New training program in Anesthesiology. Update for the challenges of anesthesiology of the XXI century | Revista Española de Anestesiología y Reanimación (English Edition)

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"apellidos" => "Álvarez Escudero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "j" "identificador" => "aff0050" ] ] ] ] "afiliaciones" => array:10 [ 0 => array:3 [ "entidad" => "Vicepresidenta de la Comisión Nacional de Anestesiología, Reanimación y Terapéutica del Dolor, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de Sierrallana, Torrelavega, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Marqués de Valdecilla, Valdecilla, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital General Universitario de Elda, Alicante, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Gerencia Atención Integrada Cuenca – Hospital Virgen de la Luz, Cuenca, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clinic de Barcelona, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela, Ex presidente de la Comisión Nacional de Anestesiología, Reanimación y Terapéutica del Dolor, A Coruña, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevo Programa Formativo de Anestesiología y Reanimación. Actualización para los retos de la anestesiología del siglo XXI" ] ] "textoCompleto" => "In Spain, Specialized Medical Training (SMT) in Health Sciences is based on the residency programme, which was introduced more than 35 years ago. This syllabus is currently undergoing in-depth changes in design, and above all, in philosophy.It is up to the National Commission (NC) to review and update specialist training syllabuses. The current training syllabus in anaesthesiology and resuscitation, which dates from 1996,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> has never been updated. This is the case with most specialties, despite 4 new versions having been submitted to the Ministry of Health, Consumer Affairs and Social Welfare since 2003. Fortunately, the current syllabus, though old, is generic, broad, and poorly defined, so over the years teaching hospitals/units have been able to introduce the many different evidence-based, fully established techniques and advances introduced since then, allowing them to continue to provide their residents with excellent, top quality training at all times.Developing a training syllabus is a considerable challenge. It must include the core knowledge and skills demanded by current international standards, it must be forward-looking and specific, but at the same time flexible enough to incorporate all the latest scientific and technical advances as they emerge in order to avoid becoming obsolete. In short, it must be a syllabus that provides future specialists with an excellent education that conforms with established international standards and is equivalent to training in other European countries.Since 1993, the European Union of Medical Specialists (UEMS) and its specialist divisions has been working with various scientific associations<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> to design and update different training programs and establish the minimum standards required. These training guidelines are not intended to derogate the authority of each state to define the content of training curricula, but to complement their decisions and ensure uniform, high quality training throughout Europe.In Anaesthesiology, training standards are set by consensus of the Anaesthesiology section of the UEMS, the European Board of Anaesthesiology (EBA) and the European Society of Anaesthesiology (ESA).<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> These organisations issue periodic updates for the purpose of establishing a training curriculum that reflects modern medical practice and scientific advances in the specialty, and providing high-quality, harmonised and standardised education at the European level in compliance with Directive 2005/36/EC.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> This directive outlines a system of automatic, mutual recognition of medical competence, thereby facilitating the exchange and movement of specialists in Europe.In the 2000s, major training institutions and societies in the US,<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> Canada,<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> and Europe (specifically, the UEMS and the World Federation for Medical Education –WFME),<a class="elsevierStyleCrossRef" href="#bib0060">12</a> introduced concrete European specifications for the progressive improvement of knowledge based on on-going technical and clinical changes in healthcare. This made it necessary to provide effective, efficient, safe, performance-based training for future specialists, and led to the introduction of competence-based training.Competence, in Health Sciences, is the acquisition over time of the knowledge, technical and non-technical skills, attitudes and values needed to perform in a given context according to prevailing standards.Training syllabuses must establish two types knowledge and skill domains:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Domains related to the specific competences of each specialty.</li><li class="elsevierStyleListItem" id="lsti0010">-Transversal or generic domains that are very similar and shared by all specialties and include skills that reintroduce humanism in Health Sciences: ethical values, professionalism, attitudes and behaviours, communication skills, management, leadership, research and teaching, information management, and self-learning, all of which are essential for any specialist practising today.</li></ul>At the state level, Act 44/2003<a class="elsevierStyleCrossRef" href="#bib0065">13</a> on the management of the healthcare profession established the need to acquire these horizontal or generic competences progressively and continuously throughout the training period, and called for certain changes to be made in training syllabuses.Regarding specific competences, a training syllabus must describe the behaviours, or skills, to be acquired at the end of the training period, and must define and establish realistic objectives for each competence, including: theoretical knowledge, practical and clinical skills, attitudes. It must also verify these competences by establishing the most appropriate modalities and methodologies for evaluating each one and accrediting the training of the future specialist.Procedure for developing the new training syllabus in Anaesthesiology and Resuscitation.In November 2016, this National Commission was ordered by the General Directorate for Healthcare Professions of the Ministry of Health, Consumer Affairs and Social Welfare (MSCBS) to develop a new specialist training syllabus (STS).The work was conducted primarily online, with a very small number of face-to-face meetings, and the project was concluded and presented on 10 May 2020.The following five documents were submitted, pursuant to the Ministry’s own regulations governing the development of new training syllabuses:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1Draft of the new specialty training syllabus (STS).</li><li class="elsevierStyleListItem" id="lsti0020">2Rationale for extending the training period to five years.</li><li class="elsevierStyleListItem" id="lsti0025">3A skills training itinerary presented in a user-friendly Excel spreadsheet.</li><li class="elsevierStyleListItem" id="lsti0030">4Proposal for a rotation schedule.</li><li class="elsevierStyleListItem" id="lsti0035">5Criteria for accrediting teaching units.</li></ul>All these are published on the Intranet established for this purpose by the MSCBS, eRoom, pending final assessment and evaluation.The new syllabus was drawn up after reviewing and evaluating various training syllabuses established according to international standards<a class="elsevierStyleCrossRefs" href="#bib0030">6–12</a> together with the CoBaTrICE syllabus,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> which establishes the minimum common standards necessary for the management of critical patients – included in this syllabus – and the recommendations of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR).