Neurosurgery Certification in Member Societies of the WFNS: Europe

Education & Training

Neurosurgery Certification in Member Societies of the WFNS: Europe Jaime Gasco1, Sean M. Barber1, Ian E. McCutcheon2, Peter M. Black3

䡲 OBJECTIVE: To objectively compare the complexity and diversity of the certification process in Neurological Surgery in European member societies of the World Federation of Neurosurgical Societies. 䡲 MATERIALS AND METHODS: The attention of this study centers on Europe. We provide here a subgroup analysis based on the responses provided to a 13-item survey. The data received were analyzed and three regional complexity scores (RCS) were designed. To compare national board experience as well as eligibility requirements to access the certification process and obligatory nature of the examinations, a RCS Organizational score was created (RCS-O, 20 points maximum). To analyze the complexity of the examination a RCS Components score was designed (RCS-C, 20 points maximum). The sum of both is presented in a Global RCS score (RCS-G). In addition, a descriptive summary of the certification process per responding society is also provided. 䡲 RESULTS AND CONCLUSIONS: Based on the data provided by our RCS system, the highest RCS-G was obtained by the United Kingdom (19/40 points) followed by European Association of Neurosurgical Societies, Poland, and Sweden (16/40 points each), Portugal (15/40 points), and Switzerland (14/40 points). The experience from these leading countries should be of value to all countries of the European Union. Peer-Review Article

Key words 䡲 EANS 䡲 Neurosurgery certification 䡲 Neurosurgery training Europe 䡲 WFNS Abbreviations and Acronyms EANS: European Association of Neurosurgical Societies EU: European Union MCQs: Multiple choice questions

OSCE: Objective Structured Clinical Skills Examination RCS: Regional Complexity Scores SNLF: French-Speaking Society of Neurosurgery UK: United Kingdom WFNS: World Federation of Neurosurgical Societies WHO: World Health Organization

INTRODUCTION The aim of this work is to provide knowledge compiled about the structure, components, and application of the certification examination process in neurological surgery in Europe. To begin such an assessment we must first discuss the origins of neurosurgical certification examinations in Europe, which began with the United Kingdom (UK) and European Association of Neurosurgical Societies (EANS) examinations in the 1990s (12). The EANS was formed in 1971, and by 1989 a committee was created in the EANS (which would eventually be called the Examination Committee of the EANS) with the aim of developing a European certification examination comparable to that provided by the American Board of Neurological Surgery (4). From its inception, the EANS certification examination was designed to follow loosely the program and format of the American examinations (4), including a written examination in multiple choice format and an oral examination. In 1992 the EANS certification examination was the second neurosurgical certification examination to take shape in the European region (the UK examination was the first, in 1991) (12), and although the EANS examination is available to all residents in accredited neurosurgical programs in Europe and to all European-certified neurosurgeons, it is—and has been—strictly voluntary (4). Both the UK and EANS neurosurgery certification examinations were born amid considerable criticism and skepticism regarding the value of such certification examinations and the motives of those seeking to implement them. Initially, the UK examination was vigorously opposed by the Neurosurgical Senior Registrar Association, in part due to the lack of standard neurosurgical curricula, training courses, or educational objectives in place, as well as the considerable amount of time spent in acquiring the Fellowship of the Royal College of

From the 1Division of Neurological Surgery, University of Texas Medical Branch, Galveston; 2Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; and 3Department of Neurosurgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA To whom correspondence should be addressed: Jaime Gasco, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2010) 74, 4/5:375-386. DOI: 10.1016/j.wneu.2010.03.019 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

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Surgeons, a professional qualification for surgery practice in the British Isles (21). At present the UK is home to one of the least-dense and most-active neurosurgical workforces in the region, with one neurosurgeon for every 294,000 citizens and each neurosurgeon performing approximately 300 cases per year (22). The Belgian Society of Neurosurgery was formed in 1960 with 12 founding members, and has now grown to include 90 neurosurgeons and 20 neurosurgical trainees (6) with 1 neurosurgeon for every 71,000 Belgians (22). In 1974, the first neurosurgical postgraduate training program in Europe was organized in Brussels, by the president of the EANS at the time, Jean Brihaye (6), yet certification in Belgium remains limited to voluntary participation in the EANS examination and certification process. The Croatian Neurosurgical society was founded in 1993 and currently consists of 64 members (26). Croatia employs a single neurosurgeon for every 72,600 Croatians, and each neurosurgeon performs an estimated 99 cases per year (22). Neurosurgery originated in the Czech Republic as early as 1882 with the work of Karel Maydl, the first Czech neurosurgeon. The neurosurgical subspecialty in the Czech Republic has since grown to consist of 55 neurosurgeons in 1993 (11) and approximately 80 neurosurgeons in 2006 (22). Neurosurgery first began to develop as a medical subspecialty in Germany in the early 1930s (9), but the initial expansion of neurosurgical interest and practice arrived after World War II, when the number of specialized neurosurgery units grew from 12 pre-War to 18 in 1950, 42 in 1972, and more than 100 in 2006 (7). Although Germany does not yet have a national written examination for neurosurgery certification, since 1978 the German Board has required a compulsory oral examination to complete training. At present Germany employs a single neurosurgeon for every 63,000 citizens, and each neurosurgeon performs approximately 150 operations per year (22). The formal practice of neurosurgery in Israel originated with the 12-bed service at the Hadassah Hospital in Jerusalem in 1942 (24). By 1986 there were six Departments of Neurosurgery in Israel with such a profound development of neurosurgical interest and practice that some feared an approaching surplus in neurosurgical manpower due to perceived overtraining of new neurosurgeons (24). The present-day Israeli neurosurgical certification process is fairly advanced, as well, with the Israeli board having more than 20 years of certification experience and a certification examination consisting of both written and oral components. At present Israel employs one neurosurgeon for every 120,700 citizens (22). In 1929 the first neurosurgical wing in the Netherlands was opened at the University Hospital of Amsterdam, and after World War II, the number of practicing neurosurgeons grew from 9 to 33 in 1970 and to 51 in 1981 (8). In 2006 the Netherlands housed one neurosurgeon for every 151,000 citizens (22). The training of young neurosurgeons also evolved in the post-War period as strict rules were established by the Dutch committee in cooperation with the “Specialisten Registratie Commissie,” including 1 year in neurology, 1 year in general surgery, and 4 years in a neurosurgical clinic (8).

