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Objectives of Training in the Subspecialty of Adult Respirology

2011

EDITORIAL REVISION - AUGUST 2016
VERSION 1.1

This document applies to those who begin training on or after July 1^st, 2011.

DEFINITION

Adult Respirology is a medical subspecialty concerned with the study, diagnosis, and management of the respiratory system in health and disease, and the prevention of respiratory disease.

GOALS

Upon completion of training, a resident is expected to be a competent subspecialist in adult Respirology, capable of assuming a consultant’s role in the subspecialty. The resident must acquire a working knowledge of the theoretical basis of the subspecialty, including its foundations in the basic medical sciences and research.

The resident will develop an in-depth understanding of problems affecting the respiratory apparatus. The resident will acquire the clinical skills to treat and counsel patients with diseases affecting the respiratory system; this will include primary and secondary prevention, treatment and rehabilitation and pulmonary rehabilitation. The graduate will be able to supervise a clinical pulmonary function laboratory. The resident will learn to work effectively with a health care team and will acquire the skills to be an effective teacher of other physicians, other health care professionals and patients. Among others, the professional attributes to be demonstrated and developed will include responsibility, intellectual curiosity, self-appraisal, compassion, and a commitment to continuing medical education. The physician specializing in adult Respirology will also learn to appraise his/her own professional performance, to assess the medical literature critically and to maintain his/her level of competence.

Only candidates certified by the Royal College of Physicians and Surgeons of Canada in Internal Medicine may be eligible for certification in adult Respirology.

Residents must demonstrate the requisite knowledge, skills, and behaviours for effective patient-centred care and service to a diverse population. In all aspects of specialist practice, the graduate must be able to address issues of gender, sexual orientation, age, culture, ethnicity and ethics in a professional manner.

ADULT RESPIROLOGY COMPETENCIES

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert

Definition:

As Medical Experts, Respirologists integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. Medical Expert is the central physician Role in the CanMEDS framework.