<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Following publication by the UEMS/EBA of their document 2018.17 outlining the new European Training Requirement (ETR) in Anaesthesiology (ETR Anaesthesiology, 2018),<a class="elsevierStyleCrossRef" href="#bib0030">6</a> this NC was compelled to return to the drawing board and adapt the syllabus to the new guidelines and competencies to be acquired during training, which was extended to a minimum of five years. This NC has incorporated these changes into the new syllabus and, together with SEDAR, has notified the MSCBS to this effect on various occasions.The main objective of the new syllabus is to provide future specialists with excellent, unified, evidence-based training and the most current clinical practice, aligning Spanish training with that offered in any European country, and facilitating the recognition, accreditation, exchange, and mobility of professionals.This up-to-date, comprehensive training will provide high-quality, transversal, multifunctional, versatile care tailored to the specific needs of each clinical areas staffed by anaesthesiologists. It will enable our specialists to deal with any situations and/or care demands and rapidly activate or deactivate these without the need for structural or personnel changes, always ensuring the presence of specialists who can provide an immediate, multidisciplinary response, especially in critical situations. This has been demonstrated during the current COVID-19 pandemic, and anaesthesiologists need to be prepared for such situations in the future to guarantee society safe, effective and efficient care in all circumstances.Pursuant to the provisions of Act 44/2003,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> this NC has drawn up a training syllabus divided in 22 domains that address the general and specific competences established in the ETR Anaesthesiology 2018<a class="elsevierStyleCrossRef" href="#bib0030">6</a> and include only the specific transversal competences of the specialty.It is important to correctly define the specialty to include all the basic competences required.Anaesthesiology and Resuscitation: Medical specialty responsible for perioperative medicine, with the knowledge and skill to perform all anaesthetic, analgesic and sedation techniques for diagnostic and therapeutic procedures, emergencies, resuscitation, care of all critically ill patients irrespective of the aetiology, and the treatment of acute and chronic pain.Duration of the training period: five yearsThe draft STS outlines the basic training elements.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">1Definition of the specialist in Anaesthesiology and Resuscitation, including the holistic competencies of the European specialist:</li><li class="elsevierStyleListItem" id="lsti0045">-Expert clinician able to work in a multidisciplinary setting in anaesthesia, perioperative medicine, intensive care, critical emergency medicine and pain therapy.</li><li class="elsevierStyleListItem" id="lsti0050">-Professional leader with skills in communication and the management and organization of the different healthcare areas of the specialty.</li><li class="elsevierStyleListItem" id="lsti0055">-Academic scholar, who develops and maintains a high degree of professionalism and competence, and contributes to the development of the specialty.</li><li class="elsevierStyleListItem" id="lsti0060">-Inspired humanitarian, who exhibits irreproachable behaviour.</li><li class="elsevierStyleListItem" id="lsti0065">2Establishment of the scope of action of the anaesthesiologist, divided into three fields: a) healthcare – in all areas within their competence, b) teaching – training both anaesthesiology residents and residents in related specialties, and c) research – basic and clinical in the different areas of the specialty.</li><li class="elsevierStyleListItem" id="lsti0070">3The fundamental objective of the syllabus is to establish the competencies to be acquired during training in order to obtain the title of Specialist in Anaesthesiology and Resuscitation. The criteria for defining each competence have been specified.</li><li class="elsevierStyleListItem" id="lsti0075">4Defining competences. The syllabus has defined the new competences to be mastered that complement the knowledge acquired during undergraduate studies. To avoid repetitions, a general framework has been drawn up that includes the core skills to be acquired simultaneously with the acquisition of competences specific to each domain. These competencies, which practice should be evidence-based, include all patients groups (adults, paediatrics, obstetrics).</li></ul>The specialist in Anaesthesiology and Resuscitation must have mastered all the competencies of perioperative medicine, which is the continuum in patient care, starting before the operative procedure with a pre-anaesthesia evaluation and lasting well into the postoperative period. The foregoing comprises the care and treatment of patients in any critical situation until resolution and the management and treatment of acute and chronic pain (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>For this purpose, the syllabus requires trainees to acquire the groups of competences specified in the training itinerary:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">-10 transversal competences common to all Health Science specialties, established by the MSCBS.</li><li class="elsevierStyleListItem" id="lsti0085">-4 generic anaesthesiology competencies.</li><li class="elsevierStyleListItem" id="lsti0090">-18 competencies included in the general framework.</li><li class="elsevierStyleListItem" id="lsti0095">-11 domains of basic general competences.</li><li class="elsevierStyleListItem" id="lsti0100">-11 domains of specific competences.</li></ul>Following the European model, which stresses the importance of training and tutorship, the syllabus describes the teaching methodology to be used by such tutors. Residents must also be familiar with this methodology, not only in terms of the knowledge they need to acquire, but also of how they must acquire it, and how that knowledge will be evaluated. SMT is based on adult teaching, emphasizing self-learning, self-assessment, the construction of knowledge, together with reflection and tutor-resident feedback. The model is learner-based, and requires the active participation of residents in an open, flexible and personalized process that is facilitated, encouraged and guided by the tutor.To facilitate this joint effort, the new programme outlines the different teaching modalities and methods, particularly problem-based learning (PBL) and evidence-based medicine (EBM), and the different evaluation methodologies used, specifying the different tools to be used to assess each competence. This is intended to facilitate the work of the tutor, and allow residents to become more directly involved in their training.Although residents Spain qualify as specialists in accordance with prevailing legislation in this regard, the new syllabus urges residents to obtain the European Diploma in Anaesthesiology and Intensive Care (EDAIC)<a class="elsevierStyleCrossRef" href="#bib0080">16</a> to be accredited as a specialist in the practice of anaesthesiology in Europe. Bear in mind that the European Society of Anaesthesiology recently changed its name to the European Society of Anaesthesiology and Intensive Care (ESAIC)<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0105">5The responsibility of the doctor is directly linked to decision-making. The resident’s performance is supervised and programmed; therefore, their decision-making capacity must be closely linked to their progressive acquisition of knowledge and skills, allowing the degree of supervision to be reduced as training progresses and giving the resident progressively greater autonomy and responsibility. The syllabus establishes the three levels of responsibility in accordance with prevailing Spanish regulations<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>; however, in line with other European countries, residents are encouraged to start training undergraduate students and residents with less experience. The aim of this strategy is to help them develop teaching skills by preparing lessons that they will later teach to younger students.