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Norwegian neurosurgery began in the late 1800s with the work of pioneers Johan Hjort, Julius Nicolaysen, and Wilhelm Magnus (14). At present the Norwegian neurosurgical workforce consists of one neurosurgeon per 85,000 Norwegians (22). Neurosurgery as a specialty was first established in Poland in 1936 with the formation of the neurosurgical ward in Warsaw (15). Since World War II, the number of neurosurgeons in Poland has expanded from 3 to 118 in 1984. At present Poland employs one neurosurgeon for every 118,000 citizens (22) and is home to more than 30 neurosurgical centers functioning in multiple locations across the country. The first Polish national written examination in neurosurgery certification originated in 1999. The Portuguese Neurosurgical Society (SPNC) was founded in 1990 (1). At present the Portuguese neurosurgical workforce consists of one neurosurgeon for every 61,000 citizens (22). Slovenian neurosurgery has developed at the hands of Vinko Dolenc and others to include one neurosurgeon for every 143,000 citizens in 2006 (22). Sweden, with a population of more than nine million (July 2008 estimate), has advanced from a single neurosurgery unit at the Serafimerlasarettet in 1912 to a multicenter neurosurgery practice with more than 300 beds (20) and one neurosurgeon per 90,000 Swedes (22). Sweden implemented its first national written examination for neurosurgery certification in 1998. The practice of neurosurgery began in Switzerland in the early twentieth century with the work of pioneers such as Hugo Krayenbühl, the first Swiss surgeon to operate on a brain tumor in Zurich in 1937 and the head of the first independent neurosurgical clinic in Switzerland in the “Hegibach” ward of the Clairmont clinic in 1948 (23). The Swiss Society of Neurosurgery was founded in 1954 in Basel, and Switzerland organized its first national written examination for neurosurgical certification in 1997 (10, 23). At present the Swiss workforce consists of one neurosurgeon per 71,000 citizens (22). The first Turkish neurosurgery department was established in Istanbul in 1923, and the first neurosurgery training program started in the late 1940s (19), but neurosurgical techniques were applied in Turkey by general surgeons as early as the late nineteenth century (19). The Turkish Neurological Society was founded in 1968 by 11 neurosurgeons in Istanbul, and later become a member of the World Federation of Neurosurgical Societies (WFNS) and the EANS (3). There are now more than 50 neurosurgery training centers and more than 500 neurosurgeons in Turkey (1 per 79,000 citizens) (22), as well as a Turkish national written examination for neurosurgery certification (begun in 2006). At present, much diversity in examination methods exists among the 30⫹ European countries with neurosurgical certification examinations, due to differences in culture, priorities in neurosurgical training, and other factors (12). Some countries participate in the EANS process, but many provide their own national neurosurgical certification examination. Analysis of the wide spectrum of neurosurgery certification examination techniques and processes is indicated to understand

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better the true magnitude of this diversity, so that one day this process might be unified, not only within the European region, but around the globe, creating an environment in which all neurosurgeons are held to similar standards, trained in similar techniques, and united in a global community of neurosurgical practice.

Table 1. List of Responding Societies Region Europe

MATERIALS AND METHODS This study analyzes in detail the certification process in European members of the WFNS. We provide here a subgroup analysis based on the responses provided to a 13-item survey (Appendix 1). This survey was sent to 37 of 40 European member societies of the WFNS. Continental member societies and redundant societies of a given country were not contacted (Central European Neurosurgical Society, FrenchSpeaking Society of Neurosurgery [SNLF], and the German Academy of Neurosurgery). The list of responding societies is included in Table 1. The data received were analyzed and three regional complexity scores (RCS) were constructed. To compare national board experience and the complexity of eligibility requirements a RCS-Organizational (RCS-O) score was designed. To compare the complexity of the examination a RCS-Components (RCS-C) score was designed. The sum of both is presented in a Global RCS (RCS-G) score. The grading system for each category is presented in Table 2. The RCS grading system follows a direct correlation between increasing degree of complexity in each category and number of points awarded. The more complex and elaborate the examination process, the higher the number of points obtained by that certification system. The scores are based only on the responses received, grading only those reported activities. The RCS-O score is defined by five categories (Written board prerequisites, Oral Board prerequisites, Level of training at which access to the first component of the examination is allowed, Board experience in conducting standardized written examinations, and Obligatory nature of the examination). The RCS-C score is defined by six categories (Multiple choice component, Oral examination component, Surgery/Productivity evaluation, Essay/Written component, Objective Structured Clinical Skills Examination [OSCE] component, Imaging component, and Computerized component). Both RCS-O and RCS-C scores produce a maximum total of 20 points each, adding to a maximum RCS-G of 40 points. These categories accommodate all reported activities that were later classified according to the perceived level of difficulty and/or experience required to obtain a specific requisite or produce and organize a particular examination component. Although this point grading system is arbitrary, we believe that it is a fair evaluation of complexity. Recertification and Maintenance of certification—although present in the survey—were not included in the grading system. The reported activity in these areas is presented in the descriptive component of our study. Those countries that delegate portions of their examination to other countries (e.g., where a national oral examination exists but the multiple choice questions [MCQs] section is delegated to another society or Board) obtain equal credit to the value obtained by the society to which the examination is partially or totally delegated. The “Additional Credit” column includes additional points if further

Responding Societies 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

European Association of Neurological Societies (EANS) Belgian Society of Neurosurgery Croatian Neurosurgical Society Czech Neurosurgical Society German Society of Neurosurgery Israel Neurosurgical Society Netherlands Society for Neurosurgery Norwegian Neurosurgical Society Polish Society of Neurosurgeons Portuguese Neurosurgical Society Slovenian Neurosurgical Society Swedish Society of Neurosurgery Swiss Society of Neurosurgery Turkish Neurosurgical Society Society of British Neurological Surgeons

difficulty of that category is observed (e.g., addition of 1 point if the time available to answer a specific MCQ is less than 60 seconds). In addition, a descriptive summary of the certification process adapted from the original responses provided by each individual participating society is provided before this analysis in the Results section.

