Development of competency framework for postgraduate anesthesia training in China: a Delphi study

Abstract

Background

Standardized postgraduate medical education (PGME) in anesthesiology is not well-defined in China. Establishing a competency framework for postgraduate anesthesia training (PGAT) is essential for standardizing and enhancing the quality of training and patient care.

Objectives

This study aimed to develop a competency framework for PGAT in China.

Methods

This study employed a multi-step approach, including a literature review, semi-structured interviews, to formulate a list of preliminary competencies. This initial list included seven roles, 26 enabling competencies, and 162 competency items. A modified Delphi method was utilized to achieve consensus involving three rounds. Experts were recruited from the Chinese Society of Anesthesiology (CSA) across various regions of the country. Consensus was determined using a 5-point Likert scale, with a mean score of ≥ 4 and a consensus rate of ≥ 80% serving as criteria for agreement.

Results

Forty-seven experts accepted the invitation to participate, with 46 returning scores for round 1 (90.2% response rate) and 45 returning scores for rounds 2 and 3 (88.2% response rate). The final competency framework includes 140 competency items within 23 enabling competencies, categorized into seven roles: medical expert, communicator, collaborator, professional leader, health advocate, academic scholar, and specialized professional.

Conclusions

This study represents an initial step towards establishing a contemporary competency-based medical education and training (CBMET) program for PGAT in China.

Introduction

China is currently undergoing a medical education reform to establish unified national training standards for physicians. This reform entails the implementation of the Chinese Postgraduate Medical Education (PGME) system, which distinguishes between professional and academic degrees [1]. The “5 + 3” model combines a 5-year undergraduate phase leading to a medical bachelor’s degree with a subsequent 3-year period involving the Master of Medicine (MM) degree and standardized residency training (SRT) [2]. To graduate, postgraduates must fulfill the requirements for both the MM degree and SRT, aimed at enhancing both academic research and clinical practice [1]. However, the integration of SRT with the MM program reform may not meet nationwide quality standards for PGME. Historically, the Chinese PGME system has been criticized for prioritizing academic accomplishments over clinical competence, and concerns persist about the efficacy of competency-based medical education and training (CBMET) due to inadequately structured residency training and professional certification processes [2].

Globally, CBMET has gained traction since the mid-1990s and has been comprehensively adopted as a nationwide model for developing and implementing medical education programs [3]. Numerous countries, including Canada, the U.S., the U.K., and Ireland [4,5,6,7,8,9,10], have established competency frameworks defining medical specialty competencies [11]. The shift towards a CBMET model in PGME aims to develop postgraduates’ competencies in achieving clinical practice training goals at specified levels, tailored to local circumstances and requirements. The quality of medical care and the expertise of medical professionals are inherently linked to the excellence of training provided and the continuous improvement of standards within the medical specialty [12]. Anesthesiologists today manage complex vital functions, diagnose and treat various types of pain, and lead healthcare services [13]. Postgraduates specializing in anesthesiology play crucial roles in patients care and contribute to the education of future anesthesiologists [14].

China cultivates the largest contingent of anesthesiologists globally, underscoring the importance of training and educational initiatives [15]. The National Health Commission has adopted CBMET in 2013, mandating completion with passing clinical practical assessments [16], yet research on PGME in this context remains notably sparse [17]. To date, standardized PGME for anesthesiology has not been defined in China, leading challenges for PGAT in implementing CBMET. The study aims to develop a PGAT competency framework, including essential competencies, to equip postgraduates to effectively address public health needs and standardize training quality in China.

Methods

Ethical considerations

This study adhered to the ethical principles outlined in the World Medical Association Declaration of Helsinki for Medical Research Involving Human Subjects. Detailed information was provided to the experts through email, elucidating the study’s objectives, methodology, confidentiality measures, and data management. This anonymous Delphi survey, classified as having negligible risk, ensured voluntary participation, with each expert providing informed consent through email by providing an affirmative reply. This study was approved by the Xuzhou Medical University Ethical Committee (ID number: 20210518).

