Trauma surgery training: the Dutch approach

In the last few decades, general surgery is getting more and more divided into subspecialties in the Netherlands. Until now, in most hospitals there is one general surgery department in which visceral, oncologic, vascular and trauma surgeons are working together. The development of specialization increases the quality of the treatment of selected diseases or injuries. However, the overview of the whole patient can become endangered. It is important to train specialists, but every surgeon has to have a wide knowledge of patient care. This is eminently important in the treatment of polytraumatized patients.

The Netherlands is a small but densely country with approximately 17 million inhabitants. Most accidents are related to traffic, work, and sports. Violence-related injuries are less common. Since 1998 the Ministry of Health, Welfare and Sports selected 11 hospitals as level 1 trauma centre. These 11 trauma centers have the responsibility to organize the trauma care in their region. They focus in particular on care for polytraumatized and tertiary referred patients, classification of the regional hospitals in level 2 and 3 trauma centers (Table 1), and registration of hospitalized trauma patients in a national database (Landelijke Trauma Registratie). The following trauma centers are having a helicopter team with a surgeon or anesthesiologist and nurse for prehospital care: Amsterdam, Groningen, Nijmegen, and Rotterdam. In contrast to Germany, there is no so-called ‘Notartzt’ system. The ambulance service personnel are trained to stabilize patients and to start CPR. They are also allowed to give selected medical treatment [1].

In the hospital the trauma surgeon is in the lead during whole treatment of a trauma patient, from the emergency department to discharge. A trauma surgeon is a general surgeon who is trained to treat thoracic, abdominal, and musculoskeletal injuries. When necessary, other disciplines are consulted. Polytraumatized patients are always treated by the trauma surgeon. Depending on local agreement, isolated fracture care can also be done by the orthopedic surgeon. Nowadays, approximately 75 % of fracture care is done by trauma surgeons and 25 % by orthopedic surgeons.

The training to become a trauma surgeon and orthopedic surgeon is separate [2]. When the basic medical training is completed, young physicians start working as resident not in training or they start a research project to write a PhD thesis. The organization of surgical training is divided into 8 regions and all regions are part of a university hospital with one main responsible trainer. Every region has several regional hospitals with local responsible trainers.

To become a surgical resident in training, someone has to apply for a residency and has to do a job interview with all local trainers. The training is competent based and every resident has a digital portfolio and has to get a mandatory amount of clinical and operative reviews from the teaching surgeons in this portfolio. Every year, the resident has to do an exam adopted from the American Board of Surgeons. The education program takes 6 years and 2 or 4 of these 6 years are respectively spent in a university hospital or in a peripheral clinic. The first 2 years is called the Common Trunk and consists of rotations in emergency department, intensive care unit, vascular, visceral, and trauma surgery. The second 2 years are aimed at advanced surgical training in vascular, visceral and trauma surgery. The resident reaches a level of independent clinical and operative skills in these first 4 years. The last 2 years are called the ‘differentiation phase’. The resident specializes in one of the subareas of general surgery: trauma surgery, visceral surgery, oncologic surgery, vascular surgery, lung surgery, or pediatric surgery. After 6 years the resident finishes the training and will be certified as general surgeon and, depending on the differentiation, for example as trauma surgeon.

The training in orthopedic surgery has a Common Trunk which is comparable except for the intensive care unit rotation, which is abolished. The following years of the orthopedic surgery training are very broad and a separate ‘differentiation phase’ is missing (Fig. 1).

In the ‘differentiation phase’ of the surgical training, the resident focuses on trauma surgery practice. One of 2 years has to be done in a level 1 trauma center and the other in a level 2 center. During shifts, the resident is responsible for the whole surgical unit and also comes in contact with patients with vascular and visceral problems at the emergency department or during operations. There are a number of mandatory courses (Infobox 1). At the end of the ‘differentiation phase’, the resident is able to stabilize trauma patients (musculoskeletal, thorax, and abdominal) and to perform definitive treatment for the most occurring injuries. After this training, there is the possibility for optional fellowship training to superspecialize in for example pelvic of spine surgery.

Since a structural collaboration between trauma surgeons and orthopedic surgeons is missing in the Netherlands, we are actively in discussion at this moment. In the very near future we are planning to create a common trauma unit where trauma surgeons and orthopedic (trauma) surgeons are working together in a so-called ‘inner ring’. These surgeons are capable to perform complete primary care for polytraumatized patients and they can also perform definitive treatment. When necessary, the ‘outer ring’ with other medical disciplines (e. g., hepatobiliary surgeon, cardiothoracic surgeon, neurosurgeon, otorhinolaryngologist) are consulted to assist in treatment. The second topic which is being discussed is the possibility for a common training in trauma surgery for general and orthopedic surgeons. However, this is still in its infancy.