RESEARCH

Open Access

<figure><img src="image_1.png" /></figure>

# First steps towards international competency goals for residency training: a qualitative comparison of 3 regional standards in anesthesiology

Clément Buléon¹,²,<fnref n="3" />*, Reuben Eng⁴,⁵, Jenny W. Rudolph<fnref n="3" />,⁶,⁷ and Rebecca D. Minehart<fnref n="3" />,⁶,⁷

## Abstract

**Background:** Competency-based medical education (CBME) has revolutionized approaches to training by making expectations more concrete, visible, and relevant for trainees. Designing, applying, and updating CBME requirements challenges residency programs, which must address many aspects of training simultaneously. This challenge also exists for educational regulatory bodies in creating and adjusting national competencies to standardize training expectations. We propose that an international approach for mapping residency training requirements may provide a baseline for assessing commonalities and differences. This approach allows us to take our first steps towards creating international competency goals to enhance sharing of best practices in education and clinical work.

**Methods:** We chose anesthesiology residency training as our example discipline. Using two rounds of content analysis, we qualitatively compared published anesthesiology residency competencies for the European Union (The European Training Requirement), United States (ACGME Milestones), and Canada (CanMEDS Competence By Design), focusing on similarities and differences in representation (round one) and emphasis (round two) to generate hypotheses on practical solutions regarding international educational standards.

**Results:** We mapped the similarities and discrepancies between the three repositories. Round one revealed that 93% of competencies were common between the three repositories. Major differences between European Training Requirement, US Milestones, and Competence by Design competencies involved critical emergency medicine. Round two showed that over 30% of competencies were emphasized equally, with notable exceptions that European Training Requirement emphasized Anaesthesia Non-Technical Skills, Competence by Design highlighted more granular competencies within specific anesthesiology situations, and US Milestones emphasized professionalism and behavioral practices.

**Conclusions:** This qualitative comparison has identified commonalities and differences in anesthesiology training which may facilitate sharing broader perspectives on diverse high-quality educational, clinical, and research practices to enhance innovative approaches. Determining these overlaps in residency training can prompt international educational societies responsible for creating competencies to collaborate to design future training programs. This approach may be considered as a feasible method to build an international core of residency competency requirements for other disciplines.

<footnote>*Correspondence: clement.buleon@unicaen.fr</footnote>

<footnote n="3">³ Center for Medical Simulation, Boston, MA, USA</footnote>

<footnote>Full list of author information is available at the end of the article</footnote>
**Keywords:** Residency, Curriculum, Clinical competences, Education, Standards, Anesthesia, Competency based education

**Background**

Competency-based medical education (CBME) has revolutionized approaches to training by making expectations more concrete, visible, and relevant for trainees [1, 2]. Yet overseeing a residency training program requires program directors, faculty and support staff, and institutions to nimbly adapt curricula to the ever-changing criteria for clinical excellence and competency-based medical education [1, 3]. The volume of medical knowledge approximately doubles in size every few months [4], so CBME requirements may change frequently and demand regular updates to account for these advancements [5]. The work to updating residency requirements is often performed at a national level, to homogenize some aspects of training, but the burden on institutional education programs to translate these guidelines is heavy and investments by volunteer committees may be uneven. The result is incomplete or patchy national and international diffusion of evidence-based practices at the residency training level in any individual country [6].

By matching the large-scale challenge of adapting curriculum through global processes, we can optimize resource management since all countries need to incorporate advancements on the same medical topics. But to do this, we need to have sufficiently common requirements for our training. This ambitious view mandates that we start with map of the current requirements for training. Outside of cardiac arrest resuscitation guidelines from the International Liaison Committee on Resuscitation [7, 8], we have few examples of shared competency training goals that are created between countries. A few recent studies have compared international training structures [9, 10], but none has considered individual competencies.

With this study we aimed to compare different regions' requirements to create a baseline map of existing anesthesia program requirements. This could be the starting point for creating a shared set of competencies for future internationally agreed-upon standards for anesthesia or other specialties' training programs. We hope to demonstrate that differences may be mapped in a way that allows for economies of effort and crowdsourcing to accelerate innovative educational design and reduce time wasted reinventing curricula. We used anesthesiology residency as a feasibility test for this conceptual approach.

**Methods**

This study conforms to standards for reporting qualitative research (SRQR) [11]. Due to the nature of the study, Institutional Review Board involvement was not required.