Design

This study utilized three rounds of Delphi survey based on a list of preliminary competencies and was conducted from May 1st to September 1st, 2021. The Delphi procedure and methodology are presented in Fig. 1. A six-member expert panel was established by the research team, comprising individuals with expertise in various relevant areas. Collaborative discussions involving the research team and expert panel led to conclusive decisions when uncertainties regarding competency inclusion arose. The panel included a recently graduated anesthesiologist with a master’s degree, an anesthesiologist serving in a medical university teaching hospital, a member of the anesthesiology accreditation committee, an educational specialist with extensive experience in anesthesiology education, a vice chairman from the Chinese Society of Anesthesiology (CSA), and a medical university vice president responsible for overseeing medical education and management.

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Generating preliminary competencies

A preliminary list of competencies for PGAT was generated through a combination of literature review and semi-structured interviews. Key competencies refer to essential abilities within each of the seven roles, while enabling competencies specific components of each role.

Literature review

This study utilized various resources to compile articles on competencies in anesthesiology. Firstly, historical context was drawn from the international competency framework, primarily including the Canadian Medical Education Directives for Specialists (CanMEDS), the American Accreditation Council for Graduate Medical Education (ACGME), the “European Section/Board of Anesthesiology/European Society of Anesthesiology consensus statement on competency-based education and training in Anesthesiology”, and Ireland [18]. Secondly, a literature review was conducted using search terms as “competency”, “competencies”, “competence”, “guide”, “education”, “training”, “mentor”, “anesthesia”, “anesthesia”, “anesthesiology”, “anesthesiologists”, “anesthetist”, “medical education”, “continuing medical education”, “graduate medical education”, “postgraduate medical education’, “postgraduate anesthesia training”, “postgraduate anesthesiology training”, and “postgraduate education”. The search covered multiple databases including Embase, PubMed, Web of Science, Medline, Wan Fang, and China National Knowledge Infrastructure (CNKI) from September 1982 to August 2021. Initially, a total 1128 references were retrieved. Following title or abstract screening, 1077 non-relevant references were excluded, and 6 references without full text were excluded. The remaining 45 references underwent a thorough assessment of their full text for eligibility. Within this subset, 37 references were deemed ineligible for inclusion as they primarily focused on the curriculum of PGAT and lacked direct relevance to competencies. Ultimately, 8 references comprising research studies, national societies’ curricula, etc., focusing on PGAT competencies, were included.

Two researchers (X.N.Z and K.M.) independently screened all the included references to extract potential competencies based on specific criteria: (1) relevance to the roles of PGAT, (2) pertinence to the training requirements of PGAT, and (3) alignment with the training objectives of PGAT. Ultimately, a total of 135 competency items related to PGAT were extracted.

Semi-structured interview

Purposive sampling was employed to invite twelve participants, including six professors from distinct universities, six junior anesthesiologists and seven senior anesthesiologists affiliated with tertiary hospitals, for semi-structured interviews. During the interviews, participants were asked to elaborate on the distinct roles, requirements, training objectives, and additional competencies pertinence to PGAT in the Chinese context in Table 1. The data collected from the semi-structured interviews underwent a systematic procedure of audio recording, transcription, and coding. Thematic analysis, independently conducted by two researchers (X.N.Z and K.M.), was utilized to identify potential competencies for PGAT. Any doubts about whether a competency should be retained were discussed by the research team and expert panel to reach a decision. Ultimately, a total of 27 competency items related to PGAT were extracted.

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Following the literature review and semi-structured interviews, researchers (X.N.Z and K.M.) engaged in discussion with the expert panel to develop the preliminary competencies. Prior to the first round of the Delphi process, the list of preliminary competencies was distributed to the seven members of the CSA for pilot testing. Minor revisions were made based on their feedback.

This structured process resulted in the identification of the preliminary competency framework, which includes 140 competency items categorized into 23 enabling competencies. These competencies are subsequently categorized into seven roles: medical expert, communicator, collaborator, professional leader, health advocate, academic scholar, and specialized professional.

Delphi procedure

A modified Delphi procedure was utilized to establish an appropriate competency framework for PGAT in China, aiming to achieve consensus among experts. The Delphi method, characterized by its iterative experts consultation without direct interaction, accords equitable significance to the opinions of all participating experts [18]. The Delphi method involved presenting experts with subsequent rounds of questions built upon insights gathered from the previous round to elicit new perspectives [19]. This iterative approach included three rounds, ultimately resulting in the attainment of consensus among the participating experts [20].