</li><li class="elsevierStyleListItem" id="lsti0110">6On-call shifts are an important part of resident training. During the first months of residency, it may be advisable to assign residents to emergency shifts. During the rest of the training period they should perform their on-call shifts in the Anaesthesiology and Resuscitation service, dividing their time proportionally between the operating rooms of each specialty and the emergency room, as well as the resuscitation units, critical care units and anaesthesia critical care units. The total number of shift hours are stipulated in prevailing legislation.<a class="elsevierStyleCrossRef" href="#bib0085">17</a></li><li class="elsevierStyleListItem" id="lsti0115">7The Rotations recommended in an addendum to the STS are for guidance purposes, and are distributed by year of residence. The aim of rotations is to master the basic professional competencies needed to achieve the teaching objectives specified in the syllabus. They must be approved by the local Teaching Commission and adapted to the requirements of each teaching unit.</li><li class="elsevierStyleListItem" id="lsti0120">8To acquire specialist competences, residents need to perform a minimum number of anaesthetic procedures, and treat patients in critical care and pain units during their rotations. These requirements have been drawn up following a comparative review of various training syllabuses, and the minimum recommended number of techniques and procedures to be performed has also been established (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The minimum number required to master each technique and procedure will be determined by their corresponding learning curves. All activities must be recorded in the Resident’s Logbook or Portfolio.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li></ul>The criteria for acquiring competencies, together with the minimum number of anaesthetic procedures and critical patients treated and the schedule of rotations, will give teaching units greater freedom and flexibility to structure and organise resident training. This is because the training activity can be redirected once the competence has been acquired and the minimum requirements have been met, thereby avoiding rigid and sometimes ineffective rotations, while improving the teaching capacity of the unit.<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0125">9The program also includes regular training tasks to be performed by the resident, such as sessions and recommended courses according to year of residence.</li></ul>The draft STS and the teaching unit accreditation document outlines the requirements of the teaching environment, including the materials, devices and different educational documents needed to comply with the training road map established in the quality plan, and also specifies the regulations governing the rights and duties of the resident.<a class="elsevierStyleCrossRefs" href="#bib0065">13,17,18</a><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130">10The program specifies the research activities residents are required to undertake, and encourages them to start their doctoral thesis during the last years of residence.</li></ul>Finally, the competencies established for each of the 22 domains are displayed in an Excel spreadsheet, specifying the most appropriate evaluation tools for each competence, the most suitable learning context, and the training activities and specific recommendations. This gives both residents and their tutors an overview of the contents of the residency curriculum.The National Commission has developed this new syllabus to update SMT in Anaesthesiology and Resuscitation in Spain, providing a new approach to training future specialists in an effective, efficient and safe way, and in accordance with European standards. The new syllabus is specific, yet flexible enough to accommodate future technical and scientific advances. It sets out the competences to be acquired, and provides the training and evaluation tools needed to facilitate tutoring, learning and training. We hope it fulfils the needs of the 21st century medical specialist.FundingThis article has not received any financial support.Conflict of interestsThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Duration of the training period: five years" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Villalonga Vadell R, Cobo Castro T, Guillén Antón J, Rabanal Llevot JM, Sánchez Pérez CA, Tamayo Gómez E, et al. Nuevo Programa Formativo de Anestesiología y Reanimación. Actualización para los retos de la anestesiología del siglo XXI. Rev Esp Anestesiol Reanim. 2021;68:5–9." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physiological and pharmacological principles of anaesthesia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intensive care medicine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Management and organization of the operating room. Safety, hygiene and risk management in the surgical patient. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Critical emergency medicine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advanced anaesthesia and monitoring equipment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstetric anaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative evaluation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiothoracic anaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Airway management. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neuroanaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Management and intraoperative care of the surgical patient. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Solid organ donation and transplantation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regional anaesthesia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paediatric anaesthesiology. Paediatric critical care. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative care and acute pain management. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Non-operating room anaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiopulmonary and cerebral resuscitation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Outpatient anaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency anaesthesiology. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multidisciplinary pain management. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaesthesia non-technical skills. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Professionalism and ethics. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2495141.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Domains of competence." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ASA: American Society of Anesthesiologists; CS: cardiac surgery; ESA: European Society of Anaesthesia; ENT: ears, nose and throat; GIS: gastrointestinal surgery; MOS: major outpatient surgery; NS: neurosurgery; URO: urology; Pat.: patients.SEDAR: Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy; TS: thoracic surgery; VS: vascular surgery." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ASA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SEDAR \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total anaesthetic procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1500 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General A. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency A. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">300 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Per. block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Children <5 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Children <5 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caesarean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Labour epidural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">URO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ENT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MOS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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Editorial article