**Context**

During fellowship training of one researcher (CB), three researchers (CB, RE, and RDM) met and began discussions on the similarities and differences in our respective residency programs in EU (CB), Canada (RE), and US (RDM). We developed a collaborative research approach to compare published formal requirements quantitatively and qualitatively within those programs.

**Sampling strategy**

We first identified each region's current governance setting standards for anesthesiology residency education, which included: the European Board and Section of Anesthesiology working under the auspices of the European Union of Medical Specialists (UEMS) [12]; the Accreditation Council for Graduate Medical Education (ACGME) for the United States; and the Royal College of Physicians and Surgeons of Canada. We reviewed available metrics for anesthesiology residency educational assessments published by these governing bodies, following White and Marsh's recommendations for choosing text to analyze [13]. Sources for consideration included the European Training Requirement (ETR) in Anesthesiology [14], the ACGME Program Requirements and the ACGME Milestones for US [15], and the Anesthesiology Competencies within Competence by Design (CBD) for Canada [16]. As the goal was to assess and compare published competencies, the ETR, the ACGME Milestones, and the Canadian Anesthesiology Competencies were chosen for comparison because they were most uniform in meeting our predefined criteria.

**Repository descriptions**

**The European training requirement (ETR) [14]**

ETR were produced by the European Committee on Education and Professional Development of the Section and Board of Anesthesiology. At the time of this writing, the ETR were intended as a shared repository for all countries in the EU training anesthesiology residents. The latest version was dated February 2018. The scope of ETR was to offer "a comprehensive and robust overall training
framework created by medical specialists and based on
assembled EU-wide educational and training experience.”
[14] Among the ETR objectives were facilitating profes-
sional mobility between European countries and promot-
ing safe and quality care. ETR were not mandatory in EU
countries, although the European Board and Section of
Anesthesiology supported their adoption [17]. Neverthe-
less, repositories and certifications in EU’s countries were
based upon or generally approximate ETR, though there
were still some heterogeneity between European coun-
tries’ programs [18, 19]. Objectives of the ETR were part
of a global framework with four generic roles: clinical
expert, professional leader, academic scholar and inspired
humanitarian. ETR consist of objectives, organized
across 16 headlines (Supplemental Digital Content 1),
which themselves belonged to two domains of (i) general
competencies and (ii) specific core competencies. Each
objective includes goals regarding knowledge, clinical
skills and specific attitudes. The clinical skills comprised
165 items and the aimed mastery follows four grades of
recommendations: (A) observer level (has knowledge of,
describes); (B) performs, manages, demonstrates under
direct supervision; (C) performs, manages, demonstrates
under distant supervision; and (D) performs, manages,
demonstrates independently. Depending on complexity
of the skills or items, residents were expected to achieve
anywhere from B (e.g. “Management of nerve blocks in
pain therapy” or “Management of organ donors in Inten-
sive care and during organ retrieval”), C (e.g. “Perform-
ing anesthesiology for kidney transplantation” or “Double
lumen tracheal intubation”) or D grades (e.g. “Manage-
ment of severe peri-partum hemorrhage” and “Manage-
ment of difficult and delayed extubation after airway
interventions”), with concessions given for rarer events.

The United States ACGME milestones [15]

The ACGME Milestones, introduced in 2013 but applied
to anesthesiology in 2015, attempted to expand upon the
six Core Competencies defined by the ACGME and the
American Board of Medical Specialties which were Pro-
fessionalism, Patient Care, Medical Knowledge, Prac-
tice-Based Learning and Improvement, Interpersonal
and Communication Skills, and Systems-based Practice
(Headlines in Supplemental Digital Content 2) [20]. The
Milestones also intended to formalize the observations
expected of residents within each of these six Core Com-
petencies, driving residencies to teach and be assessed
by how successfully their trainees met Milestones. Each
specialty training programs’ Milestones were developed
by experts within their specialty and varied in number of
Milestones per specialty. As of 2020, anesthesiology com-
prised 25 Milestones. Residents attained one of five levels

of achievement within each Milestone with clear behav-
ioral definitions and anchors [15].

