EDRA: Evolving Examinations - ESRA

ESRA Updates

October 2023 | Issue 13

EDRA: Evolving Examinations

Morné Wolmarans (Norfolk and Norwich University Hospital, UK) @docmorne
Oya Yalcin Cok (Baskent University, Faculty of Medicine, Turkey) @oyacok
Peter Merjavy (Craigavon Area University Teaching Hospital, Northern Ireland, UK) @PeterMerjavy

So many aspects of our social and working lives have been influenced by the consequences of the Covid pandemic, including the EDRA examinations. Each year from 2005 , the examination processes and procedures have been improving but Covid enabled us with a fantastic opportunity to implement the required changes faster than anticipated.

EDRA examiners

The number of EDRA examiners has been greatly increased over the last 3 to 5 years. All EDRA diplomats are eligible to apply to become an examiner, when the invitation is sent via email to all EDRA diplomats from the EDRA office. This process involves a competitive application process, but as expected has resulted in a very dynamic and diverse group of excellent and enthusiastic examiners. Not all but many of the European countries are represented by the examiners and everyone brings their own set of educational skills. EDRA examiners are expected to write and review up-to-date examination questions, review viva questions, and update the reading list and curriculum of the examination. Obviously, they are also required to attend and conduct the examinations at the annual congress and be involved at various online examinations.

From letf to right: Peter Merjavy (EDRA Vice-Chair Part II), André Van Zundert (EDRA Co-opted Member), Oya Yalcin Cok (EDRA Vice-Chair Part I) & Morné Wolmarans (EDRA Chair)

EDRA Board

The EDRA board members are elected from the pool of examiners and would usually serve a term of 3 years but may stand for re-election for another three-year term. The board consists of a chairperson (Dr Morné Wolmarans), two co-chairs (Dr Oya Yalcin Cok and Dr Peter Merjavy) and 6 elected board members (Dr. Margaretha Breebaart, Prof. Alan Macfarlane, Dr. Alexandros Makris, Dr. Barbara Rupnik, Dr. Emine Aysu Salviz & Dr. Andrea Saporito) and the current ESRA society president ( Dr. Eleni Moka). The board reserves the right to co-opt board members to help facilitate specific duties for the examination process and development. Examination is divided into part 1 and part 2.

EDRA Part 1

Under the initial leadership of Prof. Narinder Rawal and now continued by our current co-chair Dr Oya Cok, the part 1 examination has had extensive changes introduced over the last five years. From a paper-based multiple-choice question exam, ESRA has invested thousands of Euros to host the examination on a digital platform. We have moved from a multiple-choice exam to a single best answer examination which provides us with better discriminating questions. The software on the platform also allows us to interrogate the questions and evaluate the performance of a question after an exam. Badly performing questions or ones that do not provide sufficient discrimination can then be re-evaluated. The software also provides us with statistical analysis to calculate the appropriate pass mark for each exam. The extensive online security measures of the exam platform have also given us the opportunity to allow the examination to be taken online from the comfort of your own home on your own computer or device. So, from next year the part 1 examination will be offered on two occasions, an in-person exam at the annual ESRA Scientific Congress in September, which will be in Prague in 2024. Also, an online part 1 examination which will usually be at the end of March or the beginning of April, depending on holiday periods and demand for the exam. The online examination could potentially also be offered in different languages, but the National Society of the interested country need to enquire from the EDRA board at least 6 months before the examination date and be willing and able to pay for translation costs. The exam has already been successfully conducted in Turkish and Spanish. The part 1 section of the exam can be multilingual but Part 2 must currently be undertaken in English.

EDRA Part 2 A & B

Under the leadership of co-chair, Dr Peter Merjavy, the part 2 of the EDRA exam has also extensively evolved. The old examination involved a candidate receiving 4 questions in 40 minutes from 2 examiners but to further increase the objectivity of the examination, we have introduced multiple changes. The part 2 examination has been divided into Part 2A, which is the viva section of the exam, and a part 2B which is the practical or ultrasound demonstration part. The practical aspect is an important part of our examination because the EDRA board strongly feels regional anaesthesia practice is not just a theoretical subject but requires practical and clinical ability. If a candidate has met all the pre-requisites for the examinations, including the number of blocks and workshop requirements, then this part of the examination should be achievable.

The part 2 A & B are now 25 minutes each for 2 questions from 2 examiners and often an observer. So instead of getting the objective score of only 2 examiners, we now have the opinion of 4 to 6 examiners about the performance of a candidate. Part 2A and Part 2B do not have to be taken at the same exam sitting because part 2A can also be offered as a online option depending on demand from potential candidates. Part 2B will be offered at the annual scientific congress each year, but depending on available exam slots part 2A may also be available at the annual congress. Please visit the EDRA website for updates on exam dates and locations.

200 candidates taking the EDRA Part I in Paris, during the 6th World Congress on Regional Anaesthesia & Pain Medicine

Part 2 questions are clinically relevant to experts in regional anaesthesia and the questions are set to meet this standard. The management and knowledge required to deal with the questions and the practical scanning ability needs to be extremely proficient. The questions asked by the examiners are set, reviewed and the expected answer sheet and scoring system is also objectively constructed. This eliminates an individual examiner continually asking only questions about their own individual interests.

