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Surg Clin N Am 84 (2004) 1471­1491

Surgical education in the new millennium: the European perspective

Kristoffel R. Dumon, MDa, Oscar Traynor, MD, FRCSIb, Paul Broos, MDc, Jacques A. Gruwez, MDc, Ara W. Darzi, MD, FRCS, FRCSI, FACSd, Noel N. Williams, MD, FRCSI, FRCSa,*

Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA b Postgraduate Surgical Education, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland c Department of Surgery, Katholieke Universiteit Leuven, UZ Gasthuisberg (KUL), Herestraat 49, B-3000, Leuven, Belgium d Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, 10th Floor QEQM Wing, St. Marys Hospital, W2 1NY, London, England

a

In parallel to recent developments in the United States, surgical training in Europe is in a state of transition. In Europe, the changes in surgical education are driven both by changes in the educational and health care system of the individual countries and through the policies and guidelines of the European Union. Surgical training in Europe is not uniform among the member countries, but the expansion of the European Union has been a driving force in the harmonization of surgical education. On May 1, 2004, the European Union enlarged to 25 member countries with a population of 450 million. The European Work Time Directive for doctors in training has forced the member nations to redefine the framework of surgical education. The opening of borders and the mutual recognition of professional surgical degrees has led to a drive toward harmonization of surgical education among member states. Also, the public demand for accountability and the realization that proficiency in surgical management can have a positive impact on survival have been major forces for the renewed focus on objective assessment of surgical skills and formal training goals. At

* Corresponding author. E-mail address: [email protected] (N.N. Williams). 0039-6109/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.suc.2004.06.005 surgical.theclinics.com

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a national level, these developments have translated into major changes in the duration and content of surgical education in individual member states (England, Ireland, Germany, France, and Italy). Also, European organizations such as the European Union of Medical Specialists (UEMS) and the European Board of Thoracic and Cardiovascular Surgeons (EBTCS) are taking a leading role in formal training and assessment of standards, and are becoming normative benchmarks for surgical education. In addition, the challenge of educational reform has been met by an unprecedented research initiative in the field of objective quality measurement and performance benchmarks of surgical skills training. Redefinition of surgical education in the European marketplace The European Union (EU), previously known as the European Community (EC), is an institutional framework for the construction of a united Europe. The European region of the 15 member states (Europ15) is a compact region with a population close to 385 million, 1.5 times as big as the United States and three times as densely populated [1]. On May 1, 2004, the European Union enlarged to twenty-five member countries and currently has a population of 450 million (Fig. 1). The unification of Europe has created a new political order based on common values and a shared desire to construct a space of security and peace. Indeed, this process has led to a profound transformation in the political, economic, and judicial systems of these nations, and will have farreaching consequences for medical and surgical education [2]. Although still at their inception, clear changes that significantly impact surgical education can be discerned. Despite many differences, it is clear that the content and scope of surgical residency training in the United States and Europe are interlinked. Historically, Halstead's introduction of a structured and formal residency training program in the United States was strongly influenced by the surgical training program he observed in Germany, and the international exchange of residents was an integral part of his educational reform [3,4]. From a socioeconomic standpoint, surgical training in the United States and Europe is faced with the same challenges of public accountability, work hour reduction, and cost containment in an environment of health care expenditure that outpaces economic growth. The surgical resident in training is an integral part of the hospital work force, and hospitals throughout Europe are increasingly emphasizing efficiency. Recent changes such as a greater recourse to ambulatory or same-day surgical procedures, a sharp reduction in the average length of stays (ALOS) in hospitals, and a decline in the number of hospital beds in nearly all European countries are having a significant impact on surgical education [5]. In Europe, in contrast to the Unites States, there is an intricate financial involvement of the governments of the individual member states in medical

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EU-15 member states

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Population EU 15

EL NL E 11% I 15% P B S A

New member states Candidate countries

DK FIN 1% IRL L 0%

UK 16% F 16%

D 22%

2004

Symbol

D F UK I E NL EL P B S A DK FIN IRL L

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Germany France United Kingdom Italy Spain Netherlands Greece Portugal Belgium Sweden Austria Denmark Finland Ireland Luxembourg

EU 15

Country

Cyprus Czech Rep Estonia Hungary Latvia Lithuania Malta Poland Slovakia Slovenia

Symbol

CY CZ EE HU LU LT M PL SK SL

Population

82,545 59,896 59,518 57,482 40,978 16,258 11,047 10,480 10,397 8,975 8,092 5,398 5,220 4,025 451

380,762

728 10,211 1,351 10,115 2,319 3,447 400 38,194 5,318 1,997

10 New Members

74,080

EU 25: 450 Million

Fig. 1. Population figures for the European Union.

student education, compensation for residency training, and health care. Therefore quality assurance of surgical training, unlike in the Unites States, is not uniform, and is not the responsibility of a centralized European authority, but is a matter in which the different countries have autonomous regulations. Consequently, different targets for duration, content, and general principles for training in surgery have been set. Also, given the cultural and political differences among the member states, it is understandable that there are huge differences among the content and duration of surgical training in the individual member states (Table 1, Table 2).

