Original Article

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Neurosurgery Training in Greece 79
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Q6 Theodosios Spiliotopoulos1, Adamantios Kalogeras1, Nathan A. Shlobin2, Anastasia Tasiou1, Thanasis Paschalis3,
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8 George A. Alexiou4, Moschos Fratzoglou5, Theofilos S. Paleologos5, Panagiotopoulos Vasilios6, Aristeidis Prassas7, 82
9 Q2 Parmenion P. Tsitsopoulos8, Konstantinos Vlachos9, Spyridon Voulgaris4, Gail Rosseau10,11, Kostas N. Fountas1 83
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15 INTRODUCTION 89
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- INTRODUCTION: The structure and specifics of neuro- 90
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surgery residency training vary substantially across pro-
grams and countries, potentially leading to differences in
clinical reasoning, surgical skills, and professionalism.
The Greek neurosurgical training system is unique in
G lobal neurosurgery is an emerging field at the intersec-
tion of neurosurgery and global health that seeks to in-
crease access to equitable, safe, and timely neurosurgical
care through practice, research, advocacy, and education.1-3 As
awareness of the importance of sustainable action in global
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numerous respects. This manuscript delineates the current 97
24 state of neurosurgical residency training in Greece and neurosurgery has expanded; neurosurgeons have increasingly 98
25 focused on improving the availability and quality of neurosurgical 99
outlines future directions.
26 training worldwide.4,5 100
27 The structure and specifics of neurosurgery residency training 101
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- METHODS: A narrative review was conducted to 102
29 describe the Greek neurosurgical residency training varies considerably across countries and even across programs within 103
30 structure. The perspectives of the authors regarding chal- the same country, potentially leading to differences in clinical 104
31 reasoning, surgical skills, and professionalism, with a subsequent 105
32
Q3 lenges in training and future directions were synthesized. 106
33
impact on the quality of patient care.6-8 Recently, investigators have 107
34 - RESULTS: This manuscript describes the neurosurgery sought to characterize the state of neurosurgical training on the level 108
35 residency curriculum and board certification process, of countries, including Haiti, Iceland, Albania, the Democratic Re- 109
36 110
existing training programs, and key challenges in neuro- public of the Congo, Somaliland, and others.9-13 The Greek neuro-
37 111
38 surgery residency training in Greece. The authors propose surgical training system has been relatively unchanged over several 112
39
future directions to reform neurosurgical training in decades and is unique in this regard relative to other European and 113
40 North American residency models. 114
41 Greece. 115
42 In this review, we describe the neurosurgery residency curric- 116
43 - CONCLUSIONS: Neurosurgery residency training in ulum and board certification process, existing training programs, 117
44 and key long-lasting challenges in neurosurgery residency training 118
45
Greece has been largely unchanged for many years. This 119
46 review leads to suggested modification of the existing in Greece. This study led to a proposal for low-cost modifications 120
47 training process may improve the quality of training and and structural changes to neurosurgical residency training in 121
48 Greece. In addition to providing an in-depth look at residency 122
49 equip neurosurgeons to respond to the rapidly changing 123
training and associated challenges in the Greek context, this
50 landscape of the field. 124
51 manuscript may serve as a guide to other countries that seek to 125
52 reform their neurosurgical residency training pathways. 126
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64 From the 1Department of Neurosurgery, University Hospital of Larissa, School of Medicine, School of Medicine and Health Sciences, Washington, District of Columbia, USA; and 11Barrow 138
65 University of Thessaly, Larissa, Greece; 2Department of Neurological Surgery, Northwestern Global, Barrow Neurological Institute, Phoenix, Arizona, USA 139
66 140
University Feinberg School of Medicine, Chicago, Illinois, USA; 3Division of Neurosurgery, To whom correspondence should be addressed: Theodosios Spiliotopoulos, M.D.