EDRA Exam Criteria

The EDRA exam criteria also required extensive changes because there was such a huge variety in the quality of workshops offered to candidates from various hospitals and countries. Unfortunately, this lack of experience often became apparent during the part 2 examination process. For example, some candidates only attended an hour of cadaver anatomy, with 2 half-day ultrasound courses. So, a total of 10 to 12 hours of workshops. In contrast others would attend a two-day cadaver workshop and two full day ultrasound workshops, which would give them a total of more than 30 hours of workshop experience. So, the time and money invested by candidates to achieve the workshop criteria was hugely different and unfair.

To avoid this problem in the future, the EDRA board has introduced EDRA approved workshops and an EDRA points system.

Workshop and congress organisers or course directors can now get their workshop listed on the official EDRA website, which allows candidates to see which workshop in which country is approved for the EDRA examinations and how many points are allocated to each workshop. There is both cadaver workshop and ultrasound scanning workshop EDRA points required. The workshop needs to comply to certain minimal educational criteria for example the ratio of delegates to faculty or ultrasound machines. Obviously, a course with 50 delegates to one ultrasound machine will have less educational value than 6 delegates for each member of faculty and ultrasound machine. The application process is not difficult and does not have to be repeated annually.

This is not an attempt by EDRA to dictate to other regional anaesthesia workshop leaders or societies on how to manage their workshops or cadaver courses. I know that there are hundreds of excellent workshops around the world of great educational value, but we do want to list in one place (EDRA website) where potential candidates can attend these fantastic workshops and gain experience and knowledge. Therefore, I would ask if you are a workshop organizer, in a European country or abroad, and would like your workshop to be listed on the EDRA website, please follow our easy application process. But more importantly, if you are attending a workshop and you would like the workshop organisers to get the course recognised for EDRA points then please direct the workshop leaders to our website.

I hope that this may become a valuable educational resource for RA enthusiasts wanting to attend regional anaesthesia workshops and allow them easily to easily see exactly which workshops are on offer in which country.

Peter Merjavy and his team has worked tirelessly to make this application process even easier in the future and to help candidates understand exactly which criteria is required before they apply for different parts of the EDRA examinations. Please look at the EDRA website to access the full list of criteria required, the EDRA points system and look at the section of “frequently asked questions” which I think is extremely useful.

One of the criteria for the examination is to attend an ESRA workshop. This has caused enormous confusion over the years. ESRA workshops are organised by the ESRA society, for example at the ESRA annual scientific congress, the ESRA Winter week, the ESRA cadaver workshop courses in Innsbruck & Witten, the ESRA Eastern European cadaver workshop etc.

All ESRA workshops are EDRA approved workshops, but EDRA approved workshops are not necessarily ESRA workshops.

Initially the EDRA examination was set up to provide educational RA standards within Europe, but there is an international demand that requires anaesthesiologists to be recognised as regional anaesthesia experts that distinguishes them from their colleagues. Unfortunately, fellowships are not available to all the regional anaesthesia enthusiasts that fall into this category, and this is where the EDRA diploma provides a great and practical solution.

From left to right: Christine Gryparis (Administrative Assistant), Oya Yalcin Cok (EDRA Vice-Chair Part I), Sari Casaer (EDRA Examiner) Patrick Schuldt (EDRA Examiner), Roger Karlsson (Orzone)

More and more international candidates, from outside European countries, wanted to complete the EDRA examinations. But this required multiple European visits to comply with the examination criteria with enormous logistical and financial stress. The ESRA Board wanted to make it possible for candidates to be able to visit one annual congress and be able to comply with all the examination criteria.

Therefore from 2024 onwards the EDRA examinations will be conducted after the ESRA Annual Scientific Congress, which will allow candidates to attend the required ESRA cadaver workshops or ESRA ultrasound workshops, depending on how many EDRA points they still require. The EDRA board is also working with countries outside of Europe in order to get their courses EDRA approved and allocate points. Hopefully soon there will be many EDRA approved workshops available to attend in India and the Middle East.

UEMS- CESMA appraisal

This year, during the 40th ESRA Annual Congress (6th World Congress on Regional Anaesthesia&Pain Medicine), the EDRA Board members and examiners, had the pleasure of hosting Prof. Danny Mathysen and Prof. Gian Battista Parigi for EDRA examination UEMS-CESMA appraisals.

UEMS is the European Union of Medical Specialists and they are responsible for postgraduate medical education, quality assurance of examinations across Europe and to define European medical standards in each medical speciality. CESMA is the Council for European Specialists Medical Assessment which is the advisory body for UEMS and their appraisers conduct the appraisal process of postgraduate medical specialists exams. CESMA  can offer advice and provide further recommendations to ensure that examinations are of the highest quality.

Our UEMS-CESMA appraisal application was initially in 2020; however due to COVID-19 pandemic, was postponed. As noted above the examinations had undergone extensive improvements and changes and it was with great pleasure to host our appraisers from UEMS-CESMA. We had our evaluation visit on September 5th (EDRA Part II) and 6th (EDRA Part I) exam dates, 2023, in Paris. We have not yet received the outcome of this appraisal process, but I am extremely confident that it will be a favourable result and to receive recommendations how we can continue to improve our examination process. It is important to evolve and strive for excellence in order to provide our EDRA diplomats with a qualification that is meaningful. The EDRA diploma needs to distinguish you as a clinician that is proficient in the safe practice of regional anaesthesia, therefore it is not an easy exam unless you have apply real enthusiasm (and anatomy) to safely practice the art of regional anaesthesia.

Topics: EDRA , EDRA Part 1 , EDRA Part 2 , EDRA scoring system , WCRAPM

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