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Table 1 Comprehensive characterization of the European health market compared with the US and Japan EU 15 Population (millions) GDP Hlth Exp (%) Hlth Exp (USD) Pub Exp (%) 380 25,500 8.9% 2269.5 73% US 279 35,200 13% 4576 44% Japan 127 26,400 7.8% 2059.2 78%

Abbreviations: EU15, European Union member nations; GDP, per capita gross domestic product as of 2001; Hlth Exp (%), health expenditure percentage of GDP; Hlth Exp (USD), health expenditure per capita in US dollars; Pub Exp (%), public expenditure percentage of per capita health expenditure.

Current reality of surgical training in Europe A recent report of the Permanent Working Group of European Junior Hospital Doctors (PWG) showed that conditions of postgraduate training in surgery vary greatly among the European countries in relation to duration, working hours, tasks undertaken, and resources used. In this survey of trainees in 12 countries of the European member states, a trainee had to care for an average patient load varying from 30 to 80 patients at any one time. The average number of working hours ranged from 52 to 88 hours per week, including up to 18 hours of unpaid work. The different tasks performed within these working hours varied considerably, as did the proportion of tasks with educational value. Trainees participated in 4 to 11 major operations each week, but the number of operations a week did not

Table 2 Comparison of surgical training in different member countries Formal competency testing Fachartzpruefung (end of 6 years) NA State examination MRCS/FRCS/ CCST Swedish Surgical Society examination, not mandatory Common trunk Yes (2­3 years) No Yes Yes Entry requirements Individual appointment by hospital State limits training number Score on national exam NHS determines number of training positions NA

Country Germany

Duration 6 years

Italy France UK/Ireland

6 years 5 years þ 5 years 2 years (BST) 6 years (HST) 5­6 years

Sweden

Yes

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reflect the number of operations conducted under supervision. In some countries, the majority of the trainees stated that they received their training mainly through unsupervised experience. The average number of days spent on courses and congresses varied from 4 to 15 days per year, with great variation in the percentage of expenses paid. Countries with favorable working conditions (such as fewer working hours, shorter shifts, and a day off after being on duty), seemed to have gained these advantages by a reduction in working hours with educational value, rather than by a reduction in routine work [6]. Also, a German survey of surgical residents showed that 23.3% of the residents did not anticipate finishing their resident training within the allocated time period [7].

Recent changes in surgical residency training in the largest European communities: United Kingdom and Ireland, Germany, France, Italy, Sweden The four largest communities in Europe--Germany, France, the United Kingdom, Ireland, and Italy, with a combined population of 260 million--have experienced a significant change in the structure of postgraduate surgical training [8]. A brief review of the content and structure of the training for these individual states allows an insight into the significant differences in surgical training and current changes that have reshaped surgical training in these states. The way surgical education is structured in Sweden allows us to look at the current developments in the Scandinavian countries (Table 1). Surgical education and training in the United Kingdom and Ireland There has been a considerable effort toward harmonization of surgical education in England and Ireland. Entry into the European Economic Community resulted in the United Kingdom adopting the definition of a specialist as defined in Europe. The surgical royal colleges of Great Britain and Ireland set standards for training and examinations, and ensure that new surgeons are equipped for independent practice as consultants. To enter a basic surgical training (BST) program, the trainee surgeon must first complete an intern year. Training then comprises 2 years of basic surgical training, followed by 6 years of higher surgical training (HST) in a surgical specialty; however, some surgeons spend 4 to 5 years at the basic level, due to competition for places in HST. Basic surgical training has a core curriculum that is undertaken by all surgical trainees, irrespective of their future specialty aspirations. BST is intended to introduce surgeons to the principles of surgery in general, and the trainees do four 6-month rotations through different specialties. At the end of BST, trainees take the MRCS examination (Membership of the Royal College of Surgeons). They may then apply on a competitive basis for

