Miguel A. Arraez, Malaga, Spain
Burkhardt and colleagues have made a comprehensive and very interesting comparative review of the different training system in USA and Europe. There are several issues of interest, as the curriculum, work load/work hours, how to control the learning process (examinations: how and when), length of the residence program, and finally the role of women in neurosurgery. Education of the future neurosurgeons is of crucial interest, and the ideal teaching should include the preparation for the work in the clinical grounds, but also teaching and research are very important. The residence program in USA has the advantage of including a research period (usually at least 1 year), making a total of 6 years. As it seems obvious, it is difficult to compare with the “average” of the training programs in Europe that varies from country to country in contents, duration, and control of the training process. Herefrom, the first consideration: The UEMS (with the proper advice of the EANS) should keep trying to establish uniform guidelines and curriculum for the residence program and criteria for accreditation of training centers. The European Union has dictated several regulations in medical matters (i.e., the EWTD to limit the work hours), but none has been done in the above mentioned aspects of the specialty fields. This is important taking into account that nowadays, there is a free circulation of neurosurgeons in Europe, with similar title of specialist but after following very different programs in content and length.
A second issue of interest is about how neurosurgery has been losing ground among the preferences of the young doctors to become specialists in favor of “more comfortable fields.” This phenomenon is evident in Western countries in which the health system does not make distinctions among different specialties irrespective of the difficulty or how distressing they are. This reality should be considered not only for neurosurgeons but also for medical care authorities in Europe.
Hildo Azevedo-Filho, Recife, Brazil
Neurosurgical education must be one of the most important issues of an academic neurosurgical department in the world; that is why I became extremely pleased to review this paper written Dr Burkhardt et al. from the University Hospital, Zurich.
The authors have produced an overview of the differences between neurosurgical education and training in Europe and USA. They emphasized the different ways of training in Europe, mainly due to the proper socio-cultural–economical aspects that exist amongst the more than 20 countries participating of the European Union. These differences represent an obstacle to establish and implement a standard training program in Europe. In general, the European programs vary between 4 and 6 years and they lack a basic uniformity.
Although agreeing that is rather difficult to focus on this issue in the whole Europe, I would like very much to have seen the authors elaborating a bit further on the programs adopted on their continent because certainly, it would provide great help to academic neurosurgeons working around the world, mainly in Latin America and Africa.
Regarding examination in Europe, Dr Burkhardt et al. pointed out, the EANS is making tremendous effort to have its diet accepted by all. However, in many countries, after taking the primary EANS examination, young neurosurgeons are allowed to sit for their national final exam and later on do not bother to take the EANS´ final one. On the other hand, they remarked, obtaining the European certificate in neurosurgery does not necessarily constitute a license to practice the specialty in every European country.
In Europe, because of the EWTD, where the weekly load should not exceed 48 h, theoretically there would be more available time for the trainee to be engaged on research projects and they recommended that this should be much stimulated by the academic leaders of the field. In USA, training is much standardized, varying from 6 to 7 years, with the resident exposed to a higher number of surgical cases because the weekly contractual working time is 80 hours. The authors commented on the examination run by the ABNS which is divided into two parts, the primary that is multiple choice questions and the final that is taken orally. After passing the final examination, the candidate is allowed to practice neurosurgery in the United States of America. The research activity is more contemplated in the USA’s program, and this engagement also would differentiate and prepare young neurosurgeons to embrace academic careers.
The role of women in neurosurgical residency and practice in the USA is analyzed, and representing half of the medical students presently, they only reach around 3% of the board-certified neurosurgeons.
In the end, Dr Burkhardt et al. proposed to create a multinational system of neurosurgical education worldwide, enabled to establish guidelines and to control the teaching of our trainees in the several and heterogeneous parts of the globe.
