Huri, Gazi

Madanat, Rami

Mäkinen, Tatu J.

Paschos, Nikolaos

Ryan, Daniel

Vide, Joao

Helsingin yliopiston digitaalinen arkisto

Suomen Ortopedia ja Traumatologia  Vol. 39222 SOT  2•2016The Current State of Orthopaedic Residency in Europe Rami Madanat1, Tatu J. Mäkinen1, Daniel Ryan2, Gazi Huri3, Nikolaos Paschos4, Joao Vide51. Helsinki Bone and Joint Research Group, Department of Orthopaedics and Traumatology      University of Helsinki and Helsinki University Hospital2. Department of Trauma and Orthopaedic Surgery, Gloucestershire Royal Hospital, United Kingdom3. Hacettepe University School of Medicine, Orthopaedics and Traumatology Department    Ankara, Turkey4. Department of Orthopaedics & Sports Medicine, Pennsylvania Hospital of the University of     Pennsylvania, Philadelphia, USA5. Orthopaedics and Traumatology Department, Hospital Beatriz Angelo, Lisbon, PortugalThe aim of this study was to compare orthopaedic and trauma training programs across Europe. A questionnaire was sent to the FORTE (Federation of Orthopaedic Trainees in Europe) representatives of 25 European countries, of which 18 responded. The number of trainees per specialist varied between countries from a ratio of 1:2 to 1:7. The residency program was generally 5-6 years in all the countries. In more than half of the countries selection was based on an interview. Nearly all countries utilized a logbook but only a few utilized a web-based logbook. About 80% of the countries had a final exam at completion of training. When assessing the components of training it was found that only one country had mandatory minimum requirements for 1) courses, 2) surgical procedures, 3) research and 4) leadership. Nearly 40% of the participating countries had only 1 or none of these four training components as a mandatory part of training requirements. While there are many similarities across orthopaedic and trauma training programs, some important differences remain in overall requirements and final qualification. FORTE will continue to serve as a forum for sharing best practices with the ultimate goal of improving and harmonizing the level of orthopaedic training across Europe. IntroductionThe evolving paradigm of orthopaedic and trauma training is an area that remains frequently discussed among institutions responsible for orthopedic edu-cation. The European Union of Medical Specialists (UEMS) was founded in Brussels in 1958 by the rep-resentative delegates of the professional organizations of medical specialists of the six member countries of the European Economic Community (EEC) (1). The main objectives of UEMS were to establish a high quality and comparable level of medical specialist trai-ning in the EU. As in other sections of UEMS, a European Board Suomen Ortopedia ja Traumatologia  Vol. 39 2•2016   SOT  223of Orthopaedics and Traumatology (EBOT) was es-tablished in 1994, and the first undertaking was to organize a board examination. The EBOT fellowship examination has been designed to standardize and improve the standard of orthopedic training in Europe (2). Although the high quality of the diploma of the EBOT examination has been achieved by a very broad base of support and cooperation of all orthopaedic associations of the UEMS countries, it is still not a mandatory requirement in Europe. Nevertheless, within the EU, the specialist qualification of ortho-paedic surgery is automatically recognized (Directive 2005/36/EC on recognition of professional qualifica-tions) in several countries. Furthermore, even if the qualification does not meet the automatic criteria for recognition, it may still be recognised in another EU country, under the general system for recognition of qualifications (3). Nonetheless, little is known about the similarities and differences in orthopaedic and trauma training programs in European countries, as this information is, in general, not readily available. Since its inception, The Federation of Orthopaedic Trainees in Europe (FORTE) has aimed to promote and improve the standards of orthopaedic and trauma training in Europe.  FORTE also attempts to harmo-nize orthopaedic training among European countries. This objective is becoming increasingly important with recent developments in medical profession that introduced a great amount of movement of medical graduates across Europe (4). The aim of this study was to compare current orthopaedic and trauma training programs across Europe and to understand the main similarities and possible differences.Materials and methodsA questionnaire was sent by email to the FORTE representatives of national trainee societies of 25 Eu-ropean countries in September 2015. The question-naire included demographic information regarding the number and gender distribution of trainees and specialists in 2014. The survey also inquired if there was a