RESULTS Descriptive Analysis European Association of Neurological Societies. Countries represented: Armenia, Austria, Belgium, Bosnia-Herzegovina, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Latvia, Lithuania, Macedonia, Moldova, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, United Kingdom. The EANS is responsible for the European Neurosurgical Training Courses, which consist of two separate series of courses, held annually during a 4-year period, with each course lasting 6 days. The courses have been held since the 1970s and are arranged by the Training Committee. They are aimed at serving the needs of neurosurgical trainees for the last half of their training in neurosurgery. New candidates must be in their third or fourth year of specialist training. The courses can host around 440 participants in each cycle, each year. Applicants who are successful are automatically admitted for the full 4 years and must attend on 4 consecutive years. Applicants must have a high-level of English— both written and spoken—and all trainees attend the course unaccompanied. The European examination is compulsory for all fourth year trainees— unless they have already passed it—and is taken at the training course site the day before the start of the fourth training course. Further details can be obtained from the EANS Secretariat (2). The written examination was first implemented by the EANS in 1992; the oral examination was begun in 1994. Eligibility for the

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Table 2. Regional Complexity Scores RCS-Organizational Score

0 Points

1 Point

2 Points

3 Points

Additional Credit

Maximum

Thesis/dissertation

—

6

Written board prerequisites

None specified

Interview/board approval 1 Exam/prelim. course

2 or more exams/courses

Oral board prerequisites

None specified

Graduate level Pass written

Research/publications

—

Logbook required at any point (⫹2P)

6

Earliest level of training required

None specified

NS1 through NS3

NS4 until graduation

Graduation required

—

3

Board experience in standardized exams

Not specified No written exam

⬍10 years

10–20 years

⬎20 years

—

3

Obligatory nature of the exam

Not specified or not compulsory

Compulsory for certification only

Compulsory for certification & practice

—

—

2

2 Points

3 Points

Additional Credit

Maximum

RCS-Components Score

0 Points

1 Point

Multiple choice questions

None/intent

⬍100 MCQs or not specified

100–200 MCQs

200–400 MCQs

⬎400 (1P) ⬍1 min/MCQ (1P)

5

Oral examination

None/intent

Exists (duration not specified)

Exists (1–2 h)

Exists (2–3 h)

⬎3 h (1P)

4

Surgery/productivity

None/intent

Instruments’ evaluation Résumé evaluation

Live surgery evaluation

Essay/written examination

None/intent

E/W exists (⬍3 h in duration)

E/W exists (3–6 h in duration)

Clinical exam/formal OSCE

None/intent

Clinical exam NOS

Formal OSCE exists

Imaging component

None/intent

Imaging interpretation exists

—

Computerized component

None/intent

CBT exists

—

—

—

4

—

3

—

—

2

—

—

1

—

—

1

E/W/S exists (⬎6 h in duration)

Top: RCS-Organizational Score (maximum 20 points); Bottom: RCS-Components Score (maximum 20 points). The RCS-G (Global score) is the addition of both RCS-O and RCS-C (maximum 40 points). NOS: not otherwise specified; CBT: computer-based testing; OSCE: Objective Structured Clinical Skills Examination; E/W: essay/written; E/W/S: essay/written/spot; MCQ: multiple choice questions.

examination is limited to neurosurgical trainees in the last half of their neurosurgical training (specifically, those in their fourth through sixth year of neurosurgery training). A surgical logbook with a requisite number of cases is required as part of the application to take the examination to verify that a candidate has sufficient surgical experience to pass the examination. The number of examinees since 2000 has varied from 60 to 220 in a single year, with specific participation and passing rates, as well as individual subtopics given in Figure 1. The examination format consists of two parts. Part one is a multiple choice component with 200 questions, lasting 3 hours. Typically, 70% to 80% of all candidates achieve or surpass the passing score of 60% correct. Part two is an oral component, lasting 3 hours, where six examiners evaluate a single candidate. Typically, 90% of all candidates achieve a passing score on the oral component. The written examination makes use of colored pictures, imaging, and slides, and there are plans to hold the examination in a computerized or Web-based format at some point in the future. Trainees from all member countries of the EANS are welcome to take the written examination, however, the oral EANS examination is limited to those holding national board certificates to avoid conflict between EANS and national systems of certification.

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The EANS written examination is not required as compulsory for practice in each respective country except for Switzerland (which recognizes part I as their national examination). Although the EANS will probably make the examination compulsory for practice in member countries at some point in the future, they estimate that it could be decades before this is achieved. Individual countries may delegate the examination to EANS resigning from their own, like Switzerland. This process is slowed down by the diversity of languages in Europe and the fact that the EANS examination is, so far, only in English. All countries of the European Union (EU) recognize the certification in neurosurgery if obtained in another EU country. The EU is considered a “common grounds,” in which frontiers for neurosurgeons are structured on a set of reasonably limited additional requirements established by the country of destination to obtain certification or verification.

