Developing Paediatric Subspecialty Training Programmes
Last year in December, the Hong Kong Paediatric Nephrology Society celebrated its 20th anniversary with a Symposium, having renowned paediatric nephrologists from different parts of the world coming to speak. Three of the talks presented in the Symposium are published in the present issue, which include "Renal Hypertension in Children" by Professor Michael Dillon of Great Ormond Street Hospital for Children of London, "What Have We Learned from the Study on Melamine: A Personal Sentiment on Conducting Clinical Studies" by Professor Jie Ding of First Peking University Hospital, China, and "Development of Paediatric Nephrology Training" by Professor James CM Chan of Virginia, USA.
The article of "Development of Paediatric Nephrology Training" is of particular interest in the context of accreditation of subspecialties. In the paper, much discussion is on the US training programme, in which emphasis is put on research in addition to clinical training. Training programmes of other countries surveyed are diverse, including duration, structure and curriculum with 19 countries having national certification examination and training varying from 12 months to 3 years or more.1 Clinical experience is important and essential, with an addition of research as an element to different degrees in different places.
In order to formulate a structured clinical training programme, other than having qualified trainers, advanced equipments and laboratory support, sufficient clinical materials are most necessary. Taking paediatric nephrology as an example, they should include a whole range of diseases including urinary tract infections, reflux nephropathy, nephrotic syndrome, different types of glomerulonephritis, haemolytic uraemic syndrome, renal hypertension, tubular disorders, kidney failure, acute kidney injury and chronic kidney diseases etc. As for chronic kidney diseases (CKD), the management by dialysis and kidney transplantation is complex and resource demanding, however CKD are not common in children, and thus concentration of these cases into centres becomes necessary both for service and training purpose. It is generally taken that a centre / children hospital needs to be supported by at least a population of about 4-5 million population.2 As for general nephrology, since the volume is relatively bigger, it could be organised into more centres for service delivery seeing to patients' convenience. Thus, for a comprehensive training programme in paediatric nephrology, training in one of these general nephrology centres can be supplemented by rotational training to a renal centre with CKD programme which provides dialysis and kidney transplantation. It will be ideal if a network could be formed both for service and training purpose.
At present in Hong Kong, there are a few subspecialties that have concentrated tertiary care into centres, and these include cardiology with surgery, oncology, infectious diseases, and nephrology. Formulation of subspecialty training programmes may take the model described above. For those subspecialties of high patient volume load, e.g. neonatology, respiratology, neurology, and endocrinology, it will be better to concentrate the complex cases into centres for enhancing expertise and training. As Hong Kong is only a city of about 7 million populations, there are a few subspecialties that may not have sufficient clinical materials to provide comprehensive training programme without concentrating them into a single centre. The future children hospital which aims at delivery of tertiary care,3 will certainly facilitate the formulation of training programmes for these subspecialties. There may even have 1 or 2 subspecialties with so small a patient load that local patients can hardly support a full training programme. However, they may be supplemented by patients from China and other places, especially after the establishment of the future children hospital which will attract patients from abroad; or alternatively, the local programme may be supplemented by training programmes elsewhere, which form part of a rotational training scheme.
General paediatrics is an important and essential part of paediatrics; however in line with the development of advanced technology which specialises paediatric practice into subspecialties in developed countries, we would need to organise for ourselves a system which best suit our local situation to upkeep standards for the benefits of the health and medical care of our children. The future children hospital will certainly help to facilitate such advancement in the years to come. In the accreditation of these training programmes, in addition to taking into consideration standards of other countries, we need also take reference from those of other local Colleges regarding programmes, standards and requirements, such that our trainees will not be treated too differently from our counterparts, and that the ultimate goal is still what practice is 'to the best' for our children taken as a whole.
Department of Paediatrics & Adolescent Medicine
Princess Margaret Hospital, Lai Chi Kok, Kowloon,
Hong Kong SAR
1. Chan JCM. Development of Paediatric Nephrology Training. HK J Paediatr (new series) 2010:150-4.
2. McKinsey, Children's Health First-International Best Practice in Tertiary Paediattric Service: Implications for the Strategic Organization of Tertiary Paediatric Services in Ireland, 2006. www.lenus.ie/hse/handle/10147/42911.
3. A Children Hospital for Hong Kong: For the Future Generation and Paediatrics. Children Hospital Project Team, Hospital Authority, 2007.