Over the last few decades, the role of the anaesthesiologist has extended from the operating room as the main area of competence to developing responsibilities in other areas of medicine. The initial tasks, which included assessment and evaluation, maintenance of organ function and analgesia and amnesia for all patients undergoing diagnostic, therapeutic or surgical procedures, have changed. Anaesthesiology has gone towards larger, deeper and more holistic competencies in the perioperative period, in multidisciplinary intensive care medicine, emergency medicine and pain medicine, which in many countries are now an integral part of the clinical specialty.1 As a result of this evolution, shared border zones have changed or developed with several other medical specialties (e.g. internal medicine) and this development emphasises the importance of a well defined core curriculum in anaesthesiology.
In recent years, competency-based curricula in anaesthesiology, pain and intensive care have been implemented in Europe. For instance, in intensive care, the Competency Based Training in Intensive Care Medicine in Europe (CoBaTrICE) collaboration2 and the subsequent training programme have been the first examples of defining core competencies throughout Europe in a philosophy of harmonisation of specialist training.
The previous set of revised European guidelines for education and training in anaesthesiology was published in 2008.3 These guidelines were a general framework on which national training programmes could organise their own postgraduate specialty training. The main objective of the 2008 document was to propose common, agreed principles to be used when identifying institutional or national training objectives, providing a very general description of competencies or defining pragmatic and measurable endpoints of training along with proper tools for evaluation; this allowed development of a standard of practice required from a specialist in anaesthesiology, reanimation and intensive care after 5 years of training. The new postgraduate training guidelines for anaesthesiology, accompanied by the syllabus, are now freely available (European Board of Anaesthesiology, http://www.eba-uems.eu/pubs/; European Society of Anaesthesiology, http://www.euroanaesthesia.org/sitecore/content/education/guidelines/esa%20endorsed%20guidelines/eba%20guidelines.aspx).
The 2011 set of guidelines goes further than the 2008 version, using the major advances that have occurred in medical education in the last 2 decades.4 Furthermore, inspired by the Canadian Medical Education Directions for Specialists (CanMEDS) framework for doctors’ competencies,5 the new guidelines define their own framework of an outcome-based educational model. In a similar manner to the CoBaTrICE collaboration,2 the guidelines define domains of practice together with underlying competencies to be acquired in these domains. Finally, for each domain of practice, learning objectives have also been defined in order to allow appropriate evaluation and assessment of trainees.
The main intention of the new guidelines is to put forward clear learning outcomes for competence acquisition, thus helping anaesthesiologists to fulfil their roles not only in their daily work but also in a more general medical setting. Furthermore, there is now evidence that profound medical knowledge and skilful performance of practical procedures are not sufficient for good practice of anaesthesiology. A very recent study has emphasised the importance of nontechnical skills in the field of anaesthesiology and intensive care medicine education,6 showing that mastering knowledge and skills may be essential, but that anaesthesiologists today should also pay attention to team working skills, management and communication.
This editorial briefly reviews the main roles identified in the outcome-based framework, gives examples of domains and underlying competencies as well as examples of the accompanying syllabus (learning objectives).
It must be emphasised that the present guidelines are the result of the work of the Standing Committee on Education and Training (E&T) of the European Board and Section of Anaesthesiology, under the auspices of the UEMS (Union Européenne des Médecins Spécialistes). In this committee, many representatives from the European Union and affiliated countries undertook the huge task of writing the different chapters and seeking consensus within the working groups, as well as within their national specialist societies and local, national and university hospitals, before the committee made final revisions to the guidelines. After several corrections, the document was then subjected to wide consultation over several months which included not only national specialist societies of European countries but also different specialist educational and scientific groups (such as the education and training platform) of the European Society of Anaesthesiology. Last but not least, the document was also amended with the close cooperation of the organisers of the European Diploma in Anaesthesiology and Intensive Care (EDA).
Four generic competencies or roles have been identified as the most important for any European specialist in anaesthesiology based on the CanMEDS framework which defines seven roles for any physician: medical expert, communicator, collaborator, manager, health advocate, scholar and professional.5 The role of health advocate was considered as less applicable in the field of anaesthesiology. Several important aspects of three others (manager, communicator and collaborator) were amalgamated into one, that of the leader. Consequently, the four roles identified for anaesthesiologists were medical expert, leader, scholar and professional. These four generic competencies of the European guidelines and their respective definitions were subjected to much discussion before reaching a final consensus among all representatives of national societies of the Standing Committee.
