaining visibility and attractiveness for trainees and potentially being in a better position to secure research funding. Accredited centres (and those aspiring to accreditation) will be incentivised to develop or maintain high-quality training programmes and facilities.
The next challenge will be to implement an accreditation process. A pilot programme of three or four training centres is planned, in collaboration with EBAP.