New training program in Anesthesiology. Update for the challenges of anesthesiology of the XXI century

Nuevo Programa Formativo de Anestesiología y Reanimación. Actualización para los retos de la anestesiología del siglo XXI

R. Villalonga Vadella,

Corresponding author

rvillalonga@ub.edu

Corresponding author.

, T. Cobo Castrob, J. Guillén Antónc, J.M. Rabanal Llevotd, C.A. Sánchez Péreze, E. Tamayo Gómezf, C. García Colladag, C. Ferrando Ortoláh, J.A. García Martínezi, O. de la Varga Martínezf, J. Álvarez Escuderoj

a Vicepresidenta de la Comisión Nacional de Anestesiología, Reanimación y Terapéutica del Dolor, Barcelona, Spain

b Servicio de Anestesiología y Reanimación, Hospital de Sierrallana, Torrelavega, Cantabria, Spain

c Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain

d Servicio de Anestesiología y Reanimación, Hospital Universitario Marqués de Valdecilla, Valdecilla, Spain

e Servicio de Anestesiología y Reanimación, Hospital General Universitario de Elda, Alicante, Spain

f Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valladolid, Valladolid, Spain

g Servicio de Anestesiología y Reanimación, Gerencia Atención Integrada Cuenca – Hospital Virgen de la Luz, Cuenca, Spain

h Servicio de Anestesiología y Reanimación, Hospital Clinic de Barcelona, Barcelona, Spain

i Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain

j Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela, Ex presidente de la Comisión Nacional de Anestesiología, Reanimación y Terapéutica del Dolor, A Coruña, Spain