The Canadian CBD anesthesiology competencies
[Entrustable professional activities (EPAs)] [16]

When this study was undertaken, two documents
described the standards of achievement that are expected
of Canadian anesthesiology residents when they were
conferred fellowship in the Royal College of Physicians
and Surgeons of Canada [16, 21]. The EPA guide sum-
marized which EPAs residents were expected to achieve
during their residency training (Headlines in Supplemen-
tal Digital Content 3). EPAs were clinical tasks which
residents could perform with minimal or no supervision
(i.e., the task can be entrusted to them to complete); these
were considered the minimal standard of achievement
expected at each stage of residency training. The Anes-
thesiology Competencies document provided a compre-
hensive description of the specialty of anesthesiology in
Canada, and described what residents should aspire to
achieve over their residency program [21]. The Anesthesia
siology Competencies were categorized in accordance
with the CanMEDS competencies (i.e. Medical Expert,
Communicator, Collaborator, Leader, Health Advocate,
Scholar, Professional). EPAs were assessed with a 5-point
scale of entrustability.

Qualitative approach and research paradigm

From April to December 2019, we (CB, RE, and RDM)
applied content analysis methodology [13, 22] and con-
sidered each of the training requirement repositories
as data sources individually situated within an impor-
tant cultural context, a distinction highlighted by Rat-
ner [23] and uniquely suited to qualitative comparison
as it allowed interpreting these training competencies
through a sociocultural lens (pragmatic paradigm) [24,
25]. As our goal was to define similarities and differences
between training expectations, we defined that each indi-
vidually-numbered competency within any given reposi-
tory would be considered the unit of data for comparison,
which would be compared with all other competencies
within the other two repositories.

Data collection methods, processing and analysis

The three researchers (CB, RE, and RDM) entered
each of the ETR, US Milestones, and CBD EPAs into a
Microsoft Excel spreadsheet (version 2019) to serve as
each region's repository of competencies. Each compen-
tency item was reviewed by the investigator represent-
ing that region and compared with the other regions'
competencies to determine congruence. English ver-
sions of published competencies were available and
were used for comparisons; all authors were fluent in
<figure><img src="image_2.png" /><figcaption>**Fig. 1** Venn diagram of common competencies for anesthesiology residency training for EU, US and Canada. The EU's repository is the European Training Requirement (ETR), the US' repository is the ACGME Milestones (Milestones), and the Canada's repository is the Competence by Design (CBD). Incompletely matched competencies are described</figcaption></figure>

English. As cultural influences were critical for analysis, we together discussed interpretative nuances of our representative region's requirements and considered how anesthesiologists may have functioned in their scopes of practice in each of EU, US, and Canada. To avoid bias, each round consisted of separate and independent investigator review, followed by comparing and merging results, with discrepancies resolved through discussion and consensus, determining intersubjectivity [26]. For the first round of analysis, we identified whether each competency item was represented in either of the other repositories. The ETR was chosen as the reference comparison here, given that it had the greatest number of competencies. The second round of analysis sought to determine the relative importance or emphasis of specific skill sets in each country's repository, using each repository as a reference for the other two to ensure full consideration of all competencies. Competency items were identified as having equal or different levels of importance, or "emphasis" between repositories based on how they were presented within the repository (i.e., competency items which were singled out and treated in-depth as unique competencies were interpreted as more emphasized than ones which were only briefly mentioned). For first round analysis, we sought to include rather than exclude, such that if a competency did not explicitly state an action, yet it could reasonably be included within the scope of the competency, common representation was considered between competencies. However, we applied stricter definitions whether domains were emphasized equally, and cultural context was considered more heavily. We used descriptive statistics to quantitatively present

congruency and emphasis of competencies between the repositories.

## Researcher characteristics and reflexivity

Three investigators were practicing anesthesiologists having completed training in their respective regions: CB in EU (France), RE in Canada, and RDM in the US. All had domain expertise in education, including educational fellowships and advanced degrees. All three had served on their residency program's clinical competency committees (either past or current). Two researchers were current or former residency or fellowship program directors (RE, RDM), and all actively taught anesthesiology residents at the time of data analysis.

## Techniques to enhance trustworthiness

Rigor was maintained by investigator independence at each stage, coupled with demonstrating intersubjectivity through discussion. Consensus was achieved universally between researchers through these discussions, with minimal instances of disagreement. In addition, external expert reviewers were invited to critique our results prior to submission (see Acknowledgements), lending credibility to our process. Based on their feedback, minor changes and correction were performed.