Belgium. Belgium does not have a national written or oral examination for neurosurgery. Belgian neurosurgeons participate in the EANS examination process. This participation, however, is not compulsory for practice in Belgium. Croatia. Croatia does not have a written examination for neurosurgery, but instead uses an oral examination of several hours duration (not specified), which was first implemented in

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Figure 1. (A) EANS number of examinees from August 2004 (Krakow) to June 2007 (Lisbon). The number of participants is higher in Krakow as there was only a single examination location that year (2004). The following years were divided in two separate locations and times: 2005 (Prague, Poland/ Thessaloniki, Greece); 2006 (Luxemburg, Luxemburg/Bratislava, Slovakia); 2007 (Anatalya, Turkey/Lisbon, Portugal). (B) Total number of questions and

1971. Eligibility for the oral examination is limited to neurosurgery residents who have completed the entire 6-year program of neurosurgery residency. Examination candidates are also evaluated in terms of surgical experience before the oral examination. Typically, there are between 0 and 2 candidates per year taking the examination, and the majority of candidates pass. Examinees are asked to interpret imaging studies as part of the oral examination, but otherwise no color images or slides are used and there is no plan to perform the examination in a computer or Web-based format in the near future. The examination is compulsory for certification and to practice neurosurgery in Croatia, but has no retroactive effect because all neurosurgeons who graduated before 1971 have since retired. Neurosurgeons already trained in other countries are not required to take the Croatian examination once they have acquired neurosurgical accreditation from the Croatian Ministry of Health in consultation with the Croatian School of Medicine and Neurosurgical Society. At this time there is no plan to implement recertification examinations for Board certified neurosurgeons in Croatia. There is, however, a relicensing program required every 3 years for all medical specialists.

Czech Republic. The Czech Republic first instituted a national written examination for neurosurgery in 2005. The examina-

questions removed each examination year. Range ⫽ 0 – 8 questions removed (mean, 3.7 questions). (C) EANS percentage passing rates by category, August 2004 to June 2007. Cerebrospinal fluid and spaces is the category with the highest mean passing rate (75.4, SD 4), whereas peripheral nerves and plexuses obtains the lowest mean passing rate (52.5, SD 6). Note the examination is divided in 14 categories with 200 questions.

tion is available to all neurosurgery residents who have completed 2 years of training (NS-3 or greater). A logbook or other evidence of neurosurgical case experience is not a requirement to take the examination. Since 2005, there have been 10 examinees, and the passing rate of these examinees is unknown. The examination contains 200 MCQs, with subtopics including: (percentages are approximate) anatomy 20%, neurology 20%, radiology 20%, and neurosurgery (including intracranial) 40%. The examination is computerized in format, and does not make use of color images or slides. The process of certification has been compulsory for practice in the Czech Republic since the 1960s. The national Czech examination, however, was only begun in 2005. The oral component of the examination is given 5 years after the written portion is passed and is considered the final examination for board certification in the Czech Republic. All non-EU-trained neurosurgeons must pass the Czech Republic neurosurgery examination as well as an examination in the national language to become recognized. At this time there is no plan to implement recertification examinations for neurosurgeons already board certified in the Czech Republic.

Germany. Germany does not have a national written examination in neurosurgery, but does have an oral examination, organized by the Federal Medical Association, which is available to all graduates of a neurosurgery training program with

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permission from the Medical Association Board. A logbook detailing surgical experience and requisite number of cases is required to take the examination. The examination takes 4 hours, and three examiners evaluate each examinee. Topics tested include: general surgery, intensive care, conservative treatment, and neurosurgical standard procedures. The oral examination is compulsory to practice in Germany. The examination does not make use of colored images or slides, and there is no plan to use a computer or Web-based format for the examination in the future. There is no plan to implement recertification examinations for those already certified at any point in the future.

Israel. The written examination for neurosurgery in Israel was first implemented approximately 25 years ago. The written examination is available to all neurosurgery residents who have completed 3 years of training, whereas the oral component is available only to those who have completed 6 years of training and passed the written portion. A logbook or other evidence of neurosurgical case experience is not a requirement to take the examination. Since 2000, there have been 12 examinees, and the passing rate of these examinees is unknown. The written examination contains 80 MCQs testing case studies, imaging, histology, and the examinees’ ability to write three postoperative reports, whereas the oral component consists of case presentations. The written examination does make use of colored images and slides. There is no plan to perform the examination in a computerized or Web-based format at any point in the future. The examination is compulsory to practice in Israel, and only neurosurgeons trained in the USA and Canada are recognized by Israel without having to take the Israeli examination. At this time there is no plan to implement recertification examinations for neurosurgeons already board certified in Israel.

The Netherlands. The Netherlands participates in the EANS examination process and does not plan to have a separate national examination process at any point in the future, nor is there any plan to implement a national oral examination. The examination process is not compulsory for practice in the Netherlands. The Netherlands does not recognize any non-EUtrained neurosurgeons. All medical specialists in the Netherlands are required to apply for recertification every 5 years and must have earned a certain number of accreditation points and participate in the quality program of the Netherlands Society of Neurosurgeons before applying for recertification.

Norway. Norway does not require an examination— either oral or written—to become certified as a neurosurgeon. Instead, certification is based on a minimum number of training years in a neurosurgical department and the performance of a minimum number of different surgical procedures, after the completion of which the candidate may apply for certification. Norway does not recognize neurosurgeons trained in non-Nordic or non-EU countries. Norwegian neurosurgical residents use the EANS courses or the Nordic “Beitostolen courses,” but these courses are optional and participation in these courses is not common. At this time, there is no plan to implement recertification or maintenance of certification requirements for licensed neurosurgeons in Norway.

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Poland. Poland implemented a national written examination process in 1999. The eligibility requirements for the examination include completion of 6 years of training and meeting defined requirements such as a certain number of neurosurgical operations. The ability to perform a prescribed range of operations is confirmed by the chief of the applicable training program before the examinee is allowed to take the examination. The examination consists of a multiple choice component with 100 questions and a time limit of 1 minute per question. The individual subtopics tested and their approximate representation includes: neuro-oncology 15%, neuro-trauma 15%, anatomy and physiology 15%, functional neurosurgery 5%, pediatric neurosurgery 15%, vascular 15%, spinal 15%, and other topics 5%. There is also an oral examination available to those who have completed the written portion. The oral examination lasts 1 hour and consists of three questions on surgical management of cases such as “pituitary adenoma” as well as a short discussion on the case management based on images and clinical data. The board is considering extending the oral examination to 2 hours. The number of examinees per year varies from 22 to 26, and the pass rate is typically around 80%. The written examination makes use of colored images and slides, and there is a plan to implement a computerized format of the examination at some point in the future. The examination is compulsory for practice in Poland. Non-EU-trained neurosurgeons are reviewed on an individual basis by a ministerial body before recognition. There is currently no plan to implement recertification examinations for Polish board certified neurosurgeons at any point in the future. The examination is compulsory for practice in Poland.

