Expectations Sleep Medicine - cpso.on.ca ?· EXPECTATIONS OF PHYSICIANS Intending to Practise Sleep…

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  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 1

    EXPECTATIONSOFPHYSICIANSINTENDINGTOPRACTISESLEEPMEDICINECHANGINGSCOPEOFPRACTICEPROCESS

    BACKGROUND

    TheCollegeisgraduallymovingtowardasystemofperformancemeasurementbyfocusingonaphysicianscompetenceinafieldofpracticeratherthansimplyrelyingonpapercredentials(e.g.,specialtycertification).TheChangingScopeofPracticepolicyisbasedontheseprinciples.Itstatesthataphysiciansabilitytoperformcompetentlyinhisorherscopeofpracticeisdeterminedbythephysiciansknowledge,skillsandjudgment,whicharedevelopedthroughtrainingandexperienceinthatscopeofpractice.TheChangingScopeofPracticepolicyisavailableatwww.cpso.on.caunderPoliciesandPublications.

    Thepolicyindicatesaphysiciansscopeofpracticeisdeterminedbythe:

    patientsthephysiciancaresfor, proceduresperformed, treatmentsprovided,and practiceenvironment.TheChangingScopeofPracticepolicyappliestoallphysicians(hospitalandindependenthealthfacilitybased)whohaveeitherchangedtheirscopeofpracticetoincludesleepmedicinesinceJune1,2003,orintendtochangetheirscopeofpracticetoincludesleepmedicineinthefuture.1Physicianswhowerepractisingsleepmedicinepriortotheestablishmentofthepolicyarenotrequiredtoreportachangeinscopeofpractice.ASleepMedicineWorkingGroup,composedofvariousexpertsinsleepmedicinefromavarietyofbackgrounds,hasdevelopedadecisionmakingframeworktoassisttheCollegeinevaluatingrequestsfromphysicianswhoareintendingtopractiseadultandadolescent(age13andolder)sleepmedicine,bothinahospitalandanindependenthealthfacilities(IHF)setting.

    TheWorkingGroupsmaintaskwastodeveloptrainingstandardsforphysicianswishingtopractisesleepmedicineinOntariobecausetherearenonationalstandardsfortrainingoraCanadiancertificationprocessinsleepmedicine.If,inthefuture,anationalcertificationprocessinsleepmedicineisdevelopedthenthesestandardsmayneedtoberevisited.Atpresent,physicianspractisingsleepmedicinearefromavarietyofdisciplines,includingrespirology,psychiatry,neurology,internalmedicine,otolaryngology,andfamilypractice.

    1PhysicianswhochangedtheirscopeofpracticetoincludesleepmedicineduringthetimeframeJune1,2003toAugust31,2008thatwereaffiliatedwithanindependenthealthfacility(IHF)wouldhavepreviouslybeenreviewedandapprovedbytheIHFSleepMedicineReviewPanel.

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 2

    IHFRECOMMENDATIONSONTRAINING TheIHFrecommendationsontrainingrequiredforsleepmedicineforphysicianswhobeganpracticeinthisareaafter1996include:

    aminimumof12monthsfulltimeorequivalentclinicaltrainingintheassessment,diagnosis,treatmentandpolysomnographicevaluationofpatientswithabroadrangeofprimaryandsecondarysleepdisordersinarecognizedpostgraduatetrainingcentreprovidingevidenceofwhenitoccurredandverificationbythesupervisingphysician;

    or

    successfulcompletionofthecertificationexaminationoftheAmericanBoardofSleepMedicineorequivalent;

    or

    experienceobtainedfromtheassessment,diagnosisandtreatmentofpatientswithabroadrangeofprimaryandsecondarysleepdisordersandtheinterpretationofpolysomnogramsunderthesupervisionofaphysicianinasleepdisorderfacilitywhomeetsthecriteriainthisdocument.Aminimumof2,000hoursexperienceandtrainingmustbeobtainedandcanoccurinatimeframeofbetween12and36months.Physiciansmustprovidedocumentedevidenceofthistraining.

    Theminimumnumberofhoursofexperiencerequiredisbasedupontheamountoftimethatatraineewouldspendinafellowshipofoneyearsduration.