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higher surgical training. Surgical specialties after the period of basic training are: cardiothoracic surgery, general surgery, neurosurgery, ophthalmology, oral and maxillofacial surgery, otolaryngology, pediatric surgery, plastic and reconstructive surgery, trauma and orthopedic surgery, and urology. Trainees may opt to spend 1 of their HST years abroad, and they are strongly encouraged to undertake a period of research during HST. Toward the end of HST, trainees take the Intercollegiate Specialty Fellowship Examination (FRCS). A certificate of completion of specialist training (CCST) is awarded at the end of higher surgical training. The average age of completion of training is 34 to 38 years. This 8-year training period is considerably shorter than in the past, when training relied on an apprenticeship system of 12 to 14 years [9,10]. A recommended format for a future cycle of training and assessment is presented in Fig. 2. There are new proposals being discussed to change the format of surgical training further. These are in response to political pressure to reduce the time taken to train a surgeon, and to bring the training times into line with

Fig. 2. Recommended format for a cycle of surgical training and assessment. (From Moorthy K, Munz Y, Sarker SK, Darzi A. Objective assessment of technical skills in surgery. BMJ 2003;327(7422):1032­7; p. 1037; with permission.)

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the rest of Europe. Under the new proposals, all medical graduates will undertake 2 generic ``foundation years'' that will expose them to a broad range of clinical skills, and will focus heavily on interpersonal and management skills. Surgical trainees will then undertake 2 years of basic training, followed by 4 years of advanced training, for a total of 6 years surgical training. A small proportion of trainees may then opt to undertake subspecialization training for a further 2 years. Surgical education and training in France To enter any residency training, medical school graduates in France have to pass the competitive entrance examination, the Internat, in their sixth year of medical school. After passing the examination, the medical student has the title of Interne des Hopitaux, the equivalent of resident in the United States. Of 5000 ^ students who take this examination each year, about 2000 become residents. According to the rank in the entrance examination, the residents can choose among six disciplines of specialization: medical specialties, surgical specialties, biology, psychiatry, public health, and occupational medicine. Formerly, about 8.6% (430 students) would choose a surgical specialty per year, but the number of applicants has suffered a significant decline to 286 residents per year over recent years. Once again, according to rank in the entrance examination and specialty, the resident chooses the city in which he or she wants to train. ´ ´ The first part of surgical training, the Diplome d'Etudes Specialisees (also ^ called the common trunk), consists of 3 years in surgical residency training. The hospital units in which trainees work are again chosen according to ´ ´ ´ rank. Next comes the Diplome d'Etudes Specialisees Complementaire, ^ another 3 years (2 as an interne and 1 as a chef-de-clinique), when the apprentice surgeon is in his or her area of specialization, such as digestive or gastrointestinal tract, orthopedic, vascular surgery, and so on. At the end of the first 3-year period, the resident obtains a diploma in general surgery. After the initial 5 years of training, the resident becomes a chief resident (chef-de-clinique) for a minimum of 2 years. Once the resident has fulfilled his 2-year term, he or she obtains the title Ancien Chef de Clinique Assistant des Hopitaux. At that time, the chief resident can decide to either go into ^ private practice or continue with a hospital (eventually academic) career. If so, he or she can either continue as a chief resident in a university unit or apply for a full-time job as Praticien Hospitalier, a staff physician appointed to a specific clinical job in a specific hospital. This is determined through another competitive examination. If the resident wishes to continue in the hospital system or pursue an academic career, he or she has to obtain a Diploma of Advanced Studies (Diplome d'Etudes Approfondies). All ^ hospital staff members are appointed to a specific position in a specific hospital. When positions become vacant, they are usually filled by younger