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is generic&#44; broad&#44; and poorly defined&#44; so over the years teaching hospitals&#47;units have been able to introduce the many different evidence-based&#44; fully established techniques and advances introduced since then&#44; allowing them to continue to provide their residents with excellent&#44; top quality training at all times&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Developing a training syllabus is a considerable challenge&#46; It must include the core knowledge and skills demanded by current international standards&#44; it must be forward-looking and specific&#44; but at the same time flexible enough to incorporate all the latest scientific and technical advances as they emerge in order to avoid becoming obsolete&#46; In short&#44; it must be a syllabus that provides future specialists with an excellent education that conforms with established international standards and is equivalent to training in other European countries&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 1993&#44; the European Union of Medical Specialists &#40;UEMS&#41; and its specialist divisions has been working with various scientific associations<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> to design and update different training programs and establish the minimum standards required&#46; These training guidelines are not intended to derogate the authority of each state to define the content of training curricula&#44; but to complement their decisions and ensure uniform&#44; high quality training throughout Europe&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Anaesthesiology&#44; training standards are set by consensus of the Anaesthesiology section of the UEMS&#44; the European Board of Anaesthesiology &#40;EBA&#41; and the European Society of Anaesthesiology &#40;ESA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> These organisations issue periodic updates for the purpose of establishing a training curriculum that reflects modern medical practice and scientific advances in the specialty&#44; and providing high-quality&#44; harmonised and standardised education at the European level in compliance with Directive 2005&#47;36&#47;EC&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This directive outlines a system of automatic&#44; mutual recognition of medical competence&#44; thereby facilitating the exchange and movement of specialists in Europe&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the 2000s&#44; major training institutions and societies in the US&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Canada&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> and Europe &#40;specifically&#44; the UEMS and the World Federation for Medical Education &#8211;WFME&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> introduced concrete European specifications for the progressive improvement of knowledge based on on-going technical and clinical changes in healthcare&#46; This made it necessary to provide effective&#44; efficient&#44; safe&#44; performance-based training for future specialists&#44; and led to the introduction of competence-based training&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Competence</span>&#44; in Health Sciences&#44; is the acquisition over time of the knowledge&#44; technical and non-technical skills&#44; attitudes and values needed to perform in a given context according to prevailing standards&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Training syllabuses must establish two types knowledge and skill domains&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Domains related to the specific competences of each specialty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Transversal or generic domains that are very similar and shared by all specialties and include skills that reintroduce humanism in Health Sciences&#58; ethical values&#44; professionalism&#44; attitudes and behaviours&#44; communication skills&#44; management&#44; leadership&#44; research and teaching&#44; information management&#44; and self-learning&#44; all of which are essential for any specialist practising today&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">At the state level&#44; Act 44&#47;2003<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> on the management of the healthcare profession established the need to acquire these horizontal or generic competences progressively and continuously throughout the training period&#44; and called for certain changes to be made in training syllabuses&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding specific competences&#44; a training syllabus must describe the behaviours&#44; or skills&#44; to be acquired at the end of the training period&#44; and must define and establish realistic objectives for each competence&#44; including&#58; theoretical knowledge&#44; practical and clinical skills&#44; attitudes&#46; It must also verify these competences by establishing the most appropriate modalities and methodologies for evaluating each one and accrediting the training of the future specialist&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Procedure for developing the new training syllabus in Anaesthesiology and Resuscitation&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In November 2016&#44; this National Commission was ordered by the General Directorate for Healthcare Professions of the Ministry of Health&#44; Consumer Affairs and Social Welfare &#40;MSCBS&#41; to develop a new specialist training syllabus &#40;STS&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The work was conducted primarily online&#44; with a very small number of face-to-face meetings&#44; and the project was concluded and presented on 10 May 2020&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The following five documents were submitted&#44; pursuant to the Ministry&#8217;s own regulations governing the development of new training syllabuses&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1</span><p id="par0085" class="elsevierStylePara elsevierViewall">Draft of the new specialty training syllabus &#40;STS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2</span><p id="par0090" class="elsevierStylePara elsevierViewall">Rationale for extending the training period to five years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3</span><p id="par0095" class="elsevierStylePara elsevierViewall">A skills training itinerary presented in a user-friendly Excel spreadsheet&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4</span><p id="par0100" class="elsevierStylePara elsevierViewall">Proposal for a rotation schedule&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">5</span><p id="par0105" class="elsevierStylePara elsevierViewall">Criteria for accrediting teaching