Medical training in anaesthesiology

Updated European requirements

The Union Européenne des Médecins Spécialistes (UEMS) has always strongly supported the concept that the quality of medical care and expertise is directly linked to the quality of training provided to medical professionals. Accordingly, great emphasis has been given to the improvement of medical training at the European level through the development of European Standards in the different medical disciplines.

Moreover, UEMS has always intended to harmonise education and training curricula to facilitate professional mobility of specialists throughout Europe. The legal mechanism ensuring the free movement of doctors through the recognition of their qualifications was established back in the 1970s by the European Union (EU). In 2005, the European Commission proposed a unique legal framework for the recognition of the Professional Qualifications to facilitate and to improve the mobility of all workers throughout Europe. The Directive 2005/36/EC established the mechanism of automatic mutual recognition of qualifications for medical doctors according to training requirements within all Member States; this is based on the length of training in the specialty and the title of qualification. But already in 1994, UEMS adopted its Charter on Post Graduate Training aiming at providing the recommendations at the European level for good medical training. Made up of six chapters, this charter wanted to set the basis for the European approach in the field of post graduate training. With five chapters being common to all specialties, and a sixth chapter that each specialist section was to complete according to the specific needs of their discipline.

No matter where doctors are trained, they should have at least the same core competencies. The UEMS values professional competence as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’.¹

UEMS Specialist Sections and European Boards do not aim to supersede the national authorities’ competence in defining the content of postgraduate training in their own state but rather to complement these and to ensure that high-quality training is provided across Europe. The European Board and Section of Anaesthesiology (EBA) of the UEMS intends to guarantee quality of care, patient safety and welfare of anaesthesiologists by defining standards for professional development and the European Training Requirement (ETR). Constant development of specialist practice dictates the need for a periodical review of the ETR to ensure it is consistent with current practice, and fit for purpose. According to the Guidelines for the Development of UEMS European Training Requirements (https://www.uems.eu/areas-of-expertise/postgraduate-training/european-standards-in-medical-training), the original ETR published in 2013 has now been revised (https://www.uems.eu/__data/assets/pdf_file/0003/64398/UEMS-2018.17-European-Training-Requirements-in-Anaesthesiology.pdf) and approved by the European bodies. The purpose of this Editorial is to communicate general information on the ETR, and new aspects in the ETR in this update. The ETR in anaesthesiology would not exist without the close cooperation of all bodies active in anaesthesiology education [EBA, ESA (European Society of Anaesthesiology) and EDAIC (European Diploma in Anaesthesiology and Intensive Care)] along with the authoritative communication of issues around medical training as reported in the European Journal of Anaesthesiology.^2–9

Purpose of a European Training Requirement

Anaesthesiology as a specialty has grown over the years from a service specialty, strictly within the operating room, to having responsibilities in various areas of medicine. The traditional role as a medical specialty included assessment and evaluation of fitness for surgery and maintenance of organ function as well as analgesia and amnesia for all patients undergoing diagnostic, therapeutic or surgical procedures. Today, anaesthesiology is a comprehensive medical specialty (encompassing anaesthesia, peri-operative medicine, intensive care medicine, critical emergency medicine and pain medicine) that deals in daily practice with complex vital function care. The practice of anaesthesiology has changed significantly towards more holistic competencies, which in many countries are integral parts of the clinical specialty. Accordingly, training requires new generic competencies and common principles to be defined for the European specialist, fulfilling the four professional roles: medical expert, professional leader, academic scholar, inspired humanitarian. The ETR structures the acquisition of knowledge and expertise to attain these new competencies and principles.

New aspects in the European Training Requirement update

Domains

The domains of general and specific core competencies have been re-assigned according to the clinical requirement (Table 1). The main focus is the practicability of ETR implementation at a national level throughout Europe. General core domains should be achievable by most national training programmes, even in the presence of considerable national variations due to, for example infrastructure, resources, manpower, working laws, financing, tradition. Basic competence levels proposed in specific core domains may stimulate implementation of education and training plans in clinical bottleneck areas. European hospitals not offering training possibilities in specific core domain competencies may search for upgrading training quality, for example by forming training units with other training hospitals. Thereby, the ETR update may foster future clinical exchange programmes between hospitals (e.g. European fellowship) and may encourage the utilisation of novel learning modalities, for example medical simulation centres. There are implications of the UEMS ETR update for the content of the EDAIC.

Table 1: Domains in the European Training Requirement update 2018

Competences

Recommended competence levels have been redefined, revised and assigned throughout general and specific core domains. The definition for the level of competencies is given in Table 2.

Table 2: Definition of competence levels

For each domain, learning objectives are divided into the knowledge, skills and attitudes that are deemed necessary to be attained. Not all clinical skill competencies listed in the ETR update reach level D. Attaining full competencies in all domains of the broad discipline of anaesthesiology in the minimum training timeframe would be an ideal but utterly impossible demand in any European country. In-service training after completion of medical training will enrich both the number and level of competencies, including teaching skills, which are not required for competence level D in the current ETR update.

New competences^2,3 and new training activities including medical simulation training have been added, in line with the growing evidence of the high value of simulation-based learning^2–5 and communication skills.^4–7 International clinical guidelines and standards of high quality, prepared according to high methodological standards have been referenced, for example by the EBA and ESA. The process of training, attaining defined competences and applying them safely and efficiently in clinical practice require time so that trainees can mature and develop. The ETR recommends a minimum training duration of 5 years, of which at least 1 year is to be spent in an ICU.

