Abstract
The 10-year-old European syllabus for paediatric respiratory medicine (PRM; also known as paediatric pulmonology) was updated by a consensus-based method using an expert task force for redrafting, and a subsequent Delphi process to achieve consensus. There was a high degree of consensus for the final syllabus, which has been streamlined and made more relevant to current practice. All modules are now mandatory apart from the undertaking of research projects, which is optional. Although there are still a number of countries in Europe which do not recognise PRM as a separate subspecialty, there are paediatric respiratory physicians practising in every country in Europe, and a current and harmonised European syllabus in the subspecialty remains important for defining the training and areas of practice of PRM practitioners.
Abstract
The European syllabus for paediatric respiratory medicine has been updated by a task force in conjunction with the ERS Paediatric Assembly and designated national experts. It has several new modules, and only one optional module remains. http://bit.ly/2KB9wcy
Introduction
Paediatric respiratory medicine (PRM; also known as paediatric pulmonology) has been recognised as a subspecialty in the USA since 1985 and by the Union of European Medical Specialists (UEMS) since 2015. The first European syllabus for PRM was agreed by a task force in 2002, and a more formal consensus-based syllabus was published in 2009 as part of the Harmonised Education and Training in Respiratory Medicine for European Specialists (HERMES) project. While this syllabus has been recognised by the UEMS, there are still a number of countries in Europe who do not recognise PRM as a separate subspecialty. Despite these bureaucratic variations, there are paediatric respiratory physicians practising in every country in Europe, and a harmonised European syllabus in the subspecialty remains important for defining the training and areas of practice of PRM practitioners.
Project rationale
After the PRM syllabus was published in 2009 [1, 2], a more detailed and prescriptive curriculum was published in 2010 [3]. In the modern world, all fields of medical practice are subject to rapid change and regular reviews of syllabi and curricula are a necessity if they are to remain relevant [4]. An update of the syllabus in PRM was thus necessary to maintain standards in training in the subspecialty and to ensure the continued relevance of the HERMES examination for paediatric specialists. Recognition of the training requirements by the UEMS also requires that they are regularly reviewed. A revision and update of the curriculum will also be necessary in due course. The adult respiratory medicine syllabus has also recently been updated and a similar procedure was adopted for this PRM syllabus update [5].
Process and methods
As the aim was to reach consensus amongst experts on the definition and structure of topics to be included in the syllabus, the Delphi technique, a group facilitation and communication process, was applied [6]. This technique, having been continuously enhanced through its use in previous European Respiratory Society (ERS) projects [7], includes quantitative and qualitative rounds of questions with interspersed face-to-face meetings.
The first stage was a qualitative round that took place to draft the updated syllabus. The chair of the project, Robert Primhak, drafted a comparison between the existing syllabus, the ERS handbook of PRM [8] and a leading PRM reference book [9]. All task force members were then involved in the discussion of the content, which included topics which should be removed or introduced, and discussions on the structure of the syllabus. A final review took place with the chair and task force members to approve a first draft of the proposed new syllabus in the online tool “surveymonkey”.
Two quantitative Delphi rounds were then carried out, as outlined in figure 1. The respondents for the project were approached in two ways: 1) a group of “experts”, comprising one or two representatives from member countries, nominated by their national paediatric pulmonary societies (where these exist); and 2) a general group comprising all members of ERS Assembly 7 (Paediatrics).
Delphi rounds.
Respondents were asked if the modules should be either included or not included and, if included, whether they should be mandatory or optional. They were required to indicate their extent of agreement towards the inclusion of individual items on a Likert scale (from 1=strongly disagree to 5=strongly agree). An open box for comments was included at the end of each module. Consensus was then measured by the proportion of respondents with responses in the top two weights (agree and strongly agree). Universally agreed proportions do not exist for Delphi studies. The cut-off rate for consensus for this project was determined as 80%. Any items or modules below this level were discussed.
Results and discussion
Differences from the previous syllabus
The initial task force revision included some structural changes from the original syllabus. A single separate module on “structure and function of the respiratory system” was introduced instead of repeating the topic in other modules throughout the syllabus; a separate module on “respiratory consequences of systemic/extrapulmonary conditions” was created to separate these often common problems, such as obesity, from those contained within the module on “rare diseases”; and the module on rehabilitation was renamed as “long-term management of chronic respiratory disorders” and transplantation issues were moved to appear within it. In addition, it was decided to define only those areas that were relevant to the trained specialist in PRM, and to dispense with the different levels used in the 2009 syllabus and thus the modules on management, teaching and communication were removed from the syllabus; knowledge of education theory was felt to be outside the scope of mandatory training in PRM, and much of the other content in these modules were considered as generic skills that were not specific to PRM.