In Brazil, with more than 170 medical schools for a population of 192 million inhabitants, we have 55 neurosurgical residency programs approved by the Brazilian Society of Neurosurgery and the Minister of Education. After attending the medical school for 6 years, the young doctor embarks on a training program of 5 years. The first year is mostly spent on neurology, the second year is dedicated to activities on neurosurgical wards, and during the three last years the resident is gradually exposed to neurosurgical pathologies of crescent complexity.
Apart from continuously updating the log book, essential condition to take examinations every year, all residents in the country (first Friday of December) have to undertake a written examination, type multiple choice questions, and they have to reach at least 60% of correct responses. On average, 35% of them fail on the first attempt, but they are allowed to sit for a recovery test as many times as necessary. Once approved on the 5-year examinations and after finishing the residency, the candidate is entitled to sit for the final exam, which consists of analysis of the CV (20%), a multiple choice question test (40%), and an oral examination (40%), when they are examined by at least three examiners. Again, the approval average should be 60% or more, and the approved candidate is granted the Diploma of Specialist in Neurosurgery. This exam is held once a year and the candidate can sit as many times as necessary. Around 30–40% of them fail on each diet.
The Latin American Federation of Neurosurgical Societies (FLANC) is planning to adapt our protocol to the many countries in our continent where there is no organized training programs.
Together with the information added from Brazil, I do consider that this is an important paper which raises the discussion of how we are teaching neurosurgery around the world and how different each environment can be. Certainly, these differences reflect the quality and type of neurosurgeons that we are educating. Of course, I could not agree more with the authors when they state that a multinational body should be developed to care for the training of neurosurgeons in the world, and to my impression, the most appropriate entity to perform this task is the World Federation of Neurosurgical Societies (WFNS).
Alessandro Ducati, Torino, Italy
The analysis of Neurosurgical curricula in Europe and in the USA is very interesting to read, both for residents and for teachers. It gives the opportunity to choose the school fitting better to one’s needs, now that mobility is no longer a problem for students. On the other hand, it offers useful suggestions to improve teaching methods for professors.
If relevant, I would like to inform the authors that in Italy, research is mandatory, at least officially, in the residency program set up by the Ministry of Education. Every student must demonstrate that he took part, as a minimum, into two prospective randomized trials before the final exam.
Moreover, there is a different and further possibility to improve neurosurgical education, called the post-residency Master. It consists of a 2-year program treating in details a specific field of neurosurgery (i.e., microneurosurgery, skull base, spine), both theoretically and practically (namely, attending live surgery and hands-on cadaver dissection courses). This program, not a full-time one, is coordinated by one university (the title is an academic one) and may/must involve other universities and teaching hospitals.
Graham Fieggen, Cape Town, South Africa
This review succinctly analyzes a number of key differences between neurosurgical training in Europe and the USA. Whether it succeeds in its aim of “overcoming the lack of information about different training programs” is debatable as the focus is rather narrow, but it is a worthwhile contribution to the literature on neurosurgical education.
After noting the genesis of the residency concept in Baltimore a century ago, there is no comment as to the contemporary practice in Europe—surely somewhere on the continent, surgeons had been trained in the era before Halsted? Diversity presents the UEMS with a much greater challenge than the ACGME in striving for uniformity in training and outlining the relative roles of the EANS and the ABNS is examining candidates is perhaps the strength of this article.
A strong argument is made for a greater commitment to scientific training and research in the European context, and a timely opportunity to pursue this in the wake of the EWTD is identified. Surgical training requires many intensive hours “on the job” (Gladwell’s rather simple notion [
] of the “10,000-hours rule” does not seem too far off the mark here!), and it seems quite obvious that a training system that limits activity to 48 h a week is going to require a very different approach to one that allows up to 80 h. 1
The authors bravely tackle our collective failure to attract more women into a neurosurgical career, suggesting that time constraints are not the only disincentive; this imbalance is striking given the demographics of medical schools around the world.
Although the authors conclude with a plea that a greater degree of standardization in the neurosurgical curriculum (i.e., bringing European training closer to the US model) would enhance educational and scientific exchange, they do concede that “one does not necessarily need to go far to become a good surgeon.” A greater focus on the strengths within Europe, and there must be many given the diversity and rich educational traditions, may also point the way to improving practice.
