Requirements and Minimum Standards in Training for Psychiat Specialty

 I. PSYCHIATRIC SPECİALTY TRAINING PROGRAM

A. Purpose of the program
The purpose of psychiatric specialty training is to achieve high-level clinical proficiency in the field of psychiatry. The aim is to ensure that residents completing this program become sufficiently proficient in theoretical basics and have clinical experience in etiology, pathogenesis, diagnosis, treatment, care and prevention of psychiatric disorders and associated medical disorders. The program, moreover, must provide the psychiatry resident with proficiency in the fields related to the role of a physician (an advisor in the field of health, an expert in legal issues, public trainer, clinic or hospital administrator, etc.). On the other hand, the person must complete the specialist training with an awareness of its power, limits and the necessity to sustain his/her professional development.

B. Quality of the Program
The Program must be defined clearly and contain specific and valid learning targets. These learning targets must be defined in terms of theoretical content, skills and behavioral patterns. The quality of the training program shows itself in how the resident is able to theorize the psychiatric disorders within the framework of biological, psychological and socio-cultural approaches and realize the background reporting, diagnosis, treatment planning and patient follow-up processes. It must be the program’s fundamental aim to provide specialist training on the foregoing subjects based on “full competency”.

In assessing the quality of specialty training, clinical records play an important role. The clinical records must include sufficient background information, a mental status examination, physical and neurological examinations, a sufficient treatment plan, properly kept disease advancement notes, diagnosis and treatment procedures and epicrisis to be maintained by the resident. Each institution must have an operating system to ensure the supervision and regular review of the records as well as an infrastructure that would comply with this. 

The core of the psychiatric training program consists of 1) theoretical training including courses, regularly arranged seminars, conferences and panels, 2) applied training oriented towards helping the resident achieve clinical experience, skills and necessary behavior under supervision, during the training process. Besides providing the necessary knowledge, these two components of training must ensure that application skills are learned and the necessary behavioral changes are initiated.

The events arranged in the training process must have priority where the time and energy of the resident is concerned; the clinical responsibilities of a resident must not be at a level that would hinder his training.

C. Basic Areas of Psychiatry Specialty Training
Specialty training, at a sufficient level and on a systemic basis, must include basic knowledge of the social and behavioral sciences, such as psychology, sociology, and anthropology, as well as new information coming from basic medical sciences related to psychiatry (neuro-science, genetics, etc.), and in addition to biological approaches. At the same time, the training program must establish a foundation in the subject of medical and psychiatric ethics. The clinical psychiatry applications that will be placed at the top of this infrastructure will prove to be more effective as they are integrated with other clinical sciences (neurology, clinical genetics, emergency medicine, endocrinology, etc.). The program must cover all the sub-fields of psychiatry: consultation-liaison psychiatry, geriatric psychiatry, legal psychiatry, addiction psychiatry, social psychiatry, etc; the resident must be trained to use at least one psychotherapy method.

As such, it will be possible to have specialists that can approach patients in a biopsychosocially-integrated manner, and combine different treatment models.

D. Theoretical Training
Theoretical training must be implemented on the basis of a proper program that is shaped according to the principles of training and the residents must be tutored on subjects that are in keeping with their professional development levels in this training process.

Theoretical training must include a systemic and structured didactic training program (courses, seminars, etc.) to be given at least four hours per week throughout four year training. The subjects of theoretical training must be compiled and provided for the student from the most up to date information available.
Although team meetings, clinical case presentations, periodical journal clubs and seminars to be presented by guest speakers are some of the supporting aids that can be added to the training program, these nevertheless must not replace theoretical training.

In theoretical training, clinical case presentation and discussion meetings that are participated in both by trainers and students, carry a distinct importance. These types of applications will contain a wealth of experience in terms of dealing with and discussing the theoretical and application oriented subjects in the diagnosis and treatment of the case presented.   

Psychotherapy training must be included in theoretical training and theoretical courses discussing mainly psychodynamic and/or cognitive-behavioral theories must be arranged for a total of 120 hours and at least for an hour every week.

