Cardiothoracic training programmes in Europe – a mixed bag Miia Lehtinen

Cardiothoracic training programmes in Europe - a mixed bag

Miia Lehtinen, Jason Trevis, Abdul Badran

Further exploring how training happens elsewhere, following our article with the TSRA on the North American programme we reached out to European neighbors to see what pathways they have around the continent. Despite efforts to unify cardiothoracic training in Europe, a wide array of programmes with very different content and structure still exists even between neighboring countries. Moreover, no official international body or authority keeps track of these multiple programmes and numbers of trainees enrolled in them so any comparisons are challenging.

In an attempt to better understand the training in each European country, in a recent survey by EACTS completed by 219 trainees in 24 countries showed an interesting mix of training. Whilst in the UK, the Netherlands and Nordic countries, there is a cardiothoracic pathway the majority of respondents were enrolled in a cardiac only programme. This was largely down to the majority responders being from Germany, Austria and Switzerland, where cardiac and thoracic surgery are separate specialties. The same applies in Italy, Spain and Portugal.

Countries also have a variable need for preparatory general surgery rotations (often called “common trunk”) as well as in the number of procedures needed for training to be completed. In recent years, the length of the common trunk has been cut in many countries, with Germany abandoning it completely in 2018 and Finland reducing the minimum number of months required from 27 to 18 in 2020. This pattern has continued in the UK and Ireland with the new seven year curriculum shaving a year from the phase one of training and making rotations more cardiothoracic concentrated.

The majority of trainees in Europe have cumulative targets of procedures to complete before completion certification, with 60% of survey responders citing 75 to 150 procedures. However, there can also be marked variation within a country, with Finland and Denmark giving the discretion of procedures required to each individual training center. In the UK and Ireland there is a move away from the indicative numbers to a more competency based training system with the recognition of individual learning curves being variable. There is still a requirement of 250 cases with the majority being in the dominant specialty, however, certification can be considered with other evidence of competency achievement.

Most of the training programmes in Europe take 5-6 years in total with a written or oral national examination as the final imperative step before board certification. In Germany, board certification is governed on a regional rather than national level and in Russia, this responsibility lies with the individual training center. Interestingly almost a quarter of survey responders

stated no final examination was required to complete the program. Moreover, skills assessment was infrequent with just 35% of trainees reporting regular skills evaluation in their center. A stark parallel to the minimum mandatory WBAs required for each trainee in the UK and Ireland. Unsurprisingly European trainee satisfaction mainly centered around the total number of weekly theatre sessions and proportion of cases performed as first operator. Something that has also been echoed consistently with recent surveys in this country. Given the numerous challenges that cardiothoracic surgery as a specialty faces today, with the rapid development of catheter-based techniques and more complex patients referred for surgery, finding a uniform international template for training programmes in Europe remains dubious. “The majority of trainees in Fortunately, changes made to curricula in individual Europe have cumulative targets countries seems to be of procedures to complete following a common theme, with a greater focus of before completion certification, training programmes on an earlier cardiothoracic with 60% of survey responders experience. One way of ensuring citing 75 to 150 procedures.” uniform theoretical skills is the examination by the European Board of Cardiothoracic Surgery (EBCTS). However, with multiple training governing bodies at national, regional and each individual center unifying and standardizing the practical skills required is more demanding. International societies and collaborations will be a natural way forward in realizing these efforts improving training both for the sake of trainees and our patients.n