The advantages of European accreditation in thoracic surgery

Challenges for European harmonization

Europe, a continent with more than 447 million inhabitants in 2021, has a long history of conflicts fueled by ethnic, cultural, linguistic, and religious diversities amongst peoples. On the one hand, these fundamental differences make Europe unique and attractive for traveling and visiting the continent in peacetime to discover the beauty of its diversity. On the other hand, these diversities form an enormous challenge for our daily way of living together in Europe.

The European Union (EU) is a unique partnership in which member states have pooled sovereignty in certain policy areas and harmonized laws on a wide range of economic and political issues. The EU is the latest stage in a process of European integration begun after World War II, initially by six Western European countries joining the European Economic Community (EEC) in 1957, to promote peace, security, and economic development. The EU is largely viewed as a cornerstone of European stability and prosperity. The EU currently consists of 27 member states. EU members share a customs union; a single market in which goods, services, people, and capital move freely (known as the “four freedoms”) (1).

Health care in Europe belongs to the responsibility of individual sovereign member states

Up to date, each sovereign member state in Europe is still responsible for organizing its own health care system. However, as a consequence of the single European market, doctors have the rights to practice in other EU countries (EU Directive 2004/38/EC). Furthermore, according to this directive patients have the freedom to seek for cross-border health care. In addition, another Health Care Directive (2011/24/EU) stipulates the rights of EU patients. The latter entails guarantee of quality and security, informed choice and conditions form reimbursement in their home country.

In order to guarantee quality and security for the users of health services (patients) across all member states, it is obvious that there is a need to harmonize medical training and post-graduate formation of health care providers. Although the undergraduate training of medical doctors has been regulated for all member states in accordance with the Bologna agreement to ensure comparability in the standards and quality of higher-education qualifications, there is no EU directive or ministerial agreement between all member states yet defining the format of medical training and assessment as well as continuous professional development (CPD) and continuous medical education (CME) of general practitioners and other medical specialists.

In order to develop harmonized models for the training of the next generation, there is a need for a European organization to guarantee high standards of clinical practice and improved care for patients throughout Europe. So far, the European Commission has not set up any formal structure such as a European agency to organize and control these objectives by itself.

The European Union of Medical Specialists (UEMS)

The “Union Européenne des Médecins Spécialistes (UEMS)” was founded in 1958 in Brussels, Belgium, shortly after the treaty of Rome was signed in 1957 creating the EEC as precursor of the EU (2). According to its first statutes, the fundamental role of the UEMS as a non-profit, non-governmental and independent organization was to promote the highest standards of training, practice and patient care for all medical specialties in Europe for the benefit of the health of all European citizens. With the same objectives, but 10 years later, the “Union Européenne des Médecins Omnipracticiens—European Union of General Practitioners (UEMO)” was founded in 1967 in Brussels, Belgium (3).

The UEMS as an organization currently represents 40 National Professional Associations with delegates from member states all over Europe [including Norway, Liechtenstein, Iceland, Switzerland, UK; all belonging to the European Economic Area (EEA) as well as a number of countries with observer status] (2). The history and the structure and bodies of UEMS has been written down more extensively in a previous document published by the same authors (4). Currently, 43 specialist sections with over 19 divisions and 16 multidisciplinary joint committees (MJC) have been created to promote and defend the interest of all specialties at the European level. Every specialist section needs to create a board as a working party.

Being the largest and oldest European medical organization, the UEMS has gained significant influence on European institutions and provides its expertise to a wide range of stakeholders. As an example, the UEMS is involved as expert in the development and continuous update of the EU Directive 2005/36/EC on professional qualifications (5,6). This directive was installed to compare the minimum medical qualifications, i.e., training standards of doctors wanting to practice medicine in another member state than the country issuing the certificate of completion of training.

The UEMS has committed itself to contribute to the improvement of medical training at the European level through the development of European standards in the different medical disciplines supporting their boards at 4 levels: (I) medical education (knowledge, skills, and attitude); (II) competence-based training and assessment; (III) evaluation of continued competence at the European level; and (IV) organizing European examinations.