All potential experts who took part in the Delphi procedure were recruited from national representatives of the CSA, an academic non-profit organization dedicated to the education, training, and evaluation of anesthesiologists across China. The CSA is committed to maintaining high standards and ensuring quality training in the field of anesthesiology in China. To ensure expertise representation, the experts were recruited based on the following inclusion criteria: (1) more than 10 years of professional experience in anesthesiology, (2) active involvement in PGAT and employment at tertiary hospitals or medical universities, (3) a professional title of associate senior level or higher, and (4) a master’s degree or higher.

Experts completed the Delphi questionnaires using a text file attached to the invitation email. Each round allowed a three-week window for scoring, with reminder emails sent a week before the deadline to enhance response rate. To maintain objectivity, experts did not interact with each other and were not informed of the identities of their fellow experts. After each round, an anonymized summary of the combined results from the prior round was provided to the experts.

The degree of agreement regarding the importance of each competency was rated using a 5-point Likert scale with the following options: “Not at all important”, “Slightly Important”, “Important”, “Fairly Important” and “Very Important”. This scale measured the degree to which experts believed a competency should be included [21].

Experts were given the opportunity to contribute additional insights in free-text sections, suggesting potential competencies that were not initially included in the preliminary list. If two or more experts proposed additional competencies, these suggestions were included in the subsequent Delphi round. A summary of the previous round’s results was provided to experts in the subsequent round to aid the consensus-building process.

Data analysis

Data analyses were performed using R 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistical analysis, including mean values, standard deviations, frequencies, and percentages, were calculated for each competency. Competencies were categorized into high-, medium- and low-scoring groups. Predefined thresholds were established a priori to facilitate the categorization of competencies [22]. A high score was confirmed with a mean value of ≥ 4.0 and a consensus of ≥ 80%; a medium score ranged from 3.0 to 4.0; and a low score was defined as a mean value of ≤ 2.0 and a consensus of ≤ 80%. For inclusion in the final prioritization during round 3, competencies were required to achieve a mean value of ≥ 4 and a consensus of ≥ 80%. Competencies with a mean value of ≤ 2 and a consensus of ≤ 80% were excluded. Competencies falling within the mean value of 2 to 3, and additional competencies proposed by experts in the previous round, underwent reevaluation in the subsequent round [23].

Results

All eligible members of the CSA across the country were extended an invitation to participate in the Delphi survey (n = 51). Fifty-one targeted experts received email invitations, and a total 47 experts (92.2%) accepted the invitation. For the first round, 46 experts (90.2% response rate) representing 19 provinces provided scores. In rounds 2 and 3, 45 experts (88.2% response rate) from 18 provinces returned scores. The demographic characteristics of the participants are presented in Table 2.

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First round of Delphi survey

Table 3 presents an overview of adjustments and the underlying rationales made during the first round. Experts ranked the initial compilation of 26 enabling key competencies and 162 competency items. Feedback from experts prompted revisions primarily aimed at consolidating certain competencies to reduce the overall count. Among the enabling competencies, 16 competencies (61.6%) that met the threshold for higher priority scores were included in round 3. One competency (3.8%) received low scores and was excluded. Seven competencies (26.9%) received intermediate scores. Two competencies (7.7%) were merged, “Transfer medical information about clinical decision, patient safety, and privacy” and “Develop plans to reflect the healthcare needs with patients and their families” were merged into “Improvement of patient safety and care when transferring patients”.

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Among the competency items, 112 (69.1%) that met the threshold for higher priority scores were included in round 3. Twenty-eight (17.3%) received intermediate scores, and 22 (13.6%) with low scores were excluded. Nine experts (20.0%) provided comments on the items in the free-text field. Additionally, nine items (5.5%) underwent modifications. For example, “Inform management strategies for patients who do not agree to resuscitation” was revised to “Effectively inform strategies for patients and families who do not agree to resuscitation”. Furthermore, 28 experts (60.8%) suggested merging ten items. For example, the items “Manage complications from anesthesia care, procedures, and treatment, including but not limited to general and regional anesthesia” and “Effectively manage the perioperative patient” were merged into “Effective management of the perioperative patient, including complications, general, and regional anesthesia”.