Key and Enabling Competencies: Respirologists are able to…

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centred medical care
   1. Perform a consultation effectively, including the presentation of well-documented assessments and recommendations in oral, written and/or electronic form in response to a request from another health care professional
   2. Demonstrate use of all CanMEDS competencies relevant to Respirology
   3. Identify and appropriately respond to relevant ethical issues arising in patient care
   4. Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems
   5. Demonstrate compassionate and patient-centred care
   6. Recognize and respond to the ethical dimensions in medical decision-making
   7. Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed
2. Establish and maintain clinical knowledge, skills and behaviours appropriate to Respirology
   1. Apply knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to Respirology, including the following:
      1. Basic sciences
         1. Embryologic development of the respiratory system and how congenital anomalies arise
         2. Basic principles of clinical genetics relevant to Respirology
         3. Gross and microscopic anatomy of the lungs, pulmonary vasculature, chest wall, and neuromuscular apparatus and the basic anatomy of the upper airway and brainstem
         4. Respiratory physiology:
            1. Alveolar gas composition
            2. Ventilation and its control
            3. Distribution of alveolar ventilation
            4. Diffusion
            5. Perfusion and vascular physiology
            6. Ventilation perfusion relationships
            7. Oxygen delivery, utilization, and transport
            8. Carbon dioxide transport
            9. Acid base balance
            10. Mechanics of breathing
            11. Respiratory muscle function
            12. Respiratory system in sleep
            13. Respiratory system during exercise
         5. Basic principles of clinical immunology as they apply to Respirology
         6. Basic principles of molecular biology relevant to Respirology
         7. Mechanisms of action of major pharmacological agents with effects on the respiratory system
         8. Broad knowledge of microbiology as it relates to Respirology, including normal defence mechanisms
         9. Fundamental principles of epidemiology
         10. Cardiovascular physiology as it applies to Respirology and cardiopulmonary interaction as seen in various respiratory disorders
         11. Basic gross and microscopic pathology as applied to clinical disorders of respiratory system
      2. Clinical sciences
         1. Pathophysiology, clinical manifestations, differential diagnosis, general approach to prevention, diagnosis and management, natural history and prognosis of the following:
            1. Signs and symptoms: including but not limited to dyspnea, cough, snoring, hemoptysis, chest pain, cyanosis, adventitious sounds, clubbing
            2. Abnormalities of developmental origin or diseases arising from prematurity that may have continuing impact in adult life
         2. Airway diseases:
            1. Upper airway
               1. Epiglottitis
               2. Tracheal stenosis
               3. Upper airway tumours
               4. Disorders of the vocal cords
               5. Laryngotracheobronchitis
               6. Foreign bodies
            2. Lower airway
               1. Asthma
               2. Chronic obstructive pulmonary disease: chronic bronchitis, emphysema
               3. Bullous diseases
               4. Bronchiectasis
               5. Cystic fibrosis
               6. Bronchiolitis
               7. Dysmotility syndromes
         3. Respiratory failure:
            1. Acute and chronic
            2. Hypoxemic and hypercapnic
         4. Pleural disorders:
            1. Pleural effusions, pneumothorax, pleural plaques and thickening, mesothelioma and other malignancies
         5. Mediastinum:
            1. Mediastinitis, pneumomediastinum, mediastinal masses, vascular abnormalities
         6. Neoplastic disorders:
            1. Benign
            2. Malignant: primary and secondary
            3. Paraneoplastic syndromes
         7. Infectious diseases:
            1. Infections of upper and lower respiratory tract
            2. Infections in the normal host (community acquired and nosocomial) and in the immunocompromised host
            3. Infections caused by bacteria, viruses, mycoplasma, chlamydia, rickettsiae, fungi, protozoans, metazoans, mycobacteria
         8. Industrial and environmental diseases:
            1. Inorganic and organic pneumoconiosis
            2. Air pollution, sick building syndrome, and smoking
            3. Occupational asthma, reactive airways dysfunction syndrome
         9. Complications of aspiration of:
            1. Gastric contents
            2. Foreign bodies
            3. Lipoid material
            4. Water, including but not limited to immersion injuries
         10. Immunologic diseases:
             1. Rhinitis
             2. Asthma
             3. Hypersensitivity pneumonitis
             4. Eosinophilic lung disease
             5. Respiratory manifestations of collagen vascular diseases and vasculitis
             6. Organizing pneumonia
             7. Sarcoidosis
         11. Lung injury:
             1. Trauma
             2. Drugs including but not limited to recreational and illicit drugs
             3. Radiation
             4. Oxygen
             5. Thermal
             6. Barotrauma
         12. Restrictive diseases
             1. Chest wall deformities
             2. Neuromuscular diseases
             3. Interstitial lung diseases and other diffuse parenchymal lung diseases
             4. Pleural disorders
         13. Pulmonary hemorrhage syndromes
         14. Disorders of the pulmonary circulation:
             1. Pulmonary embolism: thromboembolism, fat, air, tumour, amniotic fluid
             2. Pulmonary hypertension
             3. Pulmonary edema
             4. Cor pulmonale
             5. Pulmonary arteriovenous malformations, fistulas and other vascular abnormalities
         15. Non cardiogenic pulmonary edema
         16. Sleep disorders:
             1. Excessive daytime somnolence
             2. Sleep disordered breathing
             3. Hypoventilation syndromes
             4. Non-respiratory sleep disorders: restless legs syndrome, periodic limb movement disorder, narcolepsy, parasomnias, insomnia
         17. Respiratory manifestations of extrapulmonary disorders
         18. Respiratory complications of pregnancy
         19. Rare lung diseases including but not limited to alveolar proteinosis, lymphangioleiomyomatosis, and histiocytosis
   2. Demonstrate an understanding of indications, benefit, contraindications, complications and general techniques of the following therapeutic/diagnostic interventions:
      1. Pulmonary rehabilitation
      2. Radiation therapy
      3. Chemotherapy
      4. Respiratory therapy, including but not limited to airway secretion management
      5. Physical therapy
      6. Interventional bronchoscopy including endobronchial ultrasound (EBUS) and airway stenting
      7. Common surgical interventions:
         1. Mediastinoscopy
         2. Thoracotomy and lung resection
         3. Thoracoscopy
         4. Surgical management of empyema
         5. Lung reduction surgery
         6. Lung transplantation
         7. Placement of closed pleural drainage by blunt dissection
         8. Closed pleural biopsy
         9. Tracheostomy
      8. Palliative care
      9. Advanced care planning and end of life decision making
   3. Describe the CanMEDS framework of competencies relevant to Respirology
   4. Apply lifelong learning skills of the Scholar Role to implement a personal program to keep up to date, and enhance areas of professional competence
   5. Integrate the available best evidence and best practices to enhance the quality of care and patient safety in Respirology
3. Perform a complete and appropriate assessment of a patient
   1. Identify and effectively explore issues to be addressed in a patient encounter, including the patient’s context and preferences
   2. Elicit a history that is relevant, concise, and accurate to context and preferences, for the purposes of diagnosis, management, health promotion, and disease prevention
   3. Perform a focused physical examination that is relevant and accurate, for the purposes of diagnosis, management, health promotion, and disease prevention
   4. Select medically appropriate investigative methods in a resource-effective and ethical manner
   5. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans
      1. Demonstrate proficiency in interpretation of chest radiographs
      2. Recognize common abnormalities on chest computerized axial tomography (CT) scan
      3. Interpret results of nuclear imaging studies including but not limited to positron emission tomography (PET) and ventilation perfusion studies
      4. Demonstrate proficiency in interpretation of pleural fluid analysis
      5. Demonstrate proficiency in the interpretation of common pulmonary function tests and cardiopulmonary exercise testing; understand the indications, technical aspects and quality assurance issues of such tests
      6. Demonstrate proficiency in the interpretation of blood gases
      7. Identify common abnormalities and understand basic technical aspects of polysomnography
4. Demonstrate proficiency in the performance and use of:
   1. Spirometry
   2. Oxygen delivery systems
   3. Inhalational devices
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
   1. Perform indications, contraindications, technical aspects and quality assurance issues, and potential complications of the following:
      1. Endotracheal intubation (oro and nasotracheal) with and without the use of bronchoscope
      2. Initiation, maintenance and discontinuation of acute and chronic mechanical ventilation (including non-invasive techniques)
      3. Bronchoscopy (including transbronchial biopsy,endobronchial biopsies, bronchoalveolar lavage and bronchoscopic fine needle aspiration)
      4. Thoracentesis with or without ultrasound guidance
      5. Pleurodesis
      6. Placement of closed intrapleural chest tube
      7. Arterial puncture and cannulation
      8. Venous cannulation for placement of central venous and pulmonary artery catheters
      9. Testing for latent tuberculosis
      10. Ensure appropriate informed consent is obtained for procedures
      11. Document and disseminate information related to procedures performed and their outcomes
      12. Ensure adequate followup is arranged for procedures performed
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise
   1. Demonstrate insight into their own limits of expertise
   2. Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal patient care
   3. Arrange appropriate followup care services for patients and their families/caregivers

