Gersten Jonker

General discussion   183 9 Current assessment and certification practices fail to include all facets of competence and fail to prevent underperforming trainees to get certified (Chapter 7). The systems do not always satisfactorily justify the certification decision. This means that also trainees, whom anesthesiologists directly involved in certification decisions would not entrust with the unsupervised care of their loved ones, are getting certified. This minority of newly certified specialists can be seen as “false positives”of the system: certified but not fully competent (Chapter 7). There are no reports of the prevalence of false-positives, but it is estimated that up to 10%of trainees have“questionable competence”at certification [75]. A study among newly licensed veterinarians, graduating from vet medical school into practice, found that many graduates did not feel fully competent to independently perform commonly occurring professional activities at day one of practice [76]. The prevalence ranged from 26% for ‘obtaining a diagnostic blood sample and interpret the results’ to 98% for ‘performing minor surgical procedures’. Apparently, veterinary education did not prepare sufficiently, or did not intend to prepare, for unsupervised practice of these activities. The authors argued that a curriculum with EPAs might have better exposed the gap between education and practice requirements, and they also emphasized that learning continues after graduation [76]. The certification decision is the ultimate entrustment decision in postgraduate training: to entrust the trainee with the adequate and independent performance of the specialty. Failure of the assessment and certification system to take all aspects of competence into account is a major issue (Chapter 7). Ignoring inadequate professionalism competencies leads to specialists who collaborate inadequately and have higher complications rates, endangering patient safety [77]. In a postgraduate training programwith early adoption of EPAs, portfolio entries showed an inappropriate emphasis on technical aspects of medical care and amount of exposure, neglecting competency domains such as collaboration and communication [78, 79]. Educators in anesthesiology identified five areas where trainees who have not achievedminimum competence level at certification are lacking, indicating the importance of assessing these areas [80, 81]. The areas are: synthesis of information into a clear anesthetic plan, adaptation of an anesthetic plan to changing conditions, effective interpersonal skills and communication with patients and staff, identification of opportunities to improve performance, and discernment of own limits [80]. The development of an assessment and certification system that minimizes the risk of certifying trainees who are not yet competent (false-positives) is of great importance for the quality and safety of healthcare. This development starts with the completion of data analysis from the study leading to Chapter 7.