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surgeons. Once appointed to a specific position, there is very little mobility between positions of the same rank: the surgeon usually stays in the same hospital for his or her entire career [11]. Surgical education and training in Germany and Austria Over the last few years, significant efforts have been made to restructure surgical residency training in Germany. In 2003, this new structure was ¨ approved by the German medical association (Deutsche Arztetag) and is currently in effect. The new residency training structure, Muster-Weiterbildungsordnung (MWBO), has tried to incorporate some of the recent developments in medicine, such as technological expansion and an increased demand for proficiency in a specific surgical field. One of the main elements of the new structure is the differentiation between field of specialty and the specific competencies the surgeon in training has acquired in that field [12]. Because it is felt that a 5- to 6-year training period no longer allows the resident to acquire sufficient knowledge of the entire field, the training will focus on the specific and essential core elements in that field. In collaboration with the main German surgical societies (Deutsche Gesellschaft fur Chirurgie and Berufsverband der Deutschen Chirurgen--BDC), the ¨ German medical association has introduced a new structure of surgical residency training. The late Professor Dr. J. Witte, former president of the BDC, was instrumental in these reforms. Residency training now consists of a 6-year program, with 2 years of common trunk and 4 years of specialty training in the following subspecialties: general surgery, trauma and orthopedic surgery, vascular surgery, thoracic surgery, gastrointestinal surgery, plastic surgery, pediatric surgery, or cardiac surgery. After the first 2 years, there is an optional examination, and at the completion of training there is a legally bound specialist examination [13]. Also, continuing medical education (CME) is currently being implemented (Fig. 3). In Austria, the postgraduate specialty training is regulated by Austrian medical law and postgraduate medical education rules. It lasts at least 6 years. The 6 years of postgraduate education consist of 4 years of training in the main subject (surgery), 21 months of compulsory training in a different medical field (6 months of traumatology; 6 months of internal medicine; 6 months of anatomy, pathology, and forensic medicine; and 3 months of anesthesia and intensive care medicine), and 3 months of electives. The resident in training has to maintain a logbook, and must document 400 supervised operations. Training is completed by a legally bound specialist examination. Of 138 surgical departments and clinics in 105 hospitals, 109 are authorized to provide postgraduate education in surgery. Of the 390 jobs for postgraduate education in general surgery, pediatric surgery, plastic surgery, and traumatology, there are 130 in three university hospitals and 260 in other general hospitals. A course in visceral surgery is currently under consideration is. A fusion of traumatology and orthopedics is also under discussion [14].

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nd ya y er ger ry ry y y rg r i ge e er er ry ec Su c Su urg ur rg rg p ge S a i u Su ur lS m ed al rS lS S a in ca la au op cic ic gi er cu Tr rth om ra st ur en as la ho bd O S G V P T A

cS ur g

at ri

Pe

Ca rd ia

di

4 Years Subspecialty Specific Training

One complemetary Year 2 Years Common Trunk

6 Months: ER, ICU, Ward Service, Variable

Fig. 3. Reform of surgical training in Germany. (Courtesy of the late Prof. Dr. J. Witte, former president, Berufverbandes der Deutschen Chirugen, Vorsitzender der Gemeinsamen Weiterbildungskommission von DGC und BDS.)

Surgical education and training in Italy In Italy, unlike in other countries, professional degrees, including postgraduate medical training degrees, are issued exclusively by the government. Before 1990, postgraduate schools maintained a constant number of postgraduate training positions available by law, and if the number of candidates was higher than the number of training positions, a competitive examination was implemented. Before 1990, attendance was not compulsory, the residents were not paid, and the clinical training as well as formal testing of the acquired professional skills were insufficient. A common guideline throughout the European community has led to a significant overhaul of the system, with the introduction of real residency training programs. This has been in place for over a decade now. Since 1990, postgraduate training in surgery is divided into general and emergency surgery. A common trunk for surgical specialties does not exist, and every school has its own training program. As an example, the resident can directly embark on cardiovascular surgery or thoracic surgery training. The number of training positions, available through passing a competitive examination, is reestablished every 3 years on a national scale. The resident in training is assigned the role of training assistant and is paid, but he is not allowed to have his own private practice. General surgery training lasts 6 years and the resident must prove performance of a set minimum of surgical procedures and clinical activities and pass a professional examination [15].

cS ur g

Board Certification Exam by State Medical Association LandesaerzteKammer

er y

er

ty al

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...

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Voluntary Exam by Scientific Organization

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Surgical education and training in Sweden By tradition, training to become a surgical specialist in Sweden takes place in all hospitals, from small county hospitals to the major university hospitals. When training occurs in a small hospital, it is requested that part of the training take place in a large hospital. A major problem in surgical education is the Swedish law for working hours. People are not allowed to work more than 40 hours per week, including work in the emergency room. With such a large emergency workload for residents in training in Sweden, exposure to surgical procedures is not satisfactory. This problem is currently being discussed in Sweden. In recent years, graduate education for general surgery and other specialties in Sweden has been changed from a time-based to a goal-oriented system. Specialty training in general surgery lasts 5 to 6 years. After certification by the main supervisors, the Swedish National Board of Health and Welfare, licenses the resident physician as a specialist in general surgery. The Swedish Surgical Society provides a written examination, but it is not yet mandatory for receiving specialist certification [16]. Opening of borders Although the implementation of residency training is determined at the national level and there are substantial differences among the member states, European directives such as the time directive and harmonization of degrees have had a significant impact. The unification of countries in the EU has changed the perspective on surgical education, because there is increasing impetus toward a mutual recognition of trade and education between member states. In 1975, EC directive 75/362 was adopted, which insured ``freedom of migration'' for medical doctors and other professions [17]. This directive implied that certificates, diplomas, and other documents issued by the national competent authorities proving medical qualification allowed physicians to practice in any EU country. To make this law practical, it seems essential that specialist training programs throughout the EU conform to certain agreed basic standards. Migration and exchange of physicians as residents in training as well as specialist surgeons has become a reality in many European nations. There is active exchange of specialist surgeons between the Netherlands and Belgium, and Germany and Switzerland. Some nations, such as France and the United Kingdom, rely heavily on foreign trained physicians to provide sufficient house staff, though only a small portion come from EU member states. The British government launched a £3 million initiative in February 2002 that aims to recruit 450 hospital doctors in key specialties within 3 years. The aim of the government's drive is to boost the overall number of doctors working in the National Health System (NHS). Some sources state that the British government is considering recruiting an extra 15,000 doctors by 2008 [18­20].

