Practicing Neurosurgery in Italy

The approximately 150 units of neurosurgery in Italy include units of neurotraumatology, spine surgery, and pediatric neurosurgery. Each unit serves an average of 400,000 inhabitants and performs on average 600 operations per year, with a case-mix of 50 percent to 70 percent spine and peripheral nerve surgery versus 50 percent to 30 percent of brain surgery.

Numbering about 1,500, Italian neurosurgeons serve an overall population of more than 58 million inhabitants, equating to one neurosurgeon per 38,767 citizens. This proportion represents adequate coverage for the general population. On the whole, people are satisfied with the medical delivery system, including neurosurgery, especially in the north and midsection of the country. For “minor” surgical (including neurosurgical) procedures, there are waiting lists of six or more months in almost all hospitals.

Healthcare expenditure is about 9 percent of Italy’s gross domestic product. Patients have both government-sponsored care (80 percent) and private insurance (20 percent), with sharp differences among the northern, middle and southern areas of the country; for example, comparatively few people in the south have private insurance. Nevertheless, people in the lower socioeconomic stratum throughout the country are completely covered by government-sponsored healthcare.

Malpractice litigation is increasing as a major problem for practicing neurosurgeons. This can be linked to avoidable medical errors, to the sometimes unclear information given to patients, and to patients and their relativesâ often unrealistically high expectations for outcomes.

There are 25 schools of neurosurgery in Italy. The five-year neurosurgical training program commences after the six-year Medicine and Surgery degree. Each school admits one to four new residents each year, and at the end of their five-year residency program each of them is expected to have performed approximately 500 surgical procedures. On average, residents work a minimum of 36 to 38 hours per week. Notwithstanding some difficulties in neurosurgical training and finding employment, the neurosurgical residency programs in Italy seem to attract several very good medical students every year.

The problem of practical training in cadaver laboratories has not been completely resolved. Despite the significant Italian tradition of important anatomical studies, an outdated law that was influenced historically by the Catholic Church restricts the use of cadavers for teaching and scientific purposes. Considering the new Common European Constitution, it seems reasonable that the European community could offer a political solution in this matter, improving the quality of training in neurosurgery and in other disciplines.

In concert with the 2005 Annual Meeting of the Italian Society of Neurosurgery, SINch, in Turin, the Minister of Health declared his assent for dissection courses that use cadaver heads imported from other countries during well-established educational events. The Turin meeting was the first in the history of the SINch to be both preceded and followed by dissection courses using injected cadaver heads and temporal bone specimens. The ministerâs declaration opened the doors to many dissection courses: During the last two-and-a-half years, more than 10 dissection courses were organized in Turin, Rome, L’Aquila, Naples and Como. At the moment, it seems very difficult to organize dissection courses for spine surgery that use cadavers. It is hoped that in the near future the restrictions on the use of cadavers for educational purposes will be lifted, and work toward this goal continues.

With the aim of raising standards in the care of patients and in the training of young neurosurgeons, the SINch recently submitted the following recommendations to the Italian authorities.

1. The number of neurosurgical centers in Italy should be limited.

2. Existing centers should have an adequate number of intensive care unit beds (20 percent), and independent neuroradiology and neuroanesthesia services should be created.

3. Neurosurgical subspecialty services should be encouraged and implemented in neurosurgery departments at the large medical centers.

4. New residency schools should be limited and the existing programs upgraded to European standards; the number of trainees should be reduced.

5. The presence of a consulting neurosurgeon at all local health service clinics should be ensured.

6. The training of nurses should be reorganized to include the development of university courses of diploma for operating room nurses, neurosurgical nursing, and intensive care unit nursing.

These recommendations, if implemented, are expected to significantly strengthen the specialty of neurosurgery in Italy.

Luciano Mastronardi, MD, PhD, Division of Neurosurgery, Sant’Andrea Hospital, Rome, Italy. The author reported no conflicts for disclosure.