Postgraduate Training in Anaesthesia and Intensive Care in Western and Eastern Europe, the Point of View of an Academic Anaesthesiologist Who is Familiar with Both Parts of Europe
Dan Longrois | Chair National Anaesthesiologists Societies Committee
As chairperson of the National Anaesthesiology Societies Committee (NASC) of the ESA and in close collaboration with the Board of Directors of the ESA, we decided that the 2015 NASC session during Euroanaesthesia would be the opportunity to ask two trainees representing Western and Eastern parts of our continent to freely share with us their points of view on the way anaesthesia and intensive care postgraduate training is organized in their respective countries. In addition to the NASC session, each NAS was asked during the National Villages event to present the way postgraduate training was organized in individual countries. The whole process was conceived by the Board of Directors and the NASC to improve the visibility of trainees within the ESA; the ESA Trainees Subcommittee was created in early 2016. A survey was performed whose results will soon be presented to the ESA community. The goal from all these actions is to define the trainees’ expectations and shape the way ESA will help them.
During the NASC session, two residents, Dania Fischer from Germany and Liana Valeanu from Romania, presented (and subsequently synthesized their presentations in the documents presented here) the achievements and the difficulties of their postgraduate training. Of course a person cannot be representative of a system, but my analysis is that there are differences and similarities between the two points of view.
The main difference is that from a Western Europe trainee’s point of view science and scientific writing were already a goal during postgraduate training. That was not mentioned by Liana Valeanu. This is something that ESA must consider because a gap in expectations/goals is not desirable.
The similarities are that in each of the two countries there seems to exist heterogeneity among centres in terms of quality of training. Here as well ESA can play a role in that ESA-initiated training modules (including e-learning) could help those centres with limited resources. Another similarity concerns the recognition awarded by the two trainees to those who evaluate them during and at the end of their residency. Here as well, ESA could propose structured evaluation modules for those who require them. The European Diploma in Anaesthesia and Intensive Care adopted in Romania is clearly a great ESA achievement.
Last, but not least, it seems to me as an academic anaesthesiologist that was trained in Romania and France, that the most important similarity concerns the cognitive processes that allow trainees to acquire theoretical, technical, and non-technical skills. I have always advocated for enhancing an analytical cognitive process when teaching anaesthesia and intensive care. I have also advocated that we should attempt to evolve from a model of initial/continuous medical training with unselected flow of information towards a model where initial/continuous medical training is based on acquisition of operational knowledge. The difference between unselected information, even of highest quality, and operational knowledge is based on selection/organization of information so that it allows: (i) comprehension and structuring of the knowledge; this can only be achieved by promoting analytical cognitive tools (as opposed to intuitive/pattern recognition processes) when teaching; (ii) relevance for clinical practice. The challenges from evolving from the information model to the knowledge model are huge and the efforts from teachers and trainees must be anticipated.
From the activities dedicated to postgraduate training that NASC organized during Euroanaesthesia 2015 we have learned many things and have already implemented changes. The newly reorganized ESA Education and Training Committee will enhance the ESA’s educational efforts.
Fighting for Excellence: Postgraduate Training in Germany
Dania Fischer | Department of Anaesthesiology and Intensive Care, University Hospital Frankfurt, Germany
As regards Germany, large differences exist in the structure, quantity, and quality of supervision in the residency programs of hospitals in the standard care, maximum care, and university hospital categories. However, increasing work intensification, streamlining, and ubiquitous cost pressure seem to be common features in German hospitals, often leading to narrow means of staffing levels. The situation is worsened by the fact that the costs of postgraduate training are currently neither specifically calculated nor funded by the German health care system, posing a threat to the quality of residency education in a system with scarce financial and human resources. Insufficient staffing levels and lack of postgraduate training can lower motivation and productivity, as well as significantly increase the risk of medical error in the long run. Nevertheless, some hospital centres manage to offer even personnel-intensive simulation-based training to their residents in order to increase practitioner competency. This allows for realistic encounters of even rare scenarios, which may translate into safety improvements for patients.
