How to become Pediatric Orthopedic surgeon in Europe: a long journey offering a unique career,full of satisfactions

Federico Canavese

【Abstract】 In most European countries, Pediatric Orthopedic ( PO ) surgeons graduated from an approved Orthopedic and Trauma surgery training program which lasts 5 or 6 years, depending on the country. Upon completion of the Orthopedic and Trauma surgery program, the future PO surgeon must complete an additional subspecialty training ( one to two years, depending on the country ) in PO surgery. The possibility to become a certified PO surgeon through the specialization in Pediatric Surgery ( option Orthopedics ) or through a dedicated PO surgery training program only exists in France and in Romania, respectively. Credit as active and fully responsible PO surgeon can only be claimed when the trainee has actively participated in all phases of treatment, from diagnosis to treatment, without forgetting the management of complications and the setting up of an adequate follow-up of children and adolescents with musculoskeletal disorders.

【Key words】 Pediatric orthopedic surgery; Education, professional, retraining; Orthopedic procedures;Wounds and injuries; Europe

The field of pediatric orthopedic ( PO ) surgery encompasses the surgical care of the growing individual, from fetal life to the final stages of development, and it requires specialized knowledge and skills in managing congenital,acquired, traumatic and post-traumatic disorders of the musculoskeletal system.

The PO surgeon is a surgeon specifically trained in the care of children of different ages. Therefore, the training program must expose the trainee in PO surgery to an adequate number of patients and procedures of sufficient diversity and complexity. As a result, credit as active and fully responsible PO surgeon can only be claimed when the trainee has actively participated in all phases of treatment, from diagnosis to treatment, without forgetting the management of complications and the organization of an adequate follow-up for children and adolescents with musculoskeletal disorders. As a result, and this is valid for all medical and surgical specialties, the post-graduate training ( internship or specialization ) leading to the Diploma of Specialization ( DoS ) should give the trainee the opportunity to acquire sufficient theoretical knowledge as well as clinical and surgical skills that make him / her competent in all areas of the specialty[1].

In all European countries ( Fig.1 ) but France, it is not possible to practice as PO surgeon with a DoS in Pediatric Surgery, and it is necessary to obtain first the DoS in Orthopedic and Trauma surgery.

Fig.1 Map of Europe

In each European country, the DoS will be awarded, according to the national rules, only after final assessment of theoretical knowledge,clinical attitude and surgical skills; the duration of the surgical training( 5 or more years ) can vary from country to country. During the early years of the training program ( Basic module ) the trainee is expected to acquire a central core of basic knowledge and skills while the following years ( Advanced module ) are more specifically oriented towards the specificities of the Orthopedic and Trauma surgery, including some PO surgery; afterwards, the specialist can orient him / herself towards PO surgery ( Fellowship program ). Interestingly, during the past decade or so, the number of trainees completing additional subspecialty fellowships in addition to PO surgery has increased significantly, in both Europe and North America[2-3].

In most European countries, the medical studies, lasting 6 years, are sanctioned by a final exam. In Spain, for example, this examination gives direct access to the practice of general medicine. However, the entry into the surgical career, and more specifically the access to the Orthopedic and Trauma training, differs significantly across countries.Within the countries of the European Community, multiple options to join the training program in Orthopedic and Trauma surgery are available; in particular, the surgical training program can be integrated following ( 1 ) a national ranking examination organized once a year, like in France, Italy ( since 2014 ) or Romania; ( 2 ) a specific examination to enter the Orthopedic and Trauma surgery program, and later the training in PO surgery, like in Spain;( 3 ) an examination specific to each University of the country, like in Belgium ( 7 independent Universities ); ( 4 ) an interview with a specific commission, like in Switzerland; or ( 5 ) an interview with the head of department, like in Germany. In the event of an interview, the candidates must demonstrate their motivation as well as their propensity to clinical, surgical and research activities, and must present an attractive Curriculum Vitae to be accepted into the training program[4-6].

The duration of the internship ( specialization or post-graduate training ) to become a certified Orthopedic and Trauma surgeon is generally 5 years; however, in Germany, Belgium and Switzerland the training program lasts 6 years. However, the duration of the surgical training may be longer if the candidate is willing to carry out one extra year of research. Whatever the duration, the internship ( or its equivalent ) must provide the trainee enough theoretical knowledge, clinical competence and surgical skills to enable him / her to be component in the entire field of the specialty.