Portugal. Portugal does not have a national written examination for neurosurgery, but does use an oral examination available to all residents who complete the 6-year neurosurgery training program. The oral examination is compulsory for practice in Portugal, lasts about 4 hours, and consists of three parts: 1) discussion of curriculum vitae including number of cases and surgical results; 2) practical examination with patient observation, discussion of diagnosis, treatment options, and prognosis; radiographic films are used in this portion; and 3) miscellaneous questions about any neurosurgical subject. Portugal does not recognize any non-EU-trained neurosurgeons. At this time there is no plan for implementing recertification examinations for those already board certified in Portugal, but a plan is in discussion with intent to have a recertification process in the future.

Slovenia. The written examination for neurosurgery certification in Slovenia was first implemented in 2002. Those eligible to take the examination include the Head of the clinical department as well as two neurosurgical specialists. Presentation of a logbook with a required number of cases or other evidence of neurosurgical experience and proficiency is a requirement before taking the examination. Typically one to two candidates take the examination each year. The format of the examination is 280 MCQs given during 6 hours. The examination does not make use of colored images or slides, and there is no plan to perform the examination in a computerized or Web-based format or to add an oral component to the examination. The

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examination is not compulsory for practice in Slovenia; however, no neurosurgeons from non-EU countries are recognized by Slovenia and all foreign applicants must take the examination in Slovenia. At this time, there is no plan to implement recertification examinations for those neurosurgeons already board certified in Slovenia.

Sweden. Sweden first implemented a written national examination for neurosurgeons in 1998, and participated in the EANS examination from 1994 to 1998. The national oral examination has been available since 1993. Although neurosurgeons may take the EANS oral examination there is no intent for the EANS oral examination to ever replace the national oral examination. Since 1996 a passing grade on the written examination has been required for participation in the oral examination. Eligibility for the written examination is limited to all neurosurgery residents who have completed 3 years of training, and the oral examination is limited to those who have completed the entire training program. A logbook or record of neurosurgical experience is not a requirement for participation in the examination. The multiple choice examination model is similar to that of the EANS, with 200 questions (details regarding subtopics of examination are given in Figure 1). Participation in the examination is typically one to four examinees per year. Although most departments in Sweden require a passed examination to become board certified in Sweden, the written examination is not formally compulsory and some trainees are qualified every year without passing the examination. The oral examination (both national and EANS) is also not compulsory for practice in Sweden; however, the Swedish oral examination is recommended for those who seek an academic position as a faculty. Of foreign-trained neurosurgeons from non-EU nations, only those trained and certified in the USA and Canada are recognized by Sweden. Those trained in EU countries are also required to complete courses about the Swedish welfare system and regulations and to speak Swedish. Canadian and American board certified neurosurgeons are held to the same restrictions as EU neurosurgeons and typically must practice under observation before employment. At this time there is no plan to implement recertification examinations for neurosurgeons already board certified in Sweden.

Switzerland. The written examination for neurosurgical certification in Switzerland was first implemented in 1997 and is available to all neurosurgical candidates in the fifth and sixth year of training after confirmation from the training chief. A logbook with a requisite number of cases or other evidence of neurosurgical experience is required before taking the examination. The examination format consists of a multiple choice section similar to that used in the EANS examination, as well as a 1-hour oral examination. The examination does make use of colored images or slides, yet there is no plan to implement a computerized or Web-based format to the examination. The examination is compulsory for practice in Switzerland, and only EU-trained neurosurgeons are recognized by Switzerland without having to take the examination. However, for nonEuropean neurosurgeons, the board soon plans to implement a procedure for acceptance by bilateral analogy with countries such as the USA. At this time, there is no plan to implement recertification examinations for those neurosurgeons already board certified in Switzerland.

Turkey. Turkey first implemented its national written examination for neurosurgery in 2006. The examination is available to all neurosurgery residents at levels of PGY-4 and greater. A logbook detailing neurosurgical case experience with a requisite number of cases is required before taking the examination. The written examination consists of 100 MCQs with 150 minutes allotted for completion. Examination participation numbered 122 in 2006 and 48 in 2007, with passing rates of 31% and 46%, respectively. Subtopics tested include: basic neuroscience 70%, neurosurgical technique and clinics 30% (neuroanatomy 8%, neuropathology and physiology 10%, neurology 7%, general neurosurgical tasks [general surgical techniques, e.g., craniotomy, tools] 5%, trauma 5%, brain tumor 15%, cerebrovascular disease 15%, spine and spinal cord—peripheral nerve 17%, neuroradiology 5%, pediatric neurosurgery 5%, neurosurgical intensive care 4%, functional and stereotactic neurosurgery 4%). The examination makes use of colored images and slides, and there is a plan to perform the examination in a computerized format at some point in the future. The written examination is not compulsory for practice in Turkey, but after a thesis approval step at the end of the sixth year all residents are required to take an oral examination that lasts 1 hour. Turkey intends to add an additional oral examination (similar to that provided by the EANS) at some point in the future. After completion of the examinations, neurosurgeons are certified by the Ministry of Health. Board certified neurosurgeons from non-EU countries are not required to take the examination, but they are still required to obtain permission to work from the Ministry of Internal Affairs in Turkey. Neurosurgeons from other countries who are not board certified are analyzed on an individual basis by a committee. There is currently a plan to recertify board certified neurosurgeons in Turkey every 10 years by a sufficient number of accreditation points having been accrued through surgery cases, meetings, research papers, and other.