First as a medical expert, the specialist in anaesthesiology must be familiar with anaesthetic and medical technology, general medicine, including diagnostic and therapeutic methods based on thorough basic knowledge of applied respiratory, circulatory and central nervous system associated physiology and pharmacology. The main field of an expert in anaesthesiology is perioperative medicine, and they should acquire all necessary competences enabling them to fulfil this expert role and function in a multidisciplinary setting.
As a definition, the domain of perioperative medicine comprises the continuum in patient care, starting before the operative procedure and lasting well into the postoperative period. It concerns all patient categories (including children, pregnant women and those lacking mental capacity) and comprises the tasks, the practice of which should be evidence-based. Other major domains of competencies included in this section are pre-hospital and in-hospital resuscitation and emergency management of critical conditions (including trauma and burns), intensive care medicine and pain management.
Secondly, as a leader, the specialist in anaesthesiology should have competences in communication which enable them to deal with different aspects of human interactions and relationships. Furthermore, they should have competences which permit effective organisation and management tasks to take place during professional activities.
This section includes effective, open, empathic and respectful communication with patients and their relatives, inter-professional team working, promotion of and participation in better and safer patient care and finally health economics. Effective collaboration is emphasised in the setting of multidisciplinary teams in the resolution of conflicts, decision-making skills, giving feedback and taking and assuming leadership when required. Knowledge of the relevant medico-legal and ethical frameworks is also included in this section.
Third, as a scholar, it is the specialist's responsibility to develop and maintain a high degree of professional competence, to facilitate development of colleagues and other groups of professionals and to promote development of the specialty itself.
Lifelong learning and reflective thinking are deemed essential skills for continuous professional development. Critical reading and appraisal of up-to-date information relevant to clinical anaesthesiology and intensive care medicine are also emphasised in this section. Finally, an anaesthesiologist should acquire basic tools for research as well as basic skills for teaching of young colleagues, residents and allied healthcare professionals; they should also contribute to patient education.
Finally, as a professional, the specialist in anaesthesiology will exhibit irreproachable behaviour and be aware of duties and responsibilities inherent to their role as a professional.
The anaesthesiologist should provide high-quality care with empathy, integrity, honesty and compassion. They should recognise personal limitations and abilities and seek appropriate consultation with, or delegation to, others when caring for the patient. Medical decision making should be based on thorough consideration of ethical aspects in patient care, as well as management of ethical conflict. Anaesthesiologists should have knowledge of medico-legal aspects of anaesthesiology practice, with particular emphasis on the appropriate management of anaesthetic incidents and accidents, including near misses.
In order to fulfil the four professional roles of a specialist in anaesthesiology, a list of domains of expertise and related competencies within these domains have been identified. The domains of expertise can be divided into domains of general core competencies and domains of specific core competencies (Table 1). Throughout the course of their 5-year training programme, trainees should progressively achieve the required level of competence within every domain.
By identifying the domains of expertise, it was easier to specify and list both general and specific core competencies in each domain. These were expressed in the form of a list of competence statements; for each competence, a defined level of acquisition/expertise was subsequently discussed and defined, ranging from levels A to D:
- Level A: has knowledge of, describes, understands.
- Level B: performs, manages and demonstrates under supervision.
- Level C: performs, manages and demonstrates independently.
- Level D: teaches or supervises others in performing, managing and demonstrating.
Acquisition of the level of expertise was based on the consensus model developed by the CoBaTrICE collaboration2 which was found to suit anaesthesiology as a medico-technical specialty very well. Two examples, (1) for Domain 1.4 (Emergency medicine: management of critical conditions including trauma and initial burn management), and (2) for Domain 1.8 (Anaesthesia non-technical skills) can be found below.
- During the course of their training, residents must acquire clinical abilities and skills in managing medical and surgical acutely ill patients, including life-threatening situations. These include the following competencies with their required level of acquisition:
- Is capable of handling life-threatening medical and surgical emergency conditions: D.