units&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">All these are published on the Intranet established for this purpose by the MSCBS&#44; <span class="elsevierStyleItalic">eRoom</span>&#44; pending final assessment and evaluation&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The new syllabus was drawn up after reviewing and evaluating various training syllabuses established according to international standards<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;12</span></a> together with the CoBaTrICE syllabus&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which establishes the minimum common standards necessary for the management of critical patients &#8211; included in this syllabus &#8211; and the recommendations of the Spanish Society of Anaesthesiology&#44; Resuscitation and Pain Therapy &#40;SEDAR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Following publication by the UEMS&#47;EBA of their document 2018&#46;17 outlining the new European Training Requirement &#40;ETR&#41; in Anaesthesiology &#40;ETR Anaesthesiology&#44; 2018&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> this NC was compelled to return to the drawing board and adapt the syllabus to the new guidelines and competencies to be acquired during training&#44; which was extended to a minimum of five years&#46; This NC has incorporated these changes into the new syllabus and&#44; together with SEDAR&#44; has notified the MSCBS to this effect on various occasions&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The main objective of the new syllabus is to provide future specialists with excellent&#44; unified&#44; evidence-based training and the most current clinical practice&#44; aligning Spanish training with that offered in any European country&#44; and facilitating the recognition&#44; accreditation&#44; exchange&#44; and mobility of professionals&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">This up-to-date&#44; comprehensive training will provide high-quality&#44; transversal&#44; multifunctional&#44; versatile care tailored to the specific needs of each clinical areas staffed by anaesthesiologists&#46; It will enable our specialists to deal with any situations and&#47;or care demands and rapidly activate or deactivate these without the need for structural or personnel changes&#44; always ensuring the presence of specialists who can provide an immediate&#44; multidisciplinary response&#44; especially in critical situations&#46; This has been demonstrated during the current COVID-19 pandemic&#44; and anaesthesiologists need to be prepared for such situations in the future to guarantee society safe&#44; effective and efficient care in all circumstances&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Pursuant to the provisions of Act 44&#47;2003&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> this NC has drawn up a training syllabus divided in 22 domains that address the general and specific competences established in the ETR Anaesthesiology 2018<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and include only the specific transversal competences of the specialty&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">It is important to correctly <span class="elsevierStyleBold">define the specialty</span> to include all the basic competences required&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Anaesthesiology and Resuscitation</span>&#58; Medical specialty responsible for perioperative medicine&#44; with the knowledge and skill to perform all anaesthetic&#44; analgesic and sedation techniques for diagnostic and therapeutic procedures&#44; emergencies&#44; resuscitation&#44; care of all critically ill patients irrespective of the aetiology&#44; and the treatment of acute and chronic pain&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Duration of the training period&#58; five years</span><p id="par0150" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">draft STS</span> outlines the basic training elements&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1</span><p id="par0155" class="elsevierStylePara elsevierViewall">Definition of the <span class="elsevierStyleBold">specialist</span> in Anaesthesiology and Resuscitation&#44; including the <span class="elsevierStyleBold">holistic competencies</span> of the European specialist&#58;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Expert clinician able to work in a multidisciplinary setting in anaesthesia&#44; perioperative medicine&#44; intensive care&#44; critical emergency medicine and pain therapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Professional leader with skills in communication and the management and organization of the different healthcare areas of the specialty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Academic scholar&#44; who develops and maintains a high degree of professionalism and competence&#44; and contributes to the development of the specialty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Inspired humanitarian&#44; who exhibits irreproachable behaviour&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2</span><p id="par0180" class="elsevierStylePara elsevierViewall">Establishment of <span class="elsevierStyleBold">the scope of action of the anaesthesiologist</span>&#44; divided into three fields&#58; a&#41; healthcare &#8211; in all areas within their competence&#44; b&#41; teaching &#8211; training both anaesthesiology residents and residents in related specialties&#44; and c&#41; research &#8211; basic and clinical in the different areas of the specialty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">3</span><p id="par0185" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">fundamental objective of the syllabus</span> is to establish the <span class="elsevierStyleBold">competencies</span> to be acquired during training in order to obtain the title of Specialist in Anaesthesiology and Resuscitation&#46; The criteria for defining each competence have been specified&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">4</span><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Defining competences&#46;</span> The syllabus has defined the new competences to be mastered that complement the knowledge acquired during undergraduate studies&#46; To avoid repetitions&#44; a <span class="elsevierStyleItalic">general framework</span> has been drawn up that includes the core skills to be acquired simultaneously with the acquisition of competences specific to each domain&#46; These competencies&#44; which practice should be evidence-based&#44; include all patients groups &#40;adults&#44; paediatrics&#44; obstetrics&#41;&#46;</p></li></ul></p><p id="par0195" class="elsevierStylePara elsevierViewall">The specialist in Anaesthesiology and Resuscitation must have mastered all the competencies