national association for trainees and, if so, was it dependent on the national orthopaedic associati-on. The remainder of the questionnaire was related to the structure of the respective orthopaedic training programs and included the following information with emphasis on mandatory requirements: selection process, duration, course training, number of surgi-cal procedures, research, leadership training, examina-tions, fellowship, and use of a training logbook. The information obtained from the different countries was then compared.ResultsRepresentatives from 18 countries (Croatia, Denmark, Finland, France, Germany, Greece, Ireland, Kosovo, Malta, Norway, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, and the United Kingdom) answered the questionnaire. The demo-graphic data from the different countries is presented in Table 1. Orthopedic surgeon densities (number of surgeons per 100 000 of the population) varied substantially among the participating countries. The highest densities were in the Nordic countries with nearly 20 orthopaedic surgeons per 100 000 of the po-pulation. More than half of the participating countries only had densities of only 2-6 orthopaedic specialists for 100 000 of the population. The number of trainees per orthopaedic surgeon was calculated in order to un-derstand differences in surgeon replacement rates. This ratio varied between countries from a ratio of 1:2 to 1:7, with no clear geographic patterns within Europe. The highest replacement rates were in Finland, Swit-zerland, Spain and Ireland and the lowest in France, Sweden, and Denmark. The proportion of female trai-nees was higher (mean 20%) than the proportion of female orthopaedic specialists (mean 9%) in nearly all the countries (Table 1).The selection process for entering a residen-cy program varied widely. In more than half of the participating countries selection was based on an in-terview or a combination of merit and interview. In the remainder, selection was based on the results of a national exam or a simple application process (Fig. 1). The residency program was generally 5-6 years in all the countries. Nearly all countries utilized a man-datory logbook throughout residency but only a few countries utilized a web-based logbook. There were still a small number of countries that did not require a logbook for keeping track of residents’ achievements (Fig. 1).Nearly 80% of the participating countries had a final examination at completion of residency but the remainder only had some form of interim exams without a mandatory final examination (Fig. 2). Most of the participating countries did not have a manda-tory fellowship requirement. When assessing the com-ponents of training it was found that only one country Suomen Ortopedia ja Traumatologia  Vol. 39224 SOT  2•2016Country Number of Ortho-paedic Surgeons(% female)Number of Orthopae-dic Surgeons/100 000 of populationNumber of Orthopa-edic Trainees and(% female)Number of Orthopaedic Trainees/100 000 of populationCroatia 218 (6.8%) 5.0 55 (11%) 1.3Denmark 1057 (16%) 18.9 164 (29 %) 2.9Finland 488 (14%) 9.0 248 (13%) 4.6France 3157 (5%) 5.0 450 (15%) 0.8Germany NA NA 500* (NA) NAGreece 1819 (9%) 14.2 562 (15%) 4.4Ireland 84 (0.9%) 1.8 39 (13%) 0.9Kosovo 75 (1.3%) 3.8 19 (11%) 0.9Malta 19 (6%) 3.2 7 (14%) 1.4Norway 975 (17%) 18.5 375 (NA) 7.5Portugal 1005 (10%) 9.0 262 (27%) 2.5Slovakia 550 (NA) 10.0 97 (NA) 1.7Slovenia 90 (3%) 4.5 22 (13%) 1.1Spain 2350 (29%) 15.0 1125 (41%) 2.4Sweden 1874 19.5 286 (33%)** 2.9Switzerland 889 (7%) 11.0 442 (NA) 5.5Turkey 3117 (NA) 4.0 976 (NA) 1.2United Kingdom 5071 (4.2%) 8.0 976 (19%) 1.6Table 1. Demographic data on the number of orthopaedic surgeons and trainees in 18 European countries in 2014*Approximate number**Number of orthopedic trainees who are members of the national organization. Membership is not mandatory.NA Data not availableFig. 1. Duration, selection process and log book require-ment for residency programs in the different European countries.Fig. 2. Mandatory examinations, fellowship, and training requirements (courses, surgical procedures, research, and leadership) for residency programs in the different European countries.Suomen Ortopedia ja Traumatologia  Vol. 39 2•2016   SOT  225Fig. 3. Minimum requirements for four main areas of training (courses, surgical procedures, research, and lea-dership) for residency programs in the different European countries.had mandatory minimum requirements for 1) courses, 2) surgical procedures, 3) research and 4) leadership. Surprisingly, nearly 40% of the participating count-ries had only 1 or none of these four training compo-nents as a mandatory part of residency requirements (Fig. 2). For the countries that had minimum requi-rements for course training and surgical procedures, these requirements varied from 50-360 hours and 300-1800 