    IntheUnitedStates,since2006,certificationinsleepmedicineisofferedthroughseveralboardsoftheAmericanBoardofMedicalSpecialties(ABMS).Priorto2006,physicianscouldseekspecialistcertificationthroughtheAmericanBoardofSleepMedicine,however,thisorganizationnolongerprovidesexamsinsleepmedicine.TheABMSboardsthatcurrentlyoffercertificationinsleepmedicinearethe:

    AmericanBoardofFamilyMedicine

    AmericanBoardofInternalMedicine

    AmericanBoardofPediatrics

    AmericanBoardofPsychiatryandNeurology

    AmericanBoardofOtolaryngologyTheWorkingGrouphasreliedheavilyontheAccreditationCouncilonGraduateMedicalEducation(ACGME)ProgramRequirementsforGraduateMedicalEducationinSleepMedicine

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 3

    documentdated2004.TheWorkingGroupdrewelementsfromthisdocumenttodeterminethecomponentsofatrainingprograminsleepmedicine,andisappendedtoassisttraineesinunderstandingtherequiredcontentofatrainingprograminsleepmedicine.Thefollowingrecommendationsrepresenttheminimaltrainingrequirementsintermsofprogramstructureforphysicianswishingtopracticesleepmedicine.Whilethechangeinscopeofpracticeprocessgenerallyinvolvestraining,supervisionandassessment,allofthesecomponentsmaynotapplyineverycase;inarrivingatadecision,theCollegewillrevieweachphysiciansindividualcircumstances.MINIMALTRAININGREQUIREMENTSFORSLEEPMEDICINEThefollowingsetsouttheCollegesexpectationsofphysicianswhowishtopractiseadultandadolescent(age13andolder)sleepmedicine.Notethatadditionaltraining(beyondwhatisoutlinedinthisdocument)isrequiredforphysicianswhowishtopractisesleepmedicineinrelationto:1. neonatalandpediatricpatients,and2. patientswithcomplexhealthissues,e.g.,patientswithDownSyndrome,developmentally

    delayedadolescents,complicatedrespiratoryfailurepatientswhorequiremechanicalventilation,etc.

    TobeeligibletopractisesleepmedicineinOntario,physiciansmusthaveadequatetrainingandexperience.Asthereiscurrentlynoformal,accreditedfellowshipprocessinsleepmedicineinCanada,oneofthefollowingpathwaysmaybetakeninordertodemonstratetotheCollegethatthephysicianhasappropriateandadequatetrainingandexperienceinsleepmedicine.NotethatwiththeexceptionofPathway1,allpathwaysrequireadegreeofsupervisionandtypicallyaCollegedirectedassessmentatsomepointfollowingthecompletionofthetraining.

    1. PATHWAY1AccreditedFellowshipPathway*

    a. CompletedanACGMEaccreditedtrainingprograminsleepmedicineintheUnitedStates,and

    b. Successfullycompletedthesponsoringspecialtyscertificationexaminationinsleepmedicine.

    *Notethatphysicianswhoareeligibletowritethe2011ABMSSleepMedicineexaminationthroughthepracticeeligiblerouteandsuccessfullycompletethisexaminationwillbeconsideredasPathway1physicians.OR

    http://www.cpso.on.ca/uploadedFiles/policies/policies/pathway1-training-checklist.pdf

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 4

    2. PATHWAY2AcademicNONAccreditedFellowshipPathway

    a. CompletedatrainingprogramsponsoredbyanaccreditedCanadianmedicalschooldepartmentordivisionwithadurationequivalentto12monthsoffulltimeclinicaltraining.Theprogrammustbestructuredsuchthatthereis:

    i. Adesignatedprogramdirector;ii. Standard,writtentrainingobjectives;iii. Aformal,regularevaluationprocess;iv. Amechanismtoreporttheprogramsassessmentoftheindividuals

    competenceattheendoftheprogram;v. Allmandatorycomponents(SectionA)containedwithintheattached

    documententitledComponentsofSleepMedicineTrainingProgramsinOntario;

    vi. AmechanismtodocumentalltrainingexperiencesincludingthenumberandtypesofallsleepstudiesinterpretedequivalenttothatwhichiscontainedintheCPSOIHFSleepMedicineChecklist.

    b. Theprogrammustbecompletedinlessthan36months.

    OR

    3. PATHWAY3NONAcademic,NONAccreditedFellowshipPathway

    a. Completedapersonalizedtrainingprograminsleepmedicinewithadurationequivalentto12monthsoffulltimetraining.Theprogrammustbestructuredsuchthatit:

    i. Containsallmandatorycomponents(SectionA)containedwithintheattacheddocumententitledComponentsofSleepMedicineTrainingProgramsinOntario;

    ii. Hasaminimumoftwosupervisors,acceptabletotheCollege,whoagreetoreportonthecontentofthetrainingnolessthanquarterly.Thesupervisorsagreetobethemostresponsiblephysician(MRP)forallpatientassessmentsforthedurationofthetrainingprogram;

    iii. Aformal,regularevaluationprocess;iv. Writtenobjectivesoftraining;v. Amechanismtoreportthesupervisorsassessmentoftheindividuals

    competenceattheendoftheprogram;vi. Amechanismtodocumentalltrainingexperiencesincludingthenumber

    andtypesofallsleepstudiesinterpretedequivalenttothatwhichiscontainedintheCPSOIHFSleepMedicineChecklist.