- Provides basic and advanced pre-hospital and in-hospital critical medical emergency management, including organisational aspects: D.
- Masters initial and advanced pre-hospital and in-hospital trauma management, including organisational aspects: D.
- Masters initial burn management, including organisational aspects: D.
- Is able to handle the complex organisation of healthcare assistance in cases of mass accidents and disasters: C.
- Masters pre-hospital and inter-hospital transport: D.
- During the course of their training, residents must acquire nontechnical abilities to master interpersonal and organisational tasks during the perioperative care of patients. These include the following competencies with their required level of acquisition (based on the handbook of the University of Aberdeen):
- Develops and maintains an overall dynamic awareness of the situation based on perceiving the elements of the operating room environment (patient, team, time, monitoring and equipment) and understands what they mean and anticipates what could happen in the near future: C.
- Makes decisions to reach a judgement or diagnosis about a situation, or to select a course of action, based on experience or new information under both normal conditions and in time-pressured crisis situations: D.
- Manages resources and organises tasks to achieve goals, be they individual case plans or longer term scheduling issues: C.
- Communicates effectively and works with others in a team context, in any role, to ensure effective joint task completion and team satisfaction: D.
Finally, for each domain of expertise, a detailed list of learning objectives has been identified, objectives which are presented in a separate document entitled ‘syllabus’. It is clearly stated that the prerequisite for each domain is thorough knowledge of relevant physiology and pharmacology, as well as areas of basic science (anatomy, clinical biochemistry and clinical measurement/physics), acquired during medical studies and/or during postgraduate training itself.
These learning objectives were further divided into ‘knowledge, skills and attitudes’ which were deemed necessary to achieve the required level of competencies in each domain. They were developed as realistic endpoints to be attained by the end of the 5 years of anaesthesiology residency training, representing measurable endpoints to serve as a basis for the development of reliable evaluation and assessment modalities.
However, for every representative on the Standing Committee, it was necessary to state that both the guidelines and the syllabus should be considered as a framework for commonly agreed minimum outcomes; this means that each national society, or even teaching hospital and/or regional institution, is free and encouraged to modify/expand these objectives as required to suit their own context of teaching and education. Furthermore, these objectives should be linked closely to evaluation modalities as discussed in a previous article.7 Evaluation modalities still vary among European countries. Consequently, the objectives should not only be adapted to match the existing ones but should also serve as an opportunity for development and change in these same evaluation modalities.
Both documents (the competence-based training programme and its syllabus) are written in such a way so as to emphasise trainees’ progression from straightforward to more advanced clinical cases. This progressive acquisition of professional competence renders the use of both logbooks and portfolios compulsory. Both tools are mandatory as self-assessment tools to document the quantity and quality of educational occurrences taking place during the training.3,7 As stated previously,7 trainees are expected to take responsibility for their training and, through a portfolio or other reporting tools, to provide evidence or proof that learning has taken place.
In addition, the two documents represent a challenge for the faculty and the training centres, because the acquisition of competencies by the trainees requires that the latter should be supervised and errors corrected continuously. Thus, workplace-based assessment is of great importance and can be seen as a prerequisite for learning. This involves the use of standardised grids which permit proper observation of trainees ‘on the job and in the trenches’ or in their real clinical work environment.8 According to Greaves and Grant,8 there are a number of problems when evaluating the competencies of a physician in their daily work: workplace-based assessments are time consuming; patients are not ‘standardised’; and assessors are not always educated in using new assessment methods. These problems are such that they require each trainee to have a mentor to follow their progress in constructing their knowledge, skills and attitudes as defined in the new training guidelines and syllabus.
These new guidelines for postgraduate training in anaesthesiology, intensive care medicine and pain management represent a major step forward in changing the education of new specialists according to modern educational principles. The major work ahead will be to encourage national specialist societies in European Union countries to familiarise themselves with and, if possible, endorse these guidelines. However, the biggest change, after endorsing these new guidelines, will be to develop and encourage the widespread use of workplace-based assessments in order to continuously improve the training of our future specialists in anaesthesiology.
This article was checked and accepted by the Editors, but was not sent for external peer-review.