In order to support these 4 different actions and to harmonize and structure their functioning, the UEMS Council has created several advisory bodies and taskforces and published working documents: (I) the publication of a “Charter on Training of Medical Specialist” as a general guiding principle to develop a curriculum resulting in a specific basic European Training Requirement (ETR) for each specialty reflecting modern medical practice and current scientific findings. This action is overseen by the European Training Requirements Committee; (II) the establishment of the European Council for Medical Specialist Qualifications (ECAMSQ) with the aim to establish a comprehensive mechanism of appraisal of knowledge, skills and professionalism of post-graduate medical trainees; (III) the establishment of the European Accreditation Council for CME (EACCME) as a coordinated system to provide appropriate credits (hours) for CME-CPD activities of international meetings at a European level and in an agreement also for North American (USA and Canada) meetings; (IV) the establishment of the Council for European Specialists Medical Assessment (CESMA) as a body to provide recommendation and advice on the organization of examinations at a European level.

A fifth action to be developed by the Boards is the appraisal and accreditation of trainers and training programs. Currently, this task is left to the initiative of the board of the individual specialties. No specific structure has been created within UEMS so far to develop a standard to harmonize and structure this action at a European level.

The UEMS Section of Thoracic Surgery

As a result of the growing identity of thoracic surgery as a special competence reflected by the recognition as a mono speciality in over one third of the EU member states, the UEMS council approved the creation of the UEMS Section of Thoracic Surgery in 2013 (7). The need for this new section representing specialists with a surgical practice mainly dedicated to general thoracic surgery was supported by a document on the Structure of General Thoracic Surgery in Europe jointly published in 2001 (8) and updated in 2014 (9) by the leadership of the European Society of Thoracic Surgeons (ESTS) and the European Association for Cardio-Thoracic Surgery (EACTS). The long history on the creation of this section as an independent body within UEMS has been outlined extensively in our previous publication (4). Professor emeritus Dr. T Lerut was elected as the first president of this new section.

Within the UEMS Section of Thoracic Surgery, a Board of Thoracic Surgery [European Board of Thoracic Surgery (EBTS)] has been established as of 2013 issuing a certificate of fellow of the European Board of Thoracic Surgery (FEBTS). This board is currently presided by professor Dr. Gilbert Massard. By the end of 2021, 148 thoracic surgeons from various European countries have obtained the FEBTS certificate (Figure 1).

Figure 1 The certificate of fellow of the European Board of Thoracic Surgery.

Why do you need an accreditation as thoracic surgeon working in Europe?

Training in the specialty of thoracic surgery is structured differently in all European countries as was illustrated in a survey amongst national delegates of the Section of Thoracic Surgery (10). Diversity was observed in length of training (5–10 years), in exposure to pure thoracic surgery during the training period (2–5 years), in the national authority issuing the Certificate of Completion of Specialist Training (CCST), and in the number of required operations as 1^st surgeon during training (none–1,000 interventions).

Currently, the CCST and the license to practice thoracic surgery is issued by a national competent authority in line with the sovereignty of the individual member state. So one could ask the question, “why do I then need another label to practice thoracic surgery in my own country?”. It is correct that every thoracic surgeon has the freedom to move to another country. However, not every surgical sub-specialty (general surgery, thoracic surgery, cardiac surgery) is known and recognized by every member state. Therefore, the statement that “according to the EU Directive 2005/36/EC on Professional Qualifications, my national CCST will lead to an automatic recognition of my professional qualification and therefore I can obtain a license to practice in another EU member state”, is not entirely correct.

For instance, in Belgium, “thoracic surgery” is not recognized as a competence (only “general surgery” is known by the authorities) and therefore a CCST label as “Thoracic Surgeon” for a specialist trained in, e.g., Italy will not suffice to apply for a license to independently practice thoracic surgery in Belgium. A specific period of further supervised training in “general surgery” will be needed prior to obtaining the CCST label as “general surgeon” needed to apply for a license to practice thoracic surgery in Belgium.