Communicator

Definition:

As Communicators, Respirologists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: Respirologists are able to…

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
   1. Recognize that being a good communicator is a core clinical skill for Respirologists, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence, and improved clinical outcomes
   2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy
   3. Respect patient privacy, confidentiality, and autonomy
   4. Listen effectively
   5. Be aware of and responsive to nonverbal cues
   6. Facilitate a structured clinical encounter effectively
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
   1. Gather information about a disease and about a patient’s beliefs, concerns, expectations, and illness experience
   2. Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers, and other professionals, while respecting individual privacy and confidentiality
3. Convey relevant information and explanations accurately to patients and families, colleagues, and other professionals
   1. Deliver information to a patient and family, colleagues, and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
   1. Identify and effectively explore problems to be addressed from a patient encounter, including the patient’s context, responses, concerns, and preferences
   2. Respect diversity and differences, including but not limited to the impact of gender, sexual orientation, religion and cultural beliefs on decision-making
   3. Encourage discussion, questions, and interaction in the encounter
   4. Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care
      1. Discuss with the patient/family diagnostic uncertainty and the use of controversial or toxic therapy
   5. Address challenging communication issues effectively, including but not limited to obtaining informed consent, delivering bad news, and addressing anger, confusion, and misunderstanding
      1. Describe and apply the bioethical principles in obtaining informed consent (including: for bronchoscopy, chest tubes, thoracentesis, pleural biopsies, exercise testing)
      2. Appreciate the bioethical principles involved in genetic counselling for cystic fibrosis
      3. Communicate bad news (including new diagnosis of lung cancer) in an empathetic manner. The resident will understand and apply the bioethical principle of truth telling and appreciate cultural differences with respect to death and the communication of bad news
      4. Communicate, in an ethical and effective manner, issues related to initiation and withdrawal of mechanical ventilation, death from respiratory failure and the role of the advanced directives
5. Convey oral, written, and/or electronic information effectively about a medical encounter
   1. Maintain clear, concise, accurate, and appropriate records of clinical encounters, procedures, and plans
   2. Communicate opinions clearly in the form of consultation letters/handwritten notes, telephone calls to the family doctor, specialists, and allied health professionals
   3. Present oral reports of clinical encounters and plans
   4. Convey medical information appropriately to ensure safe transfer of care
6. Present medical information to the public or media about a medical issue
   1. Provide expert legal testimony
   2. Advise insurance companies

Collaborator

Definition:

As Collaborators, Respirologists effectively work within a health care team to achieve optimal patient care.