For the first three years of the specialty training, the core theoretical training program must be implemented in line with the recommendations of the World Psychiatry Association as indicated in Annex 1 (the subjects, hours and distribution in relation to the years of theoretical training are provided in this Annex).
 
E. Practical Training
In practical training, trainees are targeted to achieve “full competency” as they are oriented toward the skills that psychiatry specialists are required to possess (Annex-2). Full Proficiency is achieved by repetitive display of the same skill with the purpose of accomplishing that skill without any mistakes and deficiencies in all the stages or phases concerning that skill. In other words, full proficiency means achieving automatism in a specific skill. To serve this purpose, certain durations must be set separately for each skill in the training program, and as such, each skill must be emphasized individually.

The behavioral patterns that a resident in psychiatry must adopt in the name of professional ethics and professionalism are listed in Annex-3. Accepting the institutional culture and trainers as role models, expert-apprentice relations and the supervision process can be used as key training tools in adopting the subject matter behavior. When necessary, the subjects must be reinforced by means of theoretical presentations.

1. Fundamental Characteristics of Applied Training

a) Gradually Increasing Responsibility in Patient Follow-up
The clinical services must be arranged in a manner that will enable residents to be primarily responsible for following a specific number of patients and at the same time, receiving adequate supervision. The degree and type of responsibility a resident undertakes must be commensurate with the progression of that trainee in his/her training.

Residents must be provided with the opportunity to apply and develop their skills and attitudes by undertaking the responsibility of clinical services preferably for a period of two to four months, and be involved in activities such as management, consultancy, etc., as well as following-up patients in their last year of training.

b) Sufficient number and variety of patients
a. Residents must be primarily responsible for diagnosis and treatment of a sufficient number and variety of patients with acute and chronic diseases classified in basic categories of psychiatric disorders.

b. Through training of skills under supervision, specialist students must accumulate experience in evaluation and treatment of patients ranging from children to the elderly from a variety of age groups and different social and economic levels.

c. The number of patients that a specialist student is primarily responsible for at any specific time must be decided in a manner that would allow that student to examine each patient in detail, provide the treatment suitable for patients and leave enough time for other subjects of the training program, making it possible for him or her to obtain the necessary depth and variety of clinical experience.

c) Individual Supervision
The clinical follow-up of patients under clinical supervision constitutes the core of practical training. Practical training must include a type of clinical supervision that is in harmony with regular clinical work.
Each and every resident, in addition to the training seminars and patient visits, must receive individual training supervision for at least an hour a week and 40 hours a year and the subject matter for supervision must be administered within the scope of an orderly program.

2. Basic Areas of Practical Training

a. Experience with In-Patients
Residents must be responsible for the diagnosis and treatment of in-patients for a period of not less than 12 months and not longer than 24 months in a five-year training program.

b. Experience with Outpatients
Residents must spend at least 16 months in the practice of psychodynamic, cognitive-behavioral and biological approaches under systematic supervision in a patient treatment program that involves short and long term patient follow-up. Long term outpatient treatment experience must include a sufficient number of patients that would be seen, under supervision, at least once every week for a period of one year or longer.

c. Consultation-Liaison Psychiatry
Residents must gain skills and experience for a period of four months in consultation and liaison psychiatry. It is preferable for this experience to be focused partly on outpatient treatment.

d. Emergency Psychiatry
Residents must participate in the evaluation and treatment processes of patients that are referred to psychiatric emergency clinics, to be handled under observation from an experienced trainer in the field of emergency psychiatry. The emergency psychiatry experience must involve the establishment of a relationship with and treatment of patients that have a potential for suicide and showing physical violence.

e. Geriatric Psychiatry
Residents must develop skills and gain experience by working on elderly patients with a variety of psychiatric disorders by undertaking responsibility in the subjects of diagnosis and treatment.

f. Alcohol – Substance Abuse/Addiction
Residents must develop skills and gain experience in the subject of alcohol-substance abuse/addiction in a manner that would involve abstinence and long-term treatment. 

g. Forensic Psychiatry
Residents must develop skills and gain experience in the subject of handling forensic psychiatric patients and legal procedures and writing legal reports.