United Kingdom. The United Kingdom implemented its first written neurosurgery examination in 1991. The multiple choice component is available to all neurosurgeons that have begun training. The second component of the examination is available to those who have completed their sixth year of training. Participation in the EANS course is not required to take the UK written examination. Applicants to take the UK written examination must hold a medical qualification recognized for registration by the General Medical Council of the United Kingdom or the Medical Council of Ireland. The applicant must also provide evidence (consisting of three structured references completed by the appropriate senior colleagues with direct experience of the applicant’s current clinical practice in the appropriate specialty) of having reached the standard of clinical competence defined in the Intercollegiate Surgical Curriculum. Section 1 of the examination uses colored clinical photographs, as well as black and white imaging, whereas section 2 uses black and white imaging only on printed sheet radiology films. There is currently no plan to hold the examination in a computerized or Web-based format, but the idea is under consideration. The examination is compulsory both for certification and practice in the UK. All foreign-trained neurosurgeons must pass a suitable test of knowledge. Specifically,

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According to the available data, the UK presents the most developed regional certification process (19 points), followed by the EANS, Poland, and Sweden (16 points each), and Portugal (15 points) and Switzerland (14 points) (Tables 3 and 4). The certification reported by EANS, Poland, Turkey, and Croatia merit presentation with “actual” and “expected scores.” Although the actual components score (RCS-C) for the EANS is 6, we expect the final format of these evolving certification components to provide an RCS-C score of at least 7 points (given the minimum for the computerized forFigure 2. Format of the UK neurosurgery certification examination. Note the examination is divided into mat they intend to develop). This would two sections. Section 1 contains 135 extended matching items multiple choice questions (MCQs) and give a total RCS-G of 17 points, closely 110 single best answer MCQs, two hours each. Section 2 contains four categories: investigations including neuroradiology (30 minutes), operative neurosurgery/surgical anatomy (30 minutes), 4 short behind the numeric score obtained by the case clinical examinations (30 minutes), and one long case clinical examination (30 minutes). certification in the UK. Similarly, if Poland extends the length of their oral examinaFellowship of the Royal College of Surgeons (SN) is automattion to 2 or more hours and implements a computerized format ically accepted. For information on other accepted examinato the examination (as they are considering), their RCS-C score tions for which a Certificate of Completion of Training would would change from 5 to 7, placing their global score (RCS-G) at be issued, the reader is referred to the UK Postgraduate 18 instead of 16. Should Turkey include an additional oral Medical Education and Training Board, articles 11 or 14. Plans component (similar to that provided by the EANS) and impleto implement recertification examinations are being develments a computerized portion in the examination (for which oped, but have not yet been finalized. Details regarding the they have expressed intent), their RCS-C score would climb specific examination format are given in Figure 2. from 4 to 6, placing their global (RCS-G) score at 11 instead of 9. The long case test category is structured with approximately 10 minutes for history and presentation of salient points, 10 minutes for examination, differential diagnosis and investigation plan, and 10 minutes for the general management plan, DISCUSSION treatment options, and potential complications (30 minutes With regard to training and certification in neurosurgery across total). The short cases test categories include: clinical knowlthe globe, in the words of D. M. Long of the Department of edge, diagnostic acumen (including differential and justificaNeurosurgery at Johns Hopkins University School of Medicine, tion for it), investigations and interpretation, treatment op“It is obvious that the fundamental issue is the assurance of tions, and taking consent. The three half-hour orals cover the competency” (18). Board certification is a qualification with following topics: operative surgery and surgical anatomy (30 great significance in the medical community that often exminutes), investigation of the neurosurgical patient including pands a neurosurgeon’s chances for achieving hospital creneuroradiology (30 minutes), and the nonoperative clinical practice of neurosurgery (30 minutes).

Regional Performance Comparative Analysis The number of examinees passing and failing the EANS examination from August 2004 to June 2007 are detailed in Figure 3. The number of examinees passing and failing the UK examination each year from 2000 to 2007 are detailed in Figure 4. Figure 5 displays the average passing rates for the EANS, Turkish, and UK neurosurgical certification examinations from 2000 to 2007.

Regional Complexity Scores The information received from the survey responders was tabulated and according to the criteria explained, a ranking of complexity of the certification system was developed. Belgium, the Netherlands, and Norway could not be included due to lack of regional certification process.

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Figure 3. Number of examinees passing and failing in the EANS examination, August 2004 to June 2007. Passing percentages: August 2004, 78%; February 2005, 80%; August 2005, 67%; February 2006, 62%; August 2006, 73%; February 2007, 68%; and June 2007, 81%.

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2. The compulsory nature of the examinations for both certification and practice in the majority of responding countries (7/12 examinations). 3. Higher levels of training required for participation in the majority of the examinations (4/12 examinations available only to graduates, 5/12 examinations available to NS4 – graduates, 2/12 examinations available to NS1–NS3, only 1/12 examinations with availability unspecified).

Figure 4. Number of examinees passing and failing per year in the UK examination, 2000 to 2007. Passing percentages per year: 2000, 75%; 2001, 60%; 2002, 79%; 2003, 66%; 2004, 82%; 2005, 63%; 2006, 71%; and 2007, 68%.

dentialing and practice opportunities, and its attainment by neurosurgeons should be limited to those providing a strict standard of competence in—and mastery of—neurosurgical practice. As noted by J. T. Hoff of the University of Michigan in reference to the American Board of Neurological Surgery certification examinations in the United States, “Board certification marks the successful completion of a well-defined curriculum designed to train safe and competent clinical neurosurgeons” (13). In establishing criteria by which to evaluate examinations in neurosurgery certification, we must consider the wide range of knowledge and skills required for competency in neurosurgical practice, including technical expertise, judgment, experience, and proficiency. Although the ideal attributes possessed by a certification examination in neurosurgery are relatively straightforward, according to K. W. Lindsay of the Department of Neurosurgery at Southern General Hospital in Glasgow, UK, “. . . to obtain a valid, objective and reliable method of assessing competence in these numerous skills . . . presents a formidable challenge” (17).