Second round of Delphi survey

An overview of the adjustments and the underlying rationales made during the second round is shown in Table 4. Experts ranked the seven enabling competencies classified as intermediate-ranked and the 28 intermediate-ranked competency items.

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Additionally, a minimum of seven experts recommended the integration of ten competency items. For example, “Application of blood products and recombinant factors” and “Management of fluid and volume resuscitation” were merged into “Management of fluid, blood products and volume resuscitation”.

As the second round concluded, this nearly final list of competencies met the threshold for higher priority scores, consisting of seven roles, 23 enabling competencies, and 140 competency items.

Third round of Delphi survey

In round 3, forty-five experts fully agreed with the final list of the competency framework, which consisted of 140 competency items. Twenty-seven experts provided suggestions for slight modifications to the competency descriptions in the final framework.

This three-round Delphi process culminated in the synthesis of a competency framework within PGAT. The framework comprises 23 enabling competencies and 140 competency items integrated into the seven roles in Table 5.

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Discussion

This study represents the first effort to establish a competency framework for PGAT in China, aiming to develop proficient anesthesiologists capable of delivering high-quality healthcare services. The construct validity of the competencies developed in this study was rigorously assessed through a comprehensive process that included the initial identification of competencies, selection of Delphi experts, iterative revisions based on evaluations, and formal adoption of the framework upon reaching consensus. By achieving agreement on the final list of 140 competencies, this study reflects a significant level of consensus within PGAT and supports the ongoing PGME reform in China. This competency framework not only provides valuable guidance for implementing a CBMET program but also benefits training hospitals, clinical practice, educators, and quality improvement processes for postgraduates [6]. Additionally, this competency framework contributes to the international discourse on medical education and holds potential applicability for global CBMET adoption.

The core roles of the competency framework should be achievable by the majority of national training programs, despite potential variations due to differences in medical infrastructure, resources, workforce, and funding. Chinese training hospitals currently lacking the capacity to implement certain competencies may consider enhancing their standards through collaboration with other institutions. Most Delphi experts advocated for a reduction in the training levels of PGAT compared to the competency frameworks established in the U.K., U.S., and Canada. This adjustment aims to align with local training context and faculty requirements in China. For example, excluding the competency “Ultrasound guidance for vascular access and common regional blocks” reflects the variability in ultrasound availability and educator resources across training hospitals. The critical role within this competency framework is specialized professional, which includes virtues such as compassion, integrity, attentiveness to patient and societal well-being, ethical conduct, and the preservation of patient privacy and autonomy. This role highlights an area often overlooked in PGAT in China and underscores the importance of emphasizing these values in medical education [24].

Despite the framework’s significance, its comprehensive implementation across all Chinese regions remains challenging [6], especially given the involvement of governmental institutions such as the National Health Commission (NHC), the Ministry of Education (MOE), and professional organizations such as the Chinese Medical Doctor Association (CMDA) and the Chinese Medical Association (CMA) and CMA. The CMDA plays a crucial role in accrediting training hospitals to ensure uniformity and quality in postgraduate training programs nationwide [25]. However, the CMDA and CMA currently lack accreditation and certification functions, highlighting the need to enhance their capabilities in professional expertise, authority acceptance, and financial resources. Establishing a new mechanism for PGME accreditation and certification in China, along with enhancing the capacity and leadership within professional institutions, is imperative [1]. Currently, PGAT primarily occurs within government-accredited training hospitals due to their human resources, equipment, and funding availability [25].

Implementing CBMET programs requires consideration of factors such as scale, rate of change, and educational structure [26]. While significant progress has been made in North America and Europe in delivering CBMET programs for anesthesiologists, adapting these programs to the Chinese context presents unique challenges [27]. These programs emphasize interprofessional collaboration and teamwork competencies, which can differ based on the specific healthcare setting and professional roles involved. Achieving successful implementation of this competency framework requires genuine collaboration among hospitals, universities, government agencies, regulatory bodies, and policymakers to optimize anesthesiologist training and meet public needs [3].

