A recently published short scientific report pointed out the need for standardization of training in Europe.12 The focus was placed on existing differences in duration of the training (recommended minimum of 5 years) and the lack of standardized final exam, mainly a few countries adopting EDAIC exam (European Diploma of Anesthesia and Intensive Care) as the structured assessment tool. Although this plea for standardization of the training is in line with the ETR document, it is still distinguishing time-based education and noncompetence-based assessment tools. Although it may be assumed that these elements of education would be the easiest to harmonize, it still does not guarantee comparable levels of training between residents and young specialists. The value of the ETR document is the guidance for implementing competence-based curriculums in different countries, describing the knowledge, skills and attitudes that young specialist in anesthesia and intensive care should have.2 It is a document based on the changed paradigm of medical education and achieving those objectives could be the common ground for standardization of training in various countries.
Our survey showed that even experienced specialists involved in delivering training and mentoring residents lack knowledge of the theory behind the new concepts and lack skills necessary to deliver it. Lack of knowledge is present even in the structure of the formal documents and recommendations in implementation of the competence-based training in both local, state or European level. At the same time, in most countries national bodies and professional societies are responsible for the curriculum development. It would be very informative to know how much knowledge on ETR and standards of education and patient care is spread within those institutions.
It is well recognized that the role of the teacher or a trainer must be changed from the position of authority and data source towards more complex performance: facilitator, role model, assessor, planner, information provider or resource developer.6 Trainers need to have more advanced competences to implement and achieve objectives from the competence-based training curriculums: knowledge and skills, support, but probably the most demanding requirement is the time dedicated to deliver educational content.7 One of the prerequisites in implementing competence-based training is that trainers understand the theory behind the new model of education and to be trained themselves to teach within the new framework.8 Core principles are assessment and evaluation, which assumes that the learner will continually receive feedback and be advised and guided to achieve the expected competence level.7
In the presented survey, the distribution of the structured assessment tools goes in line with representation of the CBME. Although most countries require an exam at the end of training (50% national and 17% university board), only around 30% have either structured (Viva, written and OSCE) or some kind of practical assessment. Strikingly, there are still countries where finishing the residency program without examination is qualifying for the specialist. It is therefore not possible to compare or objectively determine what level of competences, what skills and knowledge have been achieved at the end of the training.
Literature and previous experiences in implementing new models of training suggest that trainers are insufficiently prepared to employ active learning strategies, and instead of effectively delivering more advanced programs tend to set back to previous and known types of teaching. 7,9 Faculty lack formal training and understanding of competence-based education and have no skill in assessment which results in inconsistencies in both judgment and expectations of learner’s performance. 10,11 Trainers must be prepared in advance for the implementation of educational strategies which usually require a great amount of work and increased cost.7
On the other hand, well prepared faculty enables engagement and adoption of the new tools and techniques which may result in successfully performed training.7
The driving force in implementing change in medical education, anaesthesia and intensive care included, is the faculty.13 Many barriers in faculty development have already been recognized. Increased costs, lack of understanding and poor engagement are just some of them.7 It has been noted before that developing teaching skills should go beyond volunteerism and must be recognized as the place for general improvement and investment.4,14,15 Less than 20% of our respondents confirmed that the elements of developing teaching skills (how to teach others) are included in their residency program. However, of greater concern is that most members of the faculty still consider as the main part of their formal education teaching attendance the ALS courses. A minority of the universities have developed obligatory training in medical education. It may seem that specialists that are actively involved in training residents are mainly left on their own, their internal motivation and self-directed learning to navigate to the contemporary expectations in medical education. Yet, lessons learned from centers that have already reformed training are that significant financial and human resources are needed. It is argued that support and recognition of the teachers’ effort in teaching, observing, and giving feedback should be as equal to doing research.4 Faculty development is a long and slow process at both system and individual front-line teachers’ levels.13 The transformation from traditional education, based only on delivering core competence of medical knowledge, towards a more complex educational system requires a deep understanding of competency-based education.13 A consistent, systematical approach toward faculty development is necessary, but it seems that it is still absent in many European countries and institutions.
The lack of time and overload with work seem to be the most rated obstacles to involvement in teaching. It seems that teaching is just an add on to the everyday work, and that additional time for teaching and preparing for teaching must be over and above working hours. Fewer respondents stated that teaching is really valued or paid more in their hospitals. The question of motivation to become more educated for or to deliver high quality teaching is not easy to answer. Conflicting answers regarding the value of teaching and different level of formal training in teaching that come within the countries can be explained with different practices in different hospitals and regions, as well as different formal teaching positions. However, it still reflects diversity in the organization of teaching not only between countries, but within countries themselves. We may just speculate that different teaching experiences may result in different quality of learning as well.
Most respondents in this survey value and have an interest in teaching. But even they are with the lack of knowledge and information about recommended requirements for training in anesthesia and intensive care in Europe. If training is happening every day in operating theaters and intensive care units, while working with more senior doctors as a part of their everyday job, we may question the structure of that training if the faculty itself is so diverse and without training in teaching. Standardization of training comes not by time, but from the outcomes of education that should be structured and delivered according to the recommended requirements. This cannot be achieved without the trainers or teachers that are educated and trained in what they should perform. Substantial improvements and change of practice in education that will lead to better standardization of training in anaesthesia and intensive care, and ultimately the quality of care, will not happen without investing in training the faculty and recognizing teaching as one of the competencies of the highest priority in our profession.
Limitations
One of the most important limitations of this survey is the pretty low response rate. Although we did receive responses from anesthesiologists from almost all European countries, it may still not reflect the real cross-section of the current teaching practices and knowledge related to medical education. It is common knowledge that topics of medical education and teaching do not gain high priority and interest from many.
Generalizability
Regardless of the low response rate and considering the structure of respondents, where the majority are experienced specialists involved in teaching residents every or almost every day, we can suspect that the actual picture in everyday practice is even more discouraging. However, we consider that the results of this study highlight the existence of differences in and between European countries regarding the perception trainers have about CBME. If the obtained results do not match the existing reality, we believe they would be even more alarming and the already essential need to implement changes is deemed even more urgent.