Specialist training for physicians for people with intellectual disability (AVG)  

Department of General Practice, Erasmus MC Rotterdam, Holland 

Introduction

In 2000 the Dutch minister of Health recognised the medical care for people with an intellectual disability (ID) as a new medical specialisation. The training for this new specialisation takes place at Erasmus MC in Rotterdam and is accommodated in the institute for training of general practitioners. It is a three-year postgraduate university training for physicians. It consists of a combination of working and learning in the field of medical care for people with ID.

Part of the training is an orientation in closely related fields of medicine, like neurology, genetics and psychiatry. Finishing the training program gives the physicians the officially registered title: “Arts voor Verstandelijk Gehandicapten: "AVG ”: physician for people with intellectual disability.

A new and different specialisation

Medical care for people with ID has developed in the past twenty years towards a separate field in medicine. In the beginning it was mainly based on experiences of physicians working in the field. Recently the scientific basis of this specialisation started to develop.

Medical care for people with ID distinguishes from other specialisations:

• it is exclusively serves people with ID 
• the aetiology of the intellectual disability in this group is miscellaneous, there are often complex and multiple disorders and complications, 
• which are different from disorders in normal population 
• care for people with ID is longitudinal and has a strong multidisciplinary context 
• there is a different presentation of complaints and diseases 
• there are diagnostic and therapeutical problems caused by the intellectual and physical impairments of the patients 
• the level of intellectual impairment has a strong influence on the capacity of the patients to make their own decisions, so communication with (professional) caregivers, parents and family is frequent and requires special skills.

The attitude towards people with ID has changed tremendously in the last two decades. Not only in Holland, but also in a large part of the western world.

People with intellectual disability participate in normal society because of the replacement of residential care by community-based care. Government, parents and organisations of caregivers are pursuing full-valued citizenship. General practitioners, who are not specially trained on the medical aspects of the care for people with ID, give medical care more often.

It was feared that in the process of de-institutionalising a lot of knowledge about the medical care for people with ID was going to be lost. The NVAZ (the Netherlands Society of physicians working with people with ID) started around 1994 on a long road to getting this specialisation  recognized. With the start of the specialist training in December 2000 one of the main goals of the NVAZ was reached. Attention will now be focused on further development of the profession, both on the scientific base but also on the organization of medical care for this special group. The future position of the AVG is not yet sure, but the recognition of the specialisation  gives a lot of chances to establish a good professional basis.

Education of physicians for people with ID

The three year training course for physicians for people with ID consists, like all specialisations, of a practical part and an academic part: four days a week of practical work, and the fifth day study at the University.

The didactical principles of the training are based on modern educational principles like problem oriented learning and self-activity. The construction of the educational training resembles the training of GP’s and physicians for the elderly in Holland.

Different educational methods are being used, like group-training, bedside teaching, interactive teaching lessons of an experienced AVG, educational courses, supervision, intervision, literature study and -presentation. Practical experiences and theory are integrated. Social and communicative skills are trained.

The curriculum

The curriculum consists of three periods of 12 months. In the first year of the training the trainee works in an institute for the care of people with ID. With supervision of an experienced AVG the trainee learns with increasing independence to give adequate medical care to people with ID living in the institute. Three times a month the trainees get an educational training at the Erasmus MC Rotterdam.

The second period exists of three or four traineeships in relevant medical specialisations like neurology, paediatrics, genetics and psychiatry.

The trainee chooses his own program from four main topics:

-                     aetiology and neurological functions

-                     physical disorders and handicaps

-                     psychiatry and behaviour

-                     family medicine and care for the elderly

Also in the second year a short traineeship in an institute for people with ID and visual impairments and one in an institute for hearing impaired are organized.

Every week there is an educational training at the University in Rotterdam. The topics are related to the topics of the traineeship.

The third year of the specialist training the trainee works again in the former institute, but he has other tasks. Trainees learn to work in other services for people with ID, like group-homes, day-centers or community teams where they have an advising and consulting role.

The training at the University in the last year is focused on consultation and advice and on complex problems.

During the whole curriculum there are a few courses of several days on specific subjects like ethical aspects, scientific skills and aetiology. 

Educational program at the Erasmus University Rotterdam

As mentioned above, during the whole curriculum, the trainee participates in the educational training at the Erasmus University Rotterdam, three or four days every month. Usually the program consists of four separate parts

• exchanging experiences

• presenting results from the literature

• training in social and communicative skills

• medical topics like: general health problems, epidemiology, syndromes and co morbidity, diagnosis and  treatment of specific medical conditions, ethics and law and quality improvement.

Training in scientific skills, the process of consensus making, medical audits are part of the curriculum.

There is also an educational training program for the supervisor. This is the experienced AVG who supervises the trainee in the institutes. Every month they join in an one-day program on educational and didactic skills.

How to participate?

The specialist training is for physicians with an in the Netherlands recognised diploma (BIG-registration). Every year the Erasmus MC Rotterdam publishes a list of participating institutes. These institutes start their own procedure for selecting a trainee. The staff of the training programme finally decides about the capacities of the trainee to join in the training programme.

The language of the training program is Dutch.

Which physician is a good AVG?

Just finishing the training doesn’t mean you are a good AVG. A lot depends on the personal qualities of the AVG. For this work you need character aspects like flexibility, patience, humor, enthusiasm and affectionate feelings for people with ID, but with the abilities to keep enough professional distance. Communicative and social skills are important.

But above all: medical care for people with ID is a young and dynamic profession and the professional training has just started. A future AVG needs a pioneering mentality for helping to develop the training for this beautiful specialisation . 

Results:

68 physicians joined in the training programme in the last years, 26 of them are graduated by now. They easily found a job in the field of ID medicine.

January 2006

Marijke M. Meijer, AVG

Further information:

Specialist training for physicians for people with intellectual disability (AVG), Department of General Practice, Erasmus MC Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands,  Tel: +31-10-7043341  www.erasmusmc.nl/avgopleiding

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