In general, a UEMS Board exam cannot overrule the national exit criteria to obtain the CCST. Regulations, however, may differ across countries and specialties, e.g., the national exit exam in thoracic surgery in Switzerland has been replaced by the UEMS EBTS exam as one part in the process of obtaining the CCST in this country.

Since the UEMS is not an official European Commission-related competent authority, the EBTS fellowship is to be considered an extra “quality label” on top of the national CCST when applying for a job in any European country (including the country of training).

Importantly, this quality label serves as a recognition of competence recognized by peers matching with the UEMS EBTS quality requirements, but does not replace the national or equivalent CCST needed to obtain a license to practice in any European country.

The UEMS Section of Thoracic Surgery has expanded the EBTS activities allowing non-EU surgeons practicing thoracic surgery to apply for an international fellowship [MEBTS (Int), FEBTS (Int)]. Such an international FEBTS will offer a quality label that may be of added value, in particular in countries in the developing world.

EBTS exams

The entire regulations of the UEMS Board of Thoracic Surgery as approved by the national delegates are listed in the supplementary appendix (Appendix 1).

A summary answering pertinent questions posed by future applicants can be read below:

What is objective of the EBTS exams?

To purpose of the EBTS exams is to evaluate by a committee of peers the knowledge, skills, attitude, and competence in thoracic surgical practice acquired by the candidates. The diploma certifies that the successful applicant has reached a satisfactory level of knowledge and judgement for safe clinical practice in Europe.

What is format of the EBTS exams?

The UEMS European Board of Thoracic Surgery once a year offers a two-part examination:

Part 1 is a MCQ-based written examination with a single best answer designed to test whether the knowledge, clinical judgement, and application of principles matches with the standards expected to start practicing thoracic surgery as an independent specialist. This exam can be taken immediately upon graduation after obtaining the national CCST or to apply for the CCST when passing the EBTS exam is required by the national authority.

This is a written examination with 2×45 MCQs. Pass mark is a mean of 6/10. The official language is English.

The successful candidate will be admitted to the Membership of the European Board of Thoracic Surgery (MEBTS).

Part 2 is an oral examination in the objective structured clinical examination (OSCE) format open to MEBTS after a minimum of 2 years of independent practice. It tests whether the extend of knowledge, clinical judgement, professional attitudes, and application of principles matches with the level expected from an autonomous and independently practicing thoracic surgeon.

This is a 4-part oral examination with multiple scenario-based clinical questions scored by examiners working in teams, with 2 examiners per team. For each of the 4 teams, each examiner discusses 2 scenarios with 3 questions each; both examiners of each team mark independently. Pass mark is a mean of 6/10. The official language is English.

The successful candidate will be admitted to Fellowship of the European Board of Thoracic Surgery (FEBTS).

How to prepare for the EBTS exams?

The training syllabus (11) describing the mandatory and optional knowledge modules and the training curriculum (12) describing the mandatory and optional competences and procedural skills in thoracic surgery have been published previously.

To prepare for Part 1 exam assessing knowledge in thoracic surgery with MCQ’s, standard textbooks would suffice (ESTS textbook of Thoracic Surgery, Pearson’s General Thoracic Surgery, Sugarbaker’s Adult Chest Surgery, and others). Preparatory courses for future applicants are being organized in close collaboration with the European Scientific Thoracic Societies (ESTS & EACTS) offering regular knowledge courses in person or online through webinars. Questions mainly focus onto the mandatory items as described in the syllabus.

To prepare for Part 2 exam assessing knowledge, clinical reasoning, non-technical skills, and decision making based on clinical case vignettes, regular attendance to specific teaching sessions at the annual meetings organized by (cardio)thoracic societies [ESTS, EACTS, Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS)], as well as reading the main journals of our specialty on a monthly basis, is advised.

How and when to apply for the EBTS exam?

Application requirements to take EBTS exams are listed in detail in the appendix. Documents need to be uploaded by the deadline on the UEMS Section of Thoracic Surgery website (www.uemsthorax.eu). Files will be submitted to a peer review by national delegates and observers of the Section to decide whether the candidate fulfils all criteria to be eligible for EBTS membership examination.