Advancing postgraduates within the competency framework requires consideration of factors such as their readiness for skill acquisition, simultaneous acquisition of both general and specific competencies, and the program’s capacity to provide supervised training opportunities. This competency framework is dedicated to enhancing the process and outcomes of PGAT within national training programs, aiming to produce proficient, secure, and compassionate anesthesiologists. While some postgraduates may have diverse training objectives, an individualized CBMET program offers distinct advantages in achieving precise training outcomes [28].

Transitioning to this competency framework requires a well-structured plan inclusive of faculty and administrative support [26]. Substantial investment is required in faculty training to effectively impart the necessary knowledge, skills, and attitudes to postgraduates [29]. The utility of this competency framework lies in its capacity to optimize PGAT and improve training outcomes. As additional research data emerges, potential refinements may arise, necessitating the evolution of this framework to accommodate future advancements. Further research is imperative to establish evidence-based and experientially-grounded practical guidelines for the effective implementation of this competency framework.

Strength and limitations

This study utilized the Delphi technique, offering advantages including anonymity, providing equal weight to feedback. Preliminary competencies were rigorously identified through literature review and interviews, enhancing the framework’s validity. Experts were selected for their understanding of training and job requirements, aligning the framework with PGAT in China. The Delphi process effectively mitigated validity risks, ensuring the framework’s robustness. Delphi experts, representing various CSA members, were thoughtfully chosen to ensure comprehensive content coverage and to mitigate selection bias. The primary authors’ absence as Delphi experts prevented potential biases in the consensus-building process, enhancing the framework’s objectivity. Selection criteria ensured representation from various regions, academic seniority, practice settings, and demographic backgrounds, enriching the framework’s applicability and relevance across different contexts. Preliminary competencies, identified through a rigorous literature review and semi-structured interviews, lacked in-person meetings and discussions between experts. However, the Delphi technique typically generating new competencies. The use of email-based data collection facilitated anonymous participation, promoting equitable discussions, and effectively identifying potential competencies, thereby enhancing the framework’s robustness and validity.

Conclusion

The competency framework developed in this study represents a significant milestone in the advancement of PGAT in China. By meticulously integrating multifaceted training objectives and outcomes, tailored to profession-specific activities, this framework ensures that postgraduates can achieve the desired proficiencies at various stages of their training. The implementation of this framework has the potential to optimize PGAT outcomes, ultimately leading to the development of skilled anesthesiologists capable of delivering high-quality healthcare services. Serving as a guiding roadmap for PGAT implementation in China, this framework aims to facilitate adoption by key stakeholders. To address concerns about the feasibility of rating a large number of competencies, a phased approach would be implemented, starting with evaluating the framework and gathering feedback, ensuring its effectiveness for postgraduates.

Data availability

The datasets generated and analysed during the current study are not publicly available due to original consent, but are available from the corresponding author upon reasonable request.

Abbreviations

ACGME:

Accreditation Council for Graduate Medical Education

ANTS:

Anesthesia Non-Technical Skills

CanMEDS:

Canadian Medical Education Directives for Specialists

CBME:

Competency-based medical education

CREM:

Critical emergency medicine

GME:

Graduate medical education

ETR:

European Training Requirement

MM:

Master of Medicine

PGAT:

Postgraduate Anesthesia Training

PGME:

Postgraduate medical education

RCPSC:

Royal College of Physicians and Surgeons of Canada

SRT:

Standardised residency training

UEMS:

Union Européenne des Médecins Spécialistes (European Union of Medical Specialists)

References

Zhu J, Li W, Chen L. Doctors in China: improving quality through modernisation of residency education. Lancet. 2016;388(10054):1922–9.

Zhang X, Li C, Yue C, Jiang X, Cao J, Ten Cate O. Why clinical training in China should improve: a cross-sectional study of MD graduates. BMC Med Educ. 2021;21(1):266.

Ferguson PC, Caverzagie KJ, Nousiainen MT, Snell L, Collaborators I. Changing the culture of medical training: an important step toward the implementation of competency-based medical education. Med Teach. 2017;39(6):599–602.

Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642–7.