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European directive on reduction of work hours Study results suggest that among the 15 European member states, the average number of working hours for a surgeon in training currently ranges from 52 to 88 hours per week [6]. This is in line with a recent survey among surgical residents conducted by the Bond of German Surgeons (BDC), the largest surgical society in Europe. This study showed that the workload of 68% of residents in training currently exceeds 65 hours per week. Thirtythree percent of surgeons work even more than 75 hours per week, and only 1% work fewer than 45 hours per week [21]. But some countries already have state regulations in place that restrict work hours. In the United Kingdom, the current maximum time spent on duty is limited to 72 hours, and to 56 hours actual work. Actual work is defined as time spent performing the duties of the service, such as admitting patients, carrying out investigations, and giving treatment, but it excludes time spent resting in the hospital or elsewhere. In Sweden, a 40-hour work week, which also applies to medical staff, was made statutory more than 30 years ago. Initially, practicing doctors and faculty were allowed up to 10 or more additional work hours on an individual basis, and only a few physicians complied fully with the regulation. It is estimated that a Swedish surgeon is occupied in full clinical work for an average of only 40 weeks a year. Thus, surgeons in Sweden have a constrained work week as well as a constrained work year. Starting this year, residents in training in Europe will spend a maximum average time in hospital of 58 hours per week, a steep reduction from the current average 65 to 75 hours. On August 1, 2004, junior physicians in training throughout Europe will no longer be excluded from the provisions of the European Working Time Directive (EWTD) [22­23]. Their working hours will then be limited by law, first to 58 hours a week and then, by 2009, to 48 hours. This will demand even more profound changes for surgical residency training programs throughout Europe. The original directive on working time became law in 1993, but doctors in training were excluded, along with workers in the road, air, rail, sea, and inland waterway industries. The British government challenged the validity of the directive as health and safety law, but it was confirmed as such by the European Court of Justice in 1996 [24]. Evidence indicates that sleep deprivation, sleep restriction, and enforced unnatural circadian cycles contribute to cognitive and motor impairments, injuries, and error [25­27]. Doctors are not immune from these effects [28,29]. The European Commission and Parliament had always intended that the excluded workers should be brought within the provisions of the directive, and in August 2000, the original directive was revised with a timetable for including the exempt workers [30]. For doctors in training, an interim limit of an average 58 hour working week started on August 1, 2004. This will reduce to 56 hours beginning in August 2007, and to 48 hours in 2009.

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Under certain undefined circumstances, national governments may apply for a further extension of a maximum of 3 years to delay the final reduction to 48 hours. Several other rules in the directive are also very stringent. They include a requirement for 11 hours of continuous rest in each 24 hour period, and a maximum of 8 hours of work in 24 hours for night workers. The European Working Time Directive as it applies to doctors in training is summarized in Box 1. It was initially assumed that the definition of work would be similar to that which applies to the 1991 ``new deal'' on junior doctors' hours in the United Kingdom [31]. This agreement limited junior doctors' hours of work in the United Kingdom to 72 hours on duty and 56 hours of actual work. A recent European Court of Justice ruling (SiMAP) has, however, redefined work as all time spent on duty in the workplace [32]. Thus, for residents in training in Europe, the maximum average time spent on call when resident in hospital will be 58 hours per week. Many health care systems in Europe will need to undergo dramatic changes to comply with these rules. Residents in training, attending surgeons, and hospital managers all have worries about the effects of the changes. Residents worry that they cannot be satisfactorily trained, because the reduction in hours does not satisfy the residents' need for operative experience. Hospital managers worry about how to deliver a service that remains largely provided by resident physicians. Furthermore, time restriction abolishes the concept of continuity of care. Surgeons (residents and attending surgeons) are adamant that the concept of continuing care by the same team for the duration of a patient's admission is essential.