    b. Theprogrammustbecompletedinlessthan36months.c. Theproposedprogram,includingsupervisors,mustbeevaluatedbytheCollege

    toensurethattheyareacceptablebeforethephysicianembarksonthetraining.OR

    http://www.cpso.on.ca/uploadedFiles/policies/policies/pathway2%20-trainingchecklist.pdfhttp://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/pathway-3training-checklist.pdf

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 5

    4. PATHWAY4SignificantPracticeExperienceinSleepMedicine2

    a. ThephysicianmusthaveclinicalpracticeexperienceinajurisdictioninNorthAmericainsleepmedicinefortheimmediatepastfiveyears,inwhichatleast50%oftheirclinicaltimehasbeenspentassessingpatients,interpretingsleepstudiesandmanagingpatientswithsleepdisorders.

    b. Thephysicianmustprovideevidenceoftheamountandqualityoftheirsleepmedicinepracticethroughtheprovisionofaletterofsupportfromthedirectorofeverysleeplabinwhichtheyworkedduringthatfiveyearperiod.ThelettersofsupportshouldattesttothephysicianscompetencyinthecomponentscontainedwithintheattacheddocumententitledMandatoryComponentsofSleepMedicineTrainingProgramsinOntario.

    c. TheCollegewillevaluatetheevidenceforitsacceptability.

    SUPERVISIONANDASSESSMENTREQUIREMENTSFOLLOWINGTHECOMPLETIONOFTRAININGOncetraininginanyoftheabovepathwaysiscomplete,thephysicianmayberequiredtoundergoaperiodofsupervisedpractice,followedbyaCollegedirectedassessmentpriortobeingapprovedforthechangeinscopeofpractice.Theserequirementsareoutlinedinthetablebelow.

    PATHWAY

    ISSUPERVISIONREQUIRED

    AFTERTRAININGISCOMPLETED?

    (trainingoutlinedinthepathways)

    LEVELOFSUPERVISION

    DURATIONOFSUPERVISION

    ASSESSMENTREQUIRED?

    Pathway1:AccreditedFellowshipPathway

    NO3 N/A N/A NO

    2Thiscategoryappliestophysicianswithsignificantexperiencefromotherjurisdictionsandtophysicianswhohavesometraininginsleepmedicine,butnotenoughtosatisfytheotherpathways. 3PhysicianswhohavecompletedaUSfellowshipprograminsleepmedicineareexpectedtohavesuccessfullycompletedthesponsoringspecialtyscertificationexaminsleepmedicine;otherwise,theytoomaybesubjecttoaperiodofsupervisedpracticesimilartothosephysiciansidentifiedinPathway2.

    http://www.cpso.on.ca/uploadedFiles/policies/policies/pathway4-training-checklist.pdf

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 6

    PATHWAY

    ISSUPERVISIONREQUIRED

    AFTERTRAININGISCOMPLETED?

    (trainingoutlinedinthepathways)

    LEVELOFSUPERVISION

    DURATIONOFSUPERVISION

    ASSESSMENTREQUIRED?

    Pathway2:NONAccreditedAcademicPathway

    YES4 LOW 6MONTHS DISCRETIONARY

    Pathway3:NONAcademic,NONAccreditedPathway

    YES

    MODERATEthen

    DISCRETIONARY(afterassessment)

    3MONTHS

    DISCRETIONARY

    YESTheCollegedirectedassessmenttotakeplaceafterthreemonthsofmoderatesupervision;reassessmentcouldbedirectedifthereisaperiodofadditionalsupervision.

    Pathway4:Physicianswithsignificantpracticeexperience

    YES

    MODERATEthen

    DISCRETIONARY(afterassessment)

    3MONTHS

    DISCRETIONARY

    YESTheCollegedirectedassessmenttotakeplaceafterthreemonthsofmoderatesupervision;reassessmentcouldbedirectedifthereisaperiodofadditionalsupervision.

    4PhysicianswhohavecompletedaCanadianfellowshipprogramarerequiredtoundergoasixmonthperiodofsupervision;thissixmonthperiodoflowlevelsupervisionservesasaproxyfortheexamination.SomeCanadianfellowshipprogramsareaccreditedbytheAmericanAcademyofSleepMedicine.Inthesecases,physiciansareencouragedtosubmitevidenceofthisaccreditationandiftheywish,shouldcontacttheABMStoclarifytheireligibilitytotaketheABMSsubspecialtyexaminSleepMedicinelastofferingis2011.