Delphi responses
Overall, the PRM Delphi 1 gathered 371 responses (27% response rate). Only the 371 respondents from Delphi 1 were invited to participate in the Delphi 2, which gathered 265 respondents (71.43% response rate). The certification status of respondents for the two rounds are shown in table 1. Approximately 45% of respondents in each round held an academic position, and 31 different European countries were represented.
Certification status of respondents in the two Delphi rounds
In the first Delphi round respondents were asked “Do you think this module should be included as mandatory, optional or not included”. There were 20 modules in the draft syllabus, and eight failed to achieve at least 80% agreement as mandatory modules, including “airway endoscopy”, “allergic disorders” and “respiratory presentation or complications of systemic/extrapulmonary conditions”. The combined question on the relevance of the module and its characteristic as mandatory or not, caused confusion and the task force decided to rephrase it. In the second Delphi round, the question was split in two, with the second part of the question asked at the end of the module for the sake of clarity:
-Do you think this module should be: included or not included?
-Do you think the module should be: mandatory or optional?
There were a total of 124 items within these modules, of which nine (7.3%) failed to reach consensus. After discussion by task force members, three of these items (“atopic dermatitis”, “food allergy”, and “specific immunotherapy”) were removed, and a broader topic “diagnosis and basic management of associated allergic conditions” was included.
In the second Delphi round all 20 modules reached at least 80% consensus for inclusion. Six modules did not reach consensus as mandatory modules. The agreement ratings for making these modules mandatory were as follows: “allergic disorders” 79.0%; “sleep medicine and breathing control disorders” 73.8%; “long-term management of chronic respiratory disorders” 74.7%; “technology-dependent children” 77.6%; “epidemiology and environmental health” 70.4%; “evidence-based medicine and research” 62.5%. The task force felt that this might reflect difference in clinical practice across different European countries, but could not defend the removal of any of these modules from the “mandatory” requirements. However, there was discussion about the components of the module on “evidence-based medicine and research”. It was felt to be imperative that any specialist was capable of evaluating the scientific literature and had a basic understanding of the ethical principles involved in research. However, there was less unanimity about the need for every specialist to have been an active researcher, so this item was split off into a separate optional module.
There were 122 items in the redrafted syllabus, of which five (4.1%) failed to reach consensus in the second round, as detailed below.
Discussion
“Questionnaires in clinical assessment” was a debated topic, as some of the respondents did not use these or were unsure as to what these referred to. The task force decided to retain the item in the syllabus as it was felt that a basic knowledge of such questionnaires, including strengths and limitations was essential to contemporary practice.
“Equipment maintenance, hygiene and infection control during test procedures” only reached 79.3% consensus, but again was felt to be an essential patient safety item which could not be discarded or made optional.
“Induced sputum testing” was felt to be common enough in modern clinical practice to be included, noting the 79.7% agreement.
“Assessing respiratory risk of air travel, altitude and diving” also raised some discussion, due to a consensus rate below 70% after the first round. The item was then rephrased, from the initial name of “fitness to fly” to the current topic name with the content broadened to include other risks. Even though the consensus rate of 77% did not reach the cut-off rate of 80% during the second round, the group decided to keep the item as these assessments are frequently requested tests in respiratory laboratories in many European countries.
“Psychological evaluation tools (including quality of life)” reached 76.6% consensus, but again the panel felt that a basic understanding of quality of life tools was important in understanding the scientific literature.
The final draft syllabus contained 21 modules and 122 items, outlined in table 2.
Paediatric respiratory medicine syllabus 2019
Conclusion
Both Delphi rounds achieved a reasonable response rate from a broad group of respondents, and a relatively high degree of consensus on the content of the updated syllabus; most of the modules were agreed to be mandatory for training in PRM. In our view, through the process of revision and review, the new syllabus has been streamlined and made more relevant to current practice. This process will need to be repeated within the next 10 years to ensure that the syllabus and training programmes in Europe continue to be relevant to the needs of tomorrow's patients.
Footnotes
Conflict of interest: R. Primhak has nothing to disclose.
Conflict of interest: N. Tabin is an employee of the European Respiratory Society.
Conflict of interest: N. Beydon has nothing to disclose.
Conflict of interest: J. Bhatt has nothing to disclose.
Conflict of interest: E. Eber has nothing to disclose.
Conflict of interest: J. Hammer has nothing to disclose.
Conflict of interest: A. Martinez-Gimeno has nothing to disclose.
Conflict of interest: F. Midulla has nothing to disclose.
Conflict of interest: R. Nenna has nothing to disclose.
Conflict of interest: J. Paton has nothing to disclose.
Conflict of interest: R. Ross Russell has nothing to disclose.
- Copyright ©ERS 2019
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