Box 1. The key aspects of the European Working Time Directive as it applies to doctors in training Working hours per week In August 2004, a decrease in overall average weekly work hours to 58 An interim 56-hour workweek by August 2007 A further decrease to a 48-hour workweek by August 2009 (could be extended to 2012) Rest provisions from August 2004 11 hours continuous rest in every 24-hour period Minimum 20-minute break when shift exceeds 6 hours Minimum 24 hours rest in every 7 days, or Minimum 48 hours rest in every 14 days Minimum 4 weeks annual leave Maximum 8 hours work in 24 hours for night workers

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The outcome of working hour legislation on the quality of patient care after implementation of the EU directives has not yet been systematically studied. Indeed, no study in the international surgical literature addresses this question thoroughly. The effect of work time reduction on quality of life and lifestyle of medical personnel also has not been investigated. Even if one expects that reduced work should lead to improved quality of life, the contrary could occur for certain professional collectives. Reduction of working hours and strict regulation of work shifts may, for example, increase residency training time, and thereby adversely affect long-term lifestyle issues, as recently indicated by an interview of surgical residents at the University of Hanover [33]. Also, the 30-year experience in Sweden suggests dissatisfaction among surgeons with far-reaching subspecialization among surgeons and too many surgeons in relation to the procedure volume [16]. Increased demand for surgeons in training A result of the EWTD will be the need for a higher number of physicians in training to comply with the law [22]. This will further accentuate the current need for surgical manpower in member states such as the United Kingdom, Ireland, France, and Germany. In German hospitals, vacant residency positions in surgery are attributable to new labor legislation, and surgical departments are currently experiencing difficulty filling vacant posts for surgical personnel, particularly resident spots. Even academic centers with long-standing reputations have been significantly affected by this problem [21]. In France, at virtually every surgical meeting or social gathering during the last 2 years, surgeons discuss the catastrophic situations of the surgical specialty. The number of residents who choose digestive surgery as a profession has decreased dramatically during the last 4 years. The number of residents registered in the digestive surgery program, Diplome d'Etudes ^ ´ ´ Specialisees en Chirurgie Digestive, in France is nil in many large cities (Lyon, Marseille, Toulouse), and fewer than 10 residents are registered for the Paris region. This drastic decrease in the number of residents has resulted in many surgical departments having major difficulties in normal daily function of the service. In the United Kingdom, there are fewer surgeons per head of population than in most European countries, and a 2001 report from the Royal College of Surgeons of England (RCS) concludes that demand for services has steadily outstripped capacity for over 20 years. In Ireland, a recent study conducted by the Royal College of Surgeons in Ireland (RCSI) suggests that the number of existing surgeon posts (378) needs to be increased to 890 to respond to the growing demand for surgical services [19,20]. European recognition on training level The European Union entitles all surgeons licensed in their own countries to practice in all other countries. Due to European law, all examinations

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taken by officially recognized national boards have to be accepted in every member state. In 1958 the UEMS was founded on behalf of the European Union. Each specialty has its own section that meets regularly and reports upwards in the EU structure. Each member state has two delegates to a section. Surgeons are represented through their professional organizations (eg, surgical societies or equivalent groups of all EU member countries, plus Iceland, Norway, and Switzerland) [34]. Recently, the specialist sections have received a boost to their influence. Several divisions in the Section of Surgery and the European Board of Surgery (EBS) were given the task of establishing a European Board that is responsible for defining and achieving agreement on minimum standards for training, and for the implementation of these standards. One of the current discussions in the EBS is the concept of a common trunk in surgical training. At present, there is a wide variation between the member states. This can be exemplified by the training in vascular surgery. In some countries--such as Spain, Italy, Portugal, Greece, and Denmark-- vascular surgery is an independent specialty with little to no requirement for general surgery training (Italy and Spain), whereas in other nations--such as the United Kingdom, Ireland, the Netherlands, and Belgium--the completion of a general surgery residency is required. Also, the concept of examination at the European level was recently introduced. Since 1996, the EBS (European Board of Surgery) and the EBS-Vasc (European Board of Vascular Surgery) are offering an examination at the European level with certification by the EBS-Q (European Board of Surgery Qualification). The EBS-Col Proct (Division of colorectal surgery) started to offer an examination in 1998, and since 1999 the division of trauma (EBS-Traum) offers a European examination. The aim is to offer all recently trained surgeons in the EU an examination that incorporates agreed standards among the member states. The examinations are taken annually in different European locations. Prerequisites to taking the examination are the completion of surgical training at the national level in one of the EU member states and the documentation of a certified surgical logbook in accordance with EBS-Q standards. For cardiothoracic surgery, the European Board of Thoracic and Cardiovascular Surgeons (EBTCS) was created in 1996, with the primary goal of creating a common high standard for the quality of thoracic and cardiovascular surgery in all European countries. The European Board was set up to establish a standard for thoracic and cardiovascular surgery that can be recognized across Europe, and that should allow mutual recognition between European countries. Again, although the European Board examination (EBTCS certification) is an important vehicle to establish a standard in European thoracic and cardiovascular surgery, the intention is not to set a level of excellence so high that it is only attainable by a minority. Rather, the purpose is to recognize and award the certificate of the Board to trainees and recently appointed surgeons who attain a level of knowledge