1. Gladwell M (2009) Outliers: the story of success. Penguin, London, pp 35–68
Kazuhiro Hongo, Matsumoto, Japan
The authors nicely described the neurosurgical education system both in Europe and the United States of America. As the authors introduced, neurosurgical training system varies among countries. In Japan, we have also a different training system from that of either Europe or the United Stages of America. It is difficult to simply apply those systems to each country, also difficult to standardize the neurosurgical education system. However, knowing these differences, societies or directors of each training center can establish each training system more efficiently. Another important point is that this paper is playing the role to give information to those who wish to study neurosurgery in different countries. For the abovementioned reasons, this paper is worth reading for all the neurosurgeons including directors and young residents.
Hans Landolt, Aarau, Switzerland
This review of training modalities in Europe compared with those in the USA is a reminder of the lack of implementation of the European charter on neurosurgical training in Europe 2004.
Reasons are numerous as the differences between European nations compared with North American states. Mechanisms and motivation for implementation down to individual training programs are dependent on endless national and regional regulations, the EU being a new confederation statu nascendi compared with an operational union of states as the USA.
Clinical programs in Europe adapted to the UEMS charter are similar to the American ones, except that in the execution, the European working rules neutralize many of the aims, specially the ratio between the number of trainees and of teachers. Through the reduction of working hours, assistant positions have been created to fulfill them and “misused“ as training position. This is because of the lack of physicians interested in non-neurosurgical training in a neurosurgical unit. This problem may be partly solved by offering useful and competitive additional training for, e.g., generalists, neurologists, psychiatrists, ent-, maxillar-orthopedic surgeons, etc.
Quality of specific training by reduced case load and clinical exposition will also be lower, but less than the additional duration of training to accomplish program aims. More and more, the required 5 years of specific training are not sufficient for that.
Another solution is to differentiate between working hours, training hours, and compensation time, the latter being a new chance for trainees to progress competitively in theoretical, research-related, and even clinical training without patient-related responsibilities. A chance program directors should propose and allow.
In case of training or research abroad, the initial center should plan and offer a position when candidates return. Otherwise, they will contribute to the brain drain of theirs institutions
Examinations should rather be a proof of efficient selection, coaching and training of motivated, capacitated, and competent individuals for each training center, then a sanctioning procedure to exclude failed trainees on the end of such an important and for both sides costly period of life.
I suggest strongly all trainees to select centers according to a published program, to support director’s efforts for teaching by showing motivation and endurance, and to propose spontaneously individual aims. Responsibles are able to improve their programs much easier when supported and pushed by active young people with clear devotion to neurosurgery then by those waiting passively to be trained.
For program directors, I suggest to read and interpret once attentively the UEMS charter for neurosurgical training, to assess their own position, to check national charters, and to arrange what is good for their neurosurgical trainees. They will thank you.
Tiit Mathiesen, Stockholm, Sweden
Education is what forms the future neurosurgeons, and hence, training determines to a large extent the future of neurosurgery. We have a vision of neurosurgeons as master scientists, innovators, empathic physicians, and superb technical surgeons; we want to determine how to achieve this goal.
Training is determined among others by its formal structure, contents, methods of assessing quality, and by its controlling bodies, but also by informal structures, patients, colleagues, and national idiosyncrasies. It is necessary to compare different educational systems in order to find pros and cons and to discuss whether a unified training system for all residents or a smorgasbord of different systems best serves the future of our trade.
The first step in such an analysis is to describe existing systems, then to analyze and compare. This article has aimed for a description of training in Europe and the USA. Unfortunately, I cannot find a solid description of either system in the article. Value statements, superficial comparisons, and scattered facts fail to form a comprehensive totality or sets of comparable parameters. I would favor a comparison of a number of predetermined parameters that would lead to an analysis of pros and cons and finally lead to a logically argued conclusion. The authors unfortunately fail to recognize that different systems may exist because of their different pros and cons—but may still have more similarities than differences.