Key and Enabling Competencies: Respirologists are able to…

1. Participate effectively and appropriately in an interprofessional health care team
   1. Describe the Respirologists roles and responsibilities to other professionals
   2. Describe the roles and responsibilities of other professionals within the health care team
   3. Recognize and respect the diversity of roles, responsibilities, and competencies of other professionals in relation to their own
   4. Work with others to assess, plan, provide, and integrate care for individuals and groups of patients
      1. Develop a care plan for the patient in collaboration with members of the interprofessional team
   5. Work collaboratively in other activities and tasks: examples are research, educational work, program review, and/or administrative responsibilities
   6. Participate in interprofessional team meetings, demonstrating the ability to accept, consider and respect the opinion of other team members while contributing specific expertise
   7. Enter into interdependent relationships with other professions for the provision of quality care
   8. Describe the principles of team dynamics
   9. Respect team ethics, including confidentiality, resource allocation, and professionalism
   10. Demonstrate leadership in a health care team, as appropriate
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict
   1. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team
   2. Work with other professionals to prevent conflicts
   3. Respect differences and the scopes of practice of other professions
   4. Reflect on their own differences, misunderstandings, and limitations that may contribute to interprofessional tension
   5. Reflect on interprofessional team function
   6. Employ collaborative negotiation to resolve conflicts and address misunderstandings

Manager

Definition:

As Managers, Respirologists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

Key and Enabling Competencies: Respirologists are able to…

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
   1. Work collaboratively with others in their organizations
   2. Participate in systemic quality process evaluation and improvement, including patient safety initiatives
      1. Demonstrate knowledge of available outcome measures for a quality assurance program
      2. Demonstrate the ability to identify a problem in need of improvement
      3. Demonstrate the ability to develop standards of care
   3. Describe the structure and function of the health care system as it relates to Respirology, including the roles of physicians
   4. Describe principles of health care financing, including physician remuneration, budgeting, and organizational funding relevant to Respirology
      1. Administrative organization of health care delivery
      2. Negligence and medical fault
      3. Worker's compensation and assessment of impairment, disability and insurability
2. Manage their practice and career effectively
   1. Set priorities and manage time to balance patient care, practice requirements, outside activities, and personal life
   2. Manage a practice, including finances and human resources
      1. Demonstrate the ability to supervise a pulmonary function testing laboratory including issues pertaining to quality assurance, staffing, and reporting
      2. Demonstrate awareness of issues pertaining to running a private office, including staffing, billing, and maintaining records
   3. Implement processes to ensure personal practice improvement
   4. Employ information technology appropriately for patient care
3. Allocate finite health care resources appropriately
   1. Demonstrate an understanding of the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care
      1. Describe approximate costs and benefits of common and new investigations and treatment modalities in Respirology
      2. Allocation of scarce resources, including for lung transplantation
   2. Apply evidence and management processes for cost-appropriate care
      1. Approximate costs relative to benefits of old and new treatment modalities
4. Serve in administration and leadership roles
   1. Participate effectively in committees and meetings
   2. Lead or implement change in health care
   3. Plan relevant elements of health care delivery, such as work schedules

Health Advocate

Definition:

As Health Advocates, Respirologists responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