67 141
Department of Clinical Neurosciences, University of Cambridge, Cambridge, Cambridgeshire, [E-mail: spilteo90@gmail.com]
68 142
UK; 4Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece;
69 5 Citation: World Neurosurg. (2024). 143
70 Department of Neurosurgery, General Hospital of Nikaia-Piraeus, Athens, Greece; 144
6
Department of Neurosurgery, University Hospital of Patras, Rion-Patras, Greece; 7Department https://doi.org/10.1016/j.wneu.2024.01.064
71 145
72 of Neurosurgery, Papageorgiou General Hospital, Thessaloniki, Greece; 8Department of Journal homepage: www.journals.elsevier.com/world-neurosurgery 146
73 Neurosurgery, Hippokratio General Hospital, Aristotle University of Thessaloniki School of Available online: www.sciencedirect.com 147
74 Medicine, Thessaloniki, Greece; 9Department of Neurosurgery, ’KAT’ General Hospital of 148
Attica, Athens, Greece; 10Department of Neurological Surgery, George Washington University 1878-8750/$ - see front matter ª 2024 Elsevier Inc. All rights reserved.

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149 Q4 OVERVIEW OF NEUROSURGERY RESIDENCY TRAINING IN GREECE (75.0%) of the full neurosurgery residency programs are in the 2 223
150 224
largest cities in Greece, Athens and Thessaloniki. There are only 4
151 225
152
Structure training centers that provide coverage for the remainder of the 226
153 The duration of neurosurgery residency in Greece is 7 years. In- country, all traditionally affiliated with medical schools (Figure 2). 227
154 dividuals must complete a 12-month internship in general surgery 228
155 that is not supervised by a neurosurgery department. Then, they 229
156 Application 230
157 must complete 6 months of neurology and 66 months of neuro- 231
158 surgery. During that 66 month period, residents may participate in The process of entering neurosurgical residency requires medical 232
159 a rotation of up to 6 months or less in other services, including graduates to register themselves into the central waiting list 233
160 maintained by the Ministry of Health and list hospitals they would 234
161
pediatric surgery, plastic surgery, vascular surgery, or thoracic 235
162 surgery.14 Moreover, becoming a board-certified neurosurgeon like to train at in descending order. Candidates may list any 236
163 requires the completion of an 11e12 month mandatory service in a program that they choose. Once slots for the candidates’ prefer- 237
164
rural medical facility of the National Health System, either prior to ences open, they are assigned to that position and can begin 238
165 residency training. 239
166 residency, immediately succeeding it, or a combination of both 240
167 (Figure 1).14 241
168 242
169 Evaluation 243
170 There are no exams or other official assessments during residency. 244
171 Regulation and Existing Residency Programs However, upon completion of the 7-year period, each resident 245
172 The neurosurgery residency training system in Greece is exclu- takes the final board examination. The examination consists of a 246
173 247
sively regulated by the Ministry of Health. A total of 21 residency written multiple-choice component and an oral exam before a
174 248
175 programs exist throughout the country. Of these, 16 have been three-member committee appointed by the Ministry of Health, 249
176 approved by the Ministry of Health to provide complete 7-year consisting of an academic neurosurgeon and 2 attending neuro- 250
177 neurosurgical residency training, while the remaining de- 251
178 surgeons from the National Health System.14 Each resident may 252
179 partments offer 1e2 years of neurosurgery training. A total of 12 take the final exam up to 3 times. If a resident fails the 253
180 examination 3 times, then they must complete an additional 6- 254
181 255
182
month period of training in a nonfunded capacity in a different 256
183 residency program. 257
184 258
185 259
186 FINAL BOARD EXAMINATION Fellowship 260
187 261
As in most European countries, there are no fellowship positions
188 262
189 for sub-specialty training, and funding is lacking. Junior neuro- 263
190 surgeons who seek to sub-specialize must complete fellowships in 264
191 other countries. 265
192 266
193 267
194 268
195 LIMITATION OF EXISTING NEUROSURGERY RESIDENCY TRAINING 269
AFTER COMPLETING A
196 IN GREECE 270
197 MANDATORY 271
198 Selection of Residents 272
199
NINE-MONTH RURAL 273
Programs have no right to request medical transcripts or curricula
200 SERVICE AT ANY POINT 274
201 vitae, assess knowledge, or conduct interviews. This is particularly 275
202 uncharacteristic of the rest of the process, given that there is a 276
203 277
204
highly competitive national matriculation test for medical school 278
205 and frequent difficult examinations throughout medical school. 279
206 Once slots for the candidates’ preferences open, they are assigned 280
207 to that position and can begin residency training. Program di- 281
208 282
209 rectors or other faculty have no input regarding which residents 283
210 are selected. In theory, residents may begin their residency 284
211 without previously meeting any of the faculty. A lack of rapport 285
212 286
213
between residents and attending neurosurgeons may compromise 287
214 clinical care due to the absence of trustworthy relationships and 288
215 generate an unpleasant culture within neurosurgical departments. 289
216 290
The lack of selection criteria in conjunction with minimal
217 291
218 exposure to neurosurgery during medical school has resulted in 292
219 the resignation of many neurosurgical residents once the rigors of 293
220 neurosurgery residency become apparent. Residents may also 294
221 Figure 1. Schematic representation of the process from medical school 295
222 graduation to complete neurosurgical residency in Greece. transfer into a different program without the consent of the pro- 296
gram director.

