Orthopaedic surgery in Europe

France

I. Kempf



In the past French oéthopaedic surgeons have had to fight hard to obtain official recognition of their specialty. Although the French Orthopaedic Society was founded in 1918 and the first issue of Revue d'Orthopedie was published in 1890, the legal existence of this branch of surgeç dates from only 1949.
Men like Ollier, Mathieu, Ombredanne and Leveuf showed the way during the first half of this centuç, but they were orthopaedic surgeons with no interest in trauma surgery. It was not until after the Second World War that Robert Merle D'Aubigne and Robert Judet laid the foun- dations of modem French orthopaedic surgery including traumatology which until then had been in the hands of general surgeons and mostly neglected.
Merle D'Aubigne ensured that each surgical unit was divided into two parts, the first dedicated to visceral surgeç and the second to bone and joint surgery. Nowadays in France 95% of trauma surgery is perfonned by orthopaedic surgeons. The organisation of orthopaedic surgery in France is three-fold based on: the Socéete Franîaise de Chirurgie Orthopedique et Traumatologique (SOFCOT) which represents the scientific wing; the College Francais des Chirurgiens Orthopedistes et Traumatologues (CFCOT) which is dedicated to training; and the Syndicat National des Chirurgiens Orthopedistes, the professional Union. These three are grouped into the Federation Franîaise des Chirurgiens Orthopedistes. SOFCOT has 1406 French members and 498 foreign members.
It constantly reviews the present status of orthopaedic surgery. Its main event is the Annual Meeting held in November in Paris with up to 2000 participants. There are Instructional Lectures, round tables, `What's New', free papers and symposia which give the latest information on specific topics. The French College (CFCOT) was founded in 1977. Its members are orthopaedic surgeons including those in university hospitals, in general hospitals or in private practice. It is independent of the Government and the universities and can be compared to the American Board or the Royal Colleges in the UK. Its main role is to guarantee the quality of specialist training and to maintain the requirements of orthopaedic specialists in training (duration, content, theoretical instruction, practical clinical training, requirements for training centres, examinations, etc). These recommendations were adopted by the Government in the 1980s and are now the official rules for entrance to the specialty.
Nowadays, the College is active in organising courses, workshops and study seminars. It is the counsellor of the Govemment for all improvements and modifications to the training rules. For example, it was responsible for the extension of training to six years. Members are designated `Member of the French College of Orthopaedic and Trauma Surgeons' which, although not obligatory, is an attestation of a high level of education. Postgraduate education in orthopaedic surgeçry consists of a six-year programme of two years of general surgeç and four years of specialisation which include one obligatory semester in paediatric orthopaedics for those who are dedicated to adult orthopaedics and two semesters in adult orthopaedics for future paediatric orthopaedic surgeons. Most French orthopaedic surgeons practise either one or the other but very seldom both. The candidate is accepted for postgraduate education after a selective examination called Concours de 1'Intemat des Hüpitaux organised annually on a national level for a limited number of training places. The nominated candidate is an `Interne' for five years becoming an `Assistant' for a minimum of one year but usually two years, in what is called `Post - Internat'. During this period he must rotate between a minimum of two different clinics and spend some time in a paediatrics orthopaedic unit.
As mentioned before theoretical instruction runs in parallel with practical clinical training. Trainees interested in research can have an additional research year to obtain a `Diplüme d'¸tudes Approfon dies', i.e. a Diploma of Further Studies.
Assessment at the end of the training is by á Board Examination of practical and theoretical knowledge, case presentation and discussion and presentation of a scientific thesis. The official University Diploma of Specialist in Orthopaedic Surgeç is then awarded by the Faculte de Medecine. Man power is the most important problem managed by the Syndicat National des Chirurgiens Orthopedistes. In the last 20 years, the number of orthopaedic surgeons has increased dramatically in France due to the increased attraction and development of the specialty. At the present time, the estimated number is 1350, which is 2.26 per 100 000 inhabitants.
Each year 90 young surgeons start their professional career against 20 who retire. This is a serious imbalance; for the past two years, there has been a tendency to reduce the annual output to 60 young trainces. La Revue de Chirurgße Orthopedique et Reparatrßce de I'Appareil l.ocðmðteur is the most important and well-known French scientific publication in orthopaedics with a circulation of nearly 6000.
Like many others it has the problem of the predominance of English as the language of the scientific world. In particular, university careers are more and more determined by publication in the large English-speaking intemational journals. This evolution is dangerous because of the risk is the one hand of impoverishment of the French-speaking press and on the other of the selection of our scientific and university elite by the publishing committees of the English-language joumals. The French Revue has in the near future to solve two seemingly contradictoç problems. One is the necessaç opening into the English literature, and the other is not only the maintenance, but also the development, of publishing in the French language which is imperative from a scientific and cultural viewpoint.
This second goal is more easily attained because French orthopaedics is becoming more orientated towards French-speaking. SOFCOT was one of the founders of the Association des Orthopedistes de Langue Francaise (AOLF), the Association of French-speaking Orthopaedic Surgeons, which groups all orthopaedic societies which are exclusively or partially French- speaking. The traditional Spring meeting of SOFCOT has recently been abandoned in favour of the biennial congress of AOLF altemating with the EFORT Congress.

