Reply to Bajona.

I thank Bajona [1] for his interest in the article regarding a European Training Programme in Cardiothoracic Surgery [2] and the comments by Hamilton [3], and for the caveats raised. The selection of appropriate trainees for a training programme is of vital importance, equal to having the appropriate trainers and training programmes as one of three sides of a successful training programme triangle. The selection of trainees according to all criteria but merit is widespread and allows certain individuals in authority to manipulate and exploit training and trainees. This can only be eliminated by developing a structured, transparent and robust selection procedure with clear and valid personal and professional specifications and qualifying criteria. I certainly agree with Bajona [1] that for basic training, it could be regionor country-based, but for advanced training it should be Europewide [2] to allow trainees to optimize their training in the field of their choice in the best programme available. This competition can only help to raise the standard of training offered by various training centres across Europe to attract trainees of high calibre into their programmes. Competence should certainly be measured in an unbiased and accurate fashion using appropriate validated and reliable tools and methods. The tools chosen should have face, predictive, construct and content validity proven by educational research and be reliable enough to avoid interand intraobserver variations. The latter can be improved by incorporating training in the use of assessment methods in Train the Trainer Courses to produce trainers versed in modern training theory and practices. The assessment process can be made more sound by triangulation, removing the need for independent surgeons from a different country to perform the assessment. Manpower planning and optimal provision of trained cardiothoracic surgeons of high calibre for Europe are difficult to accurately forecast, but should at least be attempted. Non-European citizens wishing to train in Europe can be given the opportunity, but will have to compete on equal footing with all other applicants for entry both into the basic and advanced training programmes if places are available. The European Board examination is in need of urgent review, upgrade and reform, to be of a standard acceptable as a qualifying exit examination that can be recognized across Europe and the world. The harmonization of training programmes will eliminate the inequality of access to Board certification. The division of the training programme into basic and advanced stages not only ensures the optimization of the provision of training programmes, but also provides structured and achievable targets for trainees and Training Programme Directors. All trainees should have adequate surgical experience appropriate to their level. Basic qualification does not allow stand-alone practice, and only trainees who complete the advanced training would have the opportunity to become independent surgeons. This will allow the production of fully trained surgeons that can be independent of departmental chiefs. It is high time for the people in leadership positions in our speciality across Europe to act to achieve a European Training Programme in Cardiothoracic Surgery.