## Results

### Round 1: the broad view of shared competencies

Comparisons of ETR, US Milestones, and CBD EPAs competencies for anesthesiology resident training showed congruence of 93% (Fig. 1). All CBD EPAs and US Milestones' competencies were present in the ETR. ETR competencies were represented in 98% of CBD EPAs and in 95% of US Milestones. CBD EPAs competencies
were represented in 98% of US Milestones. US Milestones competencies were present in 96% of CBD EPAs. Table 1 summarizes the main results for the matching between ETR, US Milestones, and CBD EPAs' competencies. Detailed results of the first round of comparisons of the three repositories' competencies are presented in Appendix 1.

### Differences between repositories

Most of the difference between ETR, US Milestones, and CBD EPAs' competencies centered on critical emergency medicine (including pre-hospital and emergency medicine). This subject was completely absent from US Milestones. CBD EPAs' competencies covered a similar field to the ETR for critical emergency medicine, except for "assisting in rescue work" and "declaration of death at the scene of emergency," which were present only in the ETR. Skills in ultrasound and *Perioperative patient positioning avoiding tissue damage* were common for CBD EPAs and ETR but were absent from US Milestones. Three competencies were common to ETR and US Milestones and absent from CBD EPAs were: (1) *Management of brain*

death syndrome and donor management including explanation; (2) Positioning of patients with specific pathological conditions; and (3) Responsibility to maintain personal emotional, physical, and mental health.

## Round 2: emphasis of certain competencies by ETR, milestones, and CBD

Even if some competencies were cited in every repository, we did not determine all competencies had similar relative importance nor emphasis. Table 2 depicts which competencies were interpreted to have an equal expression among the three repositories, and which were emphasized equally by two or mainly by only one repository. This differential emphasis was demonstrated by comparing unique competencies such as "Promoting safety and well-being of staff" (ETR, 1.6) and "Responsibility to maintain personal, emotional, physical and mental health" (Milestones, P5) with how well-being was represented in CBD, which was dispersed within Core EPA #24, TTP #2, TTP #3, and TTP #5. Based on this deeper analysis, Venn diagrams (Fig. 2) depict the respective emphasis from each perspective (Europe, US, and

<table><caption>**Table 1** Comparison of competencies for anaesthesiology residency training for EU, US, and Canada</caption><thead><tr><th rowspan="2">ETR Domains' headlines (number of items)</th><th colspan="3">Number of items matching (%)</th></tr><tr><th>ETR with Milestones<sup>a</sup></th><th>ETR with CBD<sup>a</sup></th><th>ETR with Milestones with CBD<sup>b</sup></th></tr></thead><tbody><tr><td>Perioperative medicine, patient assessment and risk reduction (5)</td><td>5 (100)</td><td>5 (100)</td><td>5 (100)</td></tr><tr><td>General anaesthesia and sedation (25)</td><td>25 (100)</td><td>24 (96)</td><td>24 (96)</td></tr><tr><td>Airway management (4)</td><td>4 (100)</td><td>4 (100)</td><td>4 (100)</td></tr><tr><td>Regional anaesthesia (8)</td><td>8 (100)</td><td>7 (88)</td><td>7 (88)</td></tr><tr><td>Postoperative care and acute pain management (10)</td><td>10 (100)</td><td>10 (100)</td><td>10 (100)</td></tr><tr><td>Intensive care medicine (40)</td><td>40 (100)</td><td>40 (100)</td><td>40 (100)</td></tr><tr><td>Critical emergency medicine (CREM) (9)</td><td>0 (0)</td><td>7 (78)</td><td>0 (0)</td></tr><tr><td>Anaesthesia Non-Technical Skills (ANTS) (5)</td><td>5 (100)</td><td>5 (100)</td><td>5 (100)</td></tr><tr><td>Professionalism and ethics (8)</td><td>8 (100)</td><td>8 (100)</td><td>8 (100)</td></tr><tr><td>Patient safety and health economics (4)</td><td>4 (100)</td><td>4 (100)</td><td>4 (100)</td></tr><tr><td>Education, Self-directed Learning, Research (6)</td><td>6 (100)</td><td>6 (100)</td><td>6 (100)</td></tr><tr><td>Obstetric anaesthesiology (12)</td><td>12 (100)</td><td>12 (100)</td><td>12 (100)</td></tr><tr><td>Cardiothoracic anaesthesiology (9)</td><td>9 (100)</td><td>9 (100)</td><td>9 (100)</td></tr><tr><td>Neuroanaesthesiology (6)</td><td>6 (100)</td><td>6 (100)</td><td>6 (100)</td></tr><tr><td>Paediatric anaesthesiology (8)</td><td>8 (100)</td><td>8 (100)</td><td>8 (100)</td></tr><tr><td>Multidisciplinary chronic pain management (6)</td><td>6 (100)</td><td>6 (100)</td><td>6 (100)</td></tr></tbody><tfoot><tr><td><strong>Total (165)</strong></td><td><strong>156 (95)</strong></td><td><strong>161 (98)</strong></td><td><strong>154 (93)</strong></td></tr></tfoot></table>