Key and Enabling Competencies: Respirologists are able to…

1. Respond to individual patient health needs and issues as part of patient care
   1. Identify the health needs of an individual patient
   2. Identify opportunities for advocacy, health promotion, and disease prevention with individuals to whom they provide care
      1. Counsel and provide aids for smoking cessation as appropriate
   3. Demonstrate an appreciation of the possibility of competing interests between individual advocacy issues and the community at large
2. Respond to the health needs of the communities that they serve
   1. Describe the practice communities that they serve
   2. Identify opportunities for advocacy, health promotion, and disease prevention in the communities that they serve, and respond appropriately
      1. Demonstrate the ability to recognize the impact of air quality and other environmental exposures both at home and at the workplace
      2. Describe the impact of smoking on the health of all patients and its impact on society
      3. Demonstrate awareness of regional, national, and international initiatives for a smoke free society
      4. Demonstrate awareness of the global initiatives to eliminate tuberculosis
      5. Demonstrate awareness of the advocacy groups relevant to respiratory medicine and how to access their services for the improvement of lung health of their patients and the community
   3. Demonstrate an appreciation of the possibility of competing interests between the communities served and other populations
3. Identify the determinants of health for the populations that they serve
   1. Identify the determinants of health of the populations, including barriers to access to care and resources
   2. Identify vulnerable or marginalized populations within those served and respond appropriately
4. Promote the health of individual patients, communities, and populations
   1. Describe an approach to implementing a change in a determinant of health of the populations they serve
   2. Describe how public policy impacts on the health of the populations served
   3. Identify points of influence in the health care system and its structure
   4. Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity, and idealism
   5. Demonstrate an appreciation of the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper
   6. Describe the role of the medical profession in advocating collectively for health and patient safety

Scholar

Definition:

As Scholars, Respirologists demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.

Key and Enabling Competencies: Respirologists are able to…

1. Maintain and enhance professional activities through ongoing learning
   1. Describe the principles of maintenance of competence
   2. Describe the principles and strategies for implementing a personal knowledge management system
   3. Recognize and reflect on learning issues in practice
   4. Conduct personal practice audits
   5. Pose an appropriate learning question
   6. Access and interpret the relevant evidence
   7. Integrate new learning into practice
   8. Evaluate the impact of any change in practice
   9. Document the learning process
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
   1. Describe the principles of critical appraisal
   2. Critically appraise retrieved evidence in order to address a clinical question
   3. Integrate critical appraisal conclusions into clinical care
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
   1. Describe principles of learning relevant to medical education
      1. Demonstrate an understanding of and the ability to apply the principles of adult learning
   2. Identify collaboratively the learning needs and desired learning outcomes of others
   3. Select effective teaching strategies and content to facilitate others’ learning
      1. Demonstrate an understanding of preferred learning methods in dealing with students, residents and colleagues
   4. Deliver effective lectures or presentations
   5. Assess and reflect on teaching encounters
   6. Provide effective feedback
   7. Describe the principles of ethics with respect to teaching
4. Contribute to the development, dissemination, and translation of new knowledge and practices
   1. Describe the principles of research and scholarly inquiry
   2. Describe the principles of research ethics
   3. Pose a scholarly question
   4. Conduct a systematic search for evidence
   5. Select and apply appropriate methods to address the question
   6. Disseminate the findings of a study

Professional

Definition:

As Professionals, Respirologists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

Key and Enabling Competencies: Respirologists are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
   1. Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect, and altruism
   2. Demonstrate a commitment to delivering the highest quality care and maintenance of competence
   3. Recognize and appropriately respond to ethical issues encountered in practice
   4. Identify, declare, and manage perceived, potential, and actual conflicts of interest
   5. Recognize the principles and limits of patient privacy and confidentiality, as defined by the law and professional practice standards
   6. Maintain appropriate boundaries with patients
2. Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation
   1. Demonstrate knowledge and an understanding of the professional, legal, and ethical codes of practice
   2. Fulfil the regulatory and legal obligations required of current practice
   3. Demonstrate accountability to professional regulatory bodies
      1. Demonstrate awareness of the role played by each of the following professional bodies within medical practice: provincial colleges, the Royal College, Canadian Medical Protective Association, hospital boards, Ministries of Health, Health Canada, Canadian Medical Association, provincial medical associations
   4. Recognize and respond appropriately to others’ unprofessional behaviours in practice
   5. Participate in peer review
3. Demonstrate a commitment to physician health and sustainable practice
   1. Balance personal and professional priorities to ensure personal health and sustainable practice
   2. Strive to heighten personal and professional awareness and insight
   3. Recognize other professionals in need and respond appropriately

This document is to be reviewed by the Specialty Committee in Respirology by December 2018.

• APPROVED – Specialty Standards Review Committee – June 2011
• EDITORIAL REVISION – Office of Specialty Education – August 2016

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