Gersten Jonker

182   Chapter 9 complete. Time-and-rotation based apprenticeship models were ubiquitous and had an underlying traditional focus on either acquisition and assessment of knowledge or required numbers of exposures (Chapter 6). However, some countries adopted CBME totally or adopted elements, such as assessment tools. Outside of Europe, variation between countries in training duration and assessment exists as well [69]. Countries like the USA, Japan, and Brazil have a focus on required numbers of exposures [69], similar to a substantial number of European countries (Chapter 6), while Canada has a longstanding orientation on CBME. The actual implementation of CBME in Europe lags behind with the Union of European Medical Specialists / European Board of Anesthesiology training guidelines (Chapter 6). The guidelines had a procedural orientation in 2001, started adopting CBME principles in 2008, embraced CBME in 2012, and committed to CBME wholeheartedly in 2020 [70- 73]. The latest guidelines warn against minor adaptations of existing traditional time- based structures [73], which seems to have been occurring in several countries (Chapter 6). The guidelines do acknowledge that heterogeneity in programs is inevitable because of differences in rate of change, laws and regulations, scope of practice, and available resources [73]. CBME can create more conformity among training programs across countries with comparable healthcare needs [67]. Harmonization of training outcomes facilitates the transferability of medical specialists between countries [67]. In the European Union, member states areobligedby lawto recognize equivalent qualifications across. However, because of the importance to serve local demands [74] and differences in local clinical practices there will be no universal European training program [73]. Nevertheless, as noted in Chapter 6, a degree of harmonization with clear outcomes of training makes programs and graduates more readily comparable [73]. Chapter 6 also notes that the CBME frameworks provide the language that facilitates comparability and helps in safeguarding a minimal level of training of all European anesthesiologists [73]. Learning from shared best practices is a way to foster harmonization and to implement modern approaches to training. Whereas Chapter 6 provides an overview of current assessment and certification practice, the goal of the grounded theory study, of which Chapter 7 describes initial results, is to evaluate the quality of these practices and identify crucial elements of a robust assessment and certification system. Full analysis is to result in increased understanding of the certification process and in a model for assessment and certification, grounded in the data, on which to build further research on the implementation of improvements.