of <span class="elsevierStyleBold">perioperative medicine</span>&#44; which is the continuum in patient care&#44; starting before the operative procedure with a pre-anaesthesia evaluation and lasting well into the postoperative period&#46; The foregoing comprises the care and treatment of patients in any critical situation until resolution and the management and treatment of acute and chronic pain &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">For this purpose&#44; the syllabus requires trainees to acquire the groups of competences specified in the <span class="elsevierStyleBold">training itinerary&#58;</span><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">10 transversal competences common to all Health Science specialties&#44; established by the MSCBS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">4 generic anaesthesiology competencies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">18 competencies included in the general framework&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">11 domains of basic general competences&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">11 domains of specific competences&#46;</p></li></ul></p><p id="par0230" class="elsevierStylePara elsevierViewall">Following the European model&#44; which stresses the importance of training and tutorship&#44; the syllabus describes the <span class="elsevierStyleBold">teaching methodology</span> to be used by such tutors&#46; Residents must also be familiar with this methodology&#44; not only in terms of the knowledge they need to acquire&#44; but also of how they must acquire it&#44; and how that knowledge will be evaluated&#46; SMT is based on adult teaching&#44; emphasizing self-learning&#44; self-assessment&#44; the construction of knowledge&#44; together with reflection and tutor-resident feedback&#46; The model is <span class="elsevierStyleItalic">learner</span>-based&#44; and requires the active participation of residents in an open&#44; flexible and personalized process that is facilitated&#44; encouraged and guided by the tutor&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">To facilitate this joint effort&#44; the new programme outlines the different teaching modalities and methods&#44; particularly problem-based learning &#40;PBL&#41; and evidence-based medicine &#40;EBM&#41;&#44; and the different evaluation methodologies used&#44; specifying the different tools to be used to assess each competence&#46; This is intended to facilitate the work of the tutor&#44; and allow residents to become more directly involved in their training&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Although residents Spain qualify as specialists in accordance with prevailing legislation in this regard&#44; the new syllabus urges residents to obtain the European Diploma in Anaesthesiology and Intensive Care &#40;EDAIC&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> to be accredited as a specialist in the practice of anaesthesiology in Europe&#46; Bear in mind that the European Society of Anaesthesiology recently changed its name to the European Society of Anaesthesiology and Intensive Care &#40;ESAIC&#41;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">5</span><p id="par0245" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">responsibility</span> of the doctor is directly linked to decision-making&#46; The resident&#8217;s performance is supervised and programmed&#59; therefore&#44; their decision-making capacity must be closely linked to their progressive acquisition of knowledge and skills&#44; allowing the degree of supervision to be reduced as training progresses and giving the resident progressively greater autonomy and responsibility&#46; The syllabus establishes the three levels of responsibility in accordance with prevailing Spanish regulations<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#59; however&#44; in line with other European countries&#44; residents are encouraged to start training undergraduate students and residents with less experience&#46; The aim of this strategy is to help them develop teaching skills by preparing lessons that they will later teach to younger students&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">6</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">On-call shifts</span> are an important part of resident training&#46; During the first months of residency&#44; it may be advisable to assign residents to emergency shifts&#46; During the rest of the training period they should perform their on-call shifts in the Anaesthesiology and Resuscitation service&#44; dividing their time proportionally between the operating rooms of each specialty and the emergency room&#44; as well as the resuscitation units&#44; critical care units and anaesthesia critical care units&#46; The total number of shift hours are stipulated in prevailing legislation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">7</span><p id="par0255" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">Rotations</span> recommended in an addendum to the STS are for guidance purposes&#44; and are distributed by year of residence&#46; The aim of rotations is to master the basic professional competencies needed to achieve the teaching objectives specified in the syllabus&#46; They must be approved by the local Teaching Commission and adapted to the requirements of each teaching unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">8</span><p id="par0260" class="elsevierStylePara elsevierViewall">To acquire specialist competences&#44; residents need to perform a minimum number of <span class="elsevierStyleBold">anaesthetic procedures&#44;</span> and treat patients in <span class="elsevierStyleBold">critical care and pain units</span> during their rotations&#46; These requirements have been drawn up following a comparative review of various training syllabuses&#44; and the minimum recommended number of techniques and procedures to be performed has also been established &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The minimum number required to master each technique and procedure will be determined by their corresponding learning curves&#46; All activities must be recorded in the Resident&#8217;s Logbook or Portfolio&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li></ul></p><p id="par0265" class="elsevierStylePara elsevierViewall">The criteria for acquiring competencies&#44; together with the minimum number of anaesthetic procedures and critical patients treated and the schedule of rotations&#44; will give teaching units greater freedom and flexibility to structure and organise resident training&#46; This is because the training activity can be redirected once the competence has been acquired and the minimum requirements have been met&#44; thereby avoiding rigid and sometimes ineffective