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297 political, and economic contexts. However, the medical 371

298 372
associations have no role in designing or evaluating residency
299 373
300 programs, preventing incorporation of the local contexts. 374
301 375
302 376
303
Training Structure and Components 377
304 Residents may begin residency training at any point during the 378
305 year, irrespective of the current resident contingent, needs of the 379
306
training program, or existing workflows. The flow of residents 380
307 381
308 into the program may be obstructed due to bureaucratic issues, 382
309 further affecting the long-term planning and distribution of 383
310 training opportunities. Residency programs may have an excess of 384
311 385
312 residents at the same level of training. 386
313 Neurosurgery residency programs in Greece lack learning ob- 387
314 jectives, syllabi, and required activities. The Ministry of Health 388
315 389
316
maintains an outdated and ill-defined core training curriculum but 390
317 lacks a roadmap of milestones for each year of training. There are 391
318 no clearly defined minimum required cases per pathology or type 392
319 of approach, with case numbers worsened by the COVID-19 393
320 394
321 pandemic.15 However, residents are recommended, but not 395
322 required, to maintain a case log. The European Association of 396
323 Neurosurgical Societies logbook has been adopted in many 397
324 398
325
programs. Moreover, when residents lack sufficient exposure to 399
326 a given area of neurosurgery, such as functional, endovascular, 400
327 or pediatric neurosurgery, the existing system discourages 401
328 402
rotation through another service with a lack of allowance for
329 403
330 food or accommodation. Overall, the distribution of residents 404
331 Q10 Figure 2. Distribution of training programs in Greece. and catchment areas of programs may lead to high variability in 405
332 exposure among centers. 406
333 407
334 There is no financial support for participation in educational 408
335 courses, workshops, or conferences, electronic journals and da- 409
336 tabases is lacking due to the country’s financial crisis. 410
337 Role of Residents 411
338 Although there a total of 92 available residency positions, only 61 412
339 Evaluation 413
340
(66.3%) are currently occupied. There are a total of 112 trainers, 414
The Ministry of Health or another body does not evaluate the
341 including 17 academic and 95 National Health System attending 415
quality of residency programs. Program directors must evaluate
342 neurosurgeons, serving existing residency programs, yielding a 416
343 their own program. Additionally, the final examination and board 417
trainer:trainee ratio of 2:1. Moreover, the job descriptions of
344 certification process are vague, as the final examination is pass-fail 418
345 neurosurgery residents are vague, and their responsibilities are 419
only.
