1. TRAINING IN SURGERY IN GREECE George N Zografos Consultant Surgeon, Athens General Hospital General Secretary Hellenic Surgical Association National Delegate, UEMS Division of General Surgery

2. STATISTICAL DATA Panhellenic Medical Association Panhellenic Association NHS Nursing staff Greek Statistics Authority ( statistics.gr)

3. 64.003 Doctors ( 38.508 male, 25.495 female) 2.208 Surgeons 1125Surgeons in Athens - Peireus 1.143Members of the Hellenic Surgical Society

4. NATIONAL HEALTH SYSTEM 15.407 Doctors 3.161Consultants 845Chairman 2.183Staff Grade A 1846Staff Grade B 31.567Nursing staff

5. 141 National Hospitals, Infirmary( 30.400 beds) 169 Private Clinics, Infirmary (15.587 beds) 314 Total National + Private Clinics, Infirmary 483 beds / 100.000 habitants 251 Hospital Doctors/ 100.000 habitants 440 Nursing Staff / 100.000 habitants Greek Statistics Authority

6. CENTRAL STATE CONTROL OF SURGICAL TRAINING Ministry of Health Central Committee of Health ( KESY)

7. 36 Basic Medical Specialties Surgery, Vascular Surgery, Hematology, Radiology, Allergiology, Anesthesiology, Internal Medicine, Gastroenterology, genetics, General Medicine, Maxillofacial surgery, Dermatology, Endocrinology, Social medicine, Public Health, Cardiology, Cytology, Gynecology – Obstetrics, Neurosurgery, Nephrology, Orthopaedics & Traumatiology, Urology, Ophthalmology, Pathology, Psychiatry, Paediatrics, Paediatric Psychiatry, Plastic surgery, Pneumonology, Nuclear Medicine, Reumatology, Rehabilitation medicine, Thoracic surgery, Paediatric surgery, ENT, Forensic medicine.

9. DURATION OF TRAINING IN SURGEY 6 Years 5 Years General Surgery Two 6-month period in other surgical specialties: Gynecology, Vascular surgery, Urology, Neurosurgery, Orthopaedics, Plastic surgery, ENT, Pediatric surgery

10. SURGICAL TRAINING IN GREECE Application at a “ District State office” and transmission to the Hospital and Ministry of Health Waiting list in chronological order ( 1-2 years in General Surgery) Only National Health System Hospitals ( + University Hospitals) can offer surgical training Large Hospitals usually cover the whole 6-year training period District and Military Hospitals cover 1-3 years

11. Choice of the Hospital from the trainee Usually the training is completed for all the 6 years in the same Hospital The trainee can select to start with low volume Hospitals and cover the initial 1-3 years ( District Hospitals, Military Hospitals) There is a fixed number of trainees per hospital ( 1/3-4 beds)

12. SPECIAL SUPERNUMERARY CATEGORIES Military doctors Doctors with severe chronic diseases Overseas doctors sponsored by their own countries

13. DURING THE TRAINING A Number of surgical procedures ( perform/assist) Spectrum of procedures Surgical research, Medical thesis Visiting clinician overseas Postgraduate courses Chairman/ Staff surgeons of the Department of Surgery Chairman sign a testimonial in order to apply for the exam

14. DURING THE TRAINING Hands on courses, Congresses, Meetings, Medical knowledge courses Hellenic Surgical Society, Other smaller societies (Endocrine, breast, colon, HPB etc) International societies University Departments National Health System Departments Private Clinics Departments Support from Pharmaceutic/ medical supplies companies

15. FINAL CENTRAL EXAM Three Examiners ( 1 from the University, 2 from the NHS - determined by Ministry of Health) MCQs & Oral exam the following day Success rate 70-80 % Possibility up to 3 attempts Further failure repeat 6 months training in another hospital and new final exam

16. SPECIAL ISSUES IN SURGICAL TRAINING IN GREECE Full Training Hospitals are not of equal volume and spectrum Departments within Hospitals or same Hospital are not equal and the level of training varies Absence of national principles/guidelines for training Rotation of trainees is not legislated Medical research is not encouraged in all Hospitals Log book kept on volunteer basis Failed trainees can not be removed