procedures, respectively. Research and lea-dership training were only a mandatory part of ort-hopaedic training programs in 40% of the countries (Fig. 3). Finally, nearly 70% of the countries had an association for orthopaedic residents. Most of these as-sociations were dependent on the national orthopae-dic association.DiscussionThe aim of this study was to collect demographic and structural data regarding current orthopaedic and trauma training programs across Europe and make comparisons between them. We found that while there are many similarities across residency programs, some important differences still remain in overall re-quirements and final qualification.There were clear differences in both orthopae-dic surgeon densities and replacement rates across Europe, reflecting possible inherent disparities in both the structure of the healthcare systems as well as in the future need for orthopaedic specialists. The larger proportion of female trainees compared to specialists would indicate a shift in gender parity in the near future. This may be particularly important as Ortho-paedic Surgery has among the lowest percentages of women in residency programs of any surgical specialty (5). The selection process to enter a training program was based on an interview in most countries. In a few countries selection was based on performance in a na-tional examination. One could argue that some form of summative assessment might be beneficial in selec-ting appropriate candidates for residency. The training program duration in all the countries ranged from 5-6 years meeting the minimum EU requirements for or-thopaedic specialist training. Nearly all countries uti-lized a logbook for tracking the performance of re-sidents and there was a tendency for the logbook to be moving from a paper version towards a web-based form. Some countries still did not have a mandatory logbook and we believe this is an important issue that can be easily addressed.Most countries had a final exam but there were still a few that had no form of final examination. In such countries the EBOT exam could serve as a po-tential final assessment of competency. For the pur-poses of the current study, we divided the key manda-tory components of training into 4 categories: course training, surgical procedures, research, and leadership. Most would agree that the first two are essential com-ponents of training, whereas the latter two could be considered more elective in nature. Only one country had all four of the aforementioned components of training as mandatory. Nearly half of the countries did not have a minimum number of mandatory surgical procedures or course training requirements. For the remainder that did, there was a substantial variation in the minimum requirements. We believe there is defi-nitely room for improvement in both of these aspects. The current study had some limitations. We were only able to get data from 18 of 25 countries and some of the provided data from the 18 countries was unfor-tunately lacking. Another limitation is that we did not include more granular information regarding the de-tailed structure of the residency programs such as the required rotations through subspecialties as this was outside the scope of the present study. To our know-ledge this is the first study that has collected essential information regarding differences in orthopaedic trai-ning programs across Europe. Future studies should aim at including information from more countries. In addition to the European curriculum, FORTE has been actively involved in multiple endeavors aimed at improving and harmonizing the level of or-thopaedic training across Europe. Some of these pro-jects include a book series for trainees and an ortho-Suomen Ortopedia ja Traumatologia  Vol. 39226 SOT  2•2016paedic summer school, to name a few. FORTE will continue to serve as a forum for sharing best practices with the ultimate goal of building competencies essen-tial for the twenty-first-century orthopedic surgeon in Europe.References1. European Union of Medical Specialists (2012) http//www.uems.net/.2. Mäkinen TJ, Madanat R, Kallio P, Mineiro J, Kiviranta I (2014) The current state of the fellowship examination of the European board of orthopaedics and traumatology (EBOT). Eur Orthop Traumatol 5:217-220.3. Costigliola V (2011) Mobility of medical doctors in cross-border healthcare. EPMA J 2:333-339.4. Scharer S, Freitag A (2015) Physicians’ exodus: why medical graduates leave Austria or do not work in clinical practice. Wien Klin Wochenschr 127:323-329.5. O’connor MI (2016) Medical school experiences shape women students’ interest in orthopaedic surgery. Clin Orthop Relat Res. 474:1967-1972.

The current state of orthopaedic residency in Europe

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Helsingin yliopiston digitaalinen arkisto