rotations&#44; while improving the teaching capacity of the unit&#46;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">9</span><p id="par0270" class="elsevierStylePara elsevierViewall">The program also includes <span class="elsevierStyleBold">regular training tasks to be performed by the resident</span>&#44; such as sessions and recommended courses according to year of residence&#46;</p></li></ul></p><p id="par0275" class="elsevierStylePara elsevierViewall">The draft STS and the teaching unit accreditation document outlines the requirements of the <span class="elsevierStyleBold">teaching environment</span>&#44; including the materials&#44; devices and different educational documents needed to comply with the training road map established in the quality plan&#44; and also specifies the regulations governing the <span class="elsevierStyleBold">rights and duties</span> of the resident&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17&#44;18</span></a><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">10</span><p id="par0280" class="elsevierStylePara elsevierViewall">The program specifies the <span class="elsevierStyleBold">research</span> activities residents are required to undertake&#44; and encourages them to start their doctoral thesis during the last years of residence&#46;</p></li></ul></p><p id="par0285" class="elsevierStylePara elsevierViewall">Finally&#44; the <span class="elsevierStyleBold">competencies</span> established for each of the 22 domains are displayed in an Excel spreadsheet&#44; specifying the most appropriate evaluation tools for each competence&#44; the most suitable learning context&#44; and the training activities and specific recommendations&#46; This gives both residents and their tutors an overview of the contents of the residency curriculum&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The National Commission has developed this new syllabus to update SMT in Anaesthesiology and Resuscitation in Spain&#44; providing a new approach to training future specialists in an effective&#44; efficient and safe way&#44; and in accordance with European standards&#46; The new syllabus is specific&#44; yet flexible enough to accommodate future technical and scientific advances&#46; It sets out the competences to be acquired&#44; and provides the training and evaluation tools needed to facilitate tutoring&#44; learning and training&#46; We hope it fulfils the needs of the 21st century medical specialist&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0295" class="elsevierStylePara elsevierViewall">This article has not received any financial support&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Villalonga Vadell R&#44; Cobo Castro T&#44; Guill&#233;n Ant&#243;n J&#44; Rabanal Llevot JM&#44; S&#225;nchez P&#233;rez CA&#44; Tamayo G&#243;mez E&#44; et al&#46; Nuevo Programa Formativo de Anestesiolog&#237;a y Reanimaci&#243;n&#46; Actualizaci&#243;n para los retos de la anestesiolog&#237;a del siglo XXI&#46; Rev Esp Anestesiol Reanim&#46; 2021&#59;68&#58;5&#8211;9&#46;</p>"
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                  \t\t\t\t">Physiological and pharmacological principles of anaesthesia&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Intensive care medicine&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Management and organization of the operating room&#46; Safety&#44; hygiene and risk management in the surgical patient&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Critical emergency medicine&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Advanced anaesthesia and monitoring equipment&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstetric anaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preoperative evaluation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiothoracic anaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Airway management&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neuroanaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Management and intraoperative care of the surgical patient&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Solid organ donation and transplantation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regional anaesthesia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paediatric anaesthesiology&#46; Paediatric critical care&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative care and acute pain management&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-operating room anaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiopulmonary and cerebral resuscitation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outpatient anaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency anaesthesiology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary pain management&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anaesthesia non-technical skills&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Professionalism and ethics&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2495141.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Domains of competence&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; <span class="elsevierStyleItalic">American Society of Anesthesiologists</span>&#59; CS&#58; cardiac surgery&#59; ESA&#58; <span class="elsevierStyleItalic">European Society of Anaesthesia</span>&#59; ENT&#58; ears&#44; nose and throat&#59; GIS&#58; gastrointestinal surgery&#59; MOS&#58; major outpatient surgery&#59; NS&#58; neurosurgery&#59; URO&#58; urology&#59; Pat&#46;&#58; patients&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SEDAR&#58; Spanish Society of Anaesthesiology&#44; Resuscitation and Pain Therapy&#59; TS&#58; thoracic surgery&#59; VS&#58; vascular surgery&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ASA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SEDAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total anaesthetic procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spinal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epidural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Per&#46; block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Children &#60;5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Children &#60;5 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caesarean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Labour epidural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">URO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">GIS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">ENT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">MOS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Recommended&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Critical&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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