17. SPECIAL ISSUES IN SURGICAL TRAINING IN GREECE There is no Hospital/ Department evaluation (quality control) There is no surgical trainee evaluation There are no criteria for selection of trainees at the stage of program entrance Endoscopy is not included in the surgical training A number of high quality trainees do not wait at the list of the Ministry of Health and enter residency programs abroad ( U.K, USA, Germany, Sweden, France, Switzerland)

18. SPECIAL ISSUES IN SURGICAL TRAINING IN GREECE Several attempts to establish panhellenic entrance exams to commence specialty training Severe reaction from Athens Medical Association and student unions - syndicalism Repeat hesitation from the Governements to establish criteria for training commencement and transfer competence/responsibilities to the Hellenic Surgical Society

19. THE ROLE OF EUROPEAN AND US HOSPITALS Significant number of young surgeons/trainees go overseas after the final exam or during the training ( UK, USA, Germany, France) To enrich surgical training of Greek doctors During – After basic training

20. There is no official involvement of the Hellenic Surgical Society in the surgical training and exams in Greece

21. PROPOSALS OF THE HELLENIC SURGICAL SOCIETY

22. SUBJECT OF TRAINING Theoretical backround and practical training of the resident on basic rules of surgical science and diagnosis & treatment of several diseases, malformations, trauma of human organs as well as the technique of various surgical procedures

23. CONTENT OF GENERAL SURGERY Oesophagus Stomach Small bowel, Large bowel, Anus Head & Neck, Endocrine surgery Thorax, Vascular Liver, Biliary tract, Pancreas, Spleen Breast Uterus, ovaries, kidney Abdominal wall Skin, soft tissue

24. TRAINING INCLUDES PROCEDURES ON: Retroperitoneum, pelvis Various diseases of other organs Trauma Laparoscopic/Robotic surgery

25. Selection criteria for entering the residency program in Surgery Panhellenic exams / chronological list

26. Training program in Surgery only in eligible Hospitals Responsible for trainees tutor in cooperation with the chairman of the Department Training classified as basic and advanced, 3 years each Number of procedures: 400-750 ( minor, moderate, major) as a surgeon Double the number for 1 st /2 nd assistance

27. BASIC Medical knowledge Minor, moderate procedures Basic laparoscopic procedures ADVANCED Medical knowledge Major procedures Advanced laparoscopic procedures

28. Responsible for trainees at least at the level of staff grade A, or associate professor In cooperation with the team evaluation of the trainee every year a) medical knowledge- multiple choice questions b) skill evaluation c) attitude d) communication with the medical – nursing staff

29. LOG BOOK Subject of training per year Number, spectrum, category of surgical procedures ( dates, initials, Hospital number, exact operation)

30. REPORT AT THE END OF THE BASIC 3 YEARS Conducted by chairman/tutor Training centres Scoring at the annual evaluation Number, spectrum of procedures Obligatory participation at the postgraduate courses of the Hellenic Surgical Society Total score Entrance to the exam

31. REPORT –EXAM AT THE END OF THE ADVANCED 3 YEARS Conducted by chairman/tutor Training centre Scoring at the annual evaluation Number, spectrum of procedures Obligatory participation at the postgraduate courses of the Hellenic Surgical Society Total score Entrance to the exam

32. FINAL EXAM Multiple choice questions ( 150-200) Short written elucidation on current knowledge, topics, clinical scenario, innovation Oral exam

33. Committee of examiners 3 Surgeons Professor/Chairman NHS, Assoc. Professor/ Consultant Surgeon The list of examiners is proposed exclusively by the Hellenic Surgical Society vs The society decides for 1 of the 3 examiners The Board changes synthesis every 2 years Exam centre are large hospitals with significant number of trainees

34. TRAINING CENTRES - ELIGIBILITY General, or University or Prefecture* Hospitals Fully equiped laboratories Departmnent of Orthopaedics, Urology, Gynecology, ENT, Ophthalmology, Endoscopy Unit Intensive care Unit Admit emergencies 100-150 surgical procedures under G.A. per trainee ( including surgical oncology) Systematic training program * administrative area/county

36. CONTRIBUTION OF THE HELLENIC SURGICAL SOCIETY To improve standards of surgical training in Greece Achieve homogeneity of training in General Surgery in Europe