346 highly variable from center to center and often unclear. The lack of 420
347 a trauma surgery service and other fragmentation in the health 421
348 PROPOSED REFINEMENTS 422
349 system results in an overload of nonneurosurgical work for 423
350 residents. Neurosurgical residency training varies considerably across 424
351 Europe. The Greek system features many unique characteristics. 425
352 426
353 Regulation We propose a series of reforms to improve the quality of neuro- 427
354 The regulatory structure in Greece prevents independence and surgery residency training in Greece. 428
355 flexibility, as all training programs must follow rigid, unchanging 429
356 430
357 government directives. The specific needs of each residency pro- Governance 431
358 gram are frequently unknown or otherwise unmet by the Ministry Importantly, establishing an independent regulatory body to 432
359 of Health. In contrast, residency training in most European and oversee neurosurgical residency is essential in improving the 433
360 434
361
North American countries is regulated by an independent, quality of residency training. Independence will allow the regu- 435
362 nonprofit organization, which supervises the function and efficacy latory body to adapt quickly to changes in neurosurgical practice 436
363 of residency programs, periodically assesses compliance with and the needs of the population. The Hellenic Neurosurgical So- 437
364 438
existing educational standards, and provides direction for modi- ciety, regional medical associations, and the Ministry of Health
365 439
366 fications and restructuring when necessary. Additionally, Greece is may then support the regulatory body. The independent regulatory 440
367 divided by geography into 60 medical associations, and every body must have 3 primary functions: 1) facilitate allocation of 441
368 physician must be registered in the local medical association to qualified residents proportionate to the needs of the country, 2) 442
369 443
370 legally practice medicine.14 In theory, the regional medical standardize the residency curriculum and structure, and 3) eval- 444
associations have an understanding of regional needs and social, uate and reform residency programs.

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445 Resident Allocation the national neurosurgery board exam. To facilitate this process, a 519
446 520
The independent regulatory body should provide opportunities for realistic case logbook based on the Greek population must be
447 521
448 exposure to neurosurgery during medical school. The establish- created. Measures to facilitate involvement in at least the mini- 522
449 ment of a national mentorship network may allow medical stu- mum number of operations on specific pathologies or approaches 523
450 dents to participate in clinical experiences and research within required in the logbook, such as prioritization of resident 524
451 525
452 neurosurgery to a larger extent. Moreover, the independent reg- involvement in cases, must be taken. When residents are unlikely 526
453 ulatory body must make resident selection more rigorous to fit the to meet minimum case numbers in a subspecialty area, they 527
454 needs of programs while ensuring applicants are committed to the should be encouraged to rotate at other programs and provided 528
455 529
456
field. The implementation of an annual or bi-annual national ex- with sufficient financial support by their home program. In gen- 530
457 amination prior to beginning residency would stratify candidates eral, rotations at clinical sites apart from their residency program 531
458 objectively. During the residency application process, programs may inform them of differences in neurosurgical practice across 532
459 should have access to the medical school transcripts and curricula environments and provide them with more nuanced training. This 533
460 534
461 vitae of applicants. Incorporating an interview into the selection may provide the added benefit of allowing them to determine their 535
462 process would allow program directors to determine which ap- subspecialty interests. In certain cases, residents may be allowed 536
463 plicants would fit well into the program while allowing applicants to rotate through private hospitals, provided that appropriate legal 537
464 538
465
to determine which programs suit them. A short observership safeguards are used. 539
466 would allow program directors to assess the clinical skills of ap- The chronological points when residency may be started should 540
467 plicants and applicants to understand the workflow and everyday be standardized. This change will allow residency programs to 541
468 542
practice of the neurosurgery program. better coordinate the responsibilities of residents and ensure there
469 543
470 In addition, ensuring that residents remain in and complete is limited overlap between residents. It is important to note that 544
471 residency programs is important. The independent regulatory medical students may graduate at any point of the year. Utilization 545
472 body should create a forum in which residents may provide of 2 starting dates per year (e.g., September and March) may 546
473 547
474 feedback to their programs that is acted upon by program lead- minimize the lag time between medical school graduation and the 548
475 ership and encourage faculty to create a strong positive and beginning of residency. 549