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and competence that can be recognized as appropriate for independent practice throughout Europe. In addition, continuing medical education is not yet organized officially in all member states. New member states are starting to harmonize their structures, due to the demands of the UEMS. The charter on Continuing Medical Education was established by the UEMS in 1998. This concept was also accepted by the national authorities in the different member states, and will be officially structured in the member states very soon [34]. These developments indicate a significant interest among EU member countries in harmonizing medical specialist training, but there is as yet no formal legislative basis to impose these agreed standards. Therefore, any mechanism for auditing training programs and trainees, such as site visits or end-point assessments, is voluntary. It has to be emphasized that for the first 3 years in which the vascular surgical assessments have been held, they have enjoyed considerable levels of interest and enthusiasm. Many candidates seem to find it attractive to take a strictly impartial assessment, and to obtain a European Board Quality Certificate [35]. European initiatives to improve training Surgical training experts are initiating change, and are giving an enthusiastic lead in improving training, which has long been unstructured, repetitive, and at times irrelevant to the specialty ambitions of trainees. The direction toward modernization of surgical training in Europe, with a more structured and focused approach, is in line with efforts to harmonize surgical training, to respond to the public demand for quality, and to ensure better surgical training in shorter hours [8,22,36]. One aspect is an increased effort to monitor and enforce the standards for surgical practice through frequent formal independent assessment, such as a record of in-training assessments (RITA) and assessment by specialist advisory committees. It is essential that both the attending trainer and the resident in training be assessed. In England and Ireland, the Royal Colleges are involved in providing guidance to both residents in training and attending consultants in order to improve their training abilities. An additional aspect is the development of the separation of service provision from training [37]. The Royal College of Surgeons of Ireland has introduced a theoretical and practical training program with coordinated lectures or courses, when attending surgeons are free from clinical commitments. This has led to the development of distance learning programs. The RCSI is delivering a structured surgical training program for postgraduate surgical trainees over the Internet [38]. In this Basic electronic Surgical Training program (BeST online), educational principles are applied to the structure of the program to focus on learning objectives and learning outcomes, and to provide for different learning styles. The RCSI has an associated program called SCHOOL for Surgeons (surgical

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conferencing with enhanced opportunities for online learning), in which an online tutor works with surgical trainees to discuss real case presentations and take them through investigations, differential diagnosis, and management. SCHOOL for Surgeons also incorporates an online journal club, and trainees are given regular assignments that are monitored and graded. A detailed record of each trainee's performance is kept, and this is fed back to the regional vice deans. The Royal College of Surgeons of England launched the first distance learning course for the Surgeons in Training Education Program (STEP), the electronic STEP (e-STEP). The e-STEP course increases flexibility, includes interactive exercises, and stresses the importance of basic scientific knowledge [39]. A second development is the introduction of hands-on surgical skills courses. The organization of didactic skills courses allows the trainee to gain hands-on experience during practical training in surgical techniques with proper supervision, instruction, and practice. Consequently, an increased effort is made to provide training in surgical skills with simulators (eg, latex models of organs, laparoscopic boxes), anaesthetized animals (for laparoscopic and endovascular procedures), or computer-generated virtual reality (eg, laparoscopy, endoscopy) [40]. In Ireland, an active effort has been made to make such facilities widely available to all trainees. Also, a significant research interest has developed in this challenging area of objective assessment of operative skills [41­47]. Some of these projects are well established, whereas others are research tools in the process of evaluation. In general, these methods involve a standardized set of tasks. Most assessment is performed in the laboratory setting, although there are some techniques that are amenable for use in the operating room. These methods hold the promise of helping to detect underperformance early, which would allow further training and guidance. Objective structured assessment of technical skill (OSATS) The objective structured assessment of technical skill (OSATS) was first used by Reznick in Canada [48]. The basic principle is to use carefully designed and administered checklists to reduce the subjectivity of the observer's experience. There is now a significant body of work that demonstrates the reliability and effectiveness of the OSATS in assessing surgical performance. Studies at the Imperial College of Science and Technology in London demonstrate that it is more useful for simpler tasks, and hence for more junior trainees. The use of OSATS in the setting of error detection is a challenging concept that could conceivably extend the utility of this assessment modality. Imperial College Surgical Assessment Device The Imperial College Surgical Assessment Device (ICSAD) uses commercially available electromagnetic tracking equipment (Isotrak II,