4. Logbook requirements (7/12 examinations require a logbook) are an important aspect of certification, as studies have shown that better outcomes in neurosurgery are linked to higher operative volumes (5). Specifically, Solomon et al. (25) reported a 40% reduction in mortality in hospitals where surgeons performed more than 30 craniotomies for aneurysms per year. Of note, the boards of medicine of most European countries require a catalog of neurosurgical interventions, providing the numbers for the minimum of independently performed neurosurgical interventions. It is not possible to take the oral (or written) examination without having received the signatures of the responsible program directors and other supervisors (e.g., in the respective logbook). For instance, the minimum of independently performed lumbar spinal procedures in Germany or in Switzerland would be 60, and the number of supratentorial intracranial lesions, 40. These numbers are available through the respective national societies. 5. The availability of the EANS training courses and written examination in all countries as a substitute for— or in addition to—a national examination and as a model for establishment of national examinations in those countries lacking them. 6. The reciprocity of certification within the European Union (EU), allowing board certified neurosurgeons from a given EU country to travel to—and practice in— other EU countries with the fulfillment of only a limited number of additional requirements (e.g., language courses).

The state of neurosurgery certification in Europe has improved considerably during the past two decades, with five European WFNS member countries and societies organizing and implementing national written examinations in neurosurgery between 1990 and 2000 (UK, EANS, Switzerland, Sweden, and Poland), and another three countries implementing examinations after 2000 (Slovenia, Czech Republic, Turkey). Strengths in the certification process in the European region identified in the results of this study include: 1. The presence of a considerable number of European examinations with both written and oral components (5/12 examinations) and interpretation of color images, slides, or films (8/12 examinations).

Figure 5. Percentage passing rates for EANS, Turkish, and UK examinations from 2000 to 2007. Note the homogeneous cumulative performance per year obtained in the EANS examination. The UK examination, predominantly from 2000 to 2004, shows a more alternating performance each year.

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Table 3. Distribution of Countries in the Regional Complexity Score Grid RCS-Organizational Score

0 Points

1 Point

2 Points

3 Points

Correction Factors

Written board prerequisites

CRO/CZE/GER/ISR/POR/ SLO/TURK

EA/POL/SWE/SWIT/UK

EA/SWE/SWIT

—

—

Oral board prerequisites

SLO/SWIT

EA/CRO/CZE/GER/ISR(x2)/ POL(x2)/POR/SWE/UK(x2)

TURK

—

⫹2 EA/CRO/POL/POR/ SLO/SWIT/UK

Earliest level of training required

SLO

CZE/UK

EA/ISR/SWE/SWIT/TURK

CRO/GER/POL/POR

—

Board experience in standardized exams

CRO/GER/POR/SWIT

CZE/POL/SLO/TURK

EA/SWE./UK

ISR

—

Obligatory nature of the exam

EA/SLOV/SWE/TURK

CRO/UK

CRO/CZ/GER/ISR/POL/ POR/SWIT

RCS-Components Score

0 Points

1 Point

2 Points

—

—

3 Points

Correction Factors

Multiple choice questions

CRO/POR

ISR

EA/CZ/POL/SWE/SWIT/ TURK

SLO/UK

—

Oral examination

SLO

CZE/GER/ISR/SWE/TURK

CRO/POL/SWIT

EA/POL*/POR/ TURK*/UK

Surgery/productivity

EA/CRO/CZE/GER/ISR/POL/ SLOV/SWIT/TURK/UK

POR

SWE

Essay/written/spot

EA/CRO/CZE/GER/POL/ POR/SLO/SWE/SWIT/TURK

ISR/UK

Clinical exam/formal OSCE

EA/CRO/CZE/GER/ISR/POL/ SLO/SWIT/TURK

POR

Imaging component

EA/CZE/GER/SLOV

CRO/ISR/POL/POR/SWE/ SWIT/TURK/UK

Computerized component

EA/CRO/GER/ISR/POL/POR/ SLO/SWE/SWIT/TURK/UK

EA*/CZE/POL*/TURK*

⫹1 POR

—

—

—

—

—

—

—

—

—

—

—

—

— SWE/UK

RCS: regional complexity score; EA: EANS; POL: Poland; SWE: Sweden; POR: Portugal; SWIT: Switzerland; ISR: Israel; CRO: Croatia; CZE: Czech Republic; SLO: Slovenia: TURK: Turkey: GER: Germany; UK: United Kingdom. *Future positions once planned components are implemented.

Table 4. RCS Scores and Rankings per Member Society Regional Results UK

RCS-O Score

RCS-C Score

RCS-G Score

RCS-O Ranking

RCS-C Ranking

RCS-G Ranking

9

10

19

Poland

UK

UK

EANS

10

6

16

EANS

Sweden

EA/POL/SWE

Poland

11

5

16

UK

Portugal

POR

Sweden

8

8

16

SWIT/ISR

EANS

SWIT

Portugal

8

7

15

SWE/POR/CRO

POL/SWIT

Israel

Switzerland

9

5

14

Germany

ISR/CZE/TUR

Croatia

Israel

9

4

13

CZE/TURK

CRO/SLO

CZE/TURK

Croatia

8

3

11

Slovenia

Germany

Germany

Czech Republic

5

4

9

Turkey

5

4

9

Germany

6

1

7

Slovenia

3

3

6

Slovenia

RCS: regional complexity score; RCS-O: RCS Organizational score; RCS-C: RCS Components score; RCS-G: Global RCS score; EA: EANS; POL: Poland; SWE: Sweden; POR: Portugal; SWIT: Switzerland; ISR: Israel: CRO: Croatia; CZE: Czech Republic; SLO: Slovenia; TURK: Turkey.