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 7

    COMPONENTSOFSLEEPMEDICINETRAININGPROGRAMSINONTARIO

    (BasedonACGMEProgramRequirementsforGraduateMedicalEducationinSleepMedicine)

    A. MANDATORYCOMPONENTSOFTRAININGPROGRAMSThefollowingcomponentsmustbeincludedinallphysicianstrainingprogramsinsleepmedicine.

    1.TechnicalandOtherSkillsTraineesmusthaveformalinstruction,clinicalexperience,anddemonstratedcompetenceatthecompletionofeducationinthefollowing:

    A) theindicationsforandpotentialpitfallsandlimitationsofdiagnostictestsandtheinterpretationoftheresultsinthecontextoftheclinicalsituation.Thesediagnostictestsmustincludethefollowing:

    a.polysomnography,scoringandinterpretationofpolysomnogramsandrecognitionofartifacts,including:

    i)performanceandinterpretationofCPAPtitrations,(ii)performanceandinterpretationofbileveltitrations,(iii)performanceandinterpretationofadaptiveservoventilationstudies.

    b.multiplesleeplatencytesting;c.maintenanceofwakefulnesstesting;d. evaluationofpolysomnogramsthatinvolvetreatment,includingdentaldevices,positiveairwaypressuretherapy,etc.;

    e.compliancereportsforuseofpositiveairwaypressuretherapyorotherdevices. B) skillsnecessarytoperformpolysomnographiesfrompreparationandhookupofthe

    patienttothecompletionofthestudy,includingmultiplesleeplatencyandmaintenanceofwakefulnesstests.

    C) scoringandinterpretationofpolysomnogramsandrecognitionofartifacts.

    D) consultativeskillsinsleepmedicineinavarietyofmedical,surgical,andpsychiatric

    settings.

    2.FoundationalKnowledgeofSleepTraineesmusthaveformalinstructionin,anddemonstratecomprehensiveknowledgeof:

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 8

    A) fundamentalmechanismsofsleep,majortheoriesinsleepmedicine,andthegenerallyacceptedfactsofbasicsleepmechanisms:

    a. Basicneurologicalsleepmechanisms;b. Chronobiologicalmechanisms;c. Respiratoryphysiologyduringsleepandpathophysiology;d. Cardiovascularphysiologyduringsleepandpathophysiology;e. Sleepacrossthelifespan.

    B) airwayanatomy.C) nosologyforsleepdisorders:TheInternationalClassificationofSleepDisorders.D) etiopathogeniccharacterizationofsleepdisorders.

    E) pharmacologyofsleep(i.e.,medicationeffectsonsleep).

    3.ClinicalAssessmentSkillsTraineesmusthavesufficientclinicalexperienceasoutlinedintheChecklistofClinicalSleepTrainingExperiencethatisattached(Appendix1).Traineesmusthaveformalinstructionin,anddemonstratecomprehensiveknowledgeofclinicalmanifestationsofthefollowingaspectsofsleepdisorders:

    A) evaluationofpatientspresentingwithexcessivesleepiness.B) evaluationofpatientspresentingwithdifficultyinitiatingormaintainingsleep.

    C) evaluationofpatientspresentingwithparasomnias.D) biologicalrhythmdisorders.

    E) medical,neurologic,andpsychiatricdisordersdisplayingsymptomslikelytoberelated

    tosleepdisorders(e.g.,therelationshipbetweenhypertensionandsnoring).

    F) biological,psychological,social,economic,ethnic,andfamilialfactorswhichsignificantlyinfluencetheevaluationandtreatmentofsleepdisorders.

    G) thenatureoftheinteractionsbetweentreatmentforsleepdisordersandothermedical,

    neurologic,andpsychiatrictreatment.4.DiagnosticSkillsTraineesmusthaveformalinstructionin,anddemonstratecomprehensiveknowledgeofdiagnosticstrategiesinsleepdisorders.

  • EXPECTATIONSOFPHYSICIANSIntendingtoPractiseSleepMedicine 9

    A) etiologies,prevalence,diagnosis,andtreatmentofallofthesleepdisordersinthe

    currentnosologyofsleepmedicine.B) theuse,reliability,andvalidityofthegenerallyacceptedtechniquesfordiagnostic

    assessment.5.TreatmentofSleepDisordersTraineesmusthaveformalinstructionin,anddemon...