The training program is always concluded by a final exam that gives the DoS and the title of specialist in Orthopedic and Trauma surgery. However, the type of exam varies greatly among European countries; in particular,it ranges from a simple half an hour interview with the local academic team, like in Germany, to a formal exam with several pre-requirements including a dissertation ( Thesis ) and a given number of scientific publications, like in most European countries[4].

Concerning the training in PO surgery, at least one rotation in an accredited PO department is required to all trainees in Orthopedic and Trauma surgery in France, Italy and Portugal while it is simply recommended in Spain, and is optional in many other European countries. A formal PO surgery training program exists only in Romania where it includes two years and seven months in PO surgery, one year in Orthopedic and Trauma surgery ( adult departments ),one year in Pediatric Surgery, and five months in another surgical specialty ( thoracic surgery, neurosurgery, vascular surgery, … ). However, in most European countries the sub-specialization in PO surgery must follow the DoS in Orthopedic and Trauma surgery. Upon completion of the Orthopedic and Trauma surgery training program, two extra years in PO surgery are needed in France, one year and a half in Germany, two years in Croatia ( 3 out of 24 months must be spent abroad ), and two to three years in Switzerland[4-5]. Alternatively, and only after completing the specialty in Orthopedic and Trauma surgery, European nationals can join a North American Fellowship program[1-3].

The possibility to become a certified PO surgeon through the internship in Pediatric Surgery ( option Orthopedics )do only exist in France. It is important to point out that in all European countries but France, it is not possible to practice as a PO surgeon with a DoS in Pediatric Surgery as it concerns exclusively pediatric general surgery and pediatric urology. In all European countries but Romania and France to be able to work as a PO surgeon, it is necessary to obtain first the DoS in Orthopedic and Trauma surgery.

Although there are significant disparities in the Orthopedic and Trauma surgery training programs depending on the country, the equivalence of the DoS in Orthopedic and Trauma surgery is recognized between European Union countries as well as Switzerland and UK.

My personal experience, how I became a PO surgeon

I currently practice as a University Professor and Senior Consultant in PO surgery at the Faculty of Medicine and at the Lille University Centre, Lille, France.

I am Italian and the journey that brought me from Turin, Italy the city where I was born, to Lille, France, was not programmed in advance and cannot be defined as linear, even if it was very rich.

It all started in Montpellier, France where I had the opportunity to meet Professor Alain Dimeglio who made me discover and love PO surgery. In Montpellier, I held a position as a foreign resident until the completion of the DoS in Orthopedic and Trauma surgery ( University of Milan, Italy ). Once I did obtain it, I left France for four years to further train in PO surgery in United States ( Shriner’s Hospital for Children, Portland, Oregon; two years ), Canada ( The Hospital for Sick Children, Toronto, Ontario; one year ) and Switzerland ( Geneva University Hospital, Geneva; one year ). During this period I was also able to complete an International PhD in Animal Pathology at the University of Bologna, Faculty of Veterinary Medicine, Bologna, Italy to study the effects of early spine arthrodesis on thoracic cage growth,function and shape. Subsequently, I worked at the University Hospital of Clermont Ferrand, France where I was appointed as Professor of PO surgery at the University of Auvergne, Faculty of Medicine. In September 2020 I was transferred to the Lille University Center and the University of Lille, Faculty of Medicine, where I am currently working.My career path and my academic commitment led me to obtain the position I currently hold. Importantly, I have also worked for one year at the Guangzhou Women and Children Medical Centre, Guangzhou,China; this unique experience allowed me to deepen my knowledge in PO surgery, to collaborate on multiple research projects and to establish lasting relationships with my Chinese colleagues ( Fig.2 )[7]. I also had the possibility to examine and to operate patients in several other countries ( Benin, Lebanon, Morocco, Italy, India, Algeria … ) which allowed me to better understand the multiple facets of PO disorders.

Fig.2 a: Department of Pediatric Orthopedics,Guangzhou Women and Children’s Medical Center, Guangzhou, China; b: Department of Pediatric Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China;c: Prof. Lianyong Li and Prof. Federico Canavese at China Medical University; d: Morning teaching as guest professor at Shengjing Hospital, Pediatric Orthopedic Department, Shenyang

Conclusion

Becoming a PO surgeon requires a lot of motivation, perseverance and a great passion. Unfortunately, for the moment, European countries do not share a unique and standardized training program in PO surgery. If you decide to become a PO surgeon in Europe, it is essential to know the rules of the country where you live, and to be ready to travel abroad in order to complete your education in PO surgery.