It is my pleasure to contribute to this online practical clinic and tell you something about the current structures, limitations, but also future trends in European neurosurgical training. I have no financial disclosures. What I am telling you is just based upon my personal experience in the neurosurgical field, so it is not necessarily the opinion of the current ENS board. Speaking of the European Association of Neurosurgical Societies, we represent 39 national societies, so that is much larger than the European Union, which consists of 27 countries. So we have the Baltic states, former Soviet republics, Russia, Turkey, and Israel, just as an example, also being part of the ENS, so we represent quite a large area for neurosurgery. If we see the number of neurosurgeons, it is comparable to that in US and Canada, but of course it is a higher density compared to worldwide average or other regions in the world like in Africa or Asia. Nevertheless, for some very densely populated areas in Europe, the number is still considered rather low. Speaking on training, neurosurgical training should be defined as the period of a couple of years during which the trainee have to learn and will be exposed to all technical aspects, but also cognitive aspects of the specialty, so any aspects of brain, spine and peripheral nerve pathology, with the end term of becoming competent in the unsupervised practice of such techniques. If we look to the past, and I think it was for decades, maybe even a century, it was the Hallstatt methods or the master-apprentice model. That means you just follow the senior neurosurgeon, looked how he was operating, spend endless hours in the hospital and in the operating room, having an extensive clinical and operative exposure, but very often not a very structured training program with clear end terms. Nowadays, at least here in Europe, neurosurgical training requires a minimum of six, sometimes seven years after graduating from medical school, and within the ENS area, they all have now a structured educational program with end terms, sometimes only consisting of let's say the number of surgeries that needs to be performed, but mainly also developing the competences and describe how they should be developed. Well, this is a process of already a very long time. It was a directive, and actually that's the last directive from 1993, where they had general guidelines for improvement of medical specialist practice and training in the EU, the EFTA and associated member states. Within the EU, the UAMS is responsible for this. And so since that period, and that's over 60 years, the UAMS has been very active in the field of quality improvement of medical specialist training in the EU. And as you can imagine, the UAMS has a section for each medical specialty, so also for neurosurgery. They have developed specific recommendations concerning standards of training, quality of training, but also accreditation of the training institutions. And this has helped indeed to harmonize the training level, at least in the EU. Just a few of the examples that you can find on the training charter of medical specialists from the UAMS. But although this is on a European level, at a national level, medical specialist training is still regulated by national authorities. And actually, they are still setting the standards according to own national rules. Most countries, however, at least within the ENS area, take the European legislation and the recommendations of the UAMS into account. The ENS and the section of neurosurgery of the UAMS have formed already more than 25 years ago, the Joint Residency Advisory and Accreditation Committee. So the chairman of the UAMS is also a board member of the ENS. And this accreditation of training centers within Europe hopefully will be recognized by the national authorities. In many countries where there was no regular visitation, this has been done. But in other countries, especially Scandinavian countries, but also my own country in the Netherlands, there has been no regular visitation. In other countries, especially Scandinavian countries, but also my own country in the Netherlands, we had already a statutory visitation for decades. And they are more reluctant to change the rules of visitation, although they are very overlapping each other. So if we now look to the training itself, we see that the European Working Time Directive in 2003, when it was reduced to 58 hours per week, and then from 2009 onwards to 48 hours a week, it was inevitable that our trainees had less exposure in the OR and would see less clinical cases. This is just as an example from Norway that you see on the left-hand blue, the specialties that say, oh, well, 48 hours is about right. You could see for rheumatology or pathology. And some even say, well, we can do it within less than 48 hours. And the red part is where you can see that the specialties say, well, this is not adequate for us. We need longer times. And among them are thoracic surgery and neurosurgery, as you can see here. As a consequence, already three, four decades ago, there was a kind of threshold of numbers of procedures per year that the resident should do and to have adequate surgical training. That number was around 275, so fluctuated between 250 and 300. And in former times, the residents usually did much more than that. But you can see about 2003, it is declining already. And since 2009, that number of procedures done by a resident per year is 30 below that threshold. That means we can't reach competency in all areas of neurosurgery for each trainee. And the difficulty is that this is about the same time that we see our patients becoming much more informed through the internet. And we see an increase of demand from society for safe surgeries and improving outcomes. And the ones who have to fulfill this will be those lesser-trained future specialists. Well, we can argue about that, but that means that the importance is that we change our surgical training. It should be much more early on and also more goal-oriented in achieving competence in surgical areas. And not only those demands, we see that neurosurgery is expanding at an exponential rate. Just think about all of the minimal access procedures, endoscopy, endovascular neurosurgery, minimally invasive spine, and also functional. Well, it will be very difficult to reach competencies in all of these fields. In a certain amount of years. And that is at least these two challenges that we have. To fit all the subspecialties into the specific time of, let's say, the time frame of six years. And second is, how can we verify after that, that they are competent in performing the specialty in an unsupervised manner? So the idea is, at least here in Europe, to think about a kind of shorter core training, basic neurosurgical training, could be three or four or five years, and then followed by a dedicated two to three years subspecialization in one or two areas. In some countries, simply, you can't do only one or two years. In some countries, simply, you can't do only one, let's say, only functional or only pediatric, because simply the numbers are too low. But you could be one or two areas. And when I speak about that to the residents, they find that appealing. Not even to say that they indeed consider this inevitable. But that means that we have to change the training. So we introduced novel educational tools. Think of training models, simulators, and think also of virtual reality. So we as trainers need to change so that we can offer this to the trainees. And we see a plethora of models now coming up and being developed. And this is a model that was described already several years ago, a really very good model for removing of a glioma, with the arachnoid dissections, with looking to the edges, using Q-SA. So this all could be done. Even this technique, you could use the 5-ELA. And you can do this again and again and again, before a trainee ever do a real case in a patient. We also see that simulators can help. From the working group in Milano in Italy and Geneva in Switzerland, there is now the European Neurosurgery Simulation Study Group. And they found that you can indeed easily already differentiate the surgical ability of trainees and even trained neurosurgeons by testing them on simulators. But also they showed that in a, let's say, easy daily procedure like an EVD, doing it first in simulators and doing it several times, increasing competence already in the simulator, changes the learning curve in real life procedure dramatically. So this is certainly one way to improve the training. So in conclusion, we will see, at least in the next decade and after that, a really substantial change in neurosurgical training. And that's not only in response to our own new technologies that will come, think also about artificial intelligence and machine learning techniques, but also due to regulations and changing practices. We have now already, and we will see more and more teaching methods, but also methods for assessment. And that will optimize all teaching opportunities in the real arm. And it is not about the number of hours that somebody spends in the hospital. It is what you do within those hours, it is what you do within those hours, what you effectively do with the time that you are there. And this should be our goal to maximize the teaching and learning opportunities. And we already can recognize that the centers who are embracing and implement these new methods have placed themselves in the best position to train the next generation of neurosurgeons. And we need more, because at least here in Europe, if you think about the demand from the public, who don't want accepting any waiting lists anymore, but also from the neurosurgical field itself, we need more neurosurgeons. Unfortunately, at least at the moment, the current political situation and scenery is such that it is doubtful that they are willing now to invest the money that is necessary for such a reform. So this will be difficult for us to really implement all the ideas we have. So let's see how it will develop in the next couple of years. And I want to thank you for your attention to this lecture.

European neurosurgical training

limitations

competency

subspecialization

educational tools