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Polhemus, Colchester, Vermont) and custom-made software to track a surgeon's hands as he or she performs a standardized surgical task. The system generates simple Cartesian coordinates for each tracker at 20 Hz, and the software then generates data for total path length through the air, total number of movements, and the time taken. This device has proved useful in assessing surgeons and trainees as they perform both laparoscopic [49] and open surgical tasks [50]. Objective structured clinical examination This concept is essentially that of an objective structured clinical examination (OSCE) in technical skills. By reference to a simple model of competence, the chosen tasks are designed to complement each other, and hence assess all aspects of technical ability. At the Imperial College, an OSCE type examination, Multiple Objective Measures of Skill (MOMS), for basic surgical trainees (equivalent to postgraduate year 1 to 2 residents) has been developed [42,43,48]. The examination consists of six tasks: (1) knowledge of instruments, sutures, and surgical equipment (a simple answer sheet); (2) knot tying (ICSAD); (3) skin-pad suturing (ICSAD); (4) closure of an enterotomy in synthetic small bowel (video-based OSATS); (5) excision of a skin lesion (video-based OSATS); and (6) laparoscopic skills on the Minimally Invasive Surgical Trainer (MIST, Virtual Presence, Mentice, Sweden). Competence assessment It is becoming increasingly recognized that surgeons who run into problems in their professional lives rarely do so because of lack of surgical knowledge or lack of surgical skills. In most cases, surgeons who run into professional problems do so because of a breakdown in personal skills. This is an issue which training bodies must address as a matter of some urgency. The Royal College of Surgeons in Ireland has developed a modular training program in personal skills called Human Factors in the Surgical Arena. This program incorporates a practical module called ICEMAN (intraoperative critical event management) that uses an animal model to simulate critical surgical events and includes the entire surgical team (ie, surgeons, anesthesiologists, and nurses). This practical module is underpinned by theoretical modules that address issues such as teamwork and leadership, communications skills, strategies for error avoidance and error management, critical decision making, aspects of human performance, and fundamental aspects of human behavior and personality. Difficult issues arise in competence assessment, chiefly because such assessment would effectively be an examination, and issues of fairness, reproducibility, and defensibility must all be addressed. Tasks must be welldesigned to allow standardization, objectivity, and reproducibility. It is clear that a consensus of the relevant surgical colleges and of acknowledged

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experts in the relevant areas would be the most important step in ensuring acceptance by the profession generally, the public, and the courts. In the United Kingdom, the four colleges of surgeons have homogenized the FRCS examination and are in the process of merging the MRCS examination [51]. Once this is achieved, the process of incorporating a standardized technical assessment component will become more achievable. Although the development of adequate objective measures was initially seen as the most difficult aspect of assessing surgical competence, there are now several useful techniques available, with a better insight into how and where future efforts to develop further assessments should be concentrated. With the idea of implementing these measures, it becomes clear that the major challenges will be philosophical, and will relate to the proper and effective use of the tools we have at hand [51]. A conceptual framework on how technical skills as well as personal skills such as decision making and team work could be integrated into training solutions is represented in Fig. 4.

Summary Excellence in surgical care throughout Europe can be achieved through consistency in quality of training beyond language and cultural borders. This poses high demands on communication skills, and asks for innovative

Fig. 4. Conceptual framework of formal surgical training needs. (From Sarker S. Courses, cadavers, and counselors: reducing errors in the operation theatre. BMJ 2003;327:S109; with permission.)

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methods to elevate current standards of surgical education [52­54]. The recent changes show that there is the will and the investment among the member states to improve training. This implies surgeons in training, a continuing effort on better organization of surgical education, and improved training opportunities to enhance the quality of surgeons in training. In Europe, the paradigm shift from apprentice model to a structured training model in the setting of a reduction in work hours will lead to an increased level of expectation for the resident in training in surgical performance and cognitive knowledge. This can be achieved through the integration of information technology and surgical simulation in surgical training, and implementation of standards for lifelong learning and a commitment to collaboration between the surgical communities of the member states.

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