<footnote><sup>a</sup> Comparison of CBD and US' Milestones:</footnote>

<footnote>All but one (98%) CBD items were found in Milestones. The exception was C6: "Demonstrating required skills in POCUS (point of care ultrasound) to answer a clinical question."</footnote>

<footnote>All but one (96%) of Milestones items were found in CBD. The exception was P5: "Responsibility to maintain personal emotional, physical, and mental health."</footnote>

<footnote><sup>b</sup> Comparison of ETR, CBD and US' Milestones: see Appendix 1</footnote>

<footnote>The EU's repository is the European Training Requirement (ETR), the US' repository is the ACGME Milestones (Milestones), and the Canada's repository is the Competence by Design (CBD). Incompletely matched competencies are described.</footnote>
<table><caption>**Table 2** Common and emphasised anaesthesiology training competencies in EU, US and Canadian repositories</caption><thead><tr><th>Competencies equally represented for ETR, Milestones, CBD</th><th>Competencies equally represented for CBD and Milestones</th><th>Competencies equally represented for ETR and Milestones</th></tr></thead><tbody><tr><td>Perioperative medicine, patient assessment, management plan, preparation, and risk reduction (Can.TTD1, Can.F1, Can.C1, Can.TTP1, E.1.1, USPC1)<br>Perioperative anaesthetic plan, management, conduct, and monitoring (Can.TTD2, Can.F2, E.1.2, USPC2)<br>Peri-procedural multimodal acute pain management, transfer of care, and postoperative orders (Can.TTD3, Can.C19, E.1.5, USPC3, USPC7)<br>Regional anaesthesia (Can.C11, E.1.4, USPC10)<br>Assessing, diagnosing and managing critically ill patients in acute care settings (Can.F9, Can.F10, Can.C21, E.1.6, USPC6)<br>Airway management (Can.F4, Can.C4, E.1.3, USPC8) – absence of extubation in US<br>Assessing, diagnosing and managing chronic pain (Can.C20, E.2.5, USPC7)<br>Education, Self-directed Learning, Research (Can.TTP5, E.1.1, US.PBL3)<br>Honesty, integrity, and ethical behaviour (Can.C25, E.1.9, US.P2)</td><td>Anticipating, preventing, diagnosing and managing common or expected peri-anaesthetic complications (Can.F6, Can.F8, USPC4)<br>Communication with patients and families (Can.C23, US.ICS1)</td><td>Responsibility to patients, families, and society (E.1.9, US.P1)<br>Patient Safety and Quality Improvement (E.1.10, US.SBP2)</td></tr><tr><td>Competencies equally represented for CBD and ETR</td><td>Competencies equally represented for CBD and Milestones</td><td>Competencies equally represented for ETR and Milestones</td></tr><tr><td>Obstetric anaesthesia and care: including providing labour analgesia, anaesthesia for caesarean, management of complications, management of high-risk parturient, and resuscitation of unstable parturient (Can.F12, Can.F13, Can.C7, Can.C8, Can.TTP4, E.2.1)<br>Paediatric anaesthesia: including providing perioperative anaesthetic management, management of common complications (Can.F14, Can.F15, Can.F16, Can.C10, E.2.4)<br>Providing anaesthetic management for patients undergoing procedures outside the usual environment of the operating room (Can.C13, E.1.2)<br>Providing perioperative management for patients requiring shared airway procedures (Can.C14, E.1.2)<br>Providing perioperative anaesthetic management for patients undergoing intracranial procedures (Can.C17, E.2.3)<br>Providing perioperative anaesthetic management for patients undergoing thoracic surgery (Can.C.18, E.2.2)<br>Resuscitation for unstable patients, outside of the operating room or PACU (Can.C22, E.1.7)<br>Initiating and leading resuscitation for unstable patients in the perioperative period (Can.C5, E.1.6)</td><td>Anticipating, preventing, diagnosing and managing common or expected peri-anaesthetic complications (Can.F6, Can.F8, USPC4)<br>Communication with patients and families (Can.C23, US.ICS1)</td><td>Responsibility to patients, families, and society (E.1.9, US.P1)<br>Patient Safety and Quality Improvement (E.1.10, US.SBP2)</td></tr></tbody></table>