Training technique

According to the UEMS principles, specialist training is competence-based, not time-based or count-based. The superiority of such competence-based training over time-based or count-based training in acquiring competencies is obvious: trainees must be competent in performing for example central venous access and managing eventual complications rather than accumulating numbers without any documented quality and safety. However, competence-based curricula are implemented in only a few EU member states currently. Difficulties in the wider implementation of competence-based training may be multifold, including the fact that most European trainers were themselves trained using a count-based system; therefore, expertise in competence-based education and training may be lacking. To empower trainers, a handbook on delivering competence-based training is on the agenda of the EBA, including the grouping of competencies for supervision into entrustable professional activities^8,9 and standardisation of training.¹⁰ There is a misconception by national bodies that it would be easier to track numbers in a log book; electronic log books for documenting competencies are being tested in pilot projects. Another misconception is the higher time-consumption required to assess, repetitively, progress in the depth of competence gain, thus requiring more personnel. Future research may assess return of investment by higher proficiency at completion of training as the basis for improved professional standards and patient safety, avoiding resource use and indirect costs.

Formal revision

The syllabus and guidelines from the original ETR 2013 have been condensed into one single ETR in the 2018 update. By eliminating redundancy and self-evident content, for example knowledge and skills already gained during undergraduate medical studies, the ETR update has been shortened substantially, thereby increasing its applicability.

European Training Requirement update review

The next review of the ETR in anaesthesiology is planned in 2021. Feedback to the Standing Committee on Education and Professional Development of the EBA is welcome anytime.

European Training Requirement implementation

Benefit to training centres

High-quality training can only be provided in high-quality training centres by high-quality trainers, and has to be assessed in a meaningful and robust way. Training according to the ETR is a label of excellence of the specific teaching hospital. An ETR-based teaching programme is deemed mandatory for proper use of the ETR; good training conditions require standards and an educational climate. To really train in a competency-based way, a functional system of workplace-based assessment is mandatory; structures and processes are the basis for quality management in education and training. For example, faculty, teachers, trainers, consultant and tutors must be available for efficient training, at a minimum number and trainee–trainer ratio.

The ETR may facilitate interaction and communication among various domains within the hospital as well as other hospitals to organise and coordinate rotation of trainees to all core domains. Based on the EU Directive on Professional Qualifications and the UEMS Charter 1997 on visiting programmes and appraisal, which includes recommendations on the quality criteria of training centres, the Hospital Visiting and Training Accreditation Programme (HVTAP) Committee has been established. HVTAP aims to improve and harmonise training in anaesthesiology throughout Europe by ensuring that the accredited centres meet the prerequisites of training as set out in the ETR update.

Benefit to trainers

Current practice in most European countries is ‘learning to teach by doing’. The ETR update recommends ‘teach the tutors’ programmes throughout European countries which should help to implement teaching competence, learning technology and learning models focused on conceptual learning and behavioural practice. Faculty should be prepared to take on the academic challenges of instruction, along with the challenges of information delivery, active learning and effective communication across all phases of the curriculum. With the ETR update, teachers and trainers know what is to be learned and to what depth of competence.

Trainees’ perspective on the European Training Requirement

In an increasingly connected and rapidly developing world, where working in another country is no longer a rarity, trainees ask for a substantiated, evidence-based education, which is also recognised in other countries – at least within Europe. Nevertheless, although guidelines and recommendations were developed, training systems and methods still differ in European countries. Trainees are well aware that competency-based learning is more valuable than working through numbers. But national systems change slowly. Moreover, implementation of the EDAIC in national training programmes differs widely. A survey of the ESA Trainee Council showed that 74% of trainees have intermediate and final exams during their residency, 17% just have final exams and 3% neither intermediate nor final exams. Training duration differed between 2 and 7 years with an average time of nearly the 5 years recommended time. Times for specialisations like intensive care medicine differed from 6 to 24 months and were even described differently in the same country, depending on the workplace. Many trainees coming to Euroanaesthesia 2018 were impressed by the technical equipment in the simulation workshops, or by models on which training in procedures such as transoesophageal echocardiography or video-assisted placement of double lumen tubes for thoracic surgery could be undertaken. This shows that even in 2018 there is still a wide divergence in the availability of educational devices throughout Europe, and the question arises how similar levels of competency can be acquired if preconditions differ so much. However, offers of trainee exchange programmes, travel grants and basic science courses are well appreciated, and the high number of applications demonstrates the wish for European wide exchange, cross-border learning and networks, as well as a consistent residency to accomplish these goals. Training according to the ETR will be a quality marker for the specialist practice of the individual anaesthesiologist, and these qualifications will be recognised automatically in other EU countries, as established by EU law (Directive 2005/36/EC). Together with the EDAIC, a training according to ETR could be the basic requirements for the European Fellowship in Anaesthesiology.

Acknowledgements relating to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

SK is the Chairperson of the Standing Committee Education and Professional Development, European Board and Section of Anaesthesiology; AB is a member of the Trainees Committee of the European Society of Anaesthesiology and of the National Trainee Sections; EDR is the President of the European Board and Section of Anaesthesiology.

Comment from the Editor: this Editorial was checked and accepted by the editors but was not sent for external peer-review.