3. Psychotherapy
The requirements of psychotherapy training are as follows: to develop psychotherapy interview skills, to be able to realize the psychotherapeutic formulation of a psychiatric disorder and apply short-term psychotherapy to at least five cases (12 –16 sessions) and long-term psychotherapy to one case (at least 40 sessions).
Residents must primarily develop skills-attitude and gain experience in cognitive-behavioral and psychodynamic therapies. Furthermore, the training program can also include psychotherapeutic approaches such as group, family or spouse therapy.

Psychotherapy supervision must be for a minimum of 100 hours with at least half or more of this time to be conducted on an individual basis.

F. Rotations outside the Psychiatry Department
Rotations outside the psychiatry department determined as neurology, child and adolescent psychiatry, emergency medicine and an elective rotation.

a. Neurology Rotation
The duration of Neurology Rotation must be six months. Training arrangements oriented toward the objectives indicated below must be carried out in the units where the rotation will take place:
Three months of the six-month rotation period must be spent in the inpatient clinic while the remaining three-month period should be reserved for the outpatient clinic. During the outpatient clinic rotation, the psychiatric resident must work periodically in the units that examine patients with neuropsychiatry diseases (dementia), epilepsy, movement disorders and multiple sclerosis.

Theoretical Training: a didactic training program of at least 24 hours, that is in keeping with the objectives of theoretical learning, must be provided by neurology trainers (Annex –1) (dementia, epilepsy, movement disorders, cerebrovascular events, demyelinating diseases, headaches and movement disorders etiology, diagnosis and treatment, neuro-anatomy, brain imaging).

Skills Training: A psychiatry specialist student must be able to conduct a full and systematic neurological examination, diagnose neurological disorders, and differentiate between them, while being able to evaluate brain magnetic resonance and computerized topography imaging.

b. Emergency Medicine Rotation
Emergency medicine rotation must be conducted in the emergency clinic or the emergency service of the internal diseases department for a period of two months. During the rotation, the following training arrangements must be made in the units where the rotation will take place, in line with the objectives indicated below.
Although skills training will be emphasized, theoretical and skills training will still be provided together and the psychiatry resident will be expected to: (1) differentiate medical emergency cases from psychiatric emergency cases, (2) intervention of the medical emergency cases, (3) learn cardiopulmonary resuscitation, (4) perform the first intervention on a trauma patient, (5) intervention of any medical emergencies of psychiatric patients, (6) develop the skill to communicate and provide the patient and his or her family with information under emergency service conditions.

c. Child and Adolescent Psychiatry Rotation
Child and adolescent psychiatry rotation must be for a period of four months and in the units that the rotation will take place; the training arrangements must be made oriented toward the following objectives:
Theoretical Training: a didactic training program of 12-16 hours, covering the following, must be provided for the psychiatry resident:  (1) psychiatric evaluation of child and adolescent patients and biopsychosocial formulation, (2) development theories, (3) evaluation of family dynamics, (4) etiology, diagnosis, differentiating diagnosis and treatment of childhood mental disorders.

Skills Training: psychiatry resident must be able to: (1) conduct an age appropriate interview with the child, (2) listen and understand the families and be careful with any non-oral communication, (3) develop and sustain therapeutic accord by creating feelings of trust, honesty, transparency and comfort in relations with the patient, (4) evaluate relationships in the family, determine and intervene with any functional disorders/pathological behavioral patterns in parents.

d. Elective Rotation
The objective of this rotation is to make it possible for the trainee to improve his in-depth knowledge in an area he/she is interested in or feels deficient in and consequently and willingly chooses to focus on. The resident, together with the trainer, prepares a training program in compliance with the duration of rotation (theoretical and applied). Taking into consideration the means and work set-up of the institution concerned, the elective rotation period must be between one and two months.