Application for Part 1 examination:

• Candidates should have completed the training curriculum and obtained the CCST with license to practice by the national authority in their county of training or practice;
• The training period is defined as a continuum of training including the generality of surgery and thoracic surgery;
• The duration of training period should be no less than 5 years.

Application for Part 2 examination:

• Candidates must have successfully passed the EBTS membership examination within the last 7 years; the European Board of Cardio-Thoracic Surgery (EBCTS) membership certificate is accepted as equivalent;
• Candidates should have been in independent practice for at least 2 years, as certified by their head of department.

What are the advantages of European Accreditation in Thoracic Surgery?

The FEBTS credential behind the name of any thoracic surgeon:

• Adds a European quality label in addition to the national CCST as recognized by peers;
• Certifies that the fellow fulfills the high standards of knowledge, competence and skills considered necessary to practice thoracic surgery at a European level;
• Yields an added value for colleagues searching for European mobility;
• May be of help in liability issues when practicing thoracic surgery;
• The FEBTS (Int) will be of added value for colleagues born and practicing in non-European countries, in particular in the developing world.

Conclusions

The UEMS Section and the European Board of Thoracic Surgery were created in 2013 to harmonize the postgraduate medical education and assessment of trainees, the professionalization of their trainers, and the CME and CPD of thoracic surgeons in order to guarantee high standards of thoracic surgical practice and improved care for patients in all member states throughout Europe.

The Board assesses the qualification of fully trained European thoracic surgeons in a two-part examination. This fellowship adds a European quality label in addition to the national diploma of any thoracic surgeon, also outside the EU.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Francesco Guerrera and Anna Elisabeth Frick) for the series “Training and Education in Thoracic Surgery: the European Perspective” published in AME Surgical Journal. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-22-4/coif). The series “Training and Education in Thoracic Surgery: the European Perspective” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. European Commission. Single market and standards. Available online: https://ec.europa.eu/growth/single-market_en (accessed January 15, 2021).
2. Union Européenne des Médecins Specialistes/European Union of Medical Specialists. Available online: http://www.uems.eu (accessed January 15, 2021).
3. Union Européenne des Médecins Omnipracticiens/European Union of General Practicioners. Available online: http://www.uemo.eu (accessed January 15, 2021).
4. Lerut T, Van Raemdonck D, Massard G. Why do we need harmonization in thoracic surgery: a view from above by the European Union of Medical Specialists. J Thorac Dis 2021;13:2021-8. [Crossref] [PubMed]
5. European Commission. Recognition of professional qualifications in practice. Available online: https://ec.europa.eu/growth/single-market/single-market-services/free-movement-professionals/recognition-professional-qualifications-practice_en (accessed January 15, 2021).
6. Professional Qualifications Directive. Available online https://www.uems.eu/__data/assets/pdf_file/0013/1570/UEMS_News_2013.01.en.pdf (accessed January 15, 2021).
7. The UEMS Section of Thoracic Surgery. Available online: http://www.uemsthorax.eu (accessed January 15, 2021).
8. Klepetko W, Aberg TH, Lerut AE, et al. Structure of general thoracic surgery in Europe. Eur J Cardiothorac Surg 2001;20:663-8. [Crossref] [PubMed]
9. Brunelli A, Falcoz PE, D'Amico T, et al. European guidelines on structure and qualification of general thoracic surgery. Eur J Cardiothorac Surg 2014;45:779-86. [Crossref] [PubMed]
10. Depypere LP, Lerut AE. Thoracic surgical training in Europe: what has changed recently?. Ann Transl Med 2016;4:89. [Crossref] [PubMed]
11. Massard G, Tabin N, Mitchell S, et al. A harmonized European training syllabus for thoracic surgery: report from the ESTS-ERS task force. Eur J Cardiothorac Surg 2018;54:214-20. [Crossref] [PubMed]
12. Massard G, Tabin N, Konge L, et al. Training curriculum for European thoracic surgeons: a joint initiative of the European Society of Thoracic Surgeons and the European Respiratory Society. Eur J Cardiothorac Surg 2020;57:418-21. [Crossref] [PubMed]