<table><caption>**Table 2 (continued)**</caption><thead><tr><th>Competencies emphasized in CBD</th><th>Competencies emphasized in ETR</th><th>Competencies emphasized in Milestones</th></tr></thead><tbody><tr><td>Managing and coordinating patient positioning during anaesthesia care and preventing and recognizing related complications (Can.F5)<br>Assessing the indications for transfusion of blood products and managing side effects and complications (Can.F7)<br>Providing anaesthetic management for patients with defined critical illness (Can.C3)<br>Assessing, investigating, optimizing and formulating anaesthetic plans for more complex paediatric cases (Can.C9)<br>Diagnosing and providing management for patients with complications of regional anaesthesia (Can.C12)<br>Providing care for patients who have experienced a patient safety incident (Can.C24)<br>Performing the non-airway basic procedures of anaesthesiology (Can.F3)<br>Assessing pregnant patients and providing routine obstetric care or initial medical management for acute medical, surgical or obstetric conditions (Can.F11)<br>Providing anaesthetic management for patients with defined critical illness (Can.C2)<br>Demonstrating required skills in POCUS (point of care ultrasound) to answer a clinical question. (Can.C6)<br>Providing perioperative management for patients requiring airway diagnostic and therapeutic procedures (Can.C15)<br>Providing perioperative anaesthetic management for patients undergoing spinal procedures (Can.C16)<br>Managing all aspects of anaesthesia care for a scheduled day list (Can.TTP2)<br>Providing anaesthesia services for an on-call period (Can.TTP3)</td><td>Anaesthesia Non-Technical Skills (E.1.8)</td><td>Crisis management (US.PC5)<br>Technical skills: Use and Interpretation of Monitoring and Equipment (US.PC9)<br>Knowledge of biomedical, clinical, epidemiological, and social-behavioural sciences as outlined in the American Board of Anesthesiology Content Outline (US.MK1)<br>Coordination of patient care within the health care system (US.SBP1)<br>Team and leadership skills (US.ICS3)<br>Incorporation of quality improvement and patient safety initiatives into personal practice (US.PBL11)<br>Analysis of practice to identify areas in need of improvement (US.PBL12)<br>Education of patient, families, students, residents, and other health professionals (US.PBL4)<br>Commitment to institution, department, and colleagues (US.P3)<br>Receiving and giving feedback (US.P4)<br>Responsibility to maintain personal emotional, physical, and mental health (US.P5)<br>Communication with other professionals (US.ICS2)</td></tr><tr><td colspan="3"><p><strong>Can Canada, EPA Entrustable Professional Activity, TTD Transition to Discipline EPA, F Foundation EPA, C Core EPA, TTP Transition to Practice EPA, E Europe, US United States, PC Patient Care, MK Medical Knowledge, SBP Systems-based Practice, PBL Practiced-based Learning and Improvement, P Professionalism, JCS Interpersonal and Communications Skills</strong></p><p><strong>Summarizes competencies common to the three repositories (EU, US and Canada), to two repositories (EU and Canada; US and Canada; or EU and US), or rather specific to one repository (EU, US or Canada). The EU repository is the European Training Requirement (ETR), the US repository is the ACGME Milestones (Milestones), and the Canadian repository is the Competence by Design (CBD). Expressions are in percentage of their repository according to perspectives from (a) ETR, (b) Milestones, and (c) CBD.</strong></p></td></tr></tbody></table>
<figure><img src="image_3.png" /></figure>

Canada). More than 30 % of the competencies – whatever repository was taken as reference – had the same importance. ETR had only one (3%) competency that was specifically emphasized, Anaesthesia Non-Technical Skills (ANTS) [27]. Both CBD EPAs and US Milestones had more unique competencies emphasized. CBD EPAs focused on specific anesthesiology situations highlighting more granular competencies (e.g., point of care ultrasound skills, complex cases). Those competencies were included more generically for ETR and US Milestones, but without a high degree of detail. Professionalism and behavioral practices were emphasized by US Milestones (e.g., analysis of practice, education, communication).

## Discussion

This comparison provides a glimpse into common training goals shared among Europe, the US and Canada, using anesthesiology as the example discipline. We identified a high overlap rate of educational objectives (93%). The core competencies appear generally consistent as shown in Table 2 (e.g., perioperative anesthetic plan, management, conduct, and monitoring; assessing, diagnosing and managing critically ill patients in acute care settings; airway management; and honesty, integrity, and ethical behavior, among others).