II. IMPLEMENTATION OF A PSYCHIATRY SPECİALTY TRAINING PROGRAM

A. Trainers and the Management of the Program

• A specialty training program must be conducted under the management of a psychiatrist who is also a trainer and who has taken part in the training process, effectively, for at least five years. The specialty program manager must spend at least half of his/her time on managing and working on the training program.
• There must be a committee consisting of lecturers and representatives of the residents, reporting to the specialty training program manager. This committee determines the training policy. The Education Committee must participate effectively in each of the planning, developing, implementing and evaluating stages of the training program.
• The Education Committee must receive anonymous written feedback from everybody who has been trained, every year on a regular basis. The feedback must elaborate on the format and content of the training program, its quality and applicability, qualifications and participation of the trainers, and the sufficiency of the training environment. The Education Committee must ensure that the data obtained is discussed and the necessary measures are taken on an institutional basis.
• There must be an adequate number of trainers in the training institution participating in the specialty training program and experienced in many of the psychiatric applications. The number of the trainers must be proportionate to the number of the training subjects to ensure that the training area can be monitored individually and closely and that a satisfactory level of supervision is provided. The trainers must participate in the training program in a regular and systematic manner and it should be easy to provide supervision when the specialist student is faced with an issue pertaining to the diagnosis or treatment.

B. Evaluation of Competency
1. Development of each and every resident must be evaluated on a regular and systematic basis. To serve this purpose, the resident must keep a record of the facts chosen within the framework of the training program and the subject matter records should be periodically reviewed by the program manager. The records kept by residents are important in terms of revealing whether the requirements of the training program are met or not.
2. Professional development assessment sessions, in which compliance with the purposes of training is considered, must be conducted with each resident at the required frequency, time period and depth. In these sessions, which are required to be held at intervals of at least six months, the resident must be given the chance to evaluate the program and training institution.
3. The specialist students must take intermediary written and practical exams in each year of the training process. These exams must be oriented toward the testing of theoretical knowledge and clinical skills. Practical exams must address the targeted skills and attitudes to be adopted and they must be objective. This type of training activity will help determine the professional development level of any training field besides providing feedback on the quality of the program and whether it operates in compliance with the purpose.

C. Residents
 1. Residents must participate in the training program on a regular basis.  While they take theoretical courses they must also take part in the treatment of a sufficient number of in- and out- patients by performing a sufficient number and variety of procedures.  In doing so, they must acquire the skills-attitudes defined in the curriculum while, at the same time, gaining experience.

2. Residents must be in possession of adequate language skills to communicate with the patients, follow-up international literature and get in contact with their foreign colleagues. 

3. The clinical records maintained by residents must contain adequate background information on the disease, physical and neurological examination findings, an adequate treatment plan, organized notes pertaining to the progress of the disease and an epicrisis.

4. The Residents must each have an log book in which their clinical activities are recorded.

D. Specialty Training Registration Document (Log book)
The specialty training registration document is a personal training file that has been developed to ensure that the resident benefits from specialty training to the greatest extent possible. The owner of the specialty training registration document is the resident himself/herself. The specialty training registration document must be considered as a mutual undertaking between the receiver and provider of the training program, arranged for the purposes of enhancing the quality of training. The fundamental purpose of this document is to support the training of the resident in line with the generally accepted learning objectives by means of keeping records. Secondly, it confirms the completion of the specialty training program by the resident and training institution as well. The specialty training registration document cannot be used to evaluate the resident.  
Contents of the specialty training registration document
In the specialty training registration document the following must be included for each training activity:
a.     Unit, duration, number of cases, duties, name of the supervisor.
b.     Determination of the objectives of training between the trainer and resident at the beginning of the training process, and evaluation of the training provided at the end of the training process.
It is recommended that the specialty training registration document consist of the following sections:

I. Compulsory elements of training
1. Treatment environment (adult, elderly, substance abuse)
a. In-patient: Acute, medium and long term
b. Out-patient
c. Consultation Liaison psychiatry
d. Emergency psychiatry
2. Supervision
a. Treatment (patient oriented )
b. Training (resident oriented)
3. Psychotherapy training
a. Theoretical Training
b. Supervision
4. General theoretical training