Belgium

L. Van den Daelen

The opening of frontiers within the European Union has meant that many countries are being confrðnted with requests to appoint foreign European surgeons but the quality of the trainßng and the value of the diploma are ðfien undðubtedly questionable. Belgian traßning has undergone an extensßve evðlution and is at the moment at an exceptiðnally high level.
For many years orthopaedic training in Belgium was, as in many other European countries, in an `apprentice-tutor' situation. A legal base did not exist: the `Orde van de Geneesheren - Ordre des Medecins' delivered a simple certificate. The RIZIV-INAMI (Rijksinstituut voorZiekte en Invaliditeitsverzekering Institut National d'Assurance Maladie - Invalidite) tried to draw up lists of recognised specialists. This nomination was rather more permission to use the title rather than a label of quality. At that time four years of train- ing by an appointed tutoô were sufficient to allow nomination as an orthopaedic surgeon, with no further tests or examination.
In 1958 five years of full-time residency were required and from I980 onwards training has been extended to six years (even until 1976 a part-time residency of EFORT and World Orthopaedic Concern - a Joint Effort Alain Patel - Vice-President WOC and Liaison Officer WOC-EFORT Geoffrey Walker - Past President WOC six to seven years was allowed). In 1970 a ministerial committee of orthopaedic surgeons was founded which until 1990 had a pro foin«a function. Its duty was mainly to accept the plan of the training and to verify whether the training scheme was being followed. It made no attempt to improve training or to have any control over it.
In 1987 Orthopaedåca Belgåca introduced an examination for residents in the fourth or fifth year combined with an interview at the end of the sixth year and from 1989 a Committee for Education and Comprehension was charged with the organisation of the orthopaedic traumatology residency on a national level. This committee was founded by and composed of the professors of the seven universities, the chairmen of BVOT and SOBCOT, and the Board Committee of orthopaedic surgeons. The chairman is an independent orthopaedic surgeon. At present it is Dr R. Thys.
At the moment the requirements to become an orthopaedic surgeon include six years of full-time training in an appointed department. For the Dutch-speaking part of the country at least two years must be spent at a university or an equivalent department and for the French-speaking part at least one year at a university service. At the end of training a paper must be presented. In addition, the resident must pass the examination of the Committee of Comprehension either in the third, fourth or fifth year of residency, and also an interview at the end of the sixth and final year. The universities organise day courses in orthopaedics and traumatology as a preparation for the Committee of Comprehension examination.
If a candidate has not fulfilled one or more of the above requirements, the Committee may prolong the residency by one or more years. It may also refuse the nomination. In 1994 a special committee was founded to judge the teaching qualities of the tutors and the quality of the training department.
Although training in Belgium is undoubtedly on a high level and comparable with that in su§ounding countries, from 1989 onwards it was no longer acceptable because of the lack of evaluation. The recent changes have made it possible to obtain a high-quality residency so that any intemational comparison is acceptable. The nineties will enter history as the years in which Europe opened its borders.
Since 1992, every orthopaedic surgeon has theoretically been free to obtain an appointment anywhere within the European Union, but in practice immigration has not been that simple and in some countries even impossible. Many countries try to close their borders and to legalise this self-protection, they resort to the differences in training or qualifications. If an `open' Europe is to be established in which every orthopaedic surgeon can work wherever he wishes, the first requirement is uniformity in training.
Professor Jacques Duparc concluded the first Presidential Address by reminding us of the need for the Federation to concem itself actively with orthopaedics in the developing world.
WOC was founded some 20 years ago for exactly this reason, and we believe that orthopaedic surgeons are best trained in their own countries, on their own patients and with the facilities available. The orthopaedics of less and of more developed areas have become as dissimilar as chalk and cheese and many of the sophisticated procedures now regularly perfom ed in developed areas are totally unsuitable where resources are minimal. Many `old-fashioned disorders' such as bone and joint infections, tuberculosis (often complicated by AIDS), poliomyelitis, and neglected trauma present commonly in developing countries, and fractures both open and closed arnve late. Surgeons trained in total joint replacement, spinal surgery, and osteosynthesis for fractures find their experience of little value in these circumstances and often re-emigrate, if indeed they have ever retumed home after completing training in a sophisticated centre.
WOC strives to avoid this problem by supporting appropriate training schemes in less developed parts of the world. This is often difficult, and there is no common pathway. The founders of WOC originally had the idea of relatively grand intemational efforts, but all of these foundered more or less completely. Effective schemes usually follow personal contact between a visiting orthopaedic surgeon and a doctor in a developing area who is seeking help. To follow up and develop these initial contacts WOC has found it more effective to function in regional groups. Thus, we have a US Region (also known as Orthopaedic Overseas), WOC Canada, UK, Ge§nany, Australia, South- East Asia, India, Holland and others. Alain Patel is currently secretary-general of a francophone group, supported in part by the French Govemment and using French- speaking volunteers from France and from countries outside the hexagon. We believe that this co-operation at an intemational level is very important and should be encouraged.
Each region is autonomous, and has to raise its own funds. Training programmes are also custom-made to suit local conditions and to produce appropriately trained orthopaedic personnel. For example, the scheme in Bangladesh founded by Dr Ron Garst in 1972 is now totally self-sufficient, and has produced over 150 orthopaedic surgeons, most of whom work in Bangladesh. Another example is the Malawi scheme, organised some ten years ago by Dr Ed Blair. In a country with a medical school only recently opened and with very few doctors, Dr Blair has trained very successfully over 50 orthopaedic clinical officers.
They can cope with trauma and with a large proportion of elective orthopaedics. There are now one or two of these excellent orthopaedic officers in all but one of the regional hospitals of Malawi. It is very much to be hoped that EFORT will continue to be an outward-looking organisation as well as involving itself in the problems of Europe.
The need for appropriately trained orthopaedic personnel, and appropriate material and books remains enom ous in the less-developed world. The need is there: can EFORT join with WOC in making a real effort?
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Created on 21-11-1996 at 19.00 by Nicola Vachaviolos