Differences on specific competencies emphasized are nuanced and likely have historical roots. For example, emergency medicine and prehospital medicine were initiated by anesthesiologists in some European countries, and anesthesiologists still play a large role in caring for prehospital patients despite emergency medicine internationally developing as a separate specialty [28–30]. Consideration is being given in the US for anesthesiologists to fill this gap via training in emergency medicine to care for critical patients [31]. A heavy societal focus on professionalism for US trainees likely has led to more defined behavioral guidelines regarding professional care, generating this unique emphasis in the US-based Milestones [32]. The large overlap identified in educational objectives with limited differences confirm that training appears very similar between regions and that anesthesiologists can work together, both at educational and professional levels. An important consideration for future work will be the differences in competencies required to practice in lower resourced or austere settings. The skills and knowledge required for clinicians practicing in wealthy, developed countries may not be the ones needed in developing countries. Understanding these differences among residency programs in developed nations
highlighted in our study, and exploring the hypotheses stated above, should be topics for future investigation.

There are several reasons why this work has impor-
tant potential. As countries strive to build better health-
care professionals through competency-based teaching
and assessment, cross-cultural dialogue between inter-
national educational societies governing these compe-
tencies may enable effectively sharing best educational
and clinical practices. For example, recently the Royal
College of Anaesthetists in the UK adopted a curricu-
lum update, entitled the 2021 Anaesthetics Curriculum,
which included cultural values of diversity, inclusion,
and respectful interactions between team members [33],
and the Milestones were updated to include assessment
of point-of-care ultrasound [34]. These should serve as
exemplars for future updates to all repositories in anes-
thesiology. If and when this expands to countries with
different cultural norms or different levels of technology
and resources, other adaptations may need to be made.
As regions like the EU, US, and Canada revise their
CBME curricula and assessment tools, reviewing other
countries' successes and challenges in adopting changes
will allow shared insights to be efficiently incorporated
[33]. Thus, an educational global mindset may increase
adaptation of new practices. In addition, best educational
practices for adopting new techniques can offer faculty
opportunities to refresh or gain new skills without rein-
venting educational approaches, saving expert time and
organizational efforts.

Additionally, these requirements' complete revision
overburdens program directors, providing a substantial
source of their burnout [35, 36]. By focusing on similari-
ties, the workload of national and regional competency
assessment efforts could be reduced, freeing program
directors and educators to mentor trainees more effec-
tively and adapt requirements for teaching using a
regional lens. Engaging in such collaboration may facili-
tate other large-scale partnerships, such as subspecialty
educational groups, to advance the educational sciences
of teaching and learning in residency.

Many countries are in the process of developing more
healthcare provider training programs or improving
existing ones. By highlighting overlaps in competencies
between CBME residency programs around the world, an
international consensus of disciplines' competencies may
support creation of new training programs. Because best
educational practices would be shared through interna-
tional collaborations, this could facilitate training even
in low-resource settings. Established training programs
can also benefit from global innovations by identifying
and closing their own educational gaps. Working towards

a shared repository could be seen as investing time and
energy in reciprocal learning, though everyone will gain
from such a repository in distinct ways.

Limitations

Our study has limitations that need highlighting. We
focused on anesthesiology requirements in three wealthy,
developed regions to illustrate our concept as the inves-
tigators are anesthesiologists. Generalizing to other
specialties requires the existence of formally published
competency repositories as a first step of many. Exam-
ining the process of creating competency repositories
may serve as a preliminary step to unifying existing
repositories, which could be aided by shared terminology
and competency selection standards. We focused on a
restricted area (EU, US, and Canada) as the investigators
came from those areas (convenience sample). We would
need to overcome difficulties to extend our analysis to
other regions' repositories. First, not every area has an
easily accessible recent English version (or other shared
language version) of their competencies, introducing lan-
guage translation and interpretation challenges. Second,
integrating and comparing more than three competen-
cies would have been technically arduous. Nevertheless,
we offer a robust methodology in comparing CBME
training applicable across disciplines in healthcare.

The qualitative characteristic of this study may have
limited the objectivity of the comparisons. To reduce
this, we have had extensive discussion on the analysis for
each item among the three researchers and data are avail-
able for consultation (Appendix 1). We also had an exter-
nal independent review of the results.