II. Other Clinical Training Activities

• Developmental Psychiatry, Forensic Psychiatry, Administrative Psychiatry
• Laboratory, psychological tests
• other

III. Courses outside the institution and work groups
IV. Research practice
V. Posters, oral presentations and publications
VI. Congress and Symposium Participations that are graded with credits by TTB
VII. Participation in training activities abroad
VIII. Experience related to other training activities. 
E. Qualifications of Training Providing Institutions

• Training providing institutions must provide learning opportunities in a manner that would allow the specialist students to develop their skills in an understanding of teamwork on the basis of a full day’s training to be provided at a satisfactory level.
• In institutional structuring, the disciplines in psychiatry must be available at an operability level that makes it possible for the specialist student to receive sufficient training in fundamental areas and develop his/her skills in an understanding of teamwork.
• In a training institution, if training on fundamental areas cannot be provided due to insufficient resources, then inter-institutional rotations must be considered.
• For the specialty training to be implemented with success in a training institution, the following physical means must be available:
• For the residents to be successful where the objectives and purposes of the training program are concerned, they must be trained at places with a sufficient number and variety of in- and out-patient flow, applying various examination, diagnosis and treatment methods, by using specially designated and sufficient hardware and equipment.
• To be able to create a positive training environment, the residents must have easy access to information sources as well as convenient work environments (resident’s room, on-call room and internet access).
• The institution must be in possession of a sufficient number of space arrangements and structural necessary for seminars, classes and other training applications.
• Overhead projectors, slide projection and audio-visual training tools in line with technological developments must also be available.
• A library that makes it possible to access national and international literature and provides the means of access to on-line databases.
• There must be an internal system ensuring quality, as well as committees, such as an ethical committee and a pharmaceutical committee, to ensure the inspection of quality in the training providing institution.

 Annex 1. Subjects, hours and distribution on the basis of years of Core Theoretical Curriculum

 Annex 2. List of “Core Skills” Required at Full Competency Level

1. To develop the skills for conducting full psychiatric evaluation

• Making differential diagnosis in accordance with DSM/ICD systems.
• To be able to come up with a case formulation covering neurobiological, phenomenological, psychological and socio-cultural aspects in diagnosing and handling the patient.
• To develop an evaluation plan covering appropriate laboratory, imaging, medical and psychological examinations.
• To prepare a treatment plan oriented toward biological, psychological and socio-cultural areas.

2. To carry out the necessary intervention to be able to determine the biological, psychological, social and moral mechanisms used by the people to overcome mental disorders.

• To develop the habit of questioning beliefs with regard to the reasons for diseases.
• To be able to recognize ego defense mechanisms.
• To determine the coping mechanisms.
• To be able to define personal and social support mechanisms.

3. On the basis of psychiatric evaluation, to be able to assess, in a comprehensive manner, the potential of the self harm and homicide.

• To be able to evaluate the risks.
• To be able to conduct the intervention that would minimize these risks.
• To know involuntary treatment standards and procedures.
• To be able to make emergency treatment plans.
• To be able to implement the methods that would prevent the patient from harming himself or the environment.

4. To be able to conduct therapeutic interviews.

• By using the therapeutic techniques (for example supporting interventions), to gain the skill of compiling and using the necessary clinical materials.
• To be able to conduct “Individual, group and family therapies” in addition to biological and socio-cultural treatment methods.

5. As a result of comprehensive psychiatric evaluation, to display the skill of recognizing and treating psychological disorders.