Eight Domains of Good Professional Practice as devised by Medical Council. [https://www.medicalcouncil.ie/existing-registrants-/good-professional-practice/eight-domains-of-good-professional-practice-as-devised-by-medical-council.pdf]

European Training Requirement ETR in ANAESTHESIOLOGY. [https://www.uems.eu/__data/assets/pdf_file/0003/64398/UEMS-2018.17-European-Training-Requirements-in-Anaesthesiology.pdf]

Anesthesiology M. [https://www.acgme.org/globalassets/PDFs/Milestones/AnesthesiologyMilestones.pdf]

Ambardekar AP, Walker KK, McKenzie-Brown AM, Brennan K, Jackson C, Edgar L, Ellinas H, Long TR, Trombetta CE, Laskey MG, et al. The Anesthesiology milestones 2.0: an Improved competency-based Assessment for Residency Training. Anesth Analg. 2021;133(2):353–61.

Fraser AB, Stodel EJ, Chaput AJ. Curriculum reform for residency training: competence, change, and opportunities for leadership. Can J Anaesth. 2016;63(7):875–84.

Committee AS. Anesthesiology EPA Guide.Ottawa: Royal College of Physicians and Surgeons of Canada 2018.

Kealey A, Naik VN. Competency-based medical training in Anesthesiology: has it delivered on the Promise of Better Education? Anesth Analg. 2022;135(2):223–9.

Kietaibl S, Blank A, De Robertis E. Medical training in anaesthesiology: updated European requirements. Eur J Anaesthesiol. 2019;36(7):473–6.

Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–35.

ACGME Program Requirements for Graduate Medical Education. In Anesthesiology, editor [https://www.acgme.org/globalassets/pfassets/programrequirements/040_anesthesiology_2021.pdf]

Zhang C, Wang S, Li H, Su F, Huang Y, Mi W, Chinese Anaesthesiology Department Tracking Collaboration G. Anaesthesiology in China: a cross-sectional survey of the current status of anaesthesiology departments. Lancet Reg Health West Pac. 2021;12:100166.

Commission NH. Standardized Training Scheme for Graduating Residents’ Clinical Practice Ability Assessment (2022 Edition) (Anesthesiology). 2022.

Yang Q, Xie K, Xiong L. Anaesthesiology in China: present and future. Br J Anaesth. 2019;123(5):559–64.

de Villiers MR, de Villiers PJ, Kent AP: The Delphi technique in health sciences education research. Med Teach. 2005;27(7):639–43.

Zhang X, Meng K, Chen S. Competency framework for specialist critical care nurses: a modified Delphi study. Nurs Crit Care. 2020;25(1):45–52.

Singh T, Moust J, Wolfhagen I: Needs and priorities of faculty development for medical teachers in India: a Delphi study. Natl Med J India. 2010;23(5):297–301.

Khurana MP, Raaschou-Pedersen DE, Kurtzhals J, Bardram JE, Ostrowski SR, Bundgaard JS. Digital health competencies in medical school education: a scoping review and Delphi method study. BMC Med Educ. 2022;22(1):129.

Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–15.

Zhang X, Meng K, Liu H, Cao JL. Development of a competency framework for anaesthesiology residency training in China: a modified Delphi study. Br J Anaesth. 2024;133(3):677–81.

Blumenthal D, Hsiao W. Lessons from the East–China’s rapidly evolving health care system. N Engl J Med. 2015;372(14):1281–5.

Huang SL, Chen Q, Liu Y. Medical resident training in China. Int J Med Educ. 2018;9:108–10.

Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, Harris P, Glasgow NJ, Campbell C, Dath D, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638–45.

Jonker G, Manders LA, Marty AP, Kalkman CJ, Ten Cate TJ, van Gessel EF, Hoff RG. Variations in assessment and certification in postgraduate anaesthesia training: a European survey. Br J Anaesth. 2017;119(5):1009–14.

Ebert TJ, Fox CA. Competency-based education in anesthesiology: history and challenges. Anesthesiology. 2014;120(1):24–31.

Hoff RG, Frenkel J, Imhof SM, Ten Cate O: Flexibility in Postgraduate Medical Training in the Netherlands. 2018, 93(3S Competency-Based, Time-Variable Education in the Health Professions):S32-S36.