Michael W. McDermott, San Francisco, USA
The article by Burkhardt et al. compares and contrasts training in Europe with the USA. In the abstract for this review, the authors argue that a more standardized curriculum internationally would have a variety of educational and practical advantages and that an exchange of residents between centers would improve training by expanding both a knowledge base and technical skills. In the body of the article, there are no data provided or analysis of advantages and disadvantages to support their “arguments.”
Ideally, since we are human and have the same nervous system controlling us, the diagnosis and treatment of nervous system diseases should be the same no matter where we reside. However, we all know that different cultures place different values on physical and mental health and the cost of maintaining that health. Even within North America, there is a stark contrast in how two different countries, let alone the 47 in Europe, prioritize and pay for different areas of neurologic health. Standardizing training within a multitude of different health delivery systems seems impractical as the delivery of neurosurgical care may differ based on governmental and societal pressures. I agree that the exchange of residents is valuable, and at our institution, we encourage international visitors who, while not performing hands-on work, can observe every aspect of academic neurosurgical practice and take home valuable new knowledge and technical information, if not skills.
I agree that “cross talk” between neurosurgeons in different countries is a valuable thing, and many of our professional societies encourage this now. Given all the differences between states, provinces, and countries, I cannot imagine one single governing body for the world of neurosurgeons. For the time being, we should continue our frequent interactions and dialogue. Once most of us have our own national neurosurgical houses in order, it will be time to talk more globally about academic, training, and governance integration.
Laura Snyder, Robert F. Spetzler, Phoenix, Arizona, USA
This article compares and contrasts neurosurgical education in the USA and Europe. The article focuses on four elements of neurosurgical training: board certification, work hours, research, and female residents. The article suggests that both residents and patients may be better served if neurosurgical residency curricula were standardized. It is an interesting topic and one that is informative for both the neurosurgical community specifically and the public in general by explaining the wide range of techniques, practices, and levels of abilities among neurosurgeons across the world.
Standardization of neurosurgical training may be difficult because medical system differences across countries can be pronounced. For example, the article describes how radiosurgery and endovascular treatments are more often the realm of a department other than neurosurgery in Europe. Should European residents be tested in depth on these treatments on a standardized board examinations common to both Europe and America? Or is their time better spent studying in depth different knowledge that they will put to more use in their respective countries? On the other hand, should neurosurgical residents in both Europe and the USA have rotations in radiosurgery and endovascular so that the options for treating certain disorders are better understood—regardless of whether the information will be commonly used in their future career? As differences in medical systems across countries are unlikely to be changed soon, they must be considered in attempts to promote standardization in neurosurgery.
Work hour limitations vary widely across countries, and the issue is presented in this article as a major factor in how research is pursued. One can see both the benefits to a dedicated research year in programs with longer work hours and increasing the amount of research one produces in every residency year in programs with fewer hours. Thus, it is difficult to say which of these options would be better pursued in standardization. However, as work hours are often a cultural issue, they may be difficult to change one way or other in a given country regardless of the neurosurgical perspective.
Work hours are also presented in this article as a major impasse to recruiting more female neurosurgeons; however, female recruitment is also a cultural issue. Women working outside the home, especially when there are young children inside the home, are viewed more kindly in some countries than others. Moreover, the lack of female neurosurgical residents may reflect the culture of neurosurgery itself because the percentage of female residents in other surgical disciplines remains significantly higher, even in those with extensive work hours. Decreasing work hours alone will not develop female neurosurgeons regardless of whether it helps “family life.” Developing female neurosurgeons requires a culture of both male and female mentorship from inside the specialty itself.
To produce more capable attending neurosurgeons, United States residency programs could learn from European programs and vice versa. It is important to continue dialogue, as this article does, on programmatic format and changes to curricula as neurosurgery grows. However, true standardization of neurosurgical residency may be impossible due to cultural and medical system differences between the USA and the many diverse European countries.