• To know the ethnologies, risk factors, pathogenesis and basic diagnosis measures of psychological disorders.
• To be able to evaluate and, if necessary, investigate different types of psychiatric disorders.
• To be able to use and interpret correctly the basic evaluation measures (Mini Mental Status Examination, Brief Psychiatric Rating Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale).
• To select and apply the treatment that is appropriate for the diagnosis and problems of the patient as a result of biopsychosocial evaluation.
• To be able to apply ECT with anesthesia

6. The skill to conduct psychodynamic psychotherapy.

• To be able to recognize the patients and problems that would be suitable for psychodynamic psychotherapy.
• To be able to listen to the patients in terms of explicit and implicit meanings.
• To be able to observe and analyze his/her own behavior and psychological experience in relation to any clinical situations that may take place with the patients.
• To determine the communication and behavior patterns of the patient in his relations with important persons in his/her past.
• To be able to intervene by using supportive and/or interpreting techniques that would enhance the self-understanding of patients.

7. Cognitive-behavioral therapy conducting skills.

• To be able to formulate the problems of the patient by means of terms belonging to distorted thoughts and cognitive scheme.
• To use supportive, educational, cooperative and directive elements, including homework assignments, in an appropriate combination, to develop a therapeutic relationship.
• By using self-observation tools, to help the patient in determining the automatic thoughts and irrational beliefs and understanding the link between the feelings and attitudes causing the problems.
• To help the patient alter thoughts causing functional disorders by using appraisal, reality testing and thought stopping methods.
• To be able to use the behavioral techniques (relaxation training etc.) in an appropriate manner.

8. To be able to display the knowledge obtained during specialty training, both theoretically and practically.

• To show his/her knowledge in human growth and development in a manner that would include socio-cultural factors, and normal biological, cognitive and psychosexual development.
• To display his/her knowledge in behavioral sciences and social psychiatry.
• To display his/her knowledge in comparing and choosing the appropriate treatment methods from among various treatments available.
• To show his/her knowledge in sub-specialty areas of psychiatry and other areas related to psychiatry.
• To be able to show his/her knowledge in neurology and neuropharmacology.
• To show his/her knowledge on legal aspects of psychiatric and neurological diseases and to be able to write a legal report on mental disorders.

9. The skill of using effective communication techniques.

• To gain the skill of listening to and understanding patients and be careful in regards to communication that is not orally conducted; to be able to use oral, non-oral and written methods expertly in his/her communication with the patients.
• To create confidence, honesty, openness and comfort in relations with the patients, to be able to develop and sustain a therapeutic alliance.
• To be able to understand the effect of the feelings and attitude of the physician and as such ensure that they do not have an impact on the treatment.
• To train the patients and other professionals in medical, psychosocial and behavioral subjects.

10. To display the skill of establishing effective communication with patients and their families.

• To be able to conduct communication with patients and their families according to their educational and intellectual levels and to be able to provide information without using medical terminology.
• To approach the patients and their families with socio-cultural sensitivity; to be respectful towards the cultural, ethnic, religious and economic origins of patients.
• To be able to provide training that is both easily understandable and usable.
• To be in solidarity with the patients and their families; to develop and sustain cooperation.
• To include the patient and family in treatment plans by taking into consideration their requirements.

11. To show the skill to request, interpret, and evaluate consultation from other branches of medicine.

12. To provide an effective consultation service for the specialist from other branches of medicine.

13. When necessary, to direct the patients in other areas of specialty and disciplines.

14. To be able to keep high quality medical records.

• To write prescriptions that are legible and comprehendible
• To update the medical records on a regular basis; to ensure that medical records are maintained in a manner that respects the privacy of the patient while at the same time including basic information that would benefit health care professionals outside the field of psychiatry.

15. In a multi-disciplinary treatment team: to be able to show effective leadership skills, such as effective listening, obtaining and combining information from different disciplines, resolving any conflicts taking place in the team and communicating an integrated treatment plan clearly.

16. To provide information for the patients and their families in an effective manner, taking care to respect privacy. The subject matter communication must cover the following:

• To specify the results of psychiatric evaluation.
• To use informed consent procedures for advanced examinations.
• To be able to provide genetic consultancy and palliative care, if necessary.
• To approach the patient in a respectful and friendly manner when specifying medical information and prognosis.
• To indicate the benefits and risks – including the probable side effects of medication and complications of any non-pharmacological treatment – of suggested treatment plan.
• To explain the alternatives to the suggested treatment plan, if any.
• To provide appropriate training in regards to the prognosis and prevention strategies.