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Weaknesses in the certification process in the European region identified through the results of this study include: 1. National examinations: Three of the countries responding to this study (Belgium, The Netherlands, and Norway) have no national written or oral examination of any kind, but instead use the EANS examination process. 2. Computerization: Only 1/12 examinations—the Czech Republic national examination— uses a computerized or Web-based format, although EANS, Poland, and Turkey have expressed intent. This is unfortunate considering that “[neurosurgery] is a field where computerized standard examinations have enormous promise for assessment and educational purposes” (18). 3. Recertification: Turkey is the only responding country with a recertification plan already in place, although Portugal and the UK have expressed intent. Although Secretary-General of the European Union of Medical Specialists in Brussels asserts that “there is . . . little substantial evidence that periodical recertification of individual doctors improves the general quality of health care,” he also notes that in Europe, in particular, public assumption of doctors’ competency is fading, and “doctors [now] have to prove their competence” (16). In addition, the WFNS and EANS guide for good neurosurgical practice reminds us that one of our primary obligations to patients and to society in general is to “. . . maintain and improve our surgical skills through regular practice, and by keeping up to date with progress in neurosurgery, and related scientific and clinical skills” (27). Perhaps periodic recertification is the best way to ensure that this standard is upheld. 4. Clinical or OSCE components: Only 3/12 examinations use a clinical or formal OSCE component: Portugal, Sweden, and the UK. 5. Written board prerequisites: not present or not specified in 7/12 examinations. 6. Surgery, productivity: Portugal and Sweden are the only countries with examinations that evaluate aspects of either live surgery or the use of instruments. Goals for future development of the neurosurgery certification process in the European region should include the institution of national examinations with both written and oral components in all countries, the incorporation of higher level test components in all examinations (e.g., clinical or OSCE components and live surgery or instruments components), the establishment of recertification plans for each country, and the use of computerized or Web-based standardized examination formats. Finally, we would like to stress that the RCS score is a newly created matrix for this article series, exclusively to measure the complexity level of a certification process, thus the correlation between RCS score achieved by a society

REFERENCES

and the quality of the educated neurosurgeons within it should not be established. To infer that better quality of training translates into a higher RCS score is a simplification that could undermine its value as an educational reference.

ACKNOWLEDGEMENTS European Association of Neurological Societies: Kristina G. Cesarini, M.D., Ph.D., Chairman of the EANS Examination Committee and Senior Consultant and Director of Postgraduate Training, Department of Neurosurgery, University Hospital, SE-751 85 Uppsala, Sweden Belgium: Prof. Dr. Dirk Van Roost, Secretary, Belgian Society for Neurosurgery Croatia: Pavle Miklic, M.D., Ph.D., Secretary, and Jospi Paladino, M.D., Ph.D., President, Croatian Neurosurgical Society Czech Republic: Vladimír Beneš, M.D., Ph.D., President, Czech Neurosurgical Society Germany: Prof. Dr. med. W. I. Steudel, President, Neurochirurgische Akademie, Klinik fur Neurochirurgie, Universitatsklinikum des Saarlandes, Homburg/Saar, Germany Israel: Zeev Feldman, Secretary, Israel Neurosurgery Society The Netherlands: Dr. G. J. Bouma, neurochirurg, secretaris Nederlandse Vereniging van Neurochirurgen, Academisch Medisch Centrum ¨ uller, M.D., Ph.D., President of the NorweNorway: Tomm B. M gian Neurosurgical Society Poland: Prof. Tomasz Trojanowski, M.D., Ph.D., Senior Delegate, Polish Neurosurgical Society Portugal: Joao Paulo Farias, Secretary, Portuguese Neurosurgical Society Slovenia: Marjan Korsic, M.D., President, Slovenian Neurosurgical Society Sweden: Lars Kihlstrom, M.D., M.B.A., Department of Neurosurgery/Research & Development, Director postgraduate education, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Switzerland: Hans Landolt, M.D., Swiss Society of Neurosurgery Turkey: Associate Professor Dr Agahan Unlu, Turkish Neurosurgical Society United Kingdom: Owen Sparrow, ICE Chairman, Education Committee, Society of British Neurological Surgeons

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18. Long DM: The ideal neurosurgical training curriculum. Acta Neurochir Suppl 90:21-31, 2004.

25. Solomon RA, Mayer SA, Tarmey JJ: Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. Stroke 27:13-17, 1996.

12. Haase J: The European examination—its present status and potential development. Acta Neurochir Suppl 90:107-114, 2004. 13. Hoff JT, Eisenberg HM: Assessment of training progress and examinations. Acta Neurochir Suppl 69:83-88, 1997. 14. Hovind KH: Norway. Child’s Nervous System 6 (Suppl):S38-S39, 1990. 15. Lebkowski J: Perspectives in international neurosurgery: neurosurgery in Poland. Neurosurgery 14:505506, 1984. 16. Leibbrandt CC: Is there a need for periodical recertification? Acta Neurochir Suppl 78:175-176, 2001.

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1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Appendix 1. Survey Sent to Societies and Corresponding Goals for Each of the 13 Items Presented in the Questionnaire Questionnaire Items

Goal

1. Year of implementation of National/Society written examinations for neurological surgery and requirements (not applicable for countries in which examination does not exist)

To review the experience of the National Board in conducting examinations.

2. Who is eligible to take the examination/s? 3. Do you evaluate the practice of trained neurosurgeons for certification process (e.g., outcome evaluation of a representative number of surgical cases before or after the oral examination? If you do not, do you foresee a near-future implementation?

To review the eligibility and requirements of the examinees to participate in the examination process

4. Examination format (multiple choice or otherwise, number of questions, allotted time) 5. Percentage of questions per topic, including its variations per year if there have been changes in those percentages (intended format and percentage if examination does not yet exist) 6. Is there a plan to implement Oral Examination held in your country by member societies?

To review the written and oral examination components, duration, and characteristics

7. Are colored pictures, imaging, or slides presented in picture format for the questions? (indicate intent to include these in examination if they are currently not used) 8. Is there a plan to perform the examination in computerized or internet-based format instead of written?

To review the current and future use of technology in the examination

9. Number of examinees and passing rates per year since 2000 (not applicable for countries in which examination does not exist)

To review the global and topic-specific examination performance with data from the past 8 years

10. Is it a compulsory examination? 11. Is the process of examination compulsory to be able to work in your country? If it is not compulsory, will it be in the future and have a retroactive effect in already practicing neurosurgeons (e.g., a practicing academic neurosurgeon who finished residency 10 or 5 years ago will be required to take the examination to continue working)?

To review the effect of the examination on the National Workforce and retroactive effect of recently implemented examinations

12. Which countries does your health system recognize as trained neurosurgeons without need to take examination? Which are required to take the examination?

To review the validation and reciprocity with other countries

13. Is there a current or future plan for recertification for Board Certified neurosurgeons?

To review the current and future plan for recertification of neurosurgeons

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