Residency in Germany lasts at least five years and ends with an oral board examination held by the State Chamber of Physicians. Currently, the content of residency training is defined by the minimum quantity of cases the resident participated in, procedures performed, and months spent in certain areas of patient care. To assure nationwide high quality of future health care, the German Medical Council and German Medical Societies have begun to develop a competency-based and structured curriculum for residency training. It would additionally be favourable to continuously assess progress during residency in a competency-based and standardized evaluation, and advance the level of objectivity in the final examination. It is contemplated to also allow for research to play a greater role during residency. As it is now, scientific activities often prolong the residency period, leading to an increasing shortage of medical scientists and practitioners in Germany. On the other hand, dedicated teaching and supervision of residents should be honoured on a greater scale. As it is now, scientific writing is more prestigious, resulting in a lack of incentive for senior physicians to pass on knowledge and skills to young residents.
Another great challenge is to offer satisfactory conditions for residents who decide to start a family. Upholding educational progress during pregnancy despite governmental restrictions on work conditions and organizing a structured return after maternal or paternal leave is important to increase workplace attractiveness and to recruit and retain good candidates in order to develop sustainable excellence in anaesthesiology.
Dr. Fischer works at the University Hospital Frankfurt/Main as a third year resident. Her research focus is on blood products administration and transfusion-related adverse events.
Fighting for Success: Postgraduate Training in Romania
Liana Valeanu | Fundeny Clinical Hospital Bucharest, Romania and Bichat-Claude Bernars Hospital, France
Anaesthesia and intensive care is, as it is worldwide, a relatively new field of medicine in Romania in comparison to other medical specialties. With most of the financial resources becoming available and the greatest progress being made during recent years, it can be said that today we finally approach the European quality for the standard of training. The residency training in anaesthesia and intensive care in Romania lasts for 5 years, the first 3 years being dedicated to anaesthesia and the remaining 2 years to intensive care, with the possibility to obtain a competence in intensive care for specialists also coming from medical specialties such as cardiology, nephrology, and gastroenterology, with few applicants until now.
During residency, the training is organized according to the national syllabus and divided between the theoretical teaching (600 hours of theoretical teaching for anaesthesia and 400 hours of theoretical teaching for intensive care) and the acquisition of practical skills during hospital rotations. The acquisition of practical skills derives mostly from the ‘hands on training’ under the supervision of a senior attending, either in the OR or in the ICU. Evaluation of both theoretical and practical competences is assured after each rotation by the rotation coordinator. An informal evaluation is usually offered to each resident by the senior attending of anaesthesia or ICU. The final evaluation at the end of the residency consists of theoretical and practical examinations. The decision to have the European Diploma in Anaesthesia and Intensive Care (EDAIC) part I examination as the written part of the examination for obtaining the title of specialist has been a great advance, giving the Romanian residents not only a clear confirmation of their theoretical knowledge but also the possibility to have a diploma that is a mark of excellence in most European countries.
One of the problems that residents encounter during their training is the fact that in some regional centres it is quite difficult to acquire new anaesthesia and ICU techniques such as echocardiography and echo guided nerve blocks, mainly because of the lack of equipment, but also because of the lack of trainers. Finally, acquisition of theoretical and practical skills depends, naturally, on each resident’s motivation.
Projects organized during the last years with non-reimbursable European funds have given the residents the opportunity to come in contact with foreign specialists on these topics. Also, exchange programs of 6 to 18 months in countries in Western Europe, which are fully recognized by the national authorities, give residents the chance to approach new techniques such as extracorporeal life support that are not yet available in Romania, and also stimulate them to become trainers upon their return.
Last but not least, the financial issues remain a problem in a country that has recently passed from a low income to a medium income category. Because of this, national, European, and international congresses are often not affordable for residents. The low income, the work load that can go up to 80 hours per week for a resident, the limited resources especially in the non-academic hospitals, and the poor public image of physicians in general are the main reasons why during the last years 50-60% of those entering the residency decided to leave the country and pursue a career in Western European countries during the last year of residency or immediately after having become a specialist. Romania is confronted presently with a significant shortage of physicians in Anaesthesia and Intensive Care.