The US and Canada have wide national application of
their competencies. In EU, despite intentions to harmo-
nize anesthesiology training [19], ETR adoption in its
current form is less clear [18], and active complementary
national ones coexist (e.g., UK or Denmark) [37, 38]. It
is unclear how ETR have influenced the development of
other EU national programs, as differences currently exist
between length of training in EU countries, which may
also lead to differential training, assessment, and regula-
tion within the EU [18]. Gaps between these programs
are not defined and only conjectural, as interpretation
of competencies can vary by different program direc-
tors, specifically in EU where ETR application may differ
from country to country. Furthermore, a final limitation
remains that despite significant overlap in competen-
cies, uniting accreditation practices between these three
regions is likely to encounter barriers related to political
and societal considerations.
## Perspectives and future directions

With now-defined competencies of CBME anesthesiology training programs for EU, US, and Canada, we call upon educational leaders from international societies to further develop competency standards. Basic technical skills (e.g. epidural, central line placement) and common competencies from Table 2 “Competencies equally represented for ETR, Milestones, CBD” (e.g. regional anesthesia, airway management) should benefit from developing common training programs which can become international standards. Future work should focus on determining the most effective teaching and assessment methodologies for achieving these competencies. Another exciting area of further development is using shared tools for competency assessment for licensure and certification, enabling anesthesiologists to temporarily practice in other countries during disasters.

## Conclusions

With this qualitative comparison, we were able to make a map discerning a baseline of similar competencies between published anesthesiology residency training competencies among EU, US, and Canada. Our approach also highlighted unique regional differences which appeared to be based on importance and approach rather than on fundamental content. Together, these serve as learning opportunities to explore. With over 90% overlap, the anesthesiology regional requirements we compared have enough in common to serve as a springboard to develop a common core of residency requirements in anesthesiology. This conceptual approach is demonstrated to be feasible and may be applied to determine a baseline from which to build an international core of residency competencies required by other disciplines.

### Abbreviations

ACGME: Accreditation Council for Graduate Medical Education; CBD: Competence by Design; CBME: Competency-based medical education; EPA: Entrustable Professional Activity; ETR: European Training Requirement; EU: European Union; UEMS: European Union of Medical Specialists; US: United States.

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-021-03007-w.

Additional file 1: Appendix.

Additional file 2: European Training Requirement Headlines (EU).

Additional file 3: ACGME Milestones headlines (US).

Additional file 4: Competence by Design headlines (Canada).

### Acknowledgements

The authors thank Pr. Jean-Luc Hanouz MD, PhD from the Department of Anesthesiology, Intensive Care and Perioperative Medicine, Caen Normandy University Hospital, Caen, France; and Pr. Doris Østegaard MD, DMSc, MHPE from the Danish Institute for Medical Simulation and the Department of Clinical Medicine, Herlev, Region Hovedstaden, Denmark, for their reviews, excellent feedback, and support of this work.

### Authors' contributions

CB helped with study conception and design, data contribution, data analysis, data interpretation, writing, visualization, and review and editing. RE helped with data contribution, writing, and review and editing. JWR helped with writing, and review and editing. RDM helped with study design refinement, data contribution, data interpretation, writing, and review and editing. All authors read and approved the final manuscript.

### Funding

This work is a part of CB PhD which have been supported by grants from the French Society for Anesthesiology and Intensive Care (SFAR), The Arthur Sachs-Harvard Foundation, The University Hospital of Caen, The North-West University Hospitals Group (G4), The Charles Nicolle Foundation. Funding bodies did not have any role in the design of the study, collection, analysis, and interpretation of data and in writing the manuscript.

### Availability of data and materials

All data generated or analyzed during this study are included in this published article (and its supplementary information files).

## Declarations

### Ethics approval and consent to participate

Not applicable.

### Consent for publication

Not applicable.

### Competing interests

The authors declare that they have no competing interests.

### Author details

¹Department of Anesthesiology, Intensive Care and Perioperative Medicine, Caen Normandy University Hospital, 6th Floor, Caen, France. ²Medical School, University of Caen Normandy, Caen, France. ³Center for Medical Simulation, Boston, MA, USA. ⁴Department of Anesthesia, Rockyview General Hospital, Calgary, AB, Canada. ⁵Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada. ⁶Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA. ⁷Harvard Medical School, Boston, MA, USA.

Received: 27 May 2021 Accepted: 28 October 2021

Published online: 10 November 2021

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