Educational initiatives and training for paediatric rheumatology in Europe

The Paediatric Rheumatology European Society (PReS) has over many years, developed a portfolio of educational activities to address increasing educational needs of workforce and support young clinicians to acquire skills to develop new knowledge and deliver clinical care in the future. These educational activities aim to facilitate growth of paediatric rheumatology and ultimately improve the clinical care for children and families. This article describes the current portfolio of PReS educational activities and their relevance to the international paediatric rheumatology community.


Introduction
The Paediatric Rheumatology European Society (PReS) has an overarching aim to promote paediatric rheumatology as a sub-specialty across Europe and also further afield through the expanding international membership. PReS aims to improve the lives of children with rheumatic diseases through collaborative networking to raise awareness, facilitate high quality research to create new knowledge, support education and training, promote advocacy and 'best care ' based on evidence, consensus and active consumer engagement. The importance of education and training activities to achieve these aims and address unmet need within Europe has been highlighted following the SHARE initiative (Single Hub Access for Rheumatology care, European Agency Health and Consumers, grant number 2011 1202, [ [1] Wulffraat N, 2013, [2] van Dijkhuizen EHP, 2018]) and reported in Work package 4, SHARE project, Dolezolva P (submitted for publication).
The educational activities of PReS are overseen by the PReS Education and Training Committee (ETC), currently led by one of us [TA]. The PReS ETC represents rheumatology within the European Academy of Paediatrics and has contributed to the recent 2016 European Syllabus for Training in Paediatrics (https://www.pres.eu/committee-and-wp/education.html). This new syllabus ensures that rheumatology training is compliant with the revised European Syllabus structure and format. The educational activities of PReS reflect the roles of the paediatric rheumatology specialist; namely 'life-long' scholarly clinician, researcher and teacher. These roles have foundations firmly embedded in the European Syllabus which sets out the minimum requirements for training to cover knowledge (musculoskeletal conditions, multi-disciplinary team working, medications, treatment approaches), skills (clinical, consultation, procedural, teaching, research) and professional roles (managerial, leadership and mentorship). In the context of education and training, the 2016 European syllabus for paediatric rheumatology has the following aims: Harmonise training programmes across European countries. Establish defined standards of knowledge and skills required to practice paediatric rheumatology at the tertiary care level. Foster development of a European network of competent specialist centres to facilitate collaborative research and training opportunities. Improve the clinical care of children with chronic and acute rheumatic disorders within Europe. Enhance European contribution to international scientific progress in the field of paediatric rheumatology. Promote teaching of paediatric rheumatology at undergraduate and postgraduate levels to raise awareness about the importance of early diagnosis, prompt referral to specialist care and facilitate potential recruits to fellowship programmes and the future workforce.
This document describes PReS conferences, courses, online resources programmes that are overseen by the PReS ETC (with a summary given in the Table 1) and we describe their context for the international paediatric rheumatology community. These activities are complementary to existing national training programmes (which are not discussed here further).

The PReS annual scientific meeting and young investigators meeting (YIM)
The annual scientific meeting of PReS disseminates advances in knowledge and research (basic science, clinical care and education) through 'state of the art' lectures and presentations. There are active allied health and consumer parallel programmes. The annual scientific meeting has become one of the most important educational events in the paediatric rheumatology international calendar and provides a platform to disseminate knowledge, opportunities to network and foster new collaborations. The annual Young Investigators Meeting (YIM) is held over the two days preceding the annual scientific meeting and is organized with support from PReS to facilitate attendance by young researchers (PhD students, post-doctoral level) and trainee doctors. The YIM aspires to nurture the PReS research ethos and aims to promote networking and foster opportunities for international collaboration; young investigators are encouraged to present their work to an international audience with feedback and guidance from PReS & YIM senior faculty. Over recent years the number of young investigators attending the YIM meeting has increased significantly with a substantial number of trainees from non-European countries (including India, Africa, North America, South America, Asia, Australia). Proceedings of future meetings and how to apply for YIM bursaries are available on the PRES website (https://www.pres.eu).

PReS courses
The ETC oversees a 'rolling programme' of courses which are financially supported by grants from PReS. Details of future courses and how to register for them are available. (http://www.pres.eu). The aim is to have one of either the Basic or Advanced course per year and to reach audiences who may not otherwise have access to education and training. PReS members are encouraged to contact the ETC for further information if they wish to consider organizing a Basic or Advanced course in their country and seek PReS support.
1. The PReS Basic courses are set at the level of the general paediatric trainee or resident and cover the breadth of topics as outlined in the European syllabus. To date, PReS Basic Courses have been held in countries where paediatric rheumatology is less well developed Mumbai (India 2012), Sao Paulo (Brazil 2015), Budapest (Hungary 2015) and Cape Town (South Africa 2017) with future courses planned in the Ukraine and South East Asia. The aim is to promote the specialty, facilitate networking and ultimately improve patient care. The model includes an organising committee led by a local paediatric rheumatologist with faculty drawn from local and national colleagues as well as international faculty who are PReS members. Examples of previous Basic Courses are available from the ETC and it is envisaged that lectures from courses will be archived on the PReS website. The Basic Courses have a similar format (over 2-3 days with local and international faculty [n = 10-15])  (2018) was recorded and transmitted by video conferencing to colleagues in India, who were able to participate in case presentations and interactive sessions. It is envisaged that this facility will be available in future courses to reach a wider audience and especially those in low income countries. The scientific programme of an Advanced course is focused on a given condition (e.g. JIA, childhood-onset SLE, auto-inflammatory conditions) or specialist skills (e.g. Musculoskeletal Ultrasound [MSUS], or 'hands on' joint examination). The format of the Advanced Courses to date have included interactive 'state of the art' lectures delivered by international and local faculty, 'meet the expert' small group sessions, joint examination 'how to teach' workshops and interactive case presentations. It has been proposed by the ETC that future

PReS clinical skills workshops -Joint examination skills ( [3] pGALS Foster and Jandial, pREMS [11]
Foster 2011) are included in the PReS Basic Course (with a focus on pGALS) and Advanced JIA Course (with a focus on pREMS and 'how to teach' pGALS). Feedback to date has been very positive. The format includes 'hands on' workshops involving consented patients demonstrating physical signs and small groups of learners with facilitated observation and feedback from experienced paediatric rheumatologists. The ETC aims for the 'clinical skills' workshop concept to be expanded and to include, for example, scleroderma skin scores, nail fold capillaroscopy, muscle power testing, and transitional care consultation skills.
3.3 PReS 'Teach the teachers' workshops -Paediatric Rheumatologists have an integral role as educators and need to 'reach out' to medical students, general paediatricians and colleagues in orthopaedics and primary care to raise awareness, facilitate diagnosis and prompt referral to specialist care. Learning 'how to teach' is therefore an important skill and included in the European syllabus. The aim of the ETC is that all fellows will attend a 'how to teach' course during their training. PReS has included 'teach the teacher' workshops alongside the PReS scientific meetings (2016, 2017) with excellent feedback and it is envisaged that such workshops will be included in future PReS meetings and the Advanced Course rolling programme.

Conclusions
The activities of the PReS ETC aim to improve access to, and provision of, high quality clinical care delivered by an appropriately trained workforce and ultimately improve outcomes for children and families. The emergence of Basic and Advanced courses, specialist courses, online resources and the EMERGE fellowship programme, supplement the annual scientific meeting of PReS and YIM as a means to facilitate advances in knowledge being implemented into high quality evidence-based clinical care. We recognize that more work is needed to enable and support the expanding paediatric rheumatology community both in Europe and Internationally. The uptake and implementation of the new 2016 European syllabus into training programmes needs to address the accreditation of training centres, a proposed European sub-specialist examination and certification in paediatric rheumatology.
There is now an overarching structure to the education and training activities of the PReS ETC to address the expanding needs of the broad paediatric rheumatology community with the content based on the 2016 European Syllabus for training. The format and structure of the PReS educational portfolio, much of which is free and open to all, serves as a template relevant to the wider international paediatric rheumatology. There is clear synergy between the educational and training activities of PReS and other initiatives led by paediatric rheumatology organisations elsewhere in the world (such as those developed by ACR, CARRA, BSR, BSPAR, APRG). Through working with colleagues around the world, the aim has been to 'reach out' , raise awareness and facilitate growth of paediatric rheumatology relevant to the local context.