| With the approval of the European Neurosurgical Training Charter, it is possible that training programs worldwide will converge to a recognizable standard. |
Despite the recent development and approval of the European Training Charter in neurological surgery, it remains difficult to make direct comparisons between U.S. residency programs and those in Europe. Training programs and standards for acquisition of a certificate of completed training, CCT, vary significantly between EU member states, and it is not useful or accurate to speak of a “typical” European neurosurgical residency. It is possible, however, to make some broad comparisons and to contrast neurosurgical training standards in the U.S. with those approved in 2007—but not yet universally adopted—by the European Union of Medical Specialists, UEMS, Section of Neurosurgery.
Before beginning neurosurgical training, residents in both the U.S. and the U.K. must complete a formal program of postgraduate training. In the U.S., trainees complete a required internship year that has increasingly come under the control of program directors and that requires exposure to elements of general patient care. In the U.K., trainees must complete a similar basic clinical program (two foundation years). Throughout the remainder of Europe, requirements for basic clinical training prior to neurosurgical residency are variable.
As in the U.S., European neurosurgical trainees are recruited and enrolled in a home-base program where most training takes place over nearly a decade. In the U.S., approved residency tracts last six or seven years.
In most of Europe, the formal training period is of similar length (five to six years) although many graduates continue a less formal education for an additional two to five years in a non-private, state hospital setting—often at the home-base institution. Neurosurgical residents in the U.K. train for eight to nine years (specialty training, termed STn), after which, like U.S. graduates, they seek positions as independent consultants or fellows.
Like U.S. trainees, European neurosurgical residents obtain the bulk of their training experience at the home-base institution. In some instances (in the U.K. and Germany), trainees must “log-in” threshold numbers of cases across a range of procedures to obtain a CCT, a custom that echoes American neurosurgical Residency Review Committee requirements for program accreditation. Utilization of nonneurosurgical training time during residency varies throughout Europe, although neurology, radiology and laboratory rotations are not uncommon. Interestingly, European training programs, including those in the U.K., have not embraced the American notion of “chief resident,” and there is no consistent counterpart of this period of enhanced administrative responsibility outside the U.S.
Certification examinations similar to those administered by the American Board of Neurological Surgery are utilized throughout Europe, although they typically vary in content among EU member states. U.K. trainees at the ST-7 or ST-8 level are required to take the intercollegiate Fellowship Examination in Neurosurgery (written, oral and clinical-practical) to obtain FRCS-SN (Fellow of the Royal College of Surgeons- Surgical Neurology) status. Other EU member states require similar, although country-specific, oral and written certification examinations. In addition, the European Association of Neurological Surgeons, EANS, offers a certification exam that can be taken by EU trainees, although not all member states recognize the results. At present, the UEMS is working on the development of a “standard European examination” that may be more broadly accepted.
Program directors, mentors and trainees in both the U.S. and the EU are confronting stringent and evolving government generated resident work hour constraints. In the U.S., restrictions on the number of hours trainees spend “in hospital” have been imported by the Accreditation Council for Graduate Medical Education from the New York State Health Code and applied across all specialties, including neurosurgery. The current ACGME work hour requirements limit resident in-house activities to roughly 80 hours per week and rigidly define periods of rest. In the EU, enactment of the European Working Time Directive presently limits trainees to 56 hours in-hospital weekly. Allowed to evolve as planned, the EWTD constraints automatically will become more severe in 2009 (48 hours per week with a 15,000 euro penalty for program chairs with trainees in violation.) U.S. bureaucrats are contemplating the adoption of similarly restricted work hours.
With the approval of the European Neurosurgical Training Charter, modeled in part upon the perceived strengths of U.S. and U.K. residency training and certification, it is possible that training programs worldwide will converge to a recognizable standard. Devised by a joint committee of the EANS and the UEMS Section of Neurosurgery, the European Charter outlines parameters for program accreditation and training that are largely consistent with those in the U.S. and U.K. and may contain some improvements. Model programs would be six years in duration (four years of clinical neurosurgery and a minimum of three years at a UEMS member state institution) and would be required to demonstrate periodic progress for individual trainees through log book documentation, training portfolios and case mix and quantity standards set by the EANS and UEMS. The charter also describes a plan for trainee remediation. Certification exams would be prepared and administered throughout the EU by the EANS.
Despite present differences in U.S. and EU neurosurgical training, educators in both regions face similar challenges and evolving constraints. Adaptation and improvement may lead us to common ground.
James W. Holsapple, MD, is associate professor of neurosurgery at the State University of New York, Syracuse. Lawrence S. Chin, MD, is chair of the Department of Neurosurgery at Boston University School of Medicine and a member of the AANS Maintenance of Certification Committee. Send topic ideas for this department to Dr. Chin, Education editor, at [email protected]. The authors reported no conflicts for disclosure.
Acknowledgements The authors wish to thank Nur Altinors in Turkey; Vladimir Benes in the Czech Republic; Hans-Jurgen Reulen, Ulrich Sure, and Manfred Westphal in Germany; and H. Ian Sabin in the U.K. for their kind assistance and helpful correspondence.
For Further Information
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