17. To know the limitations of his/her clinical skills and knowledge and to be aware of the necessity for lifelong learning.

18. To obtain and evaluate literature and up to date information that would improve the quality of patient care oriented toward scientific application from various sources. To be able to accomplish the foregoing at minimum:

• To use medical libraries.
• To use informatics technology in a manner that would cover researching literature databases over the internet.
• To use pharmaceutical information databases.
• Effective participation in training courses, conferences and other educational activities arranged both on a local and national level.

19. To evaluate systematically the patient’s burden and professional experience.

• Case based learning.
• To realize the best professional applications by means of implementation guides or clinical algorithms.
• To review the patient records and course of disorders.
• To ask for the evaluations of the patients (results, patient satisfaction, etc.).
• To obtain appropriate supervision.
• To set up a system that would determine and correct application mistakes.

20. To display the skill of “critical evaluation” of medical literature.

• This skill covers the following: To use his/her knowledge pertaining to the frequently used methods in psychiatric and neurological research studies.
• To be able to investigate and summarize, from the literature, a problem that one of his patients experiences.
• To review and evaluate scientific literature from the aspect of advancing his/her own professional work; to determine whether the research findings can be generalized and implemented within the context of the sociodemographic and clinical characteristics of his or her own patients.
• To develop and sustain critical evaluation of scientific literature, as well as effective correction strategies to be used in professional applications.

21. To show professional responsibility in regards to patient care.

• To respond, in a timely manner, to the communication held between  patients and colleagues.
• To have backup arrangements in place to be used when necessary, and to inform the patient of the same (for example, what to do in cases of emergency and in situations requiring care).
• To perform patient care in cooperation with the members of the multi-disciplinary.
• To ensure the sustainability of patient care (appropriate consultations, when necessary to transfer or refer to someone, etc.).

22. To display his or her knowledge with regard to the support and care providing societal systems to ensure that the patient has access to appropriate care and other support systems; to have knowledge on institutions applying different treatment methods, as well as patient acceptance procedures at these institutions.

• To be aware of the running, means and limitations of open-closed services, daytime hospitals, rehabilitation institutions, substance abuse/addiction centers, retirement homes, patient associations and non-governmental organizations.
• To determine the best treatment that can be given within the restrictions imposed by limited medical resources.  

Annex 3. Minimum number of the tasks to be completed for the acquisition of core skills and their distribution over years.

 Annex 4. List of Attitudes to be acquired during the training process

1. In performing his or her duties, the physician must observe the universal ethics of medicine and take care not to cause damage, and be helpful, just and independent.
2. The physician is informed on the subject, and including the professional behavioral patterns and conflicts of interest, learns to act ethically, with care and discretion, displaying an attitude that is consistent and honest.
3. The physician must be respectful towards the patients and their families, individually. This means to be respectful where their ages, cultures, disabilities, ethnical origins, genders, socio-economic infrastructures, religious beliefs, political opinions and sexual tendencies are concerned.
4. Attitudes pertaining to therapy:
• The physician must be emphatic, respectful, curious, open, non-judgmental, cooperative and patient in therapeutic relationships established with the patients.
• The physician must be sensitive in regard to any socio-cultural, socio-economic or educational issues that may arise in the therapeutic relationship established with the patients.
• In regard to supervision, treatment sessions can either be observed directly, or reviewed by means of tapes/video tapes, and the physician must be open to both alternatives.
5. The physician must review and, if necessary, correct his or her own professional attitude.
6. The physician must participate in professional attitude review sessions, to be held among colleagues.
7. The physician must be aware of, and respect, the boundaries between his/her and other specialty areas.
8. The physician must be able to play an effective role in professional organizations, while displaying solidarity and cooperation amongst his or her colleagues.
9. The physician, in performance of his or her profession, must take care to maintain his or her relations with the pharmaceutical industry, and other commercial entities, within the appropriate boundaries and subject to ethical rules.