476 educational culture in residency programs. Sufficient funding for A frequent complaint from residents is the absence of younger 550
477 551
478
educational experiences, conferences, and research will allow attending neurosurgeons on the teaching faculty. Most teaching 552
479 residents to engage in scholarly work that they may enjoy. personnel across residency programs are advanced in age, as there 553
480 Reducing barriers to balancing neurosurgical training with per- was a no hiring policy in public teaching hospitals from 2009 to 554
481 sonal responsibilities will reduce attrition. Fortunately, the 2019 due to the financial crisis in Greece. Allowing departments 555
482 556
483 parental leave allowance in Greece is generous.16,17 with residency programs to hire their own graduates or other 557
484 The independent regulatory body should consider mechanisms recent graduates as junior attending neurosurgeons would facili- 558
485 to increase the proportion of neurosurgery residency positions that tate a resident-friendly, educational environment and learning of 559
486 560
487
are filled. Although one aspect of this is recruitment and reten- different approaches to neurosurgical care. 561
488 tion, another is the distribution of residency programs across Lastly, the creation of funded fellowship positions in the 562
489 Greece. At present, neurosurgery residency training is quite frag- neurosurgical subspecialties may motivate residents to become 563
490 564
mented. The independent regulatory body may facilitate the specialists in an area of neurosurgery and improve the quality of
491 565
492 consolidation of existing duplicative programs into a smaller neurosurgical care. Centralization of certain subspecialty fellow- 566
493 number of programs covering Athens and Thessaloniki. Moreover, ships at a few hospitals may facilitate the formation of centers of 567
494 the establishment of residency programs outside of Athens and excellence. 568
495 569
496 Thessaloniki according to the needs of each constituent region 570
497 may assist in addressing the burden of neurosurgical disease. This 571
498 process should be based on meticulous evaluation of the coverage Evaluation and Reform of Residency Programs 572
499 The independent regulatory body must conduct annual meticulous 573
500
and scope of existing training programs and may require an in- 574
501 dependent organization. assessments of the quality of training across residency programs 575
502 based on predetermined benchmarks and incorporate anonymous 576
503 Residency Curriculum and Structure feedback from residents to determine which programs are effec- 577
504 578
The roles of residents must be clearly elucidated and standardized tively training residents and those that are not. Programs not
505 579
506 across programs to motivate residents and incorporate them meeting benchmarks should be provided with additional support 580
507 productively into the operations of neurosurgery departments. from the regulatory body, create a plan to meet benchmarks over 581
508 time, and abide by a stringent review process. 582
509
Redesigning the neurosurgery curriculum through the establish- 583
510 ment of key competencies by year of training and the subsequent 584
511 creation of a roadmap of milestones may provide residents and 585
512
program directors with direction regarding expected capabilities. CONCLUSION 586
513 587
514 Competencies may span clinical evaluation and reasoning, tech- The neurosurgery residency training system in Greece has 588
515 nical skills, and communication. Annual evaluation of these remained nearly untouched over many decades, leading to inad- 589
516 competencies may differentiate residents who are able to progress equate recruitment and selection, a poorly defined and unstan- 590
517 591
518 to the next year of training from those who require additional dardized core curriculum, and a lack of periodic evaluations to 592
support. All competencies must be mastered prior to sitting for facilitate improved and modernized residency training. Large-

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593 scale changes are required to transform the residency training and edit. Theofilos S. Paleologos: Review and edit. Vasilios Pan- 667
594 668
paradigm into a maximally educational and efficient model. agiotopoulos: Review and edit. Aristeidis Prassas: Review and
595 669
596 edit. Parmenion P. Tsitsopoulos: Review and edit. Konstantinos 670
597 CRediT AUTHORSHIP CONTRIBUTION STATEMENT Vlachos: Review and edit. Spyridon Voulgaris: Review and edit. 671
598 Rosseau Gail: Study conception and design, supervision and 672
599 Theodosios Spiliotopoulos: Material preparation, data collection 673
600 and analysis, drafting of the manuscript. Adamantios Kalogeras: analysis, critically revising the article. Kostas N. Fountas: Study 674
601 Review and edit. Nathan Shlobin: Review and edit. Anastasia conception and design, supervision and analysis, critically revising 675
602 the article. All authors commented on previous versions of the 676
603 Tasiou: Study conception and design, drafting of the manuscript, 677
604 supervision and analysis. Thanasis Paschalis: Review and edit. manuscript. All authors read and approve the final manuscript. All 678
605 George A. Alexiou: Review and edit. Moschos Fratzoglou: Review authors